special subjects
Symptom Relief for the Dying Patient
Dyspnea
Dyspnea is one of the most feared symptoms and is extremely frightening to dying patients. The main causes of dyspnea are heart and lung disorders. Other factors include severe anemia and chest wall or abdominal disorders that cause painful respiration (eg, rib fracture) or that impede respiration (eg, massive ascites). Metabolic acidosis causes tachypnea but does not cause a sensation of dyspnea. Anxiety (sometimes due to delirium or pain) can cause tachypnea with or without a feeling of dyspnea. Reversible causes should be treated specifically. For example, placing a chest tube for tension pneumothorax or draining a pleural effusion provides quick and definitive relief. Supplemental oxygen can sometimes correct hypoxemia. Nebulizedalbuteroland oral or injectable corticosteroids may relieve bronchospasm and bronchial inflammation. However, if death is imminent or a definitive treatment for the cause of dyspnea is not available, proper symptomatic treatment assures patients they will be comfortable, regardless of the cause. If death is expected and the goals of care focus on comfort, then pulse oximetry, arterial blood gases, electrocardiography, and imaging are not indicated. Clinicians should use general comfort-oriented treatments including positioning (eg, sitting up), increasing air movement with a fan or open window, and bedside relaxation techniques. Opioids are the drugs of choice for dyspnea near the end of life. Low doses ofmorphine2 to 10 mg sublingually or 2 to 4 mg subcutaneously every 2 hours as needed helps reduce breathlessness in an opioid-naive patient.Morphinemay blunt the medullary response to CO2 retention or O2 decline, reducing dyspnea and decreasing anxiety without causing harmful respiratory depression. If patients are already taking opioids for pain, dosages that relieve the new onset of dyspnea must often be more than double the patient’s usual dosages. Benzodiazepines often help relieve anxiety caused by dyspnea and the fear of a return of dyspnea. Oxygen may also give psychologic comfort to patients and family members even if it does not correct hypoxemia. Patients usually prefer oxygen via nasal cannula. An oxygen face mask may increase agitation of a dying patient. Nebulized saline may help patients with viscous secretions. The death rattle is noisy breathing that results from air moving across pooled secretions in the oropharynx and bronchi and often portends death in hours or days. The death rattle is not a sign of discomfort in the dying patient but can disturb family members and caregivers. To minimize the death rattle, caregivers should limit patients' fluid intake (eg, oral, IV, enteral) and position patients on their side or semi-prone. Oropharyngeal suctioning is generally ineffective in reaching the pooled secretions and may cause discomfort. Airway congestion is best managed with an anticholinergic drug such asscopolamine,glycopyrrolate, oratropine(eg,glycopyrrolatebeginning with 0.2 mg subcutaneously every 4 to 6 hours or 0.2 to 0.4 mg orally every 8 hours, with dose increases as needed). Adverse effects mostly occur with repeated doses and include blurred vision, sedation, delirium, palpitations, hallucinations, constipation, and urinary retention.Glycopyrrolatedoes not cross the blood-brain barrier and results in fewer neurotoxic adverse effects than other anticholinergics. 