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There can be a reflex to ‘do nothing’ for palliative patients at the end of life, but making them comfortable in the dying hours takes intent. We don’t resuscitate these patients in the same way as say, a healthy 20 year old, but they deserve acute management. It's just different in technique and goals.
Dyspnea in the Palliative Care Patient
Justin Morgenstern MD
Take Home Points
▪ Patients with respiratory failure and do not resuscitate status still need aggressive, palliative resuscitation.
▪ Palliative resuscitation is focused on the rapid identification and treatment of symptoms.
▪ Positioning, silencing monitors and alarms, fans directed at the face and occasionally oxygen may increase patient comfort.
▪ Noninvasive positive pressure ventilation may be offered for patient comfort. If it makes them uncomfortable, stop it.
● A 63 year old woman is arriving via EMS with a complaint of severe shortness of breath. She has accessory muscle use and low oxygen saturation. When EMS arrives, they advise the patient is palliative.
● What does palliative mean? Does it make the patient any less sick? Does the DNR relieve their dyspnea? These patients are sick and they still need full-blown, aggressive palliative resuscitation.
● In an ideal world, palliative patients would not be treated in the emergency department. However, this is where the sickest patients end up. We need to be experts. We need to be comfortable with concept of palliative resuscitation. What do you do?
● Step 1. Triage. Palliative patients are often put in a quiet room at the back of the department. This is nice because it is private. However, this is not the right spot. It is too easy to ignore the patient and fail to reassess the patient. A patient who arrives critically ill still needs resuscitation, even if they are palliative.
o For the first hour, the patient will need rapid titration of therapy. These patients deserve 1:1 nursing ratios. Put these patients in a resuscitation room to get things started.
o Be clear why these patients are being placed in a resuscitation room. They are not there for the monitors or procedures. They are there for 1:1 nursing.
● Step 2. Call for help early. Get in touch with social work, a chaplain or, if you are lucky, a palliative care team.
● Step 3. We are most comfortable with rapid resuscitation interventions. However, unlike our usual approach which rapidly identifies and treats pathology, palliative resuscitation is focused on the rapid identification and treatment of symptoms. Severe dyspnea is the scariest symptom for most patients. Take a few steps to make the patient comfortable.
o Positioning. Allow the patient to choose the most comfortable position for them. For most, this will be the sitting position.
o Arranging the room. Turn off the monitors. Make sure family and friends are at the bedside and as comfortable as possible. Find a few chairs.
o A fan aimed at the face or open window (if possible) can help relieve some of the symptoms of dyspnea. You can cut the tubing from nasal prongs and let the family direct the air over the patient’s face.
o Oxygen. Our patients often find the oxygen mask uncomfortable and its use is debated in palliative care. Start the patient on oxygen but reassess frequently. Stop any intervention that is not providing relief.
● Step 4. Rapidly review goals of care and communicate. What do you understand about your condition? How do you normally spend your days? How much has that changed over the last month? What is important to you right now?
o Use the word death; “What is the meaning of a good death versus a bad death for you? Is there anything you want me to do for you now?” If the patient is unable to communicate for themselves, ask the family. “What was she like when she was healthy? What would she want if she was able to talk for herself?”
o Communicate as clearly as possible that you think the patient is dying. “I understand Mrs. Smith has been sick for a while now. She is a lot worse tonight. I am really sorry but I think she is dying. From what you have told me, it sounds like she wanted to experience a natural death and be as comfortable as possible. I am going to do everything I can to make sure she remains comfortable. Does that sound right to you?”
o There are some patients who are not ready for this discussion and no matter how much time you spend, you will be unable to make a decision in the emergency department. Leave those conversations alone. Admit the patient and it can get sorted out later.
● Step 5. Specific medical therapy for dyspnea; opioids. Opioids are the key to palliative dyspnea. It doesn’t matter which agent you use. Morphine is fine.
o IVs are often avoided in palliative care but the benefits of rapid titration of medications probably outweigh any discomfort in the severely dyspneic patient.
o Start low and rapidly titrate up. You can start with hydromorphone 0.2-0.5 mg IV. Redose every 4-5 minutes and double if the dose if it is not effective after two doses. This is why the 1:1 nursing is essential.
o Opioids probably don’t shorten life in palliative patients.
o For most cases, you will only need opioids. However, some like to add a small dose of benzodiazepine as an anxiolytic. This is reasonable.
● Step 6. Non-pharmacologic therapy. The most important non-pharmacologic therapy is the presence of family and friends at the bedside. This is an essential component of almost everyone’s concept of a good death. Family interactions can distract from distressing symptoms. Encourage the family to interact with their loved one.
● Does non-invasive ventilation have a role in palliation? There isn’t any evidence. We all know that it relieves dyspnea in a lot of patients. It may be uncomfortable and interfere with communication and oral intake. Offer it to the patient with the simple goal of relieving symptoms. If comfort is not improved, stop it. Reassess them.
● Humidified high-flow nasal oxygen. There is no supporting evidence. However, it may improve dyspnea and seems to be well-tolerated.
● The death rattle. As patients lose consciousness, their secretions pool resulting in a gurgling noise. There is no evidence that it is distressing to patients but it is often very distressing to families. It may sometimes be addressed by positioning the patient and reassuring families.
o If this doesn’t work, there are some pharmacologic options. You can use glycopyrrolate 0.2mg IV or subcutaneous and repeat as needed.
● When done well, palliative resuscitation can be one of the most satisfying parts of emergency medicine. You can have a profound impact on a critical moment in a patient’s life.
Justin M. - January 5, 2017 8:45 AM
I wanted to share some feedback on this piece that I received from Dr. Stephen Singh, a director with the Canadian Society of Palliative Care Physicians.
First, he wanted to point out that although I use the term "palliative patients", a much more appropriate phrase would be "patients requiring palliative care". I think this is a very important distinction that underlies a lot of the fears people have about palliative care. In current practice, the label "palliative" can completely change the way a patient is approached. We have to remember the patient still comes first.
Second, he agrees that IV opioids are valuable up front, but highlights an important reason to change to oral or subQ once an effective dose has been determined: the length of action of IV opioids is too short and we don't want the effect of these medications to wear off.
Chuck S. - January 10, 2017 10:35 AM
Loved the talk agree with above changes. Another way to treat dyspnea that I learned when a colleague was dying of mesothelioma was nebulized morphine (standard titrated dose) have used several times since with often dramatic success in alleviating the dyspnea while leaving the patient awake and conversant with family. Confess that I haven't done any research on the topic so pure anecdote that I share. Have noticed best success in patients with primary lung problems (lung cancer, end state COPD etc.)