Dr. Harvey is an Assistant Professor in the Department of Emergency Medicine at the University of Michigan Medical School, Assistant Residency Program Director, and is board-certified in both Emergency Medicine and Critical Care Medicine. PalliEM.org is very grateful for her contribution of original content.
You are working a busy day shift when you receive an overhead alert of a new patient in the resuscitation bay, who was brought directly from triage for respiratory distress. From the doorway, you see that the patient is a young male who is sitting perfectly upright and struggling to breathe. The nurse tells you that he is 39 years old, has a history of sarcoma with a chest mass, and that triage vital signs noted a respiratory rate of 36 bpm and room air SpO2 78%. The patient cannot provide any additional history at this time due to respiratory distress, but his mother is present and states he is DNR after his most recent admission two weeks ago. You ask the nurse for that discharge summary, which outlines the prognosis of his sarcoma – it is not curable, he received an experimental chemotherapy during the admission to try and shrink the tumor, and his Oncologist had several goals of care discussions throughout his admission that culminated in the patient wishing to be DNR and not to undergo mechanical ventilation in the future.
With this new information, your initial thoughts of aggressive measures for a young, unstable patient have shifted. Since intubation is no longer the desired intervention, you now wonder how to manage his symptoms, how much workup for reversible causes to pursue, and if his presentation today is actually a terminal event.
In 2012, a study examining a decade worth of Medicare data found that half of older Americans are seen in the ED in the last month of life, with most admitted, and almost two-thirds dying in the hospital . Emergency clinicians can thus expect to care for patients presenting with a terminal event and should be proficient in basic palliative skills. These skills have been termed primary palliative care and include assessment and treatment of physical symptoms, which for emergency clinicians, often means symptom management at the end of life .
The patient is placed on continuous cardiac and pulse oximetry monitoring and has an IV established. He is initiated on a non-rebreather mask with improvement in SpO2 to 90%, though he is tugging at the mask and remains tachycardic and tachypneic. His pulmonary exam is notable for absent breath sounds on the right. Chest radiograph is ordered. In the interim, how should you treat his dyspnea?
This patient is experiencing a dyspnea crisis, with air hunger and hypoxia. Addressing his symptoms first will not only help alleviate his suffering but may also allow for a goals of care discussion if he stabilizes.
The first-line treatment for dyspnea is morphine. The effective dose will vary depending on pre-existing opioid tolerance, but a safe starting dose for any patient is 2-4 mg IV . If symptoms are severe, you may need to redose as frequently as every 20 minutes to effect. If unable to obtain an IV, morphine solution can be given buccal. Most imminently dying patients will not require an infusion and can be appropriately managed with intermittent bolus dosing . Contrary to popular belief, morphine administration at end-of-life to relieve suffering does not hasten death, and is considered ethically permissible .
Correcting his hypoxia may provide subjective relief and also has the potential to stabilize other vital signs and improve level of alertness, all of which allows more time to have in-depth goals of care conversations. Since this patient still has uncertain goals of care, it would be reasonable to aggressively treat hypoxia. In this case, a trial of heated high-flow nasal cannula could be considered. The high flow rates can help reduce work of breathing, the humidified oxygen is less drying to the mucosa, and the nasal prongs are usually better tolerated than a mask, which can feel suffocating . A fan blowing a breeze at the patient’s face has been proven to improve dyspnea symptoms .
You administer morphine 2 mg IV and initiate hHFNC at 60 lpm and 70% FiO2. Oxygen saturation normalizes, but he is still tachypneic, pursed lip breathing, and unable to meaningfully converse. In reviewing his medication list, you see that he is prescribed opioids for cancer-related pain, including a fentanyl patch and oral oxycodone. After 20 minutes, you have not achieved the effect you desire and want to give more morphine for his dyspnea. How much do you give?
Many advanced cancer patients are on chronic opioids and will have significant tolerance, which can lead to underdosing in a crisis due to fear of unwanted side effects. As a general rule of thumb, you can assume opioid tolerance if the patient has been on opioids for greater than one week, is wearing a fentanyl patch, and/or is prescribed extended release formulations [7**]. A patient’s daily opioid regimen can be estimated as IV morphine equivalents using a reputable conversion table or calculator, with a breakthrough dose equal to 10% of the daily dose [8-10]. It is important to be aware of cross tolerance, which is the concept that tolerance of one opioid does not completely extend to another. In outpatient titration of opioids, a typical approach is to decrease the dose of the new opioid by 25%, to avoid overdose. This reduction may be ignored in a crisis and when the patient is being closely monitored, however, clinician judgement should always be used .
You review the patient’s medication list with his mother and confirm he is prescribed fentanyl 75 mcg/h patch and oxycodone 20 mg PO TID. Using an online calculator, this converts to an estimated 80 mg of IV morphine per day, with a breakthrough dose of 8 mg IV. After doing the math, you (and your nurses) feel more comfortable administering larger IV doses. You administer morphine 8 mg IV and on your next assessment 20 minutes later, his respiratory rate has decreased to 20 bpm. He appears markedly calmer and though fatigued, is able to converse. You decide now is a good time to readdress his goals of care. How do you approach this?
Communication at End of Life
In time-sensitive scenarios, utilizing a “big picture” open-ended question to rapidly clarify goals can help formulate recommendations about treatments .
Consider the following:
- “What are you hoping for today?” allows space for the patient to talk about what is important to them.
