Chapter 4: Palliative Care for Cardiac and Respiratory Disease

Introduction

Cardiac and respiratory diseases are among the most common reasons people in the United Kingdom (UK) will be admitted to palliative care settings; it is therefore essential that nurses working in palliative care settings are able to effectively care for patients with cardiac and / or respiratory disease. This chapter introduces evidence-based strategies, based on UK guidelines, which nurses should use in the care of patients with cardiac and / or respiratory disease in palliative care settings. It begins with an overview of terminal cardiac disease, including the signs and symptoms of heart failure, and describes the management of heart failure in the palliative setting. This chapter then discusses respiratory disease - including the management of terminal respiratory disease, and distressing symptoms such as dyspnoea and cough - in the palliative setting. This chapter will provide you with the fundamental skills and knowledge required to provide effective nursing care to patients with cardiac and / or respiratory disease in palliative care settings.

Important note

This chapter assumes a basic knowledge of human anatomy and physiology. If you feel you need to revise these concepts, you are encouraged to consult a quality nursing textbook.

Palliative care for cardiac disease

There are a variety of different cardiac diseases for which a person may receive palliative care - including uncontrolled hypertension, atrial fibrillation, myocardial infarction, valve disease, cardiomyopathies and coronary artery disease. Generally, however, these conditions lead to heart failure. Heart failure is not a single disease, but rather a complex clinical syndrome of structural and / or functional impairment which results in the ventricles of the heart becoming unable to fill with and / or eject blood.

A patient with heart failure may present with a variety of different symptoms, which are eventually unrelieved by medical intervention. Consider the following case study:

It is important to highlight that the symptoms of heart failure, described in greater detail in the following section of this chapter, are highly variable. Some patients will decline slowly and progressively over a number of years, whereas others will experience a cardiac event which causes them to die quite suddenly. For this reason, it can be difficult to predict end-of-life progression and death in patients with heart failure. Typically, patients with heart failure are considered to be at the end-stage of their illness if they have a combination of: (1) dyspnoea at rest despite optimal treatment, (2) persistent low systolic blood pressure, (3) cachexia and / or (4) inotropes (indicators of increased cardiac contractility, or 'work') present in blood sample/s.

Nurses working in palliative care settings must recognise that patients with heart failure often experience complex comorbidities - including diabetes mellitus (often Type 2), renal disease, sleep-disordered breathing, obesity, pulmonary disease and depression. These comorbidities not only complicate the progression of heart failure, but they may also make its effective management in the palliative care setting more difficult. If heart failure is to be managed effectively, it is essential that a patient's comorbidities are also addressed.

Signs and symptoms of heart failure

As you saw earlier in this section of the chapter, a patient with heart failure may present with a variety of different symptoms, which are eventually unrelieved by medical intervention (signalling the patient's impending death). Patients typically present to palliative care settings with the following 'classic' symptoms of heart failure:

• Recent decreased exercise tolerance (e.g. due to dyspnoea and / or fatigue).
• Dyspnoea and orthopnoea. Most patients with heart failure will experience these symptoms, triggered by hypoxamia due to low cardiac output. Patients may explain a feeling of 'suffocating' or 'drowning' - particularly if there is associated retention of fluid.
• Fluid retention - particularly in right-sided heart failure.
• One or more of the following: abnormal heart sounds, abnormal electrocardiogram (ECG), arrhythmia, hypertension OR hypotension, thrombosis, chest x-ray showing cardiac enlargement, or an acute cardiac event (e.g. a myocardial infarction).
• Cachexia and malnutrition. Hypoxia impairs gastrointestinal function and exacerbates symptoms such as anorexia and early satiety. Eating also increases myocardial oxygen demand, and patients with heart failure may simply be too fatigued to eat.
• Renal failure, due to decreased blood flow to the kidneys; this exacerbates fluid retention.

Patients with heart failure may also present with general symptoms of decline - such as pain, nausea, limited mobility (often with a history of falls), depression and / or anxiety, insomnia, constipation and loss of appetite.

