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DOCUMENTS
An Official American Thoracic Society Workshop Report: Assessment
and Palliative Management of Dyspnea Crisis
Richard A. Mularski, Lynn F. Reinke, Virginia Carrieri-Kohlman, Mark D. Fischer, Margaret L. Campbell, Graeme Rocker,
Ann Schneidman, Susan S. Jacobs, Robert Arnold, Joshua O. Benditt, Sara Booth, Ira Byock, Garrett K. Chan,
J. Randall Curtis, DorAnne Donesky, John Hansen-Flaschen, John Heffner, Russell Klein, Trina M. Limberg,
Harold L. Manning, R. Sean Morrison, Andrew L. Ries, Gregory A. Schmidt, Paul A. Selecky, Robert D. Truog,
Angela C. C. Wang, and Douglas B. White; on behalf of the ATS Ad Hoc Committee on Palliative Management
of Dyspnea Crisis
THIS OFFICIAL WORKSHOP REPORT OF THE AMERICAN THORACIC SOCIETY (ATS) WAS APPROVED BY THE ATS BOARD OF DIRECTORS, JUNE 2013
This document has an online supplement, which is accessible from this issue’s table of contents at www.atsjournals.org
Ann Am Thorac Soc Vol 10, No 5, pp S98–S106, Oct 2013
Copyright © 2013 by the American Thoracic Society
DOI: 10.1513/AnnalsATS.201306-169ST
Internet address: www.atsjournals.org
obstructive pulmonary disease (COPD) and effective for dyspnea, and reassessment Methods
cardiomyopathy. This man had severe, and adjustment of interventions.
slowly progressive chronic dyspnea. The d System-based approaches directed An Ad Hoc Committee was commissioned
patient and his physician ultimately agreed toward prevention and early by the ATS to organize a workshop with
that cardiopulmonary resuscitation and management of dyspnea crisis are the goal of summarizing clinical approaches
mechanical ventilation would not be in important elements of a comprehensive to a novel construct of acute dyspnea
accord with his goals of care. Nevertheless, response, and include care coordination episodes termed a “dyspnea crisis.” Four
episodes of dyspnea crisis prompted strategies, checklists, and practiced co-chairs were selected by the project
numerous urgent trips to the community interventions. organizers, and then participants were
hospital emergency department, usually by d Early involvement of palliative care chosen by solicitation from the Behavioral
ambulance. Therapies directed at anxiety specialists and use of individualized care Science, Clinical Problems, and Nursing
and panic failed to control his symptoms, plans along with time-limited trials of assemblies. All participants were vetted
and he experienced substantial suffering up therapies may increase palliation of for potential conflicts of interest
until the time of his death. dyspnea. according to the policies and procedures
d Advance directives and articulations of of the ATS.
preferences, such as by Physicians Orders In preparation for the workshop,
Definition of Dyspnea Crisis for Life-Sustaining Treatment (POLST) we conducted a comprehensive search
The Ad Hoc Committee members offer the forms, may increase adherence to stated (see expanded METHODS in the online
following definition of a novel clinical entity care and treatment goals. supplement) of the medical literature
of dyspnea crisis as “sustained and severe for existing data on the management
resting breathing discomfort that occurs in or palliation of dyspnea from1990
patients with advanced, often life-limiting Introduction through 2009. Four reviewers evaluated
illness and overwhelms the patient and systematic evidence-based reviews
caregivers’ ability to achieve symptom Dyspnea is a common and often (SEBRs) using a modified tool for the
relief.” progressively debilitating symptom in assessment of multiple systematic reviews
advanced chronic disease that is associated (AMSTAR) that was adapted to grade
with fear, anxiety, activity limitations, and the quality of reviews and evidence as:
profound suffering (1–6). Recently, there high, moderate, low, or very low and
Key Conclusions
has been national recognition of dyspnea summarized findings for Workshop
d Dyspnea crisis most commonly occurs as a priority topic for assessment, participants (17–21).
