This series takes a detailed look at the domains of the Decision Support Tool (‘DST’). This week we examine the first three descriptors in the Breathing domain and help you to assess your or your relative’s “level of need” in this important domain.
Breathing is one of only three domains in the DST that includes all six levels of need: ‘No Needs’, ‘Low’, ‘Moderate’, ‘High’, ‘Severe’ and ‘Priority’ (the other domains are Behaviour and Medications). This week we will look at the first three of those domains, which are by far the most common.
NOTE – The bar in this domain is set very high: even those with a diagnosed respiratory condition, who require the use of inhalers, or even oxygen, are often surprised to discover that they “only” present with a ‘Low’ or ‘Moderate’ level of need in the Breathing domain.
In the 2012 version of the DST, the Breathing domain was near the end of the assessment, at domain number 9. The 2018 revisions reordered the domains of the DST, with Breathing coming first. Its new proximity to the Nutrition domain (number 2) is important, as individuals who have swallowing difficulties are at higher risk of suffering aspiration (inhalation of food or fluid particles into the lungs), which may cause infection and breathing difficulties. For those with existing breathing problems due to an underlying condition, aspiration is likely to cause increased exacerbations and complexity.
IMPORTANT – In this domain, and several others in the DST, the term “daily living activities” is crucial. Whether or not symptoms of breathlessness are impacting on these activities, and to what degree, is a deciding factor in assessing the level of need. Therefore, it’s really important to understand that when the NHS refers to “daily living activities” in this domain, it usually means the following:
- Moving around (including manual handling, e.g., repositioning)
- Going to the toilet
The following clinical factors are relevant to the assessment of NO, LOW or MODERATE level needs in this domain:
- No problems with breathing.
- Mild-moderate shortness of breath (SOB), breathlessness or difficulty in breathing (DIB).
- Is this due to a chronic (long term) or acute (short term) condition?
- Consider diagnosis of heart/circulatory problems, COPD, COAD, asthma, bronchitis, pneumonia, or any other condition that might impact on breathing.
- Medication prescribed and route of delivery: steroids, inhalers, nebulisers.
- Is the prescribed treatment effective, i.e., does it relieve symptoms of breathlessness?
- Is medication prescribed routinely (at the same time each day) or as-required (PRN)?
- Can the person communicate symptoms of breathlessness, or does this require anticipation?
- Does shortness of breath occur on exertion and/or at rest?
- Does shortness of breath impact on other domains, e.g., Mobility, Nutrition, Medication, Communication? (“Daily living activities”)
- Is there a risk of aspiration? Is the Speech & Language team involved?
- Can the person cough and expectorate secretions effectively?
- Does the person suffer respiratory tract infections? Are these recurrent? Do they respond to prescribed antibiotics?
- Does the person suffer from anxiety and/or panic attacks, which impact their breathing?
NOTE – A respiratory tract infection will usually only impact the level of need in this domain if it results in shortness of breath and/or an exacerbation of an underlying condition (e.g. COPD). A person who suffers a chest infection, or even recurrent infections, but does not experience any shortness of breath, will be usually assessed as having ‘No Needs’. In our experience, some Independent Review Panels (IRP) will assess a ‘Low’ level of need due to respiratory tract infections, but there is no hard-and-fast rule.
If your relative is due to be assessed for CHC, make sure you’re fully prepared using our helpful guides:
Now that we’ve outlined the type of things the MDT will be considering in this domain, let’s take a look at the descriptors for the levels of need. For each descriptor, we provide a case study to give you a better understanding of how the levels of need might be applied at your relative’s assessment.
|Normal breathing, no issues with shortness of breath.|
No evidence of breathlessness
Does not require the use of any inhalants to aid breathing
CASE STUDY 1 – NO NEEDS
Mrs. X is not diagnosed with any long-standing respiratory or cardiac condition which would give rise to any breathlessness symptoms.