Read through the following common signs of left-sided versus right-sided heart failure:

If failure occurs on the LEFT side of the heart:	If failure occurs on the RIGHT side of the heart:
Dyspnoea, including orthopnoea. Pulmonary oedema. A dry cough. Abnormal heart sounds (e.g. S3, S4). Fine crackles in the lungs. Wheezing. Fatigue, which may be extreme. Hypoxaemia (SpO2 <96% on room air).	Retention of fluid, characterised by: Abdominal pain, bloating. Distention of the jugular vein. Oedema in the peripheries. Engorgement of the liver, spleen. Significant recent weight gain.

As described above, patients with heart failure are considered to be at the end-stage of their illness if they have a combination of: (1) dyspnoea at rest despite optimal treatment, (2) persistent low systolic blood pressure, (3) cachexia and / or (4) inotropes (indicators of increased cardiac contractility, or 'work') present in blood sample/s. In patients with heart failure, the following clinical indicators may also to predict the person's impending death:

• Recurrent emergency admissions and / or hospitalisations for related problems.
• Need for frequent or continuous intravenous therapy to control symptoms.
• Dependency, partial or complete, with activities of daily living.
• Loss of >10% of non-fluid body weight, often with cachexia. 
• Cardiac arrhythmia, particularly if these are symptomatic or 'malignant'.
• Persistent low systolic blood pressure.
• A cardiac ejection fraction of <20%.
• Associated peripheral arterial disease.
• Episodes of syncope.
• Embolic stroke.
• Blood tests with albumin of <2.5g/dL, low sodium, increased blood urea nitrogen, troponin.
• Persistent poor quality of life.

Management of heart failure in the palliative setting

There are two key goals in the management of heart failure in the palliative setting:

1. Identifying and treating reversible causes of decline (e.g. anaemia, infection, dysrhythmia, pulmonary disease [e.g. embolism].
2. Achieving control of symptoms.

Medication therapy is a mainstay in the management of heart failure in the palliative setting. The National Institute of Health and Clinical Excellence's Chronic Heart Failure in Adults: Management (2010: p. 18) guideline recommends "the use of angiotensin-converting enzyme (ACE) inhibitors and beta [] blockers for first-line treatment" in all patients with heart failure. Read the following:

• ACE-inhibitors help to manage hypertension and fluid retention. In cases where patients are unable to tolerate an ACE-inhibitor, angiotensin receptor blockers may be prescribed.
• Beta-blockers decrease the activity, or 'work', of the heart, by reducing its contractility.

As most cases of heart failure are chronic in nature, it is likely that patients in palliative care settings will have been taking ACE-inhibitors and -blockers for some time. It is important for palliative care nurses to check the types and doses of all prescribed medications for their appropriateness to the palliative care setting. Nurses must be aware that some medications may be reduced or even discontinued in patients receiving palliative care, in an attempt to decrease the associated negative symptoms and improve the patient's quality of life.

In addition to ACE-inhibitors and -blockers, there are also a variety of other medications which may be used to treat heart failure in palliative care settings. The following are all recommended as options, depending on an individual patient's clinical situation, by the National Institute of Health and Clinical Excellence's Chronic Heart Failure in Adults: Management (2010) guideline:

• Diuretics (particularly loop diuretics, such as furosemide), which act to reduce fluid retention. The National Institute of Health and Clinical Excellence's Chronic Heart Failure in Adults: Management (2010: p. 20) guideline recommends that diuretics "should be routinely used for the relief of congestive symptoms and fluid retention in patients with heart failure". Doses of diuretics may be regularly adjusted up or down depending on a patient's symptoms.
• Aldosterone agonists (e.g. spironolactone); these may help to reduce issues such as coronary inflammation, cardiac hypertrophy / fibrosis, arrhythmia, etc.
• Hydralazine and nitrates - these combination medications act as vasodilators, relaxing the blood vessels, improving blood flow and decreasing the heart's work.
• Inotropic agents (e.g. dobutamine, digoxin); these improve the heart's contractile capacity, and so may improve blood flow through the heart and to the body.

The National Institute of Health and Clinical Excellence's Chronic Heart Failure in Adults: Management (2010) guideline also recommends angiotensin-II receptor agonists, calcium-channel blockers (e.g. amlodipine), amiodarone and anticoagulants (including aspirin) for some patients with heart failure. Many medications - including anti-arrhythmic agents, calcium-channel blockers and non-steroidal anti-inflammatory drugs (NSAIDS) - must be used with caution in patients with heart failure, as they may increase a patient's cardiac risk and / or exacerbate their symptoms.

