Emergency Department Management of Dyspnea in the Dying Patient

Table of Contents

 

Up to three quarters of patients with terminal cancer experience dyspnea, and many patients near the end of life will present to the ED seeking help. For emergency clinicians, the goals of care for patients with terminal illness are very different. This issue reviews what emergency clinicians must know to safely, effectively, and sensitively manage the distressing symptoms of breathlessness.

Advance directives explained: What’s the difference between DNR/DNI, living will, and power of attorney?

Why you should never ask “Do you want everything done?”

How can you tell how close a patient is to death? Does it matter?

How can you initiate the conversation about palliative care with family members?

Do opioids hasten death? How do you manage dosing in patients who are opioid-naïve and opioid-tolerant?

Should you try secretion management, NIPPV, or high-flow nasal cannula?

1. Abstract
2. Case Presentation
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology and Pathophysiology
6. Prehospital Care
7. Emergency Department Evaluation
   1. History
      1. Is this patient dying?
      2. Assessing Goals of Care
      3. History of Present Illness
   2. Physical Examination
      1. Is this patient dying?
      2. Focused Examination
      3. Advance Directives
8. Diagnostic Studies
   1. Laboratory Testing
   2. Electrocardiogram
   3. Radiographs
   4. Ultrasound
   5. Telemetry
9. Treatment
   1. Opioids
      1. Do opioids hasten death?
   2. Benzodiazepines
   3. Nonpharmacologic Therapies
   4. Secretion Management
   5. Social Work and Chaplaincy
10. Special Circumstances
11. Controversies and Cutting Edge
12. Disposition
13. Summary
14. Risk Management Pitfalls for Dyspneic Patients at the End of Life
15. Time- and Cost-Effective Strategies
16. Case Conclusion
17. Clinical Pathway for Emergency Department Management of Dyspneic Patients at the End of Life
18. Tables and Figures
    1. Table 1. Differential Diagnosis of Dyspnea
    2. Table 2. Terminology of Advance Directives
    3. Table 3. Prognostic Signs in the Dyspneic Patient at the End of Life
    4. Table 4. Opioid Conversion Table
    5. Figure 1. Sample POLST From Oregon
19. References

Abstract

Dyspnea is one of the most distressing symptoms experienced by dying patients, and it is a common reason for such patients to seek care in the emergency department. Many underlying disease states and acute illnesses cause shortness of breath at the end of life, and management tends to be symptomatic rather than diagnostic, particularly in those for whom comfort is the most important goal. Opioids are the most effective and widely studied agents available for palliation of dyspnea in this population, while adjuvant therapies such as oxygen, noninvasive positive pressure ventilation, and hand-held fans may also be used. Benzodiazepines may also be helpful in select patients. The early involvement of palliative medicine specialists and/or hospice services for dying patients can facilitate optimal symptom management and transitions of care.

Case Presentation

On a quiet overnight shift, you receive a call from EMS. They are en route to your ED with a 55-year-old woman in respiratory distress. You walk to the resuscitation room and prepare for rapid sequence intubation, wondering what catastrophic event might have precipitated this patient’s respiratory failure. When the patient arrives, you notice that she is cachectic and pale, gasping for breath as she tries to pull off the nonrebreather mask on her face. Her distraught husband walks alongside the stretcher, stroking her hair and crying. The patient appears to be terminally ill, and when you ask her husband what’s going on, he says, “She has lung cancer. We just stopped chemo because it wasn’t working anymore. We’re supposed to get hospice, but it hasn’t been set up yet.” Meanwhile, the paramedics read her vital signs out loud: “temp 99°, heart rate 120, respiratory rate 40, pulse ox 90%, blood pressure 100/50.” You briefly wish that it was the middle of the day so your hospital’s newly formed palliative care service would be available. Faced with this clearly uncomfortable, dying patient, the traditional emergency medicine tools of endotracheal intubation and mechanical ventilation seem inappropriate, but what other medical strategies exist to help this distressed, symptomatic patient? You have read that patients often receive morphine at the end of life, but you don’t want to be accused of hastening anyone’s death. Her husband pleads, “Please help her, doctor. I can’t watch her suffer like this.” Despite your desire to do everything possible to make this patient comfortable, you reflect on the unique legal and ethical framework that surrounds care of the dying patient and want to ensure that you do the right thing.

Introduction

The American Thoracic Society defines dyspnea as “...a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.”¹ Patients suffering from dyspnea or shortness of breath commonly seek care in the emergency department (ED).² Anticipating the dangerous diagnoses lurking behind this complaint and preventing the associated morbidity and mortality from such conditions has been the primary focus of emergency medicine. Early and aggressive control of derangements in a patient’s airway and breathing often necessitates use of medical devices such as endotracheal tubes, noninvasive positive-pressure ventilation (NIPPV), and mechanical ventilation.

