MANAGEMENT OF THE PATIENT IN CARDIAC FAILURE

THE LONG-TERM MANAGEMENT OF THE PATIENT IN CARDIAC FAILURE
In the preceding pages attention has been devoted to the management of
cardiac failure in its extreme forms as met with in hospital practice. Such management generally involves several weeks of intensive therapy, after which the patient is discharged to his home. There, over a period of months or years, he will require skilled supervision by his family doctor. Many patients who have been in gross failure and who have been rescued by treatment can be maintained in a state of relative well-being, fit for a fair amount of activity and possibly even able to continue their normal occupations provided their treatment is closely supervised. It is with this highly important aspect of treatment that the follow¬ing paragraphs are concerned.
As a first step after convalescence, the patient should take stock of his whole environment and activities with a view to reducing expenditure of energy to an amount within his cardiac capacity. Attention by the doctor to matters of detail is of inestimable value : for example, the avoidance of fatigue and exposure to inclement weather on the way to and from work may be more important to the individual than the nature of his occupation, since many patients with sedentarv work can carry on without ill effects provided they are not exhausted by the effort of getting to it. So also in the home, by attention to such apparently trivial details as the location of bedroom and lavatory the patient may be spared fatigue in climbing stairs. In the case of a patient whose home is in an upstairs flat a certificate by the doctor recommending a ground-floor house may result in appropriate action by the local housing authority, to the great benefit of the individual and his family. Further, the securing of adequate rest is vital. The patient who continues at work perhaps with some difficulty, should be encouraged to spend at least eight hours in bed each night and should also be advised to take things very quietly at weekends. A day's rest in bed each week—be it Saturday or Sunday—is of great value and can readily be achieved ; the only exception in this present age is the housewife, whose work goes on seven days a week with no trade union to guard her interests. Even in her case, however, it is often possible to arrange that she spends a part of each day resting, say in the afternoon from 2 to 4, once the midday dinner is over and before the children come home from school. It may also be possible to arrange through the Social Services for home help of one sort or another—a woman may come in, at public expense or partially subsidized by the state, to do the heavy housework; cooked meals may be provided by one of the voluntary services ; young children may be cared for in a creche. The doctor who is familar with the patient and family and with the particular environmental conditions may be of great help in giving advice about these matters.
On the major question of occupation the doctor's help may be of great value. Manifestly many will be unable to continue their previous occupation once they have suffered from congestive failure. Arduous manual labour is out of the question, and to re-engage in such employment is to court disaster. It is often possible for the doctor to suggest a suitable occupation for young people. In the case of the middle-aged or elderly individual, particularly the wage-earning man, it may be difficult to secure a niche in industry into which the handicapped person can be fitted. There are, however, facilities in rehabilitation centres for the training of patients in new skills, and up and down/the country factories have been established in which sheltered employment can be given to those unfitted by physical handicap for the rough and tumble of ordinary industrial conditions. It should be emphasized that some occupation even for the gravely handicapped is of the greatest therapeutic value and conversely that prolonged unemploy¬ment through sickness is demoralizing. The conscientious family doctor will endeavour to secure employment appropriate to his patient's capabilities,and will encourage him in every way to continue wage-earning so long as .circum¬stances permit.