Download - The Oregon Hospice Association

2014 PPE
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Puff: Not-so-magical
Strategies for Breathlessness
Georgann Wingerson, MSW, LCSW, MPA
Michelle Bearden, MBA
Providence Hospice
September 2014
Bios
• Georgann has worked in health care as an ICF administrator, a customer service manager in both
PPO and hospital settings, and a health plan contracts administrator. She always wanted to work
for hospice, but the opportunity did not present itself. Nine (9) years ago, she returned to school to
get her MSW in order to work in a hospice. She is pleased to say that she has worked the last seven
(7) years as a hospice social worker, her favorite position in her career.
[email protected]
• Michelle started her health care career over 25 years ago as a CNA at Molalla Manor as a senior in
high school. After working in facilities for a couple years while attending the UofO, she found home
care to be her passion. After graduating with her BA, she was promoted to field staff supervisor,
and since then has taken positions with progressively more responsibility. After attaining her MBA
in Healthcare, Michelle was mentored by the retiring Director of Willamette Falls Hospice and was
promoted to that position. Through the merger between Willamette Falls Hospital and Providence
Health and Services, Michelle eventually transitioned
to her current role with Providence Home Services.
[email protected]
•
Disclaimer: we are not nurses 
Learning Objectives
• Participants will learn
– the results of research about breathlessness at the end-of-life
– alternatives to oxygen for the palliation of shortness of breath,
including the treatment of anxiety
– about our hospice’s journey to increase staff, patient and family
confidence around non-use of oxygen, supplanted with use of
more effective comfort measures that are currently less well
understood, especially by the general public
– strategies to assist participants in
translating the information learned into
program implementation within their
representative hospices
Definition
• Dyspnea - is shortness of breath, difficult or
labored breathing, air hunger and the
subjective symptom of breathlessness.
Dyspnea usually connotes serious disease of
the airway, lungs, or heart.
Definitions, cont.
• Orthopnea - occurs when lying flat, often a
late manifestation of heart failure
• Platypnea-Orthodeoxia syndrome - relieved
when lying down, and worsens when sitting or
standing up, which could be related to
pulmonary,
hepatic or cardiac diseases
Definitions, cont.
• Trepopnea - sensed while lying on one side
but not on the other, it results from disease of
one lung, one major bronchus, or chronic
congestive heart failure
Definitions, cont.
• Eupnea - normal respiration
Dyspnea and the Hospice Patient
• Georgann’s Patient Story
Oxygen Usage Data
• Michelle’s Story
• Literature on the benefits and costs of oxygen
use at EOL
• Data and our experience
Literature Search on Palliation
of Breathlessness at EOL
First question we asked when performing our
literature search:
Does the administration of oxygen relieve symptoms
at end of life for patients who experience
shortness of breath even when oxygen saturation
levels (O2
sats) are within normal range?
Literature Search on Palliation
of Breathlessness at EOL
• Studies have only found symptom relief for moderate or
greater Dyspnea
– “Oxygen…is of disputed value when breathlessness is not
accompanied by hypoxia.” (Quinn-Lee, Gianlupi, Weggel, Moch.
Mabin, Davey, Davis & Williams, 2012)
– “Less clear benefits from oxygen administration have been
identified across samples of patients with advanced illness,
particularly in the face of normal oxygenation.” (Campbell, Yarandi
& Dove-Medows, 2013). The
authors went on to say, “most patients
near death receive no palliative benefit from
oxygen.”
Literature Search on Palliation
of Breathlessness at EOL
– “Palliative oxygen is routinely prescribed for a number
of reasons, including to ‘do something.’ A growing body
of evidence supported by these findings suggests that
oxygen is a useful palliative intervention when the
patient is experiencing distress and is hypoxemic.
There is no support from these findings for the
initiation or continuation of
oxygen therapy when the patient
is comfortable and near death.”
(Campbell et al., 2013)
Literature Search on
Palliation of Breathlessness at EOL
Second question we asked when performing our
literature search:
What are some of the negatives to administering
oxygen at the end of life?
Literature Search on
Palliation of Breathlessness at EOL
• Interferes with talking, coughing and eating
• Discomfort
– Irritating to nose & ears (nasal cannula)
– dryness can cause nose bleeds
• Mobility restriction & fall hazard
(continued on next slide)
Literature Search on
Palliation of Breathlessness at EOL
• Noise & heat from machine
• Expensive
– Often the top one or two most expensive categories of
home medical equipment provided by Hospice
– Hospices are potentially put in the role of taking away
the patient’s oxygen if the patient is discharged from
hospice.
• Fire hazard
(continued on next slide)
Literature Search on
Palliation of Breathlessness at EOL
• Decreased Quality of Life
– “it has been reported that the potential restriction on mobility imposed by
using the oxygen device may be an important factor that counterbalances
any improvement by using supplemental oxygen on quality of life. Quality
of life has been reported not to improve when patients received oxygen
therapy for 6 months while using an oxygen concentrator.” (Criner, 2013)
– “oxygen is not a benign intervention. Quality of life may be limited as a
result of functional restriction from tubing, tanks, or concentrators; there
may be psychological distress in
being reliant on a machine.” (Uronis,
Currow, McCrory, Samsa & Abernethy, 2008)
Literature Search on
Palliation of Breathlessness at EOL
• May Prolong the Dying Process
Research on Palliation of
Breathlessness at EOL
“The common thought that a breathless patient needs
oxygen for comfort may be based on attitudes and
beliefs held by practitioners, patients, and family
members rather than scientific evidence or expert
knowledge.”
