Palliative Care and the Management of Dyspnea

The Role of the APN in Symptom Management

The Scope and Standards for Hospice and Palliative Nursing Practice (2002) state: "Because of their proximity to patients, APNs are in ideal positions to assess, diagnose, and treat pain and other symptoms."^[12] Given the advanced clinical knowledge and experience of the APN, providing quality symptom management is easily within the practitioner's purview. In order to offer care from a palliative perspective, there are some general principles that the clinician should bear in mind when treating the patient and caring for the patient's family.^[3,13,14]

First, discuss the goals of care and treatment options with the patient and family. This should be an ongoing discussion, as decisions and wishes that are appropriate at one point might not apply a few months later. An individualized plan should be created in collaboration with other team members, taking into consideration the patient's general condition, the presence and severity of symptoms, the expected survival, and the preferred place of care.

The APN may be the most appropriate team member to guide discussions about advance directives. According to Dahlin, advance care planning is "a process of initiating discussion, reflection and understanding of one's health state in terms of goals, values and preferences for future treatment, including decision making around life sustaining treatments. The process begins with the patient's understanding of the disease and discussion related to possible medical scenarios, leading up to death."^[14]

These discussions should begin as early in the relationship as possible, before the patient and family are in the midst of crisis. This allows them to come to terms with difficult choices at their own pace, not because of a medical emergency. By discussing some of the burdens and benefits related to life-sustaining treatments, the APN can empower the patient and family to make informed decisions, possibly even giving them a sense of control at a time when everything can feel out of control. These conversations will foster a sense of trust between the patient, the family, and the APN. Once wishes are known, the APN can then advocate for the patient and assure the communication of those wishes to the relevant caregivers and healthcare providers.

Second, treat the underlying cause of a symptom whenever possible and be consistent with the goals of care. For example, if treating a respiratory infection with antibiotics will facilitate management of dyspnea and if the patient and the family are in agreement, this intervention should be one of the first implemented. If, however, the patient has already received multiple courses of antibiotics without improvement, this therapy may be futile and would not be in the patient's best interest.

Third, avoid new problems when intervening. Be sensitive to the possibility of side effects or the complex burden of an intervention, be it physical, psychological, social, or even financial.

Fourth, consider whether a treatment will be worthwhile. For example, a nephrologist might recommend that a patient receive outpatient hemodialysis, which might have only a slight life-extending promise, without discussing or considering the logistics of getting the patient to and from treatments.

Finally, anticipate and prepare family and caregivers. Prevent rather than react to crises. For example, educate families and caregivers about potential medication side effects, complications, or emergencies. Provide concrete interventions that the caregivers might implement to manage these situations.

Cite this: The Advanced Practice Nurse's Role in Palliative Care and the Management of Dyspnea - Medscape - Dec 31, 2006.

Etiology of Dyspnea ^[1,15,16]
Physiologic System	Disorder
Pulmonary	Asthma
	Adult respiratory syndrome
	Bronchial obstruction
	COPD (bronchitis, emphysema)
	Cystic fibrosis
	Interstitial lung disease
	Lung cancer
	Patient/ventilatory asynchrony
	Pleural effusion
	Pneumonia
	Pneumothorax
	Pulmonary embolism
	Chemotherapy toxicity
	Chest wall fractures related to metastatic disease
Cardiovascular	Congestive heart failure
	Fluid overload
	Superior vena cava syndrome
	Arrhythmias
	Cardiomyopathies
	Valvular or pericardial disease
	Congenital abnormalities
	Chemotherapy toxicity
Hematologic/Metabolic	Anemia
Hematologic/Metabolic	Electrolyte abnormalities
Neuromuscular	ALS
	Muscular dystrophy
	Multiple sclerosis
	Myasthenia gravis
	Reduced respiratory muscle force (deconditioning)
Psychological/Spiritual	Anxiety
	Depression
	Spiritual distress

ALS = amyotrophic lateral sclerosis; COPD = chronic obstructive pulmonary disease.

Scheduling of Opioids for the Management of Dyspnea ^{[1,41,60,80,81]}
	Opioid Naive*	Opioid Tolerant*
Mild dyspnea	Hydrocodone (5 to 10 mg) or codeine (30 mg) orally every 4 hours	Increase dose by 25% to 50%
Severe dyspnea	Morphine sulfate 5 mg orally every 4 hours, or oxycodone 5 mg orally every 4 hours, or hydromorphone 1 mg orally every 4 hours	Increase dose by 25% to 50%
Severe dyspnea	Parenteral morphine 2.5-5.0 mg subcutaneously or intravenously every 3-4 hours	Increase dose by 25% to 50%
Titration	Increase orally by increments of 50% to 100% every 24 hours as needed; titrate parenterally to effect	Increase by increments of 50% to 100% every 24 hours as needed

*If a patient is elderly or has severe pulmonary disease, such as COPD, start at 50% of the above doses and titrate more conservatively with increments of 25%. If the patient requires frequent dosing, the 24-hour total can be calculated and then converted into a sustained-release preparation, with the availability of a short-acting breakthrough dose every 2 hours as needed.

Benzodiazepine Therapy for the Management of Dyspnea ^[1,24]
Benzodiazepine	Dosage and Titration
Short-acting Formulations
Lorazepam	Starting dose: 0.5 to 1.0 mg orally every hour until the symptom is controlled, with routine dosing every 4-6 hours thereafter
Midazolam	Starting dose: 0.5mg IV every 15 minutes until dyspnea is controlled, then maintenance of a continuous subcutaneous or intravenous infusion
Long-acting Formulations
Diazepam	Starting dose: 2-10 mg orally every hour, then routinely every 6-8 hours
Clonazepam	Starting dose: 0.25-2.0 mg orally every 12 hours

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

My Alerts