when the following factors interact: acute management, and care improvement (2, 3, The workshop was conducted on May
worsening of dyspnea experience, 5, 7–11). Quality measurement bodies such 15, 2009. During the workshop, members
a heightened psycho-social-spiritual as the National Quality Forum have used the systematic evidence review
patient response, and a setting by emphasized the need for patient-centered (see EVIDENCE SUMMARY in the online
unprepared caregivers who are too quality of care evaluation and innovation in supplement) to develop a consensus
overwhelmed to respond in the optimal advanced lung disease, including a focus on definition for the novel clinical entity
manner. palliation and end-of-life care (7, 12, 13). of dyspnea crisis. They also discussed
d Identification of dyspnea crisis should However, the evidence summarized in key areas for future study and
begin with first responders who may be these statements and reviews suggest that clinical refinement along six domains:
lay or minimally trained. across diseases and settings, dyspnea assessment of dyspnea crisis; ethical
d Since dyspnea crisis often occurs in the palliative care management is inadequate and professional considerations;
home or in a care facility away from (1, 3–7, 12, 14, 15). efficient utilization, communication,
more advanced medical resources, Although existing American Thoracic and care coordination; clinical
preparation and practice of simple, Society (ATS) Dyspnea Position Statements management of dyspnea crisis;
effective, and stepwise interventions that summarize the evaluation and clinical development of patient education
are individualized for patients are approaches to dyspnea, they do not address and provider aid products; and enhancing
needed. acute crises of dyspnea that can occur implementation with audit and quality
d Responding to dyspnea across the disease suddenly, that may be unresponsive to improvement. Following the workshop,
experience requires comprehensive immediate symptom relief, and that may conclusions and recommendations were
patient-centered assessment and result in intensive medical utilization, refined via e-mail and teleconferences.
treatment using coordinated, especially at the end of life (1, 6). We The literature was searched annually for
interdisciplinary care teams. conducted an ATS-funded project, new evidence that may affect our
d Guideline recommended care includes Palliative Management of Dyspnea Crisis, to conclusions and recommendations.
measurement using a dyspnea intensity focus on identification, management, and Finally, this report was developed to convey
scale augmented by assessment of resource optimization for patients who our key conclusions, recommendations
a patient’s subjective experience, experience acute episodes of dyspnea. The for future research, and suggestions for
optimization of disease-modifying early proceedings of the Committee and the educational endeavors that might aid
treatment strategies, use of palliative Consensus Definition have been previously assessment and management of this
medical and nonmedical approaches reported in the form of an abstract (16). clinical entity.
control of acute dyspnea, this approach cannot be controlled, palliative sedation is strategies with proven efficacy (oxygen,
carries substantial burdens that may an option (2–4). Palliative sedation offers mechanical ventilation, opioids, etc.) and
not be consistent with patients’ treatment medical management targeting relief of avoiding unwanted or ineffective therapies
preferences and goals. Other patients may otherwise intractable pain, dyspnea, or (2, 3, 5, 7–11, 34). Proficiency or expert
have poorly formulated preferences about other distressing symptoms that consultation in current opioid preparations
mechanical ventilation; for these patients, intentionally causes sedation in a patient and delivery methods is essential. Integral
it is important to clarify goals of care before who is otherwise close to death. to coordination are communication skills
intubation, whenever possible. One in anticipatory planning that includes:
approach that may be particularly beneficial (1) assessing whether the patient wishes to
for patients who are unclear about their Efficient Utilization, be involved in decision making and
goals of care is the notion of a time-limited Communication, identifying surrogate decision makers; (2)
trial—use of a treatment, such as and Care Coordination assessing patient/family’s goals and
mechanical ventilation or non-invasive concerns about progressive disease and
ventilation, with frequent time-delimited Workshop participants recognized that likely outcomes (rather than merely asking
assessments of whether interventions are successful approaches to the management of about their desire for specific therapies);
meeting agreed upon therapeutic goals. dyspnea crisis will require coordinated (3) describing and recommending therapy
efforts across care settings, especially within aligned with the patient’s goals and
Principle of Double Effect the home or community where expert care concerns; and (4) discussing uncertainty
When a dyspnea crisis occurs, some providers may not be readily available. inherent in medical therapy and
patients’ symptoms may not be readily When clinicians are only available remotely, negotiating how to proceed within such
controlled with nonpharmacologic such as through telephone or other uncertainty.