She is not noted to suffer with any breathing difficulties. She has a history of respiratory tract infections, but none has been noted in the past 6 months. Her chest sounded crackly on the day of assessment, but Mrs. X did not appear short of breath.
Mrs. X presents with NO NEEDS as she has normal breathing and no issues with shortness of breath.
IMPORTANT – Note that Mrs. X is assessed as having ‘No Needs’, despite having a history of chest infections and sounding “crackly” at the assessment. A diagnosis of respiratory tract infections and/or symptoms of chestiness or coughing may not necessarily indicate difficulty in breathing, for the purposes of the DST. If the person recovers following a course of antibiotic treatment, does not suffer shortness of breath and does not require the use of an inhaler, it is unlikely this will impact their assessed level of need in this domain.
CASE STUDY 2 – NO NEEDS
Mr. X has a history of Tuberculosis and it was reported by family that he suffered with variable breathlessness which required him to stop and rest whilst mobilising.
Prior to admission to the care home, Mr. X was mobile with assistance. However, since Mr. X was discharged from hospital, he is no longer able to mobilise and is nursed permanently in bed for his own comfort. There is no evidence to suggest Mr. X suffers with breathlessness during any intervention and thus a level of ‘No Needs’ would be appropriate.
Mr X presents with NO NEEDS as he has normal breathing and no issues with shortness of breath.
IMPORTANT – Mr. X does suffer some shortness of breath when moving around due to a history of Tuberculosis. If the DST had been completed while he lived at home, Mr. X would have been assessed as having a ‘Low’ level of need in this domain. However, since a recent admission to hospital, Mr. X has been unable to mobilise and is nursed permanently in bed. Consequently, he no longer experiences breathlessness and presents with ‘No Needs’ in this domain. This is a good example of how a deterioration in the person’s physical health may sometimes lead to a reduction in their assessed level of need on the DST.
|Shortness of breath or a condition which may require the use of inhalers or a nebuliser and has no impact on daily living activities.
Episodes of breathlessness that readily respond to management and have no impact on daily living activities.
Some episodes of breathlessness, responsive to rest/medication
May require the use of and inhaler and/or nebuliser
Daily living activities not affected
CASE STUDY 1 – LOW
Mr. X has a diagnosis of COPD; he takes both a nasal spray (Flixonase 0.005%) and inhalers (Fostair, Ventolin, Titropium) throughout a 24-hour period. At this present time, he self-administers the inhalers when indicated by senior care staff at appropriate times.
His condition would appear to be well-managed and he does not present with breathlessness at rest. On occasion, Mr. X would become breathless when mobilising longer distances; however, he now uses a wheelchair which has reduced these symptoms.
Mr. X presents with a LOW level of need as he suffers shortness of breath and a condition (COPD) which may require the use of inhalers or a nebuliser and has no impact on daily living activities.
NOTE – Mr. X uses a wheelchair for longer distances. Were he fully ambulant, this might have the effect of increasing his level of need to MODERATE, as he would present with more frequent or severe bouts of breathlessness and his “daily living activities” would be affected.
CASE STUDY 2 – LOW
Mrs. X has no history of breathing problems or shortness of breath. However, she can be observed panting at times; this is related to feelings of anxiety. Mrs. X is encouraged to take slow breaths and is able to settle soon after. Staff monitor her breathing pattern daily and encourage her to sit and relax when she becomes restless or anxious, which appears to be effective.
Mrs. X presents with a LOW level of need as she suffers episodes of breathlessness that readily respond to management and have no impact on daily living activities.
|Shortness of breath or a condition which may require the use of inhalers or a nebuliser and limit some daily living activities.
Episodes of breathlessness that do not consistently respond to management and limit some daily living activities.
Requires any of the following:
low level oxygen therapy (24%).
room air ventilators via a facial or nasal mask.
other therapeutic appliances to maintain airflow where individual can still spontaneously breathe e.g. CPAP (Continuous Positive Airways Pressure) to manage obstructive apnoea during sleep.
