Palliation

Environmental Measures

Fan

Palliation to achieve maximal patient comfort is the main goal.
Simple things such as positioning in bed, opening the window, instituting oxygen therapy, and reassurance are often very helpful.
Look for simple, easily correctable problems such as oxygen on/off, kinked oxygen tubing or other cause.
Cool air flowing from a fan directed at the face have provided some benefit (Bredin 1999).

Psycho-Social Interventions

  Assess and treat for underlying anxiety and depressive disorders.
Consider supportive counseling.
Reassurance and provision of psycho-social support by providers and patient’s family are often helpful.
Non-pharmacological approaches such as cognitive behavior therapy, relaxation therapy, art therapy, massage therapy, guided imagery may be of benefit.
Consider care-giver support as care-giver stress affects the patient and also influences the patient’s site of death (increased emergency room visits and increased hospitalizations).

Rehabilitative Measures

  Pulmonary rehabilitation should be considered in consenting patients who have a life expectancy of months to years. Breathing exercises if the patient is capable if the patient is able to cooperate (Bredin 1999).
Rehabilitative measures may not be a feasible option in terminally ill patients with a life expectancy of days to weeks. Such patients should be encouraged to use a wheelchair and to rest.
Patients who have not stopped smoking should not be pressured to stop at this time (as smoking may be one of the few remaining pleasures that the patient experiences in the last few days of their lives).

Pharmacotherapy to alleviate dyspnea

Treatment of underlying cause

Pill

Nebulizer

Problem

Drug intervention

Broncho-constriction Albuterol and ipratropium bromide inhalers and nebulizers
Fluid overload Diuretics
Cough Anti-tussives and opioids (opioids help alleviate pain, dyspnea and cough)
Dyspnea secondary to end stage COPD with acute exacerbations Steroids
Dyspnea secondary to Superior Vena Cava Obstruction Steroids
Dyspnea secondary to lymphangitic carcinomatosis. Steroids
CHF therapy optimization Diuretics and afterload reduction
Anxiety and depression Anxiolytics for patients who are anxious despite optimal management of dyspnea.
Selective Serotonin Reuptake Inhibitors (SSRIs)
Anxiety and depression with panic attacks Selective Serotonin Reuptake Inhibitors (SSRIs) in conjunction with benzodiazepines
Pneumonia or other infectious processes when intended for relieving dyspnea Antibiotics
Terminal pneumonia Note: Antibiotics are often not helpful in actively dying patients, many of who may have “terminal pneumonia” in the last two or three days of life. These patients should be managed symptomatically with supplemental oxygen via nasal cannula, opioids to relieve dyspnea, anxiolytics for any anxiety and drugs like atropine, scopolamine and glycopyrrolate to decrease secretion (please see module on “last 48 hours”)

Symptom palliation

IV

Problem

Drug intervention

Dyspnea not responding to other interventions Opioids (oral and parenteral) are the drugs of choice for palliation.
Palliation of dyspnea with opioids is often achieved with lower doses of opioids than are usually required for palliation of pain. Start low and go slow, in opioid naive patients (Abernethy 2003).
Higher doses will be needed for patients on chronic opioids (50% > baseline).
Parenteral opioids (8) may be indicated for patients in acute dyspnea (e.g. morphine 0.5 to 1 mg IV or SC Q 10-20min until relief or consider low dose continuous infusion).
There is some anecdotal evidence that nebulized opioids, especially inhalational fentanyl may be beneficial in acutely dyspneic patients (Chandler 1999) (Tanaka 1999) (Sarhill 2000) (Coyne 2002).
Anecdotal evidence has shown that nebulized furosemide may be helpful (Shimoyama 2002).
Nicotine craving Nicotine patches should be considered for smokers who are dying and too weak to smoke, but may still have the craving induced by nicotine addiction. The intent of the nicotine patch in these cases is palliation and not smoking cessation.
A clonidine patch is also helpful in these situations as it decreases the craving for nicotine while also serving as an adjuvant analgesic.
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