The Advanced Practice Nurse's Role in Palliative Care and the Management of Dyspnea

Rose Anne Indelicato, MSN, APRN-BC, PCM-BC, OCN

Disclosures

Topics in Advanced Practice Nursing eJournal. 2006;6(4) 

In This Article

Abstract and Introduction

Dyspnea is one of the most common symptoms reported by patients receiving palliative care. It is not only a symptom of severe or chronic pulmonary disease, but is also associated with a wide variety of illnesses such as cancer, heart failure, and dementia, as well as neurologic disorders such as cerebral vascular accidents, amyotrophic lateral sclerosis, and AIDS. Given its subjectivity, the assessment and management of this distressing symptom can be challenging. This article will highlight the core principles of palliative care and will illustrate the role of the advanced practice nurse (APN) specifically in the management of dyspnea.

Dyspnea can be defined as "an uncomfortable sensation or awareness of breathing... patients may describe the feeling as shortness of breath, inability to get enough air or suffocation."[1] It differs from tachypnea (increased respiratory rate) and hyperapnea (increased depth of ventilation). It is frequently described in terms of air hunger, choking, or heavy breathing, and it can be extremely distressing for families and caregivers to witness.[2] The word "dyspnea" is derived from the Greek "dys," meaning "hard," and "pnoia," meaning "breathing."[3]

Similar to pain, dyspnea is a subjective experience that is influenced by many factors, both physiologic and psychological. Due to its subjectivity, the patient's intensity report may not correlate with pulmonary dysfunction as evaluated by objective tests such as pulse oximetry, chest x-rays, or pulmonary function tests.[4]

The prevalence of dyspnea in the palliative care patient has been well documented in the literature. In the cancer population, one study found that 21% to 78% of patients experience dyspnea days or weeks before death, with an increased prevalence during the last 6 weeks of life.[5] The SUPPORT study reported severe dyspnea in 32% of patients with lung cancer and 56% of patients with chronic obstructive pulmonary disease (COPD).[6] In the AIDS population, Greenberg and colleagues[7] reported the incidence of dyspnea as 68% at the time of death.

Breathlessness can be quite prevalent in patients with congestive heart failure, with 61% experiencing dyspnea during the last year of life and 72% of them having the symptom for 6 months or longer.[8] Similarly, dyspnea occurred in 37% of patients who sustained a cerebrovascular accident, and 57% of them experienced the symptom for 6 months or longer.[9] Dyspnea was identified in 47% to 50% of patients with amyotrophic lateral sclerosis (ALS), and in 70% of patients with dementia.[10]

Breathlessness is not limited to patients with known respiratory impairment caused by neoplasms, AIDS, or chronic cardiopulmonary disease. According to data from the 1986 National Hospice Study, 24% of the patients who complained of dyspnea did not have any evidence of pulmonary or cardiac impairment.[11]

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