Patient Care Endocrinology & Cardiology - October 2007 - (Page 26)

The15-MinuteVisit What you need to keep in mind during patient encounters Dyspnea at the end of life I Problem The patient is a 76-year-old man with a 4-year history of idiopathic pulmonary fibrosis who has been oxygen dependent for 2 years. He has been treated with prednisone and other immunosuppressive medications with minimal success. In the last 3 months, his exercise tolerance has markedly declined. He becomes breathless while eating or dressing. What would you do if . . . 1. The patient’s anxiety worsened? 2. The patient’s breathlessness worsened? Answers 1. After discussion with the patient, consider a lowdose anxiolytic (eg, lorazepam [Ativan, Lorazepam Intensol], 0.5 mg po bid). 2. After discussion with the patient, slowly increase the dosage of oxycodone. Prescribe stool softeners and laxatives to prevent constipation. Patients need to be aware that higher opioid dosages may increase drowsiness. Some patients will trade anxiety for drowsiness. Others, who want to be mentally clear and alert, will decline further medication. I Approach Before concluding that the patient has progressive pulmonary fibrosis, the physician needs to consider the common causes of dyspnea, including pneumonia, congestive heart failure, asthma, chronic obstructive pulmonary disease, pulmonary emboli, and pneumothorax. These conditions were not present in this patient. Other causes to consider in patients with chronic lung disease include increased secretions, anemia, and anxiety. The physician determined that the patient indeed had end-stage pulmonary fibrosis, which has a median survival of 2 to 4 years at the time of diagnosis. The physician used the office visit to review goals of care and to make sure the patient had a durable power of attorney for health care. During the visit, the patient expressed his desire for comfort measures only and said he did not want to be resuscitated in case of acute respiratory or cardiac decompensation. He stated that he wanted to die at home. I Management This patient has expressed his desire for “comfort care.” To understand what that phrase means to any particular patient requires clear and honest communication between patient and physician. This patient also had significant anxiety about smothering to death. In addition, he worried about the fate of his children after his death. Patients like this one often require multidisciplinary management as provided by hospice organizations, most of which have access to chaplains, social workers, and pharmacy and nursing services. To reduce the patient’s sense of dyspnea, nonpharmacologic measures such as fans and family support may be helpful. Small doses of opioids have been shown to provide some relief to patients such as this one. The dosages required to relieve dyspnea (eg, starting dosage of oxycodone, 5 mg po bid) are much lower than those required to relieve pain. Nebulized opioids are ineffective. The patient bought a fan and was placed on oxycodone. Hospice was consulted. The patient felt more at peace after these interventions. DEAN G. GIANAKOS, MD Contributing Editor Associate Professor of Clinical Family Medicine, University of Virginia; Associate Director, Lynchburg Family Medicine Residency, Lynchburg, Va; and a member of the Patient Care Board of Editors. 26 PATIENT CARE ENDOCRINOLOGY & CARDIOLOGY www.patientcareonline.com http://www.patientcareonline.com

Table of Contents Feed for the Digital Edition of Patient Care Endocrinology & Cardiology - October 2007

Patient Care - Endocrinology & Cardiology - October 2007 Research Digest Contents Medicine in the News Recognizing and Managing Patients with the Metabolic Syndrome and Prediabetes Using Troponins to Evaluate Cardiac Injury The 15-Minute Visit Classified Advertising Clinical Clips

Patient Care Endocrinology & Cardiology - October 2007

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.