In contrast, for patients with dyspnea in the setting of a terminal condition and limited prognosis, these tools can artificially prolong dying and increase suffering. Nonetheless, these dying patients often have acute needs that require skilled medical interventions. Ensuring that such patients receive high-quality compassionate end-of-life care is increasingly recognized as falling within the domain of emergency medicine.^3,4

Despite widespread and increasing utilization of hospice services⁵ and consistently stated preferences of most terminally ill patients to die in the home,⁶ many patients visit the ED at the end of life. High rates of ED utilization have been demonstrated in cancer patients, with up to one-third visiting the ED in the last 2 weeks of life.⁷ A similar trend has been observed in the elderly, with half of Medicare recipients visiting the ED in the last month of their lives.⁸ About half of the ED visits in the elderly population are associated with a cancer diagnosis and an anticipated death.⁹ The current rise and predicted trends in geriatric visits to the ED suggest that emergency clinicians will face end-of-life situations with increasing frequency.¹⁰

There are a multitude of factors that drive patients who are at the end of life into the acute-care setting. Broadly speaking, in the cancer population, independent predictors of hospital versus home death include non–solid tumor diagnosis, ethnic minority status, and high regional availability of hospitals and inpatient beds.⁹ At the patient level, however, it is often intense symptoms (particularly dyspnea) coupled with the unavailability of timely support in the outpatient setting that lead patients to the ED.^11,12 While these visits are often prompted by an inability to manage distressing symptoms at home, emergency clinicians have expressed discomfort and demonstrated limited knowledge in tending to the nuanced needs of patients with recognized terminal conditions.^13-15 It is not surprising, then, that the ED experience of dying patients is often poor.^12,16

Dyspnea is one of the most common symptoms that patients encounter at the end of life. In patients with terminal cancer, 70% to 80% experience dyspnea at some time during the last 6 weeks of life, and they commonly experience a significant increase in dyspnea in the last 2 weeks.^17,18 In patients with non–cancer terminal diagnoses such as chronic obstructive pulmonary disease (COPD) and congestive heart failure, the severity of dyspnea is highest, but it remains relatively stable until death.¹⁸ Dyspnea ranks as one of the most distressing symptoms to the patient and the family, leading to restrictions in quality of life and an increase in anxiety and fear.^17,19 This issue of Emergency Medicine Practice reviews the current literature on ED management of adult patients with serious or terminal illnesses who present to the ED with dyspnea, taking into account many of the issues surrounding the end of life and palliative care that arise.

Critical Appraisal of the Literature

A PubMed search was conducted with the search terms dyspnea, breathlessness, air hunger, end-of-life, palliative, hospice, emergency, and opiate/opioid, for articles published from 1981 to 2018. A search of the Cochrane Database of Systematic Reviews was also conducted using the search term dyspnea, which identified 17 systematic reviews. ED-related palliative care literature remains sparse and has been published largely within the last decade, while the literature base on inpatient palliative care and hospice care is significantly more robust. Additionally, the bulk of emergency medicine literature concerning end-of-life care focuses on models, perspectives, and education, while nearly the entirety of trial data is drawn from inpatient and hospice populations. As a result, much of the data presented in this issue are drawn from studies conducted outside of the emergency setting. Furthermore, limitations on the quality of evidence for various modes of treatment exist. These limitations arise from the paucity of true randomized controlled trials and the heterogeneity of both medication selection and dosing between currently existing trials. The recommendations made in this issue make reference to the quality of evidence, when appropriate, and recommendations based on expert opinion or current standard of practice are also noted.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

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2. National Hospital Ambulatory Medical Care Survey: 2009 Emergency Department Summary Tables. 2009. (NHAMCS data summary)
3. Todd KH. Practically speaking: emergency medicine and the palliative care movement. Emerg Med Australas EMA. 2012;24(1):4-6. (Editorial)
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34. Lunney JR, Lynn J, Foley DJ, et al. Patterns of functional decline at the end of life. JAMA. 2003;289(18):2387-2392. (Prospective cohort; 4190 patients)
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56. Bourke DL, Malit LA, Smith TC. Respiratory interactions of ketamine and morphine. Anesthesiology. 1987;66(2):153-156. (Randomized double-blinded trial; 6 patients)
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73. Cuomo A, Delmastro M, Ceriana P, et al. Noninvasive mechanical ventilation as a palliative treatment of acute respiratory failure in patients with end-stage solid cancer. Palliat Med. 2004;18(7):602-610. (Prospective nonrandomized trial; 23 patients)
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76. Rosenberg M, Rosenberg L. Integrated model of palliative care in the emergency department. West J Emerg Med. 2013;14(6):633-636. (Review)
77. Casarett D, Johnson M, Smith D, et al. The optimal delivery of palliative care: a national comparison of the outcomes of consultation teams vs inpatient units. Arch Intern Med. 2011;171(7):649-655. (Survey; 5901 family members of palliative care patients)
78. Lamba S, Quest TE, Weissman DE. Initiating a hospice referral from the emergency department #247. J Palliat Med. 2011;14(12):1346-1347. (Review)
79. Grudzen CR, Hwang U, Cohen JA, et al. Characteristics of emergency department patients who receive a palliative care consultation. J Palliat Med. 2012;15(4):396-399. (Retrospective chart review; 100 patients)