Respiratory therapists can play a vital role in providing palliative care for hospice patients. In addition to addressing respiratory care issues, we can be a liaison between patients, family, and hospice staff for pain management, spiritual and social support, and other concerns. The goal is to allow for a more peaceful and comfortable transition to the end of life.
Hospice and palliative care focus on the relief of pain and other distressing symptoms of serious illness rather than a cure. When a patient's illness progresses to the point that it is likely to be terminal within six months, a physician, nurse, case manager, or family member can refer the patient to be evaluated for hospice services. Many families and patients choose hospice because they would rather experience end of life at home and not in an acute care setting where they may require more interventions that can be uncomfortable and prolong suffering. Hospice does not hasten or postpone death. It affirms life and regards dying as a normal process.
A Change of thinking
Patients with advanced disease need and deserve excellent symptom management, capable psychological support, assistance in making difficult medical decisions, and warm healing relationships with their caregivers. Hospice care is administered by qualified professional hospice team members who are experts in end-of-life care, and it is a relatively new venture for RTs.1 RTs coming from an acute and critical care setting may require a change of thinking in order to work effectively in the hospice environment.
The focus in acute and critical care is often quick and highly technical interventions that attempt to bring about a rapid restoration to health. In hospice, RTs do not have access to arterial blood gases, chest X-rays, or other diagnostic testing. Pulse oximetry is used primarily for evaluating changes in oxygen delivery systems or to obtain a baseline value for the initial assessment or by the order of the physician. It is also used for certifying or recertifying hospice appropriateness.
For the most part, RTs working in a hospice setting must rely on their assessment skills. The diagnoses of hospice patients that are seen by a RT for an initial baseline assessment are the following: end stage chronic obstructive pulmonary disease, lung cancer, pulmonary fibrosis, tracheostomy, pneumonia, end stage heart disease, and any other disease process that brings about a worsening of the patient's respiratory status. We also see all patients who are using positive airway pressure systems for either sleep apnea or respiratory support. In addition, we assess all patients with high flow and high oxygen concentration requirements.
After a baseline assessment is completed, the RT discusses any findings with the hospice nurse or physician and makes recommendations for respiratory care interventions. The recommendations can be modifications in the form of oxygen delivery systems, oxygen appliances, or changes in respiratory treatment modalities or medications that will enhance the patient's comfort. A physician's order is required to initiate the RT's recommendations.
A personal experience
Prior to being hired by a hospice program, Anton Lukcevic's father became seriously ill. Although he had a DNR order, his father was resuscitated and intubated at home, and then placed on mechanical ventilation at the hospital. After seven agonizing days, a decision was made to take him off mechanical ventilation. He died a short time later.
A year later, Anton's father-in-law became seriously ill and entered a hospice program. He experienced a peaceful and comfortable death. A compassionate team comprised of nurses, CNA's, chaplains, social workers, and music therapy were available for his support and the entire family.
It is critical for the RT to teach the patient, family or other hospice staff to effectively administer any respiratory therapy prescribed by the physician. Instruction by RTs can include nebulizers, oxygen concentrators, portable oxygen, positive airway pressure systems, sterile suctioning technique, tracheotomy care and cleaning, and safety issues related to all equipment, supplies, and medications.
Positive airway pressure therapy has seen rapid growth among respiratory and cardiac patients in the acute and critical care settings. As such, we are seeing increasingly more hospice patients who require continuous or bilevel positive airway pressure therapies for sleep apnea or respiratory failure or support when they are discharged from the hospital. RTs can set up and monitor these positive airway pressure systems, masks, and other accessories for the patient, the family, and the caregivers.
Terminal ventilator patients are sometimes discharged to their homes on hospice services at their families' request or the patients' request in order to spend their last days at home. We have established a protocol for the discontinuation of ventilator support that provides pain free, drug and oxygen supported comfort for the patient. The protocol also provides the terminal ventilator patient and family with spiritual and emotional support during this difficult time.