Remember: the goal of these medications in the palliative care setting is not to 'cure' a patient's heart failure, but rather to effectively manage their symptoms and, so, improve their quality of life. As the patient approaches end-of-life, the side-effects of these medications and the burden of polypharmacy must be considered when deciding whether medication administration is to continue.

As you saw in previous chapters of this module, palliative care involves assessing and managing a patient holistically - that is, as a whole person. It is important that nurses in palliative care settings consider a variety of other strategies when caring for a patient with heart failure at the end of life. Read the following examples:

• Fatigue may be managed using a variety of strategies, such as responding to reversible causes such as anaemia, infection and obstructive sleep apnoea; treating depression; and promoting adequate rest cycles.
• Anaemia is a common problem in patients with heart failure; indeed, up to 50% of patients with heart failure may experience some degree of anaemia. Treating anaemia usually involves correcting reversible causes (e.g. nutritional deficiency, renal dysfunction, haemodilution, etc.).
• Skin care is an important consideration - particularly for patient with heart failure-related oedema and resulting skin ulcers and cellulitis. Compression stockings are often used in patients with severe peripheral oedema.
• Psychological care is crucial, as more than one-third of patients with heart failure may suffer anxiety and / or depression related to their condition.

• The National Institute of Health and Clinical Excellence's Chronic Heart Failure in Adults: Management (2010) guideline recommends that, wherever possible, patients with heart failure are encouraged to exercise within the limits of their tolerance; this is generally considered a rehabilitative strategy, but in the palliative care context exercise can also help to improve and sustain a patient's quality of life.
• As with all patients in the palliative care context, patients with heart failure are likely to be immunocompromised and prone to infection; therefore, the National Institute of Health and Clinical Excellence's Chronic Heart Failure in Adults: Management (2010) guideline recommends that all patients with heart failure be vaccinated against influenza and pneumococcal disease.

You studied advance care planning in a previous chapter of this module; you should revise this chapter now, if required. Advance care planning is crucially important for patients with heart failure; this is because research suggests that, in contrast with other patients receiving palliative care, patients with heart failure often prefer resuscitation. It is important for nurses working in palliative care settings to clarify and document each patient's preferences and wishes whilst they are still competent to make choices about their care.

It is also important to note that the immediate end-of-life period for patients with heart failure can be distressing, particularly if the patient is acutely dyspnoeic. Often, opioids (with or without relaxant benzodiazepines) are administered to relieve a patient's dyspnoea by slowing the respiratory drive. It is common for patients and their families / carers to believe that opioids are given with the goal of hastening the patient's death, and it is important for nurses to provide reassurance that this is never the case. Remember: euthanasia, or 'assisted suicide', is currently illegal in the UK.

Palliative care for respiratory disease

As with cardiac disease, there are a variety of different respiratory diseases for which a person may receive palliative care. All of these conditions lead to dyspnoea - or 'shortness of breath'. You studied dyspnoea briefly in the previous section of this chapter; however, this section will consider dyspnoea in greater detail. Begin by reading the following case study:

In palliative care settings, dyspnoea is often accompanied by cough. You will study cough in greater detail later in this section of the chapter.

As described above, dyspnoea is simply 'shortness of breath'. It may be due to a variety of causes - including those which impair pulmonary ventilation, circulation and / or gas exchange. In the palliative care setting, dyspnoea is generally due to:

• Obstructed ventilation (e.g. upper airway tumour, lower airway inflammation, etc.).
• Restricted ventilation (e.g. muscle weakness due to neuromuscular disease or cachexia, reduced pulmonary compliance due to pulmonary fibrosis, compression / replacement of the lung tissue, reduced elasticity of the lung tissue, etc.).
• Reduced perfusion (e.g. due to pulmonary embolism / hypertension, cardiac failure, etc.).
• Interstitial disease (e.g. pulmonary fibrosis, pneumonitis, oedema, emphysema, etc.).