(Quinn-Lee et al., 2012)
Our usage & experience
• Our Primary IDG committee created a new staff tool in July
2013, Use of Oxygen at End of Life
– Oxygen for patients with O2 sats below 92% at rest may not be any
more beneficial than moving the room air with a fan
– Ordering oxygen for a patient with an O2 sat of 92% or greater at rest
requires a consultation with one of our hospice physicians and
authorization from a supervisor or manager
• Non-pharmacological interventions are recommended instead, such as
raising the head of the head, repositioning the patient, adding a fan to the
room or opening the window
• Opioids, such as Morphine, and
benzodiazepams, such as Lorazepam, are
recommended for relieving breathlessness
Our usage & experience
Concentrators per ADC
0.60
0.50
0.40
0.30
0.50
0.54
0.20
0.10
no change
0.00
July 2013
Jan 2014
Breathlessness Cycle
Creating Patient/Family
Education
• Creating a patient/family teaching handout for
staff use
– For all patient care staff
Additional Information
• Sometimes patients can feel air hunger due, in part, to
bloating:
• Often treated with simethicone or Gas-X
Breathlessness Sample Scripts
1. In hospice we use many medications to address comfort and
oxygen is one of many measures we use. However, oxygen
will not help shortness of breath for patients with normal
oxygen saturations other than by the feeling of air blowing.
There are several other ways to help you feel more
comfortable when you are experiencing shortness of breath.
I have some information
about those ways to share with you.
Breathlessness Sample Scripts
2. Have you ever felt shortness of breath? Breathlessness can
be very frightening.
– Shortness of breath is physiological. Anxiety increases
shortness of breath and relaxation decreases it. In the
past, a standard method of treating breathlessness was
by using oxygen tanks or concentrators. Research has
concluded that use of oxygen does not help
people with normal oxygen
saturation.
(continued on next slide)
Breathlessness Sample Scripts
– Many people near the end of their lives have shortness of breath,
and many have normal oxygen saturation levels. There are a
number of ways to relieve breathlessness and they deal with
reducing activity – sitting down, changing position, cooling the
room, using a fan, relaxing or meditating or praying, using oxygen
if your oxygen saturation level is below 90%, and taking
medications – such as roxinol which works very well for most
people. Roxinol/morphine helps by relaxing muscles of the lungs
so people feel like they breathe better. It is a wonderful
medication when used as prescribed
by the doctor and explained by your nurse.
Let’s look over the handout that I brought.
(continued on next slide)
Breathlessness Sample Scripts
– If asked about oxygen, explain that for people who do
not need it, it serves to move air around and may force
relaxation once a person is seated. The downside of
oxygen is tubing, discomfort around the nose and ears,
a fire hazard. There is much to be said for not using
oxygen.
Definition
• Anxiety: An unpleasant emotion triggered by
anticipation of future events, memories of
past events, or ruminations about the self.
• (This is not the DSM-5 definition that refers to
anxieties lasting
six or more months.)
Relieving Anxiety
– Social Workers and Chaplains
– Guided imagery
– Acupuncture
– Massage
– Music
– Music Thanatology
– Presence
– Aromatherapy
– Threshold Choir
Use of Aromatherapy
• We have used lavender and chamomile oils to relieve anxiety and patients
have reported that this helped them. Another useful oil is ginger which
when put into the aroma stick, is beneficial to manage episodes of nausea.
Our community team have also used the aroma sticks and found them to
be effective.
– Melody Hornblow, Activity Co-ordinator, Day Hospice.
– Willen Hospice is situated in Milton Keynes and provides specialist care for adults with
life-threatening illness. The services provided include; In-Patient Unit, Day Hospice,
Community Care Team, Social Care and Lymphoedema Clinic. The Day Hospice operates
3 days a week, on these
days patients are offered a range of complementary therapies.
Oxygen Usage – where
we are now
Concentrators per ADC
0.60
0.50
0.40
0.30
0.50
0.54
0.42
0.20
0.10
0.00
July 2013
Jan 2014
July 2014
Relieving Anxiety
• Threshold Choir
» Kate Munger founded the Threshold Choir organization in 2001
in El Cerrito, California. She teaches workshops nationally about
how to sing to the ill and dying. Today, 100 Threshold Choirs
exist in the U.S., Canada and Australia.
Puff: Not-so-magical
Strategies for Breathlessness
Questions?
And Puff that mighty
dragon, he ceased his
fearless roar
Thank You
References, p. 1 of 3
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breathless in advanced stages of malignant and non-malignant diseases (Review). The Cochrane
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Campbell, M., Hossein, Y. & Dove-Medows, E. (2012) Oxygen Is nonbeneficial for most patients who are
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References, p. 2 of 3
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Horne-Thompson, A. & Grocke, D. (2008) The effect of music therapy on anxiety in patients who are
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Quinn-Lee, L., Gianlupi, A., Weggel, J., Moch, S. Mabin, J., Davey, S., Davis, L. & Williams, K. (2012) Use of
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