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Hospitalists frequently need to address the needs of the dying patient. At times questions and dynamics of the family and loved ones surrounding that patient may elevate the challenges and complexities of an already difficult situation. It takes a different skill set – one often not taught during medical education – to do this well.
Over the last few decades, research shows, approximately 50% of adults who die in the United States do so in the hospital setting. These factors have led the Society of Hospital Medicine (SHM) to advocate that hospitalists be effective at caring for the dying patient, even including palliative care within the Core Competencies of the specialty.
The mechanism of dyspnea is not completely understood, but its impact on patients and families is undeniably negative and profound. Just the description is discomfiting: It is "not a single sensation and there are at least three distinct sensations including air hunger, work/effort, and chest tightness" (Br. J. Anaesth. 2011;106:463-74). More than 50% of patients with cancer, cardiopulmonary disease, and neuromuscular disorders experience dyspnea; and more than 70% of all people experience this during the last few weeks of life (Palliat. Med. 2006;20:219-30).
All attempts to prevent or relieve dyspnea should be undertaken. Evidence-based strategies exist for and include both pharmacologic and nonpharmacologic approaches. Examples of the former include opioids, bronchodilators, and benzodiazepines while the latter group varies from guided imagery, noninvasive positive pressure ventilation, and fans, among others.
The benefit of oxygen therapy is at best controversial (Curr. Opin. Support. Palliat. Care 2008;2:89-94).To date there is a lack of evidence that providing oxygen to an actively dying patient is beneficial. In the most well-designed trial to date of patients with life-limiting illnesses and refractory dyspnea, palliative oxygen delivered via nasal cannula failed to demonstrate symptomatic improvement (Lancet 2010;376:784-93).
["Routine Oxygen at End of Life is Typically Unhelpful" -- Hospitalist News, 6/4/12]
Despite this, oxygen is frequently found on dying patients. From personal experience, at multiple centers, I have found this to be the case even when an order is written to discontinue any form of oxygen delivery. Why might the avoidance of oxygen in this situation be important?
• Hospitals spend money on obtaining, maintaining, and providing oxygen.
• Patients and third-party payers incur charges related to oxygen.
• Medical equipment can carry risks ranging from discomfort to a source of infection for those in contact with it.
• Delivery systems produce noise, and nurses and aides need to interrupt family time to administer this and follow-up on the intervention.
• It may send mixed messages to families about treatment goals.
• The cannula or masks can be seen as a barrier by loved ones wishing to express physical affection.
• It has not been shown to provide any benefit.
Anecdotally, the only time I have stronger feelings about leaving the oxygen in place during the dying process is when patients, who are still aware of their surroundings, have been on long-term oxygen and understandably feel anxious or naked without it. Otherwise, Dr. Mary L. Campbell’s suggestions for discontinuing oxygen and emphasizing good communication with the family about the situation are on point.
Dr. Bekanich is with the department of medicine and is medical director of palliative care, Seton Healthcare, Austin, Tex.
Hospitalists frequently need to address the needs of the dying patient. At times questions and dynamics of the family and loved ones surrounding that patient may elevate the challenges and complexities of an already difficult situation. It takes a different skill set – one often not taught during medical education – to do this well.
Over the last few decades, research shows, approximately 50% of adults who die in the United States do so in the hospital setting. These factors have led the Society of Hospital Medicine (SHM) to advocate that hospitalists be effective at caring for the dying patient, even including palliative care within the Core Competencies of the specialty.
The mechanism of dyspnea is not completely understood, but its impact on patients and families is undeniably negative and profound. Just the description is discomfiting: It is "not a single sensation and there are at least three distinct sensations including air hunger, work/effort, and chest tightness" (Br. J. Anaesth. 2011;106:463-74). More than 50% of patients with cancer, cardiopulmonary disease, and neuromuscular disorders experience dyspnea; and more than 70% of all people experience this during the last few weeks of life (Palliat. Med. 2006;20:219-30).
All attempts to prevent or relieve dyspnea should be undertaken. Evidence-based strategies exist for and include both pharmacologic and nonpharmacologic approaches. Examples of the former include opioids, bronchodilators, and benzodiazepines while the latter group varies from guided imagery, noninvasive positive pressure ventilation, and fans, among others.