As a patient's condition progressively declines, it is likely that dyspnoea will be provoked at lower and lower exercise thresholds. For example, initially a patient will experience dyspnoea only during exercise, then during activities of daily living (e.g. bathing, dressing, etc.), and eventually they may be dyspnoeic at rest. It is important for nurses working in palliative care settings to recognise that environmental factors - hot air, high humidity, environmental pollutants, anxiety, etc. - may trigger acute dyspnoea in patients with respiratory disease; an individual patient's triggers should be identified, where possible, and a plan developed to avoid these triggers.

Management of terminal respiratory disease in the palliative setting

There are a number of goals for the management of a patient with respiratory disease and dyspnoea:

1. Identifying and treating reversible causes of decline.
2. Achieving control of symptoms, including enhancing the patient's coping capacity and preparing the patient for acute episodes of dyspnoea.

As with end-stage cardiac disease, medication therapy is a mainstay in the management of respiratory disease in the palliative setting. One of a variety of different medications may be prescribed, including opioids, corticosteroids, phenothiazines, bronchodilators, benzodiazepines, and diuretics such as furosemide, etc. The type/s and combination of medication prescribed depends on the patient's clinical condition in addition to the symptoms they experience.

For patients who are hypoxic (SpO₂ <96% on room air), the administration of oxygen via nasal prongs or a face mask may also be beneficial. Short-term oxygen therapy may be useful in increasing the tolerance of patients when they are completing exercise or engaging in activities of daily living. However, it is important for nurses working in palliative care settings to recognise that excessive oxygen administration can lead to hypercapnoeic respiratory failure in patients with some diseases, including COPD. Furthermore, although it is frequently prescribed, research suggests that if patients are not hypoxic, oxygen probably does not confer any physiological benefit - however, it may be reassuring for dyspnoeic patients. Nurses must remember that oxygen is a medication that must be administered with a prescription; nurses must be familiar with their organisation's policies and procedures for the use of oxygen in patients with terminal respiratory disease. 

Nurses working in palliative care settings must recognise that dyspnoea, both chronic and acute, can be one of the most distressing symptoms that a patient will experience. Patients with end-stage respiratory disease often describe feeling 'hungry' for or 'starved' of air, or that they are 'drowning' or 'suffocating'. Patients with dyspnoea often experience significant psychological comorbidity - such as anxiety and panic attacks. The psychological care of a patient with dyspnoea is therefore just as important as their physical care. There are a number of important psychological support strategies that nurses working in palliative care settings can use when caring for patients with dyspnoea:

• Teaching coping skills. There are a range of strategies that a patient can use to improve their management of their own breathlessness - for example, breathing techniques (e.g. paced breathing, diaphragmatic breathing, pursed-lips breathing, etc.), adopting a forward-leaning or high side-lying position (supported by pillows, where required), using aids and oxygen during mobility, engaging in relaxation and mindfulness activities, activity pacing and energy conservation techniques.
• Educating patients and their significant others. People often fear they will die during an episode of acute dyspnoea; however, people must be assured that dyspnoea is a manageable symptom. Education may include a review of the recognised triggers for a patient's dyspnoea (if applicable), and the development of a written stepwise plan for the management of dyspnoeic episodes.
• Improving the patient's independence. Nurses should work collaboratively with allied health professionals - including occupational therapists and physiotherapists, where available - to improve a patient's functional capacity, particularly in relation to their activities of daily living. This may involve, for example, installing raised toilet seats and grab bars, and assisting the patient to use mobility aids, etc.
• Improving the patient's social engagement, and supporting the patient's caregivers.

In caring for a patient with respiratory disease, nurses must also ensure that they prepare the patient for acute episodes of dyspnoea. This may involve the development of a written, stepwise plan for the management of dyspnoeic episodes, as described earlier in this chapter. This plan must include all the coping strategies available to the patient, prescribed medications and their doses / frequencies, and emergency contact information. This plan can be used as a prompt for the patient and their family / carer / significant others during distressing episodes of dyspnoea.

As described in an earlier section of this module, a patient's dyspnoea often worsens significantly at the end-of-life. Dyspnoea which is severe and frightening should be considered a medical emergency. Remember: opioids (with or without relaxant benzodiazepines) are often administered to relieve a patient's dyspnoea by slowing the respiratory drive. Sedatives such as midazolam may also be administered to relieve a patient's anxiety. In patients with pending respiratory failure, non-invasive positive pressure ventilation may also be administered. Again, it is essential that nurses working in palliative care settings clarify and document each patient's preferences and wishes in relation to these types of end-of-life care whilst the patient is still competent to make choices about their care.

