The effectiveness of nurse-led palliative care interventions for patients with serious respiratory diseases

Dyspnea is a highly prevalent debilitating symptom for patients diagnosed with advanced cancers and for those with chronic respiratory illnesses (1). Dyspnea can negatively impact all aspects of one’s life, including physical activity, psychological well-being and overall quality of life (2). Unfortunately, there are few effective pharmacologic and non-pharmacologic interventions to mitigate dyspnea.

Greer and colleagues (3) present important findings from a randomized clinical trial (RCT) testing a nurse-led brief behavioral intervention for dyspnea in patients with advanced lung cancer. The researchers taught practicing oncology nurses about the relationship between dyspnea and the psychological stress response and the fundamentals of cognitive-behavioral therapy. The education focused on relaxation skills including guided breathing exercises such as taking slow deep breaths. Additionally, the nurses were taught three evidence-based physiological dyspnea reduction approaches: (I) breathing techniques, e.g. pursed-lip breathing; (II) postural positioning; and (III) use of a handheld fan. The nurses conducted two 30–45 minute sessions with patients, either in-person, by telephone or virtually, to educate them on how to use both behavioral approaches and dyspnea management techniques. Adherence to the techniques as well as assessing which techniques patients used most frequently was recorded.

Patients in the intervention group demonstrated a reduction in dyspnea as measured by the modified Medical Research Council (mMRC) dyspnea scale (4) at 8 weeks. Additionally, patients in the intervention group reported improved functional well-being measured by the functional assessment of cancer therapy—lung (FACT-L) (5). The intervention did not improve patients’ quality of life, psychological symptoms or physical activity level. Nevertheless, the benefit of combining physical dyspnea-reducing techniques with psychoeducation resulted in observed improvements in dyspnea outcomes. An interesting finding noted by the authors is that dyspnea improved in both study groups, although a greater proportion of intervention patients reported improvement versus the control group. This finding may be related to current cancer treatments.

The results and design of this study are promising for several reasons. First, these evidence-based behavioral and physical interventions are easy for nurses to gain competence in, given that they build upon nursing education essentials. Thus, nurses can teach the interventions to patients facilitating integration into routine clinical practice. Educational tools including handouts or videos can reinforce the techniques. Second, utilizing practicing oncology nurses to deliver the intervention, as opposed to hiring study nurses, promotes implementation and sustainability in clinic settings. Third, the intervention was brief, making it feasible for patients who may be suffering from fatigue or other cancer-related symptoms to participate. Fourth, patients can use these techniques for any degree of dyspnea, at rest or with exertion. Lastly, the interventions have no adverse side effects.

There have been several recent studies testing nurse-led palliative care interventions, some positive and others negative. Reinke et al. (6) trained study nurses on how to deliver primary palliative care for patients with any stage of lung cancer. This comprehensive intervention included assessment and management of symptoms, lung cancer education, initiating goals of care discussions and addressing social needs. The nurses prioritized patients’ needs resulting in the majority of time spent on coordinating care among medical providers and problem-solving social and financial needs. Thus, the intervention did not improve patients’ quality of life. One important finding was that 93% of patients in the intervention group reported the nurses helped them think about their goals of care by reviewing the Conversation Starter Kit (7) and 80% initiated goals-of-care conversations or completed advance care planning (ACP) documents with their clinicians and caregivers (8). Schenker et al. (9) conducted a trial training oncology infusion nurses to deliver primary palliative care to patients with advanced cancers, including lung cancer. There was no improvement in quality of life, anxiety, or depression; however, there was a significant improvement in ACP rates (10). Houben and colleagues (11) conducted a RCT testing a single 1.5-hour ACP session with patients with chronic obstructive pulmonary disease and their caregivers. The brief session improved the quality and occurrence of patient-physician end-of-life communication and did not result in negative psychosocial distress. Results from a recent systematic review corroborated Greer et al., findings by demonstrating effectiveness of nurse-led dyspnea-reducing interventions from physical and mental functioning perspectives (12). The interventions most effective were the use of a handheld fan, position changes, breathing techniques, music and guided imagery. Collectively, all of these effective dyspnea-reducing interventions fall within the scope of professional nursing practice.

The message gleaned from Greer and others’ is that targeted nurse-led palliative care interventions may be more effective than comprehensive interventions. Thus, future research designs that are practical to test and implement in clinical settings should be considered. Given the American Association of Colleges of Nursing (AACN) (13) mandates that all nurses learn the principles of palliative care, utilizing nurses to implement specific, evidence-based interventions to improve symptoms, quality of life and support goals of care discussions is ideal.

We commend Greer and colleagues for their thoughtful research design and exciting results. Future research is warranted on approaches to enhance dyspnea-reducing interventions over time, as well as expanding the study to community settings.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine. The article has undergone external peer review.

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-25-11/prf

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-25-11/coif). The author has no conflicts of interest to declare.

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