Breathing Life Into Dyspnea Relief

TON - AUGUST 2012 VOL 5, NO 7 — August 23, 2012

A program conducted at Cedars-Sinai Medical Center, Los Angeles, California, improved oncology nurses’ awareness of dyspnea in patients with advanced cancer. Sarah Kang, RN, MSN, described the program at the 37th Annual Congress of the Oncology Nursing Society.

“Refractory dyspnea is especially frequent and distressing to terminally ill adults with advanced cancer at the end of life, and it is estimated that 60% to 70% of patients experience this,” Kang said. “Because of the great suffering it inflicts, dyspnea is consistently the primary or secondary indication for palliative consultations.”

The program aimed to educate nurses on the pervasive and distressing nature of dyspnea, the recommended assessment, evidence-based interventions, and current research, measured through a pretest and posteducation questionnaire. The program included a brief in-service session on managing dyspnea in patients with advanced cancer without chronic obstructive pulmonary disease. It also included an educational flier and a large poster placed in the floor hallway.

The program components covered the following areas: (1) What is dyspnea? (2) How common is dyspnea? (3) How can you assess for dyspnea? and (4) How can you alleviate dyspnea?

While nurses tend to be able to identify when dyspnea occurs, prior to the program few could name 5 evidencebased interventions and few knew how to properly assess for it. “Studies show that healthcare professionals often fail to correctly identify and assess for the severity of dyspnea,” with “a huge disparity between what nurses see and what patients report,” she added. “So part of the educational program was to enhance assessment.”

The program instructed nurses to assess for dyspnea at the end of life as often as they assess for pain or nausea. They should ask the patient, “Are you having any difficulty breathing?” and “Did you feel breathless or feel as if you are not getting enough air?”

The program, attended by 15 nurses, was effective at raising awareness of the incidence of dyspnea at the end of life and in increasing knowledge of evidencebased interventions, Kang reported.

In particular, nurses better understood the potential effect of providing increasingly high doses of opioids at the end of life—an area where there has been confusion, she noted.

Prior to the program, 9 of 15 nurses suggested higher doses of opioids decrease respirations, 2 of 15 said they hasten death, 1 believed they increase agitation, and 1 suggested they are overly sedating. After the program, 11 believed that increasingly high doses of opioids alleviate dyspnea or provide comfort, and only 3 still believed this approach produces respiratory depression.

“For the typical cancer patient at the end of life, high doses of opioids do decrease respiratory rate, but when done appropriately there is no change in oxygen saturation, carbon dioxide retention, or survival time. In fact, sometimes they prolong life, because they decrease the work of breathing. This is a surprise to some nurses,” she explained.

In addition, in the pretest only 5 of 15 nurses listed interventions that reduce anxiety as a way to manage dyspnea, while this increased to 11 in the posttest.

“These responses demonstrate that education had a positive impact on the nurses’ knowledge of dyspnea in cancer patients during end of life, and therefore on their practices,” she said. “In addition, nurse feedback and anecdotal responses suggested that the educational project has also positively impacted patients who experience dyspnea.”

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