As described earlier in this chapter, in palliative care settings, dyspnoea is often accompanied by cough. Cough is (usually) an involuntary reflex characterised by the forced expulsion of air from deep within the lungs. In palliative care patients, poorly-controlled cough can be problematic for a number of reasons - particularly as it is associated with issues such as insomnia, exhaustion, musculoskeletal pain, urinary incontinence, anxiety and social isolation. Furthermore, paroxysmal cough - that is, a cough with deep inspirations and multiple forced expirations - may result in an acute exacerbation of dyspnoea in some patients.

In palliative care settings, cough is managed in one of a number of different ways. Again, medication therapy is a mainstay in the management of heart failure in the palliative setting. Medications which may be prescribed to patients with a problematic cough in the palliative care setting include:

• Bronchodilators, which act to relax the smooth muscle in the airways.
• Anti-inflammatory medications, including corticosteroids with an antitussive effect.
• Syrups and lozenges, which act to soothe and reduce irritation in the upper airways.
• Expectorants, which assist in the removal of secretions from the airways.
• Antitussives, which act to supress the cough reflex in the brainstem.

In addition to medications, there are a number of other interventions which nurses may use in a palliative care setting to assist a patient to manage their problematic cough:

• Educating patients and their significant others. People may be taught about the environmental triggers for cough. Nurses should work collaboratively with allied health professionals - including occupational therapists - to assess and manage a patient's swallowing and aspiration risk (e.g. by providing thickened fluids.).
• Non-pharmacological treatments. There are a range of non-pharmacological treatments which may be used to manage cough in the palliative care setting. For example, upright positioning may aid in the efficiency of coughing and help to prevent aspiration. Humidified air delivered via a nebuliser, chest physiotherapy and breathing techniques such as forced expiration may also be useful.

It is important for nurses working in palliative care settings to recognise that cough is often associated with haemoptysis, or the expectoration of blood. This is most often seen in conditions such as bronchogenic carcinoma and chronic bronchiectasis, as well as other diseases of the airways, lung parenchyma and pulmonary circulatory system, and systemic diseases resulting in impairments to the coagulation cascade. Although haemoptysis is often mild and transient, it may also result in major haemorrhage (typically when a cancerous tumour erodes into a major blood vessel). Aside from emergency surgery, which may or may not be beneficial, there is often little which can be done to manage major haemoptysis; usually, a patient will rapidly lose consciousness (i.e. within 1-2 minutes) before dying. Nurses should act in a calm and reassuring way. Witnessing death by haemorrhage in the respiratory system can be extremely distressing; therefore, it is important that nurses prepare a patient's significant others for this possibility where clinically indicated.

So far, this section of the chapter has considered cough in patients with end-stage respiratory disease. It is also important to note that many patients in palliative care settings - including those with respiratory disease, and with other conditions (e.g. neurological and neuromuscular conditions) - may experience ineffective cough. This is often due to decreased level of consciousness, poorly-controlled pain, central pathology (e.g. central nervous system tumour, stroke, etc.) and / or muscle weakness. Ineffective cough results in an inability of the patient to clear secretions which accumulate in their upper airway; this increases the risk of dysphagia and aspiration. Nurses must assist patients with ineffective cough to maintain their airway - for example, through suctioning.

Conclusion

Cardiac and respiratory diseases are among the most common reasons that people in the United Kingdom (UK) will be admitted to palliative care settings; it is therefore essential that nurses working in palliative care settings are able to effectively care for patients with cardiac and / or respiratory disease. This chapter has introduced a variety of evidence-based strategies, based on UK guidelines, which nurses should use in the care of patients with cardiac and / or respiratory disease in palliative care settings. It began with an overview of terminal cardiac disease, including the signs and symptoms of heart failure, and described the management of heart failure in the palliative setting. This chapter then discussed respiratory disease - including the management of terminal respiratory disease, and distressing symptoms such as dyspnoea and cough - in the palliative setting. This chapter will provide you with the fundamental skills and knowledge required to provide effective nursing care to patients with cardiac and / or respiratory disease in palliative care settings.