interventions or initial doses of opioids. In electronic mechanisms, and are unable to Vital to an action plan is identification
these circumstances, symptom control may personally examine the patient, they may be of who to call for help and when to modify
require escalating doses of opioids and reluctant to manage any necessary dose efforts to achieve symptom management
anxiolytic drugs that carry the potential escalation of opioids. Family members play or consider transfer to a higher-level care
to impair respiratory drive and could a vital role in caring for patients with facility. Although care plans and prepared
possibly hasten the patient’s death. Therapy chronic, terminal illness. Dyspnea crisis is responses may mitigate emergency or
should be guided by and tailored to frightening and anxiety provoking to the tertiary care needs, coordination should
patients’ individual preferences. The patient, family, and caregivers. Therefore it is expand to involve emergency providers
principle of double effect is relevant in the critical to anticipate, educate, and plan for and systems. Among topics, workshop
management of these situations, and the these events by creating an action plan participants emphasized expert application
correct balance between symptom control that is agreed on and periodically reviewed by of disease-modifying therapies and
and risk of hastened death will vary from healthcare providers, the patient, and caregivers. aggressive symptom management with
patient to patient (2–4). The principle As a patient’s disease worsens, the transfer to more advanced care settings that
suggests that it is morally permissible dyspnea management plan will likely should include continued conversations
to accept the possibility of impaired require revision and distribution to with the patient and/or family regarding
ventilation if the clinical intention is potential providers, especially with transfers their understanding of the disease
a response to the patient’s desire for relief between different levels of care. The use progression, prognosis, goals of care, and
of distressing symptoms such as of electronic records may facilitate expectations. The patient’s care should then
overwhelming dyspnea (32). caregivers’ access to the plan of care be informed by expected responses to
updates, though such systems are still therapy aligned with expressed preferences,
Aid in Dying not widely used. In addition, having the and may include readdressing the plan of
Circumstances may arise in which patients family embrace a single spokesperson care or initiating a time-limited trial of
in the midst of a dyspnea crisis request to communicate with healthcare certain aggressive interventions (2–4, 34).
a prescription for medications intended to providers may empower their role in care Successful coordination with emergency
actively bring about their death. Although coordination and mitigate deviation from response may be improved with the use
physician-assisted suicide is legal in Oregon established care plans. Palliative care and portability of preference articulations,
and Washington, its legal implementation consultation is a resource that should be such as by Physicians Orders for Life-
requires a number of procedural steps that considered early in the care of patients with Sustaining Treatment (POLST) forms or
cannot be achieved in response to a new worsening dyspnea to assist in symptom registries. Finally, at the time of discharge
request during a dyspnea crisis. We management, end-of-life planning, and or transfer from one level of care to
therefore suggest that assisted suicide not be care coordination (2–4, 33). another, a written management plan should
viewed as an option for patients in acute Care plans should be interdisciplinary be used to coordinate treatment and ensure
dyspnea crisis who have not previously and revised frequently to include appropriately alignment of preferences and strategies
considered this option. Rather, we increasing or decreasing use of acute care for future episodes of dyspnea crisis.
recommend aggressive symptom control resources depending on the patient’s disease Individualized plans should include
measures, including expert consultation if trajectory and/or changing goals of care. a checklist of specific written instructions
needed. If, despite maximal efforts at Assessment of the plan will have the for symptom-controlling medications,
symptom control, intractable dyspnea goals of maximizing appropriate use of nonpharmacologic interventions, and
instructions for when to contact alternate Table 1. COMFORT mnemonic record or diary of dyspnea, therapy
caregivers such as a particular family member, summarizing key therapeutic effectiveness, and modifying factors (36, 37).
hospice, a triage nurse, or other professionals. considerations Close attention to other factors in the
patient’s environment and ways to mitigate
C—Call for help. Calming voice and psychosocial responses may also be important.
