NURS 519 Week 4 Case Study 1 on Symptom Management at Home Example

Case Study 1: Pain, Breathlessness and an Exhausted Caregiver in Home Hospice for Metastatic Lung Cancer

The Case

A 68-year-old retired postal carrier with metastatic non-small cell lung cancer enrolled in home hospice two weeks ago after stopping chemotherapy. The patient has bone pain in the right hip and lower back rated 7 out of 10, breathlessness when walking to the bathroom, and poor sleep. The spouse of 40 years, the only caregiver, has not slept a full night in a week, is afraid to give the liquid morphine because "the last dose will be the one that kills" the patient, and asked whether they are "giving up too soon."

What Should the Nurse Assess First?

The nurse should assess the patient's symptoms in detail and the caregiver's capacity at the same visit. For pain, that means location, character, intensity, timing, what helps and what has been taken, distinguishing bone pain from nerve pain. For breathlessness, it means the patient's own rating, triggers, oxygen saturation, signs of reversible causes such as pleural effusion, infection or anemia, and the anxiety that often accompanies it (Matzo & Sherman, 2018). Constipation, nausea, delirium and mood should be screened too. The caregiver assessment covers sleep, health, understanding of medications, other supports and fears. In my experience, asking the caregiver to show how they draw up a dose often reveals more than asking whether they understand.

How Should the Pain Be Managed?

The patient needs scheduled, not only as-needed, analgesia. A long-acting opioid, such as extended-release morphine, with liquid immediate-release morphine for breakthrough pain at about 10% to 20% of the total daily dose, follows standard palliative practice, with doses titrated every 24 to 48 hours (Matzo & Sherman, 2018). Because bone pain responds to anti-inflammatory effects, a nonsteroidal drug or dexamethasone may be added if not contraindicated, and the hospice team can ask about a single-fraction palliative radiation treatment to the hip, which often relieves bone metastasis pain. A stimulant laxative with a softener should start with the opioid, since constipation does not improve with time. Heat, positioning with pillows, and a raised toilet seat reduce movement pain.

How Should the Breathlessness Be Managed?

Breathlessness should be treated in layers. Reversible causes come first: a large effusion might be drained, and an infection treated if the patient wishes. Simple measures help at every stage: a handheld fan directed at the face, sitting upright, pacing activity, a bedside commode to avoid the walk, and a calm presence. The ASCO guideline on dyspnea in advanced cancer supports these nonpharmacologic steps and recommends that clinicians offer opioids for breathlessness that remains distressing (Hui et al., 2021). The evidence is not uniform: in a recent trial of low-dose sustained-release morphine for chronic breathlessness among 143 adults, morphine did not reduce worst breathlessness at 28 days and caused more adverse events than placebo (Johnson et al., 2025). That result is a reason to judge each patient's response, not a reason to withhold relief from a dying patient whose breathlessness frightens them. For this patient, the as-needed morphine already prescribed for pain can be used for breathlessness, and its effect on the patient's own rating should be recorded.

How Should the Nurse Respond to the Fear That Morphine Will Hasten Death?

The nurse should acknowledge the fear as loving, then correct the misunderstanding. When opioids are started at low doses and increased gradually to relieve symptoms, they do not shorten life in a way research has shown, and uncontrolled pain and breathlessness themselves exhaust the body. Ethically, the principle of double effect holds that an action intended to relieve suffering is permissible even if a harm is foreseen but not intended, provided the relief is proportionate (Matzo & Sherman, 2018). Practically, the nurse can give the first dose with the spouse watching, explain what to expect, and leave a written log. To the question about giving up, the nurse can respond that choosing comfort is not abandoning the patient; it is changing what the care is for.

How Should the Team Support the Caregiver and the Patient's Spiritual and Cultural Needs?

The caregiver needs relief now. In a review of 21 studies of family caregivers in home palliative care, burden rose with the patient's care needs and disease progression, the caregiver's psychological state and role restrictions, and logistical and financial problems, and the authors called for support that combines medical and psychosocial help (Koh et al., 2026). For this spouse, the plan includes a hospice aide for bathing, a volunteer for two afternoons a week, a short inpatient respite stay if needed, and teaching that builds confidence with each medication. Spiritually, the nurse asks what sustains the couple; if they share a faith, the hospice chaplain or their own pastor can address the question of "giving up," which may carry spiritual weight. Culturally, the nurse asks how the family makes decisions and what a good death would look like to them, rather than assuming, and records the answers so every visiting clinician honors them.

What Should the Plan for the Coming Week Include?

The plan for the next seven days should set measurable comfort goals, a visit schedule and clear instructions for the night hours, when a frightened caregiver is most likely to call 911. A reasonable goal is pain at or below the level the patient calls tolerable, which this patient set at 3 out of 10, and the ability to reach the bathroom or commode without stopping to catch breath. The nurse visits twice in the first week to review the medication log, check bowel function, ask the patient to rate pain and breathlessness, and adjust doses with the hospice physician. The team leaves a comfort kit in the home with written steps for a sudden spike in pain or a frightening episode of breathlessness, and the spouse is told to call the hospice line, not emergency services, at any hour (Matzo & Sherman, 2018). Each visit also asks what the patient wants the coming weeks to hold. If the patient hopes to attend a grandchild's graduation in a month, the team times the radiation referral and the dose adjustments around that goal. The plan is written in plain words, posted on the refrigerator, and reviewed at each visit so that both the patient and the spouse can see progress. Because breathlessness guidelines recommend rechecking a patient's response after every change (Hui et al., 2021), the log includes a column for the patient's own breathlessness score before and an hour after each as-needed dose. Those numbers help the hospice physician decide whether the opioid is helping, and they give the spouse proof that the medicine is doing what it was meant to do.

References

Hui, D., Bohlke, K., Bao, T., Campbell, T. C., Coyne, P. J., Currow, D. C., Gupta, A., Leiser, A. L., Mori, M., Nava, S., Reinke, L. F., Roeland, E. J., Seigel, C., Walsh, D., & Campbell, M. L. (2021). Management of dyspnea in advanced cancer: ASCO guideline. Journal of Clinical Oncology, 39(12), 1389-1411. https://doi.org/10.1200/JCO.20.03465

Johnson, M. J., Williams, B., Keerie, C., Tuck, S., Hart, S., Bajwah, S., Chaudhuri, N., Pearson, M., Cohen, J., Evans, R. A., Currow, D. C., Higginson, I. J., Hall, P., Atter, M., Norrie, J., Fallon, M. T., & MABEL collaborative. (2025). Morphine for chronic breathlessness (MABEL) in the UK: A multi-site, parallel-group, dose titration, double-blind, randomised, placebo-controlled trial. The Lancet Respiratory Medicine, 13(11), 967-977. https://doi.org/10.1016/S2213-2600(25)00205-X

Koh, W. L., Lau, J., Ang, C., Yee, C. M., Ho, S., & Tan, K. K. (2026). Factors associated with caregiver burden among family caregivers of patients on home-based palliative care: A systematic review. Palliative Medicine, 40(6), 757-776. https://doi.org/10.1177/02692163261428948

Matzo, M., & Sherman, D. W. (Eds.). (2018). Palliative care nursing: Quality care to the end of life (5th ed.). Springer Publishing Company.