End of life care is never easy for clinicians who are trained to help people recover from their diseases and conditions. But for many it is unavoidable, and respiratory therapists who treat people suffering from severe respiratory illnesses are among that group.
Three RTs explain what palliative care means to them and how they believe their fellow therapists can help ease the final journey for their patients.
Kristina Dzwonchyk, RRT, CPFT, works as an RT at the Hospital for Special Care in New Britain, CT. It’s a long-term acute care hospital that serves patients with a range of needs, and while some patients do get better and go home to live long and full lives, others are facing the end of their days. To her, palliative care is an essential service for these patients and their families.
“I feel it is so important to be part of the palliative care process, as many patients fear suffocating and difficulty breathing at end of life,” she explained. “Forming a bond of trust with my patients throughout the process helps to ease their fears and let them know that I, or the RT caring for them, will make sure that we make their breathing as easy as possible.”
Dzwonchyk believes RTs who have received the proper training can adjust devices and suggest medications to ease the work of breathing and keep patients as comfortable as possible.
“RTs bring an added level of expertise and comfort to the table for the patients, families, and caregivers and can also ease the burden on physicians who are managing the patients and orders for setting changes,” Dzwonchyk said.
To Cheryl Hoerr, MBA, RRT, who manages respiratory therapy and sleep services at Phelps Health in Rolla, MO, palliative care can be defined as a holistic approach to providing care to people with serious health issues.
“While palliative care can involve administration of pharmaceuticals to ease the physical suffering of disease, it is often by recognizing and managing the psychosocial and spiritual needs of the individual that provides the most comfort,” she said. “The concept behind palliative care is to help individuals with serious impairment related to their health care issues live their best and fullest life throughout the ongoing course of their disease.”
She says it takes a team to deliver that level of care and RTs are an important component.
“Obviously, the RT can provide expert assessment of pulmonary issues and, with the patient’s and family’s input, recommend and/or implement an optimal course of therapies that can provide relief of breathlessness and optimize secretion clearance,” Hoerr said.
RTs can help ensure patients and families are aware that palliative care services are available to them in the first place as well and explain what the various options entail.
“RTs should also participate in the development of policies within their organizations to address their patients’ palliative care needs,” Hoerr said.
Of course, hospitals first must embrace the concept of palliative care. RTs can be an advocate for the service in cases where it is not in place. Mary Ann Couture, MSc, RRT, RRT-ACCS, RRT-NPS, who spent 40 years in RT clinical and educational roles before retiring last year, believes personal experiences can help drive an RT’s motivation to help.
That was certainly the case for her.
“My aunt was one person who I needed to be an advocate for,” she said. “At age 97 and mentally intact, she went into heart failure and found herself hospitalized. She hated the medication side effects, which left her nauseous and down to 80 pounds. She begged me to speak on her behalf.”
Couture did just that, but the hospital did not respond. A few days after her aunt was transferred to rehab, staff told Couture that she was refusing her medications.
“This is where I asked again for a hospice consult and finally got it through persistence,” she said.
The whole experience moved her to include more material on palliative care in her RT educational curriculum. She particularly zeroed in on terminal extubations and the role her students might one day be asked to play in that process.
“It starts with taking the time to explain how to create a personal ethical decision in order to do a task that we may not like,” she explained. “We have to change our actions from a ‘rule of rescue’ to one of support in helping a life to exit by doing ‘no further harm.’”
She recalls one student situation where it all played out in the hospital. The student was in her first days of a ventilator clinical class when she got an order to terminally extubate.
Another teacher might have decided to spare the student this duty and take over the task, but Couture knew she would not be helping her student prepare for future incidents like this if she just did it for her.
“We did a quick briefing with the nurse on how we would do this as a team,” she said. Then they all went into the room together and she explained what would be happening to the family. The patient’s son addressed the student and told her she was doing the right thing and the family was grateful for her actions. That helped to ease the student’s conflicted feelings and she was able to proceed with the extubation.
“He also struck up a conversation and asked what RT students do, so she could not just leave the room after completion of the task,” Couture said. “It turns out that the son was the chancellor of her college,” she continued. “He recognized her uniform.”
It was an experience neither teacher nor student nor family member would ever forget.
“It is not often that family shows appreciation for us and what we do,” Couture said. “Through that experience they both forged a friendship through the duration of her student life.”
Kristina Dzwonchyk believes palliative care is best when patients and families feel in control of the situation. She like to tell her patients that they can start the process, and if they don’t like it, they can cancel it.
“I find that most patients and families are relieved once they start palliative care and are thankful for the care they receive,” she said. “I do feel that this helps to aid in the transition to hospice level when the time is appropriate.”
Cheryl Hoerr agrees.
“Effective palliative care requires the patient and family to be involved in determining the goals of care,” she said. “By communicating openly with the patient about the anticipated course of their disease, the patient is empowered to determine how much, what kind, and when to provide care. It gives them a sense of control in a situation that can seem completely out of their control.”
Mary Ann Couture says RTs need to be open to discussing palliative care with patients, recognizing that in some cases they may have already broached the topic with their family members and been met with resistance.
“It is important that when a patient wants to talk about dying or if they are telling you that they don’t want to continue with their treatments, they are seeking help,” she said. “It may mean their family, or their supports are unwilling to listen.”
If you ever find yourself in that position, she suggests you document the conversation in the patient’s medical record and bring it to the attention of your boss or the patient’s physician. In some hospitals, the electronic medical record will even allow the RT to enter in an order for a consult.
It’s the best way to advocate for your patient who may not have another willing ear to listen to his concerns.
Join the AARC’s Palliative Care Forum to network with members who are interested in this area of care.