Improving Care for the End of Life, Online Edition The Palliative Care Policy Center

Sourcebook : 4.0 Managing Dyspnea and Ventilator Withdrawal : 4.0.1 Case Study - Hospice Care of Rhode Island

The team from Hospice Care of Rhode Island focused on improving dyspnea management for two reasons: Families reported that dyspnea was one of the most troublesome symptoms, and nurses identified managing dyspnea as an opportunity to improve their practice. Hospice Care of Rhode Island provides care for approximately 1,000 dying patients each year, with a daily census of about 375 patients.

The team aimed to reduce dyspnea by half in patients admitted to the inpatient hospice unit, while providing care that was consistent with patient preferences for avoiding dyspnea and sedation.

The team's first step was to establish uniform assessment for dyspnea, a process that included development of a dyspnea assessment tool for patients unable to rate their dyspnea. The team proposed dyspnea management competencies for nursing staff. Competencies included:

As part of its clinician education program, the team developed principles of dyspnea management, which are highlighted in the following box.

Graphs from Hospice Care of Rhode Island show just how dramatic improvements can be in managing dyspnea. In a five-month period, the Breakthrough Series team reduced rates of unrelieved dyspnea per shift from more than 50 percent to less than 5 percent.

Episodes of Severe Dyspnea, Hospice Care of Rhode Island. Severe Dyspnea in Last 48 Hours,Hospice Care of Rhode Island. Dyspnea Not Relieved by End of Shift, Hospice Care of Rhode Island.
Principles of Dyspnea Management
  • Dyspnea is burdensome for patients and loved ones.
  • All patientsí status will be monitored based on patient self-report, if possible. Since dyspnea, like pain, is a subjective experience, patient report is paramount to treatment decisions
  • Assess the patientís dyspnea
  • Key to determination of severe dyspnea is not only its severity, but the patientís perceived suffering. For example, a patient with COPD may have severe symptoms which are not perceived as bothersome
  • Acute dyspnea in a dying patient shall be treated as a medical emergency; prompt relief of symptoms is mandatory
To measure its progress in controlling dyspnea, the group used three indicators:
  • Severe dyspnea defined as >3, not relieved during 8-hour nursing shift
  • Several episodes of severe dyspnea in patients with more than 24 hours in hospice
  • Severe dyspnea in the last 48 hours of life in patients with more than 24 hours in hospice
Reprinted with permission of Hospice Care of Rhode Island

Guidelines and Standing Orders
  • Before severe dyspnea occurs, RN will assess and document patientís goals for care regarding dyspnea management and the desired level of consciousness the patient wishes to maintain
  • If the patient has severe dyspnea and wants to remain conscious, contact the MD for orders
  • If the patient has severe dyspnea and has not been on opiates, contact the MD and administer morphine between 2.5 mg to 10.0 mg SQ once
  • If the patient has severe dyspnea and has been regularly taking opiates for more than 72 hours, contact MD and administer morphine between 5 mg and 20.0 mg SQ once
  • Reassess severity of dyspnea 20 minutes after SQ injection
  • If the patient is very anxious, administer lorazepam 0.5 mg to 2.0 mg to equal volume (diluted, and less than 2 mg/min) IV or IM, once. Contact MD for further orders
Reprinted with permission of Hospice Care of Rhode Island

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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.

For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].

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