Pearls

Dyspnea is a very common symptom in patients with advance illness.
There is poor correlation between oxygen saturation and the perception of dyspnea.
Identify reversible causes and treat as appropriate.
Interventions should be kept in line with goals of care with dyspnea relief as one of the therapeutic goals. Benefits and burdens must be carefully considered.
Non-pharmacologic approaches are often useful, readily applicable, and inexpensive.
Morphine is the mainstay of treatment for dyspnea in terminally ill patients.
Opioid titration requires repeated assessments to achieve maximal benefits and to avoid side effects.
The best indicator of moderate opioid toxicity is bradycardia.
Respiratory depression rarely occurs when opioids are titrated upward in a step-wise fashion.
Document justification for any dosage increase of opioids.
Any change in intensity or quality of dyspnea merits a review of therapy and possible adjustment of opioids.

Palliative Care