Reference list

British Lung Foundation. (2016). What is COPD? Retrieved from: https://www.blf.org.uk/support-for-you/copd/what-is-it

Ernst, P., Saad, N. & Suissa, S. (2015). Inhaled corticosteroids in COPD: The clinical evidence. European Respiratory Journal, 45(1). DOI: 10.1183/09031936.00128914

Faull, C., de Caestecker, S., Nicholson, A. & Black, F. (Eds). (2012). Handbook of Palliative Care (3rd ed.). Hoboken, NJ: Wiley-Blackwell.

Gadoud, A., Jenkins, S.M. & Hogg, K.J. (2013). Palliative care for people with heart failure: Summary of current evidence and future direction. Palliative Medicine, 27(9), 822-828.

Matzo M. & Witt Sherman, D. (Eds). (2010). Palliative Care Nursing: Quality to the End of Life (3rd ed.). New York, NY: Springer Publishing Company.

National Health Service. (2012). An Outcomes Strategy for COPD and Asthma: NHS Companion Document. Retrieved from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216531/dh_134001.pdf

National Institute of Health and Care Excellence. (2010). Chronic Heart Failure in Adults: Management. Retrieved from: https://www.nice.org.uk/guidance/cg108/resources/chronic-heart-failure-in-adults-management-35109335688901

National Institute of Health and Care Excellence. (2010). Chronic Obstructive Pulmonary Disease in Over-16s: Diagnosis and Management. Retrieved from: https://www.nice.org.uk/guidance/cg101/resources/chronic-obstructive-pulmonary-disease-in-over-16s-diagnosis-and-management-35109323931589

National Institute of Health and Care Excellence. (2014). Acute Heart Failure: Diagnosis and Management. Retrieved from: https://www.nice.org.uk/guidance/cg187/resources/acute-heart-failure-diagnosis-and-management-35109817738693

Jaarsma, T., Beattie, J.M., Ryder, M., Rutten, F.H., McDonagh, T., Mohacsi, P., Murray, S.A., Grodzicki, T., Bergh, I., Metra, M., Eckman, I., Christiane, A., Leventhal, M., Pitsis, A., Anker, S.D., Gavazzi, A., Ponikowski, P., Dickstein, K., Delacretaz, E., Blue, L., Strasser, F. & McMurray, J. (2009). Palliative care in heart failure: A position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology. European Journal of Heart Failure, 11(3), 433-443.

'Hands on' scenario

Palliative care of a patient with end-stage chronic obstructive pulmonary disease (COPD) and respiratory distress

Mo is a graduate nurse working in a palliative care hospice. One of his patients is Mr Smith, a 77-year-old man with end-stage chronic obstructive pulmonary disease (COPD). Mr Smith has been admitted to the palliative care setting because he is constantly dyspnoeic, even at rest, despite the delivery of 2L/min of oxygen via nasal prongs. On his admission to the hospice, Mo completes a holistic assessment of Mr Smith (remember: you studied holistic assessment relevant to palliative care setting in an earlier chapter of this module; you should revise this chapter now, if required). In his assessment of Mr Smith, Mo seeks information about:

• The duration, frequency and onset (including precipitating factors) of Mr Smith's dyspnoea. Mr Smith reports that his dyspnoea worsens when he completes his activities of daily living, and also when he experiences anxiety about his condition.
• Symptoms associated with Mr Smith's dyspnoea; during a standard nursing examination, Mo identifies lung crackles with wheezing, hypoxia (SpO₂ <87% on room air), accessory muscle use, a deviated trachea and pain, as well as psychological complications (anxiety, distress) related to the dyspnoea.
• Factors which alleviate Mr Smith's dyspnoea; Mr Smith uses an inhaled bronchodilator (often referred to as a 'puffer'), which assists his breathing.
• The quality of the dyspnoea - that is, how the patient describes it. Mr Smith tells Mo he feels like he is 'starved' of air, or that he is 'drowning' or 'suffocating'.

