Home Health & Hospice Week

Don't fall short in managing shortness of breath in terminally ill patients.

Hospices serving large numbers of patients in nursing homes are firmly in the feds' crosshairs. But you can use a recent study to show just how much hospice care is helping the nursing home patients you serve with one specific measure.

A recent study from Brown University states that "for nursing home patients not in hospice, one in five family members reported an unmet need for shortness of breath while that was only 6.1 percent for people in hospice." But to tout this quantifiable measure of hospice care's benefits, you should make sure you're addressing the problem.

Assessing shortness of breath "in this population of patients is no different from what should be the good practice of medicine, based on the context of where the patient is in their life's trajectory," advises physician Joel Policzer, national medical director for VITAS Innovative Hospice Care in Miami, Fla.

The patient "should be evaluated to determine whether the dyspnea is of cardiac or pulmonary origin, due to anemia or ... to an increase in general debilitation increasing the 'work' of breathing," says Policzer. The physician can determine this "with good accuracy knowing the patient's past history, the current history and course of onset of the symptom -- and by doing a good physical examination," he adds. "The need for 'technology' (X-rays, blood gases, scans, etc.) is limited and often duplicative."

Once you identify the cause of the problem, then you begin therapy in the facility that matches the patient's and family's goals of care, adds Policzer.

Examples: "If the patient has congestive heart failure, diuresis (using medications to get the patient to urinate the excess fluid) may help," says Policzer. Antibiotics may help a patient with chronic lung disease who has a lung infection, he adds.

Low-dose morphine can be a "useful addition" for the patient with "non-remedial shortness of breath, heart failure or lung disease that can't be made better -- or a lung replaced by cancer, etc.," Policzer advises.

Season's Hospice in Baltimore, Md., uses morphine to treat dyspnea in some cases, reports physician Harold Bob, the medical director there. "When a person has tachypnea, we titrate morphine to their respiratory rate," he explains. "Hospice has the capability to use low-dose opioids in opioid naïve patients, which can effectively palliate dyspnea without significant risk of shortening the person's life."

"Morphine rarely suppresses respirations at very low doses," says Bob. "Non-hospice nurses, however, often fear that they will give someone in respiratory distress morphine, and the person will die -- and they will be held liable."

You administer the low-dose morphine "either orally or by subcutaneous injection," explains Albert Barber, consulting pharmacist for Clinical Rx Consulting in Stow, Ohio, who says he's also seen it administered by inhalation. That's "where you take the parenteral product and put it in the nebulizer and give it that way," he adds.

"Anxiety can cause shortness of breath in someone" who is terminally ill, says nurse Lynn Serra, a consultant with Beth Carpenter and Asso-ciates in Lake Barrington, Ill.

Potential remedies: "When people who are dyspneic talk about their spiritual beliefs, it can have a calming effect," says Bob. "In working with patients and families, we have the social worker and chaplain talk to them about their spiritual beliefs--- and what they believe happens when they transition or die (we use either word). I find that 90 percent of our patients/families believe in an after life. When asked whom they expect to see on the other side, they will say 'my mother, brother or wife, etc.' And when they talk about their own beliefs and faith, they become calm."

Also: Season's Hospice "permeates its inpatient unit with a calming approach," adds Bob. For example, staff "routinely integrate music, aromatherapy and simple touch."