Some episodes of breathlessness, usually, but not always, responsive to rest/medication
May require the use of an inhaler and/or nebuliser and/or oxygen via cannula
Some daily living activities affected (e.g., mobilising)
Low-level oxygen or ventilation to maintain airflow, but can always breathe spontaneously
CASE STUDY 1 – MODERATE
Mr. X is wheezy and breathless when exerting himself, for example when he tries to propel himself in his wheelchair. Due to advanced dementia, he needs encouragement to rest and full assistance to use his inhaler. He is not usually breathless at rest but is sometimes observed to be slightly breathless when eating. He needs 1:1 supervision at mealtimes and prompts to take his time.
Mr. X requires Salbutamol inhaler PRN, which staff need to administer for him. He is largely unable to express his needs, even if he is having problems with his breathing.
He has chest infections in the winter months, which impact on his breathing. Antibiotics are prescribed by the GP, usually with good effect.
Mr. X experiences excess saliva in his mouth and has a diagnosis of dysphagia (difficulty swallowing). His fluids are thickened. He experienced a recent aspiration pneumonia, requiring hospital admission and antibiotic therapy.
Mr. X was observed to have noisy breathing today and was experiencing profuse salivation.
Mr. X presents with a MODERATE level of need as he experiences shortness of breath or a condition which may require the use of inhalers or a nebuliser and limit some daily living activities.
NOTE – Mr. X “only” presents with a ‘Moderate’ level of need. However, there is considerable interaction (complexity) between his needs in the domains of Breathing and Nutrition, due to excess saliva and swallowing difficulties which give rise to a high risk of aspiration. Mr. X has already suffered an aspiration pneumonia and is vulnerable to further infection, which would lead to exacerbations of breathlessness and possible complications. He also suffers from dementia and is unable to communicate his needs, meaning he is reliant on staff to monitor his symptoms and administer his inhaler as required. These factors should be carefully considered in the analysis of the four Key Characteristics. This is a good example of why the assessed level of need does not always have to be ‘High’ (or ‘Severe’ or ‘Priority’) to have a considerable impact on the overall assessment, and why the Key Characteristics really are the key to understanding the eligibility criteria.
CASE STUDY 2 – MODERATE
Mrs. X has a history of bilateral pulmonary embolism and takes anticoagulant therapy daily to prevent further emboli. This has impacted on her breathing.
Mrs X is short of breath on exertion and occasionally at rest. Her lips and fingers can often be blue and her average blood saturations are 95% on room air. When she is feeling breathless, she needs staff to help her to sit upright and provide reassurance.
Community matron and carers report they have witnessed the shortness of breath, especially when moving and eating.
Mrs X presents with a MODERATE level of need as she suffers episodes of breathlessness that do not consistently respond to management and limit some daily living activities.
CASE STUDY 3 – MODERATE
Mr. X has a diagnosis of obstructive and central sleep apnoea and has used a CPAP (Continuous Positive Airways Pressure) machine overnight for several years.
He needs staff to fit the mask securely when he goes to bed and ensure the CPAP machine is working correctly. He needs staff to check on him and the machine at regular intervals throughout the night to ensure the mask remains in place. The staff report no problems or concerns with the CPAP machine since admission (6 months).
Mr. X is slightly breathless on exertion; however, there are no nebulisers or inhalers prescribed.
Mr. X presents with a MODERATE level of need as he requires a therapeutic appliance to maintain airflow where he can still spontaneously breathe e.g., CPAP (Continuous Positive Airways Pressure) to manage obstructive apnoea during sleep.
We hope this has helped you to understand the first three levels of need in the Breathing domain. Don’t miss part 2, coming very soon!
If you need help assessing your relative’s level of need in any domain on the DST, don’t hesitate to contact one of our specialist Advice Lines to discuss your case today. If you need expert advocacy support with any stage of your assessment or appeal, visit our 1-2-1 Support page.
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