Based on the results of his assessment and other assessments, including diagnostic imaging, Mo develops a plan of care for Mr Smith. To do this, he works closely with members of a multidisciplinary health care team, including general and specialist doctors, allied health practitioners (e.g. pharmacists, physiotherapists, social workers, etc.) and a psychologist. Mo ensures that Mr Smith and his next of kin, a younger brother, also play a key role in decision-making in relation to Mr Smith's care, including in the development of advanced care planning documentation such as a 'do not attempt resuscitation' (DNAR) order. Once Mr Smith's management strategies - described following - have been discussed, clarified and agreed upon, a written plan of care is developed; this care plan supports Mr Smith's advance care planning documentation. 

The care of Mr Smith's COPD generally, and his dyspnoea specifically, centres on the use of medication therapy. As Mr Smith is acutely hypoxic, his continuous oxygen via nasal prongs is continued. However, the dose is carefully controlled to avoid triggering hypercapnoeic respiratory failure, a problem for some patients, such as Mr Smith, with advanced COPD. The bronchodilator Mr Smith has been taking - a -agonist - is also continued, and doctors also prescribe an inhaled corticosteroid to support lung function. Because Mr Smith experiences significant anxiety in relation to his condition generally, and his dyspnoea specifically, he is prescribed a regular anti-anxiolytic. Doctors also prescribe an opiate and midazolam, a sedative, both of which may be given as required when Mr Smith's dyspnoea becomes particularly distressing.

In addition to medication therapy, there are a number of other, nurse-led, strategies that Mo uses to help manage Mr Smith's dyspnoea. Mo begins by teaching Mr Smith a number of coping skills he can use to manage his own breathlessness. These skills include breathing techniques such as paced breathing, diaphragmatic breathing and pursed-lip breathing, both of which are designed to assist Mr Smith to manage the rate and depth of his breathing during episodes of dyspnoea. Mo also teaches Mr Smith positioning strategies, such as adopting a forward-leaning or high side-lying position, supported by pillows where required, to open Mr Smith's chest and so decrease his work of breathing. Mo also teaches Mr Smith energy conservation techniques, such as pacing himself when completing activities of daily living to reduce oxygen consumption. Mo provides Mr Smith with aids in his hospice room - including a walker, a raised toilet seat and grab bars - with the aim of improving his functional capacity. Mo also provides Mr Smith with information on distraction techniques, such as meditation and music therapy, which can decrease anxiety related to dyspnoea, and Mr Smith agrees to try the latter.

Complementary therapies are important considerations for patients with dyspnoea. It is important to highlight that many complementary therapies lack current evidence to support their efficacy; however, if they are unlikely to be harmful, and may convey some benefit (physical and / or psychological) to the patient, nurses working in palliative care settings should support patients in their use. Mr Smith's brother tells Mo that he read online that some essential oils, including peppermint oil, can help with dyspnoea; as Mr Smith supports this idea, and the peppermint oil does not appear to exacerbate his dyspnoea, Mo is supportive of his wish to use this therapy.

In working with Mr Smith, Mo applies many of the communication strategies described in an earlier chapter of this module (you should revise this chapter now, if required). To ensure he understands Mr Smith's wishes for his end-of-life care, which change as his condition progresses, Mo takes the time to listen actively to Mr Smith. He also ensures he is emotionally supportive - for example, responding in a positive, caring and meaningful way when Mr Smith describes his anxieties about 'suffocating to death'.

As described in this chapter, dyspnoea at the end of life can be very distressing for patients. Indeed, as Mr Smith's condition progresses, he becomes increasingly more distressed - which subsequently worsens his dyspnoea. As per Mr Smith's advance care planning documentation, Mo administers Mr Smith with prescribed doses of morphine and the sedative midazolam. This is effective; Mr Smith becomes less dyspnoeic and distressed, more alert, and more able to engage with his visitors - particularly his brother, who spends many hours with him. Mr Smith's brother plays his favourite country and western music and reminisces about the past, which provides a useful distraction for Mr Smith.

Eventually, Mr Smith slips into a semi-conscious state. Mo, recognising that Mr Smith's death is imminent, stays close to provide support to Mr Smith and his significant others, including his brother. Mo is cautious of doing so in a respectful and unobtrusive way. Because of the effective care provided by Mo and other members of the multidisciplinary health care team, Mr Smith dies peacefully and comfortably.