The benefit of oxygen therapy is at best controversial (Curr. Opin. Support. Palliat. Care 2008;2:89-94).To date there is a lack of evidence that providing oxygen to an actively dying patient is beneficial. In the most well-designed trial to date of patients with life-limiting illnesses and refractory dyspnea, palliative oxygen delivered via nasal cannula failed to demonstrate symptomatic improvement (Lancet 2010;376:784-93).
["Routine Oxygen at End of Life is Typically Unhelpful" -- Hospitalist News, 6/4/12]
Despite this, oxygen is frequently found on dying patients. From personal experience, at multiple centers, I have found this to be the case even when an order is written to discontinue any form of oxygen delivery. Why might the avoidance of oxygen in this situation be important?
• Hospitals spend money on obtaining, maintaining, and providing oxygen.
• Patients and third-party payers incur charges related to oxygen.
• Medical equipment can carry risks ranging from discomfort to a source of infection for those in contact with it.
• Delivery systems produce noise, and nurses and aides need to interrupt family time to administer this and follow-up on the intervention.
• It may send mixed messages to families about treatment goals.
• The cannula or masks can be seen as a barrier by loved ones wishing to express physical affection.
• It has not been shown to provide any benefit.
Anecdotally, the only time I have stronger feelings about leaving the oxygen in place during the dying process is when patients, who are still aware of their surroundings, have been on long-term oxygen and understandably feel anxious or naked without it. Otherwise, Dr. Mary L. Campbell’s suggestions for discontinuing oxygen and emphasizing good communication with the family about the situation are on point.
Dr. Bekanich is with the department of medicine and is medical director of palliative care, Seton Healthcare, Austin, Tex.
Hospitalists frequently need to address the needs of the dying patient. At times questions and dynamics of the family and loved ones surrounding that patient may elevate the challenges and complexities of an already difficult situation. It takes a different skill set – one often not taught during medical education – to do this well.
Over the last few decades, research shows, approximately 50% of adults who die in the United States do so in the hospital setting. These factors have led the Society of Hospital Medicine (SHM) to advocate that hospitalists be effective at caring for the dying patient, even including palliative care within the Core Competencies of the specialty.
The mechanism of dyspnea is not completely understood, but its impact on patients and families is undeniably negative and profound. Just the description is discomfiting: It is "not a single sensation and there are at least three distinct sensations including air hunger, work/effort, and chest tightness" (Br. J. Anaesth. 2011;106:463-74). More than 50% of patients with cancer, cardiopulmonary disease, and neuromuscular disorders experience dyspnea; and more than 70% of all people experience this during the last few weeks of life (Palliat. Med. 2006;20:219-30).
All attempts to prevent or relieve dyspnea should be undertaken. Evidence-based strategies exist for and include both pharmacologic and nonpharmacologic approaches. Examples of the former include opioids, bronchodilators, and benzodiazepines while the latter group varies from guided imagery, noninvasive positive pressure ventilation, and fans, among others.
The benefit of oxygen therapy is at best controversial (Curr. Opin. Support. Palliat. Care 2008;2:89-94).To date there is a lack of evidence that providing oxygen to an actively dying patient is beneficial. In the most well-designed trial to date of patients with life-limiting illnesses and refractory dyspnea, palliative oxygen delivered via nasal cannula failed to demonstrate symptomatic improvement (Lancet 2010;376:784-93).
["Routine Oxygen at End of Life is Typically Unhelpful" -- Hospitalist News, 6/4/12]
Despite this, oxygen is frequently found on dying patients. From personal experience, at multiple centers, I have found this to be the case even when an order is written to discontinue any form of oxygen delivery. Why might the avoidance of oxygen in this situation be important?
• Hospitals spend money on obtaining, maintaining, and providing oxygen.
• Patients and third-party payers incur charges related to oxygen.
• Medical equipment can carry risks ranging from discomfort to a source of infection for those in contact with it.
• Delivery systems produce noise, and nurses and aides need to interrupt family time to administer this and follow-up on the intervention.
• It may send mixed messages to families about treatment goals.
• The cannula or masks can be seen as a barrier by loved ones wishing to express physical affection.
• It has not been shown to provide any benefit.
Anecdotally, the only time I have stronger feelings about leaving the oxygen in place during the dying process is when patients, who are still aware of their surroundings, have been on long-term oxygen and understandably feel anxious or naked without it. Otherwise, Dr. Mary L. Campbell’s suggestions for discontinuing oxygen and emphasizing good communication with the family about the situation are on point.
Dr. Bekanich is with the department of medicine and is medical director of palliative care, Seton Healthcare, Austin, Tex.