Clinical Management of approach among patient and caregivers
O—Observe closely and assess dyspnea for
Dyspnea Crisis ways to respond
M—Medications to be tried Development of Patient
Dyspnea crisis is a medical emergency, and (recommendations from providers for Education and Provider
thus the evaluation and management of opioid/other use) Aid Products
dyspnea crisis may best be presented in an F—Fan to face may decrease shortness of
breath
algorithmic format to ensure a specific O—Oxygen therapy as previously found Patients are at the center of the dyspnea
sequence of evidence-based therapies (see useful crisis, yet for many family members,
the online supplement for evidence tables R—Reassure and use relaxation techniques caregivers, and clinicians these situations are
from systematic reviews as general T—Timing interventions to reduce dyspnea – also a crisis (38, 39). Although family
guidance in dyspnea management). work together – reassess – repeat
caregivers, nurses, emergency department
Guidelines in general advocate assessment (ED) personnel, and hospice personnel are
with a dyspnea intensity scale augmented n-of-one trial (apply a palliative the usual “first responders,” there are
by assessment of a patient’s subjective intervention with subsequent subjective currently no recommendations for how
experience, optimization of disease- assessment as to whether the benefit they should handle this emergency
modifying treatment strategies, use of outweighs its burden). Assessments may situation. Poor recognition of dyspnea,
palliative medical and nonmedical approaches include a patient or a primary caregiver termed by one author the “invisibility of
effective for dyspnea management, and
reassessment and adjustment of interventions
(1–11, 14, 23, 24, 35).
System-based approaches to
prevention and early management of
dyspnea crisis are important elements of
a comprehensive response, such as care
coordination strategies, checklists, and
practiced interventions. Among the key
elements are emergency symptom-
controlling medications, recognition by lay
and professional caregivers, and organized
steps to quickly and safely intervene. The
current state of the science does not support
a standardized emergency treatment
recommendation to specifically address
dyspnea crisis (clinicians should apply
currently recommended care for dyspnea
management as summarized in the existing
literature; see the online supplement).
Review of existing practice protocols
emphasize the importance of developing
individualized plans for dyspnea crisis based
on the patients’ and caregivers’ previous
experiences, preferences, and available
treatments and resources. One approach
that workshop members advanced was the
“COMFORT” mnemonic that might be
used in developing individualized care
recommendations between patients and
providers (see Table 1 and Figure 2).
When palliation is the focus of care,
clarification of the indication and rationale
for an intervention should be explained to
the patient, family, and caregivers. To assess
the effectiveness of various dyspnea
treatments, it is helpful to consider an Figure 2. Customizable caregiver plan for episodes of crisis dyspnea.
breathlessness,” contributes to less continuing education programs that deal Table 2. Components for patient
widespread education and may increase the with end-of-life and palliative care, education in dyspnea crisis
potential for caregivers to be underprepared and ongoing orientation programs in
(30). Education should be early and ongoing institutions such as hospitals, nursing Basic facts about causes and triggers of
and should involve patients, families, homes, skilled nursing facilities, and dyspnea crises
caregivers, and all members of the health team, hospice care programs. How to identify signs and symptoms that
are an indication of a dyspnea crisis
including medical assistants, acute care staff, How to recognize and measure changes from
palliative care teams, and hospice personnel. Methods and Modes for Delivery baseline for both intensity of dyspnea and
There are numerous avenues for teaching an affective component (anxiety or distress)
Patients, Caregivers, and Families healthcare professionals, patients, families, Breathing retraining including pursed lip
and caregivers about dyspnea crisis. breathing, slowed pattern of breathing,
Dyspnea crisis education for patients, prolonged exhalation, and posture
caregivers, and families should be initiated Methodologies considered by the Ad Hoc modification
at the time of diagnosis and reinforced Committee include: web-based programs Relaxation techniques, mindfulness
throughout the course of the patient’s for chronic symptom management that meditation, guided imagery and
illness. Individualized or tailored patient could incorporate essential skills similar distraction strategies (e.g., music, TV,
reading by self or caregiver)
education including action plans for the to those taught for “panic” experiences, Appropriate and individualized use of
patient and caregivers are essential. pulmonary rehabilitation programs that oxygen, ventilation, and/or fans
Techniques for managing dyspnea crisis could develop simulations for the patient Use of a written action plan that includes
should be anticipated and taught before and caregiver to practice necessary skills, appropriate administration and dosing of
dissemination of algorithms for assessment medications and stepwise titration regimens
a dyspnea crisis and reinforced at every
encounter, with possible practice of “rituals and management of the patient in dyspnea
for dyspnea crises” to heighten patient crisis, education sheets or scripts for
caregivers and healthcare providers for implementation aids to support practice
and caregivers’ sense of control and self-
outlining appropriate strategies for patients improvement for dyspnea crisis.
