Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with ...

Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with Chronic Obstructive Pulmonary Disease (COPD)A meta-analysis by Devine and Pearcy (1996) reviewed 65 studies from 1954-1994 measuring the effect ofeducation, exercise and psychosocial support on function and well being for COPD patients. Studies includedpulmonary rehabilitation involving large muscle exercise, education and behavioural interventions over afour to six week period, and education alone. Although limited by lack of randomized controlled trials andsmall sample size, the evidence from Devine and Pearcys’ meta-analysis supported the role of educationaland behavioural interventions for improving the COPD patients’ functional health status.Although the terminal phase of COPD will vary from patient to patient, in the later stage any exacerbationmay lead to respiratory failure and the eventuality of death. Recent studies of outcome of hospitaladmissions for COPD (Connors, Dawson, Thomas, Harrel Jr., Desbiens, Fulkerson et al., 1996; Nevins & Epstein, 2001;Roberts, Lowe, Bucknall, Ryland, Kelly & Pearson, 2002), suggest that there are some prognostic indicators ofterminal disease including age of the patient, extent of airflow obstruction, low body mass index, inabilityto perform activities of daily living, increasing dyspnea despite maximal treatment and respiratory failurewith admission to the intensive care unit and intubation. These criteria provide guidance for bothcaregivers and patients involved in the decision making process.In a culture where death is difficult to talk about, patients with advanced COPD are often not given theopportunity to discuss their wishes with respect to the level of care they would like to receive as COPDprogresses to its late stages (Heffner, 1996; Heffner, Fahy, Hilling & Barbieri, 1996). McNeely and colleagues (1997)suggest that end-of-life discussions regularly take place in the intensive care unit. They recognize that thisenvironment is, to say the least, suboptimal. Patients are often unable to comprehend the informationbeing provided, the questions being asked or the decisions being requested. In these times of extremedistress, family members are frequently asked to make critical decisions, including whether or not toprovide life support, on behalf of the patient.McNeely et al. (1997) contend that the primary setting provides a more appropriate venue for discussionabout end-of-life care. It is important for healthcare providers to give patients and their families theopportunity to articulate and explore fears and concerns and to make decisions about end-of-life carebased on those discussions. Critical decisions that must be made when a patient is in the terminal stage ofCOPD include: whether he/she wants active treatment for the next exacerbation, intensive care andintubation should the situation arise, antibiotics or comfort measures only.Singer, Martin and Kelner (1999) identified patients’ perspectives related to quality end-of-life care. Theseindividuals state that they want: adequate relief of symptoms such as pain and shortness of breath, noinappropriate prolongation of life, a sense of control over their own person, opportunity to reduce theburden to their family of having to make end-of-life decisions, and a strengthening of family relationships.Advance directives, informing both caregivers and family members of the patient’s wishes, can bedeveloped based on the information exchanged during end-of-life discussions thus improving thelikelihood that patients will receive the level of care they would choose when they are unable to make thosedecisions for themselves.44