Nursing Care at the End of Life

Dyspnea can be defined as “the unpleasant sensation of being short of breath” or simply as the perception of breathlessness. It is a common occurrence in patients with advanced disease, with up to 70% experiencing some dyspnea in the last six weeks of life (Waller and Caroline, 2000).

Like pain, dyspnea can have varied causes with accompanying subjective elements. Anxious or depressed patients and patients with underlying psychological disorders have been shown to have a more intense experience of breathlessness. Anxiety in particular appears to be significantly associated with dyspnea. It is important, then, to explore the emotional and spiritual components as well as the physical causes of dyspnea when deciding on treatment.

Physical causes of dyspnea:

	Tumors or metastases to the lungs
	Pleural effusion
	Underlying infections such as pneumonia
	Pneumothorax
	Anemia
	CHF
	COPD
	Ascites
	GERD

Management of dyspnea
Assess lungs for crackles and wheezes that may signal CHF or an exacerbation of COPD; also assess for any underlying infection or abdominal ascites that may be interfering with pulmonary excursion. Direct the treatment toward the assessed cause.

Non-pharmacological interventions

	Initiate non-pharmacological interventions along with pharmacological interventions.
	Change the position of the patient to facilitate the expansion of the lungs: elevate the head of the bed, position the patient leaning forward with their arms supported by a table (orthopneic position).
	Place a small fan so that the breeze is felt on the cheek or nostrils of the patient. This can relieve breathlessness and encourage deeper respirations by stimulating the trigeminal nerve receptors.
	Teach the patient and family/caregiver pursed-lip breathing. This technique can reduce dyspnea by increasing the tidal volume and decreasing the respiratory rate. Pursed-lip breathing is an effective tool for patients with COPD.
	Anxiety and depression can be treated with techniques such as Therapeutic Touch, music therapy, spiritual counseling, life review, and other psychological interventions.

Pharmacological interventions

	Oxygen therapy as appropriate
	Opioids for bronchodilation. Start early with low doses, and titrate upwards in opioid naïve patients. This gives time for tolerance to develop to the respiratory effects of the opioid. There is evidence that use of opioids in this manner does not hasten death, and can actually prolong life by decreasing the distressing symptoms and fatigue that dyspnea can cause (Ferrell and Coyle, 2001).
	Antibiotics for underlying infection if it causes discomfort from cough, fever, and/or fatigue.
	Anxiolytics such as lorazepam or diazepam.
	Steriods such as dexamethasone may be used for inflammation or obstruction of the bronchus by a tumor. Beclomethasone inhalers are useful for patients with COPD or asthma.
	Furosemide and spironolactone together may help with pleural effusion and ascites.