Fast Fact and Concept #27: Dyspnea at End-of-Life

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Title: Fast Fact and Concept #27: Dyspnea at End-of-Life

Author(s): Weissman, D.E.

Few problems cause as much distress for patients, families and the care team, as the management of dyspnea at end-of-life.

Assessment Dyspnea at end-of-life may be present during the Syndrome of Imminent Death (Fast Fact #3) or occur earlier in the disease trajectory. 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 seeking reversible causes. If the patient is clearly dying, and the goals of care are comfort, then pulse oximetry, blood gas, EKG, CXR, etc. 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; decrease or discontinue use of IV fluids.

Treatment w/ Opioids is the drug 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 (50% over baseline). 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. Nebulized morphine can be used, but its relative benefit compared to po/IV in controlled trials has not be proven.

Treatment w/Oxygen Nasal cannula is better tolerated than a mask, especially in the terminal setting; Oxygen is not always helpful; a therapeutic trial, based on symptom relief, not pulse oximetry, is indicated. 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, anti-cholinergics (e.g. Scopolamine) will help reduce secretions and anxiolytics (e.g. lorazepam) can reduce the anxiety component of dyspnea.

Family/Team Discussions While there is no good evidence that proper symptom management for terminal dyspnea significantly 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: Morphine and Hastened Death).

References: Bruera E and Ripamonti C. Dyspnea in patients with advanced cancer. In: Principles and Practice of Supportive Oncology. Berger A, Portenoy R and Weissman DE (eds). Lippincott-Raven, 1998.

Bruera E, Stoutz N, Velasco-Levla A, et al. Effects of oxygen on dyspnea in hypoxamic terminal cancer patients. Lancet 1993;342:13-14.

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

Chandler S. Nebulized opioids to treat dyspnea. Am J Hosp Pall Care 1999; 16: 418-422.

Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339-340.

Copyright Notice: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman DE. Fast Facts and Concepts #27: Terminal Dyspnea, November, 2000. End-of-Life Physician 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

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide

Training: Fellows, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care
Non-Physician: Nurses

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Cardio-pulmonary diseases, Family conference, Hydration, Interventional procedures, Negotiating treatment goals, Oral/communication, Pain treatment

The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).