Relieving Terminal Dyspnea: Oxygen Or Air

Respiratory therapists treat dyspnea daily with vast resources ranging from nasal cannulae to mechanical ventilators; from relaxation and breathing exercises to pharmacological agents. Dyspnea presents in up to 70% of patients in the last 6 weeks of life, according to a National Hospice Study.1 It is one of the more common symptoms that bring terminally ill patients to the hospital. There is a process of treating patients in a curative or restorative manner and then a process of providing palliative care. The relationship of the two processes varies greatly. In a perfect world, patients would receive both concurrently. Clearly, any treatment that palliates discomfort benefits the patient.

Models of CareThe World Health Organization (WHO)2 presents interesting models of the relationship between curative/restorative care and palliative care. The American Thoracic Society (ATS),3 in its policy statement on palliative care in respiratory and critically ill patients, takes these models further. All models begin with the onset of disease. The models have two different endpoints. Two end with the patient's death. The other two extend beyond the patient's death to family bereavement. All models can exist in the same health care facility. Acute care hospitals are geared to restorative/curative care. Often palliative care is considered only when acute, curative care is no longer possible and medical futility is reached. This represents one model: Curative care ends and palliative care begins. Another model, with patient death as the endpoint, shows a linear relationship between curative care and palliative care. The other two models have curative/restorative care paralleling palliative care but to different degrees. Both take divergent paths as patient death approaches.

What makes so many models exist relates to more problems with terminal dyspnea, those being etiology, definition, and recognition of medical futility. Some etiologies are the natural progression of a chronic disease process. Heart failure and chronic obstructive pulmonary disease are two such examples. Other etiologies are acute, treatable sequelae of disease processes such as a malignant pleural effusion. Pleural effusions bring the added troublesome symptom of pain as sensory fibers are located in the parietal pleura. Some identify terminal dyspnea as the terminal event in a chronic disease process for which palliative care is initiated. Others see the onset of dyspnea as the beginning of the end, so to speak, for some disease processes such as cancer. Dyspnea can herald a change from intensive treatment and curative/restorative care for a patient to palliative care. Note that palliative care does not mean "do not treat" acute problems. Palliative care is comfort care. Hospice care does not provide curative or restorative therapies or treatments for any underlying conditions.

Curative or Palliative Care?

In hospitals, some intensive care treatments are so encompassing that patient comfort can be overlooked, but the transition from intensive care to palliative care or the introduction to palliative care can be a seamless one when barriers to this transition/addition are recognized and addressed. For example, a 70-year-old male with severe COPD is in the CCU awaiting evaluation for aortic valve replacement. He tolerates various amounts of time off mechanical ventilation on a trach collar on a daily basis. After several weeks, a speech pathologist is consulted to perform a bedside swallow evaluation. The speech pathologist asks the respiratory therapist to join in the evaluation at the bedside to consider the patient's risk for aspiration and the presence of the trach tube. The final determination was that with several patient safety protocols in place, the patient could have pudding, applesauce, and thickened liquids. This provided a great deal of comfort and satisfaction for an acutely ill patient. How often is such an evaluation done in an intensive care unit?

Another barrier to palliative care in an ICU is medical futility. Patients vary greatly in their recognition and acceptance of medical futility. Some patients who have been ill for a prolonged period of time battling a particular disease become sick and tired of being sick and tired. Other patients seek curative treatment to the very end. Neither position is being judged; they are presented solely for the degree to which patients recognize medical futility. Medical futility is not a concept the health care team and family arrive at together. Medical futility is often identified by physicians first, then by allied health professionals, and last by the families. Families and loved ones should be involved to the extent of the patient's wishes. Ideally, advance directives will identify health care surrogates who will use substituted judgment in the event the patient can no longer participate in health care decision-making processes.

Communicating with patients and families regarding end of life issues requires certain skills. The ATS policy statement even outlines them. Candor and compassion are vital during this process. Curtis et al provide a good discussion of missed opportunities during family conferences and end of life care.4 Patients and their families need assistance putting palliative care plans into activities of daily living. Some interventions are pharmacological. Some involve health care providers in the home. Palliative therapies for dyspnea include treating the underlying cause when possible. These can be pneumothorax, pleural effusion, anemia, a reversible component of obstructive airway disease, secretion management, congestive heart failure, pain management, and relieving anxiety. Other strategies to relieve terminal dyspnea include using a fan to blow cool air on the patient's face, opioids, anxiolytics, and noninvasive ventilation when tolerated.

Oxygen Versus Air

Other strategies involve the use of oxygen. Oxygen in the home conjures up fears in the minds of many a family member. "What if the oxygen tank falls?" "What if there is a fire?" The list is long. The guidelines for home oxygen in the hypoxemic patient are clear-cut. The patient must have a Pao2

Comments? Questions? Email Here

© HowtoAdvice.com

How to Advice .com