Fast Fact and Concept #027: Dyspnea at End-of-Life

2nd Edition

Author(s): Weissman, D.E.

Dyspnea is defined as a subjective sensation of difficulty breathing. This Fast Fact reviews key elements in the assessment and treatment of dyspnea near the end-of-life.

Etiology the causes of dyspnea include a wide spectrum of serious lung or heart conditions, anemia, anxiety, chest wall pathology, electrolyte disturbances or even urinary retention or constipation.

Assessment Looking for simple problems is always warranted: is the Oxygen turned on?, is the tubing kinked?, is there fluid overload from IV fluids or TPN?, is dyspnea part of an acute anxiety episode, severe pain, constipation or urinary retention?; is there a new pneumothorax or worsening pleural effusion?. Understanding 1) where patients are at in the dying trajectory and 2) their identified goals of care, is essential to guide the extent of workup to discover reversible causes. If the patient is clearly dying (see Fast Fact #1), and the goals of care are comfort, then pulse oximetry, blood gas, EKG, CXR are not indicated.

Treatment—General Measures Positioning (sitting up), increasing air movement via a fan or open window, and use of bedside relaxation techniques are all helpful. In the imminently dying patient, discontinuing parenteral fluids is appropriate.

Treatment w/ Opioids Opioids are the drugs of choice for dyspnea. In the opioid naïve patient, low doses of oral (10-15 mg) or parenteral morphine (2-5 mg), will provide relief for most patients; higher doses will be needed for patients on chronic opioids. When dyspnea is acute and severe, parenteral is the route of choice: 2-5 mg IV every 5-10 minutes until relief. In the inpatient setting, a continuous opioid infusion, with a PCA dose that patients, nurses or families can administer, will provide the timeliest relief (see Fast Fact #28, 54). Nebulized morphine has been reported to provide benefit in uncontrolled case reports. Controlled trials have not demonstrated any benefit compared to placebo, confirming the low bioavailability of nebulized opioids

Treatment w/ Oxygen Oxygen is often, but not universally, helpful. When in doubt, a therapeutic trial, based on symptom relief, not pulse oximetry, is indicated. Patients generally prefer nasal cannula administration than a mask, especially in setting of imminent death when agitation from the mask is commonly seen. There is little reason to go beyond 4-6 L/min of oxygen via nasal cannula in the actively dying patient. Request a face-tent for patients who are claustrophobic from a mask.

Treatment w/ other drugs Anti-tussives can help with cough, anit-cholinergics (e.g. Scopolamine) will help reduce secretions, anxiolytics (e.g. lorazepam) can reduce the anxiety component of dyspnea. Other agents that may have specific disease modifying effects include diuretics, bronchodilators and corticosteroids.

Family/Team Discussions While there is no evidence that proper symptom management for terminal dyspnea hastens death, the course and management of terminal dyspnea, especially when opioids are used, should be fully discussed with family members, nurses and others participating in care to avoid confusion about symptom relief vs. fears of euthanasia or assisted suicide (see Fast Fact #8).

References

Bruera E, Sweeny C and Ripamonti C. Dyspnea in patients with advanced cancer. In: Principles and Practice of Palliative Care and Supportive Oncology. 2 nd Ed Berger A, Portenoy R and Weissman DE (eds). Lippincott-Raven, 2002.

Chan KS et al. Palliative Medicine in malignant respiratory diseases. In Oxford Textbook of Palliative Medicine 3 rd Ed. Doyle D, Hanks G, Cherney N and Calman N. Oxford, 2005

Fohr SA. The double effect of pain medication: separating myth from reality. J Pall Med 1998; 1:315-328.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman DE . Dyspnea at End-of-Life. Fast Fact and Concept #27; 2nd Edition, July 2005. End-of-Life / Palliative Education Resource Center @ www.eperc.mcw.edu .

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 11/2000; Second Edition July 2005

Purpose: Instructional Aid, Self-Study Guide

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Non pain symptoms & syndromes