efficacy (38, 39). Acute exacerbations can
experiencing dyspnea crisis, periodic In addition to publication of this
be an opportunity for the professional
practice exercises of treatment skills, Workshop Report, teaching, dissemination, and
healthcare provider to teach patients and
and development of video training or implementation aids will be needed to produce
caregivers what to expect, and what actions
resources for dyspnea management that changes in practice. The education subgroup
are appropriate, and to help the patient
might also target instructions on pursed lip in collaboration with the ATS Education
practice care plans. We recommend that
breathing and other nonpharmacological Committee will develop and disseminate
the ATS and other organizations develop
strategies. specific provider and patient/caregiver aids (see
templates and patient education materials
Figure 2). The Working Group acknowledged
to enhance dissemination and
potential barriers to the more widespread use
implementation of dyspnea crisis
of opioids and calls attention to efforts and
management Targets that might be Enhancing Implementation advocacy currently underway to advance
included in education are suggested in with Audit and Quality appropriate implementation of dyspnea care
Table 2 and may be aided by Figure 2. Improvement recommendations into clinical practice.
Although multiple tools have been identified
Education for Healthcare A number of recent guidelines and task
for assessing dyspnea, there remains no
Professionals forces have identified assessment of dyspnea
consensus for the optimal assessment strategy.
Education for healthcare professionals also as underdeveloped in clinical practice and
We recommend that clinicians regularly assess
needs to take an interdisciplinary approach suggest that performance measures should
both dyspnea intensity and the distress
to assessing and managing patients who be part of the approach to improving
associated with the dyspnea. We also
are experiencing dyspnea crisis. Educational care across cardiopulmonary disorders
recommend that quality metrics be used
topics should include: self-reporting associated with this symptom (3, 8, 9, 13, 14,
to enhance recognition and practice
measurement tools, measurement of distress 40, 41). Reliable and responsive quality
improvement toward these goals (3, 8, 9, 13,
related to dyspnea, nonpharmacologic metrics will be needed to support
14, 23, 24, 40, 41).
and pharmacologic interventions, the implementation of the assessment and care
COMFORT acute treatment aid (see management recommendations suggested
Table 1), noninvasive positive pressure by this report; existing metrics recommend
ventilation, invasive mechanical ventilation, at a minimum assessing dyspnea in Directions for Future Research
and nonmedical treatment strategies. critically and/or chronically ill patients
A dyspnea management checklist and (currently approved quality metrics can Calls for appropriately designed studies have
algorithms for essential steps in care and be found at the National Quality been made by two Institute of Medicine
comfort during dyspnea crisis could be Measures Clearinghouse at http://www. committees, an NIH Consensus panel, the
helpful for providers. Education about the qualitymeasures.ahrq.gov/). Following the National Hospice and Palliative Care
prevention, assessment, and treatment of basic tenet that “you can’t improve what Organization, and the Hospice and Palliative
dyspnea crisis needs to be accessible to you don’t measure,” we advocate an Nurses Association (42–45). However, the kinds
healthcare providers at all levels, including emphasis on patient-centered quality of of randomized clinical trials common to
medical and nursing school curricula, care enhancement and recognize the need palliative phases of illness are difficult to conduct
Table 3. Potential study questions posed by committee members LYNN F. REINKE, PH.D, A.R.N.P. (Co-chair)
VIRGINIA CARRIERI-KOHLMAN, R.N., D.N.Sc.
