Dyspnea: A Symptom of Disease or of Psychological Distress?

I made a visit to a patient yesterday who was complaining of shortness of breath, or dyspnea. She's living in a board and care facility, which acts like an assisted living of sorts. Board and cares are usually set up in a home setting with a few patients (or residents) and one or two staff members to attend to their needs and administer medications. She also has a hired caregiver who visits her for a few hours a day and provides extra care. This patient, we'll call her Sue (not her real name to preserve anonymity), can no longer do anything for herself. She has congestive heart failure and a generalized rapid decline. I had just admitted her to hospice 4 days prior to this event and she has made a drastic change for the worse.

Sue was on oxygen and had been getting oral morphine solution every two hours to help with her dyspnea. I knew that her congestive heart failure could be causing her dyspnea but I wanted to explore every possible option.

I was able to sit down with Sue and discuss how she was feeling. I asked her what she thought was happening to her and she told me she knew she was getting ready to go to heaven. I asked her if she was afraid of dying and she told me she was absolutely not afraid and that her mom and aunt would be waiting in heaven to greet her. I asked her if she was afraid of anything else. This is when she started to moan and her breathing became more rapid. I touched her soothingly and encouraged her to share with me what was troubling her. She told me she felt awful and with further prodding, she revealed to me that she was terrified of being alone. She was nearly in tears at this point and gasping for air.

Her caregiver said she would like to stay all night. I called the patients son and recieved his authorization for the caregiver to stay with Sue. I then told Sue that her caregiver would stay through the night and asked if that would make her feel better. I was amazed to see Sue instantly settle down. She said "Oh, yes. That's wonderful!", and although she was still breathing faster than normal, she was no longer gasping for air or moaning. This made me wonder how much of her dyspnea was related to her illness and declining health status versus her fear of being alone. On a side note, Sue told me she would die on her birthday, which is about two weeks from now. I'll be curious to see if that happens! What are your thoughts about her dyspnea and her revelation of her death date?

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