Specific Situations

Dealing with Specific Situations

Superior Vena Cava Syndrome Radiation therapy is definitive treatment for patients with life expectancy greater than four weeks; otherwise, palliative treatment with morphine and steroids is more appropriate.
Lymphangitic Spread Characterized by cough and dyspnea. Treatment consists of controlling cough and giving morphine and steroids for treatment of dyspnea.
TE Fistula Usually poor surgical candidate due to advanced stages of cancer. Endoprostheses (stent) placement may allow for palliation and occlusion of TE fistula, permitting oral intake.
ALS BiPAP and full time ventilator support required. When co-morbid medical complications develop, or patient determined quality of life deteriorates, ventilator support can be withdrawn and symptom control provided to allow for a comfortable death.
Hemoptysis Treatment of cough may resolve precipitating factor of hemoptysis. Massive hemoptysis requires urgent and aggressive comfort measures, including:

  • parenteral opioids,
  • benzodiazepines such as midazolam or lorazepam for sedation, and
  • covering all signs of blood with dark towels to decrease the patient’s and family’s fear and anxiety.
Pleural and Pericardial Effusions Whenever appropriate, symptom relief with thoracentesis or pericardiocentesis should be attempted.
Dyspnea with normal oxygen saturation Patients can experience dyspnea even with normal oxygen saturation (SaO2).

Room Air Concentrator While oxygen supplementation is most beneficial for patients with decreased oxygen saturation (SaO2), many terminally ill dyspneic patients may benefit by the use of air concentrators (Medicare oxygen ruleshave specific requirements for prescription oxygen supplementation. However the Medicare Hospice Benefit will pay for a room air concentrator for all terminally ill patients).
Respiratory Infections Respiratory infections can be diagnosed clinically and managed empirically with antibiotics with the intention of augmenting comfort in terminally ill patients. Imaging may not be a feasible option in terminally ill patients who may be too frail to endure the hospital and clinic visits required for these procedures.
Terminal secretions / Death rattle Antibiotics are neither indicated nor helpful terminal secretions or death rattle.
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