(Co-chair)
Care coordination 1. Does a written, interdisciplinary plan of care MARK D. FISCHER, M.D. (Co-chair)
decrease utilization of inappropriate resources MARGARET L. CAMPBELL, PH.D., R.N.
for the treatment of episodes of dyspnea crisis?
(Subcommittee co-leader)
2. Does the use of electronic records facilitate GRAEME ROCKER, M.A., M.H.Sc., D.M.
efficient transfers of patient information between (Subcommittee co-leader)
different levels or settings of care? ANN SCHNEIDMAN, M.S., C.N.S., R.N.
Communication 1. Does the use of a written “Dyspnea Management (Subcommittee co-leader)
Checklist” decrease the incidence of acute SUSAN S. JACOBS, R.N., M.S. (Subcommittee
episodes of dyspnea? co-leader)
2. Does identification and avoidance of patient-
ROBERT ARNOLD, M.D.
identified precipitants of dyspnea decrease the JOSHUA O. BENDITT, M.D.
frequency of acute episodes of dyspnea? SARA BOOTH, M.D.
Utilization 1. Does the use of an interdisciplinary treatment plan IRA BYOCK, M.D.
decrease the incidence of readmission for episodes GARRETT K. CHAN, R.N., Ph.D.
of acute dyspnea in chronically ill patients? J. RANDALL CURTIS, M.D., M.P.H.
2. What is the frequency of chronically ill patients
DORANNE DONESKY, Ph.D., R.N.
being admitted to an inappropriate level of care JOHN HANSEN-FLASCHEN, M.D.
for dyspnea crisis and what might prevent this? JOHN HEFFNER, M.D.
3. Does the anxiety of dyspnea crisis lead to RUSSELL KLEIN, M.D.
extensive testing in the hopes of identifying TRINA M. LIMBERG, B.S., R.R.T.
reversible factors; does this lead to more HAROLD L. MANNING, M.D.
aggressive care at the end of life and do written
R. SEAN MORRISON, M.D.
care plans mitigate this experience? ANDREW L. RIES, M.D., M.P.H.
Therapy 1. Do palliative care interventions improve symptom GREGORY A. SCHMIDT, M.D.
management for patients with advanced diseases PAUL A. SELECKY, M.D.
who are not within 6 months of death? ROBERT D. TRUOG, M.D.
2. Do palliative care evaluations and interventions ANGELA C. C. WANG, M.D.
improve symptom management and health- DOUGLAS B. WHITE, M.D., M.A.S.
related quality of life for patients and caregivers
with advanced diseases receiving care in
emergency departments? ATS Documents, Development, and
Implementation Committee Liaison:
MICHAEL GOULD, M.D., M.S.
Author disclosures: M.L.C. reported receiving
and may not reflect ideal methodology in this pharmacological and nonpharmacological textbook royalties from McGraw-Hill (amount
setting. Other designs that incorporate therapies. The participants in this ATS unspecified). R.A. reported receiving textbook
qualitative elements to understand patient Workshop have developed a working royalties from Cambridge University Press (up to
and caregiver perspectives are also definition of this entity and hope to $1,000), Johns Hopkins University Press (up to
$1,000), and Oxford University Press (up to
appropriate. For the individual patient, an advance the recognition and attention to
$1,000). S.B. reported receiving textbook
n-of-one study can be justified, and trial assessment and management with this royalties from Oxford University Press (amount
designs that include variations on that report. We emphasize that practitioners unspecified). J.H.-F. reported receiving textbook
approach may well advance the field (3, 14, should not underestimate the profound royalties from American College of Physicians
37). The Workshop members recognize that psychosocial impact that dyspnea has and UpToDate (amounts unspecified). J.H.
reported holding stocks or options in Entrovita
approaches are needed that advance reliable on the quality of life of both patients ($1-999). R.A.M., L.F.R., V.C.-K., M.D.F., G.R.,
measures of dyspnea across cognitive and their families. Patients and families A.S., S.S.J., J.O.B., I.B., G.K.C., J.R.C., D.D.,
states; non–disease-directed treatments of living with dyspnea need clinicians to R.K., T.M.L., H.L.M., R.S.M., A.L.R., G.A.S.,
dyspnea and its sequelae; and optimal understand both their chronic illness P.A.S., R.D.T., A.C.C.W., and D.B.W. reported that
they had no relevant commercial interests.
