Dyspnea Psychological Impact on Patients Families Health Care

Dyspnea: Psychological Impact on Patients & Families & Health Care Providers Larry Librach MD, CCFP, FCFP Professor, Dept. of Family & Community Medicine Sun Life Financial Chair in Bioethics & Director Joint Centre for Bioethics, University of Toronto QI Lead , Temmy Latner Centre for Palliative Care

Importance • Perception of dyspnea is considered analogous to the perception of pain & consists of sensory (intensity) & affective (unpleasantness) dimensions • Similar cortical processes appear to underlie experience of dyspnea & pain Temmy Latner Centre 2

Importance • Both symptoms result in added suffering üAnxiety, depression, & other psychological factors occur frequently in patients with advanced disease & influence breathlessness • Distressing symptom that requires attention, consideration, & treatment by healthcare providers Temmy Latner Centre 3

Importance • HCPs are ethically obligated to treat dyspnea, & patients & their families should be reassured that they will be provided the means to effectively treat this symptom • Approach to care should be reflected in goals of care & care plan that involves a holistic approach Temmy Latner Centre 4

Goals of Care for Dyspnea • Because patients do not experience dyspnea in isolation but rather in conjunction with other symptoms, concomitant stressors, & spiritual or existential distress üDyspnea cannot be fully addressed unless these physical & nonphysical factors are understood. Temmy Latner Centre 5

Psychological Impact Temmy Latner Centre 6

Psychological Impact-Patient FEAR ! üOf suffocation üAdded suffering üAdded burden for family üNeed for hastened death Temmy Latner Centre 7

Neurophysiology • Anterior cingulate gyrus on cortex is area of brain that is responsible for emotional impact of physical symptoms like pain & dyspnea üLinked to thalamus by opioid sensitive pathway Temmy Latner Centre 8

Psychological Impact-Patient • Manifestations include: üAnxiety üPanic üPoor sleep üDepression Temmy Latner Centre 9

Psychological Impact-Patient • Opioids appropriate • Approach requires more than medication • Oxygen is not a panacea and may actually increase anxiety • Counselling important üReassuring conversations & education üOutline expectations üDiscuss continuing evaluation Temmy Latner Centre 10

Psychological Impact-Family • Again fear of suffocation & witnessing an agonizing death • Sense of helplessness • Anxiety about the very end of life & whether hospital the best place Temmy Latner Centre 11

Psychological Impact-Family • Approach requires regular visits, reassurance re: accessibility • Also reassurance re: role of oxygen as it is not a panacea Temmy Latner Centre 12

Psychological Impact Health Care Providers • Sense of “need to do something” • Anxiety around need for oxygen • Foreboding about suffocation • Anxiety around when to institute sedation Temmy Latner Centre 13

Summary • Dyspnea is a common symptom in palliative care üInduces great fear • Success is most likely when as many as possible of the patient’s individual dyspnea stressors & concomitant symptoms (i. e. , anxiety, depression, panic attacks) are identified & addressed Temmy Latner Centre 14