- If you still feel like you need clarification, but want to avoid a laundry list of specific interventions, try “What do you hope to avoid at all costs?”
- For cancer specifically, try “Is your cancer curable?” This is a simple but effective question that invites the patient to tell us their understanding of their prognosis, which informs the discussion moving forward .
Again, the purpose of eliciting these goals is so that you can provide a recommendation. As the emergency clinician, you have the medical knowledge and expertise to help patients and families navigate decision-making in the context of their complex illness.
As the emergency clinician, you have the medical knowledge and expertise to help patients and families navigate decision-making in the context of their complex illness.
When asked these questions, the patient’s goal is to not feel like he was suffocating. His mother added that she wants to know if the recent experimental chemotherapy had worked. He does not want NIV due to prior intolerance of the mask. When asked about his prior discussions about code status, he confirms that he is DNR. His insight into his cancer prognosis matches what was documented by his Oncologist. You therefore recommend to treat ongoing dyspnea with oxygen by nasal cannula and intermittent morphine as needed, limit diagnostic testing to a CT chest to evaluate his tumor size, and not escalate to NIV or heroic measures, even if his breathing worsens. Unfortunately, the CT chest showed interval progression of the tumor, which is now taking up his entire right hemithorax. You are able to contact his Oncologist, who confirms there are no further life-prolonging therapies available. After delivering this serious news, the patient wishes to transition fully to a comfort-focused plan of care.
A comfort-focused plan of care means that each intervention is done with the intention of providing comfort. There is no one right answer, as decisions are individualized for every patient and scenario. In general, it is recommended to stop parenteral fluids (which can worsen dyspnea due to volume overload as anuria develops), tube feeds (which can cause abdominal distention, nausea, or vomiting), routine lab draws, or further diagnostic testing . Interventions such as nasogastric tube, non-invasive ventilation, and antibiotics may provide comfort or not, and need to be weighed on an individual basis. If oxygen is continued for comfort, you can discontinue pulse oximetry as you are titrating for symptoms, rather than a number. Other maneuvers, such as positioning for comfort, dimming lighting, removing unnecessary monitoring equipment, acquiring personal objects of comfort, and allowing food/drink as desired, are encouraged.
You stop the maintenance IVF you had previously ordered, remove all by one IV, and cancel labs and empiric antibiotics. You move the patient from your resuscitation bay to a quieter room, remove the pulse oximeter, decrease his oxygen to 6 lpm without any subsequent increase in air hunger, and turn off the bedside monitor. He is then admitted to the hospital for ongoing care. When you return the following day for another shift, he is still in the emergency department due to boarding. At handoff, you learn he has become less responsive overnight, with the last dose of morphine several hours ago. When you re-evaluate him, you note that he is agitated but not responding to voice, hands and feet are cool, and he has noisy breathing, which is distressing to his mother. How do you treat these new symptoms?
The syndrome of imminent death are typical signs or symptoms that occur in the final hours to days of life . Early, the patient will spend more time sleeping, lose their appetite, and may be intermittently delirious. The patient will then progress to being bed bound, with only brief periods of wakefulness. The late state is characterized by abnormal respirations, death rattle, mottling, and coma.
Common symptoms during the late phase of imminent death include terminal agitation and the death rattle, which are often distressing to family members and thus require you to deftly manage. If agitated, always consider incompletely treated pain first. If pain is felt to be appropriately addressed, pharmacologic and non-pharmacologic options exist for agitation. Research does not clearly show superiority of any one agent, with options including typical or atypical antipsychotics, benzodiazepines, and dexmedetomidine . The death rattle is due to pooling of secretions in the pharynx as the swallowing reflex gradually goes away. Anticholinergic agents such as atropine, glycopyrrolate, and scopolamine are often utilized to minimize secretions, though of uncertain benefit . Atropine eye drops can also be given sublingual if there is no IV access [17**]. Scopolamine patches take 24 hours to reach steady state, so they are not the best option for immediate relief.
After morphine 4 mg IV, atropine ophthalmic 1 drop SL, and olanzapine 5 mg ODT, the patient is breathing quieter and now rouses infrequently. Two hours later, he dies peacefully with his mother at his side.
- Smith AK, McCarthy E, Weber E, et al. Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there. Health Aff (Millwood). 2012;31(6):1277-1285.
- Schenker Y. Primary Palliative Care. In: UpToDate, Post TW, Givens J, and Arnold RM (Eds). UpToDate, Waltham, MA. Retrieved September 28, 2021 from: https://www.uptodate.com/contents/primary-palliative-care#H2293634038
- Weissman DE. (2015). Dyspnea at End of Life. Palliative Care Network of Wisconsin Retrieved September 28, 2021 from: https://www.mypcnow.org/fast-fact/dyspnea-at-end-of-life/
- Weinstein E, Arnold R, Weissman DE. (2015). Opioid Infusions in the Imminently Dying Patient. Palliative Care Network of Wisconsin Retrieved September 28, 2021 from: https://www.mypcnow.org/fast-fact/opioid-infusions-in-the-imminently-dying-patient/
- Von Gunten CF. (2015). Morphine and Hastened Death. Palliative Care Network of Wisconsi. Retrieved September 28, 2021 from: https://www.mypcnow.org/fast-fact/morphine-and-hastened-death/
- Shah N, Mehta Z, Weissman DE. (2018). High Flow Nasal Cannula Oxygen Therapy in Palliative Care. Palliative Care Network of Wisconsin. Retrieved September 28, 2