initiation dose, dosing interval, titration and their palliative care needs. Patients
schedule, and delivery route of medications. who do not want to use mechanical Acknowledgment: The Ad Hoc Committee
In addition to the need for differently ventilation, in particular, need effective acknowledges the assistance of the ATS
designed studies, we have identified several ways to manage their symptoms during members Jerry Krishnan, M.D., Ph.D. and
gaps in research and practice that need to dyspnea crisis. Improved education Michael Gould, M.D., M.S.; the expert editorial
guidance by Kevin Wilson, M.D.; the aid by ATS
be addressed. Study questions summarized about how to plan for and manage episodes
staff Judy Corn, Eileen Larsson, Miriam
in Table 3 remain key areas relevant to of dyspnea crisis will give clinicians, Rodriguez, Jessica Wisk, and Lance Lucas; and
management of dyspnea crisis. patients, and family caregivers important they are grateful to the officers and membership
tools and guidance to handle these crisis of the ATS Behavioral, Nursing, and Clinical
Conclusions situations. n Problems Assemblies for their support and
encouragement. The Committee also
These guidelines were prepared by an ad hoc acknowledges participation in deliberations and
Patients with advanced cardiac and lung committee of the Behavioral Science, Nursing, reviews by Kathleen O. Lindell, Ph.D., R.N.
diseases may suffer from unrelenting and Clinical Problems assemblies and Suzanne C. Lareau, R.N., M.S. of the ATS
Patient and Family Education Committee; and by
dyspnea and are at risk of experiencing Members of the Committee: Paula Meek, Ph.D., R.N.; Huong Nguyen, Ph.D.,
dyspnea crises. Such crisis events may occur RICHARD A. MULARSKI, M.D., M.S.H.S. MCR R.N.; Karen Mularski, M.D.; and Catherine
despite optimal conventional (Co-chair) Simpson, M.Div.
38 Dorman S, Jolley C, Abernethy A, Currow D, Johnson M, Farquhar M, Efficacy Assessment Subcommittee of the American College of
Griffiths G, Peel T, Moosavi S, Byrne A, et al. Researching Physicians. Evidence-based interventions to improve the palliative
breathlessness in palliative care: consensus statement of the care of pain, dyspnea, and depression at the end of life: a clinical
National Cancer Research Institute Palliative Care Breathlessness practice guideline from the American College of Physicians. Ann
Subgroup. Palliat Med 2009;23:213–227. Intern Med 2008;148:141–146.
39 Booth S, Moosavi SH, Higginson IJ. The etiology and management of 42 Field MJ, Cassel CK. Approaching death: improving care at the end of
intractable breathlessness in patients with advanced cancer: life. Washington, DC: National Academy Press; 1997.
a systematic review of pharmacological therapy. Nat Clin Pract 43 National Institutes of Health. State-of-the-Science Conference
Oncol 2008;5:90–100. Statement: Improving End-of-Life Care, December 6–8, 2004,
40 Nelson JE, Mulkerin CM, Adams LL, Pronovost PJ. Improving comfort Bethesda, Maryland, USA. J Palliat Med 2005;8:8,S1.
and communication in the ICU: a practical new tool for palliative 44 Campbell G, Happ MB, Hultman T, Kirchhoff KT, Mahon MM, Mayo
care performance measurement and feedback. Qual Saf Health Care MM, McMillan S, Raudonis B. The HPNA Research Agenda: 2009–
2006;15:264–271. 2012. Journal of Hospice and Palliative Nursing 2009;11:10–18.
41 Qaseem A, Snow V, Shekelle P, Casey DE Jr, Cross JT Jr, Owens DK, 45 Foley KM, Gelband H. Improving palliative care for cancer.
Dallas P, Dolan NC, Forciea MA, Halasyamani L, et al.; Clinical Washington, DC: National Academy Press; 2001.