Using a Dyspnea Assessment Tool to Improve Care at the End of Life

Lorri Birkholz, DNP, RN, NE-BC; Tina Haney, DNP, CNS, RN

Disclosures

Journal of Hospice and Palliative Nursing. 2018;20(3):219-227. 

In This Article

Discussion

After receiving the RDOS educational program, there was not a significant difference in the nurse's ability to assess the patient's overall level of perceived comfort ("Does the patient appear comfortable?") and determine a differential diagnosis. However, there were statistically significant differences in the nurse's treatment selection and ability to correctly determine the patient's level of dyspnea after receiving education on the RDOS.

Assessment skills are fundamental to nursing practice and require nurses to use many of their senses, especially when they are providing care to patients who cannot self-report. As shown in this study, nurses' experiential assessment skills remained highly accurate when determining the patients' perceived level of comfort prior to receiving RDOS education. This said, and knowing there is a high prevalence of end-of-life dyspnea in patients, nurses can enhance their assessment of dyspnea severity and treatment options by using the RDOS to assign a numeric value to the patient's presenting dyspnea symptoms. Through the adaptation of standard assessment variables, nurses can reduce between care provider disparities and reduce the physical and emotional suffering attributed to end-of-life dyspnea, thus improving the patient's and family's quality of life and quality of death.[24]

Limitations

Limitations of this study include a small sample size (n = 39), and the populations of hospice nurses and medical nurses were disproportionate (n = 32 and n = 7, respectively). Despite the instructions asking participants to select their most appropriate differential diagnosis and treatment option, many selected more than 1 answer, which complicated the analysis and resulted in multiple answers being scored as incorrect even if the correct answer was one of the choices. Ideally, this pilot study should be replicated with a larger population and longitudinally to assess adaptation of the RDOS into practice and knowledge retention. An additional study also exists in evaluating family perceptions of dyspnea management in patients whose symptoms are assessed and managed using the RDOS.

Conclusion

Despite how common dyspnea at the end of life is, there remain relatively few operationalized measures in place to evaluate and treat dyspnea to improve quality of life at end of life.[8] Knowing that end-of-life dyspnea is distressing to patients and their families, nurses could integrate an easy-to-use evidence-based tool into their assessment tool kit. Like pain scales, which have become a patient care standard over the past 20 years, the RDOS allows the clinician to numerically score the patient's symptoms and adjust their treatment modality accordingly. Because the RDOS is specifically designed for patients who cannot self-report, this tool has applicability in many other areas of nursing including intensive care units, emergency departments, and long-term-care settings but requires training prior to utilization.

The results of this study demonstrate that nurses who provide end-of-life care can increase their ability to identify dyspnea severity and treat dyspnea in patients who cannot self-report by integrating the RDOS into their current practice. Nurses in this study demonstrated accuracy in their subjective assessment of patient's overall level of comfort/discomfort, which was not influenced by integrating the RDOS into their assessment. However, when using the RDOS to obtain a numerical value, there was a significant increase in the nurse's ability to appropriately categorize the patient's level of dyspnea, which in turn affects treatment selections. The ease of use of the video format allows for ongoing training and future research using the same multiethnicity scenarios. This existing program could also be easily adapted to an online learning format. Using the foundations of this study, future research could examine the effectiveness of dyspnea management using the RDOS when it is integrated into an electronic health record, compare results to determine whether access to palliative care services influences the nurse's ability to assess and manage end-of-life dyspnea, and examine RDOS assessment scores with treatments to determine whether there is improved consistency in care delivered and thus the patient's overall comfort.

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