1. The Continuum of Pulmonary Rehab and Palliative Care in Advanced Lung Disease: An Interprofessional Approach
DorAnne Donesky, PhD, ANP-BC, ACHPN Chaplain Judy Long, MS, MA
Pulmonary Quality of Life Clinic

2. Goals for today’s session
Explore the overlap between palliative care and pulmonary rehabilitation
Discuss the unique roles of the expanded interprofessional team
Review resources appropriate for palliative care in pulmonary patients

3. QUESTION: Do you know your closest pulmonary rehabilitation staff members? OR Do you have experience in collaborating with pulmonary rehabilitation in the care of your palliative care patients?

4. Why Pulmonary Rehab? Reverse the cycle of deconditioning
Weak, out of shape muscles require more oxygen
Toned and strong muscles use less oxygen
Exercise helps decrease the demand on the lung by toning muscles

5. Aspects of Care
Pulm Rehab PC
Holistic approach ++
+++
Interdisciplinary approach
Patient centered
Based on patient preferences +
Family Support
Focus on Disease modification
Principles applicable throughout disease
Focuses on Symptom Mgt and QOL
Focuses on Maximizing Functional Status
Promotes Self Management Strategies
Psychological support
Bereavement counseling
Formal exercise training
Promotes advance directives
Spiritual Dimension
Retiker, CRD 2012

6. Question: When caring for patients with pulmonary disease, what interprofessional team members could be helpful in addition to the 4 core disciplines of PC?

7. Interprofessional TeamRN MD
Pharmacist
Respiratory Therapist
Physical Therapist
Occupational Therapist
Speech Therapist
Interpreter
Administrator
Chaplain
Social Service
Nutrition
Psychologist
Patient
Caregiver
Dental Hygienist
CNA/MA/HHA

8. Question: What self-care strategies do you see patients using to manage their shortness of breath?

12. Symptom Management: Dyspnea
Oxygen
Opioids
Benzodiazepines (not 1st line)
Nebulizer
Fan
Pulmonary Rehabilitation
Breathlessness Intervention
Acupuncture/acupressure
Exercise/Yoga/Tai Chi
Education
Posture
Pursed lip breathing
Spinal movement
Abdominal breathing
Pacing
Relaxation/MBSR
Biofeedback
Cognitive Behavior Therapy
Music
Chest wall vibration
Non-invasive ventilation
Cochrane, 2008,
Chest 2010, Marciniuk 2011

13. Additional Symptom Mgmt Strategies
Somatic Grounding
Focus attention on present moment
Name Emotions
Distance and choice to regulate the emotion
Resourcing
Engage parasympathetic nervous system
Clinician’s Touch
Many people are hungry for touch
Be sensitive to asking permission
Advanced breathing strategies
Counteract “freeze” response

14. Somatic Grounding
A. Shift attention to sensation of the support of the chair beneath your body B. Gently shift your attention to the soles of your feet Press the toes toward the floor; Notice the support of the floor beneath the toes; Shift the attention to the outsides of the feet and press them harder into the floor Notice the support of the floor beneath the outsides of the feet Repeat with the insides, the heels, and the soles of the feet Sustain attention for a few seconds C. Shift attention back to the sensation of the support of the chair
Adapted from “Somatic Experiencing” (Peter Levine)

15. Name Emotions
Notice when you are starting to feel strong emotion Silently name the emotion in a kind or neutral voice For example, “Oh, this is anger” Scan your body to notice if there is a place where you hold the feeling Direct your attention to that part of the body or around it Silently repeat the word “soften” while directing your attention to that area Allow the feeling to be there until it dissolves
Adapted from “Mindful Self-Compassion” (Kristin Neff & Christopher Germer)

16. Resourcing Recall an experience that you enjoyed
Intensify the memory in each sense
Use that memory when beginning to notice stress
Allow this memory to become a felt experience, not just a thought
Adapted from “Somatic Experiencing” (Peter Levine)

17. Clinician’s Touch
Ask for permission to hug Take your time during physical assessment Be aware that it matters
John Cacioppo, Loneliness: Human Nature and the Need for Social Connection

18. Advanced Breathing Strategies
Variations on pursed lip breathing
Pressure
Position of mouth
Practice
Pace and rhythm
Spinal movement up with inhale; bending forward with exhale
Notice lower ribcage for expansion on inhalation
Allow “whooshing” sound with exhalation
Inhale through nose; exhale through pursed lips
“Sniff the rose, cool the soup”

19. Question: What published, online or support resources do you recommend for your patients with lung disease?
1-800-LUNGUSA
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20. Resources for pulmonary patients

23. Take Home Points:
1. Pulmonary rehab is a resource for symptomatic patients with lung disease
2. Use the extended interprofessional team
3. Let patients teach you what works best for them (and then reflect it back to them)
4. Many resources available to support patients with chronic lung disease

24. Thank you