Read the notes and greet the patient/family by name. It is very distressing for patients if the clinician appears to have no knowledge of the patient or even makes basic mistakes, e.g. in diagnosis. This does not preclude you from making your own assessment of key issues.
Questions to establish history of breathlessness
Are you troubled by breathlessness?
What makes you breathless?
What helps your breathlessness?
What have you stopped/reduced doing to prevent you getting breathless?
Are you breathless when you are sitting completely still?
What happens when you feel breathless? (e.g. How does it come on? How do you try to improve it? How long before you feel better? What makes it better/worse? Are you taking any medications to help it?)
(Ask carer) What do you notice when patient X becomes breathless?
How do you feel when you become breathless? Some people say being breathless makes them feel very anxious, some people even use the word panicky. Does that sound familiar? Have you always been troubled by anxiety?
What do you think is causing your breathlessness? (Ask the carer the same question)
Do you have times when a worsening of breathlessness does not settle as usual, or when it seems to come out of the blue/from nowhere? (Start asking about feelings/emotions/thoughts about breathlessness, which may be triggering breathlessness without the patient being aware of what is preceding it) [40]
Was there a particular episode after which your breathlessness seemed to get much worse? (It is not uncommon for there to be an episode of breathlessness that is particularly frightening or associated with panic, after which breathlessness seems to get much worse generally, i.e. a “trigger” episode. Unpicking this, e.g. with the BTF model, may help bring about improvement.)
What do you when this kind of crisis happens? And your wife/husband/carer/partner or other carer? (Gives a basis for education and “ritual for crises”) [18, 41]
Have you attended pulmonary rehabilitation? If yes: how you did/felt about it/changes made afterwards. If not: why was this? e.g. lack of confidence, not referred, not available, etc. and rectify or consider specialist palliative care, advanced lung clinic, etc.
What is the worst thing for you at the moment? (Ask carer too. Note: this may not be breathlessness, may be cough, fatigue or other concern. Ask about cough and fatigue using similar questions. See text and other boxes.)
Summarise and plan
Summarise what you have learned, for the patient to check.
Lead onto management plans, for example:
This is a very difficult symptom and sounds as if it is making life very hard for you. There has been a lot of research in this area in recent years and now we do have ways we can help.
It does take a bit of time and work and different skills from different members of the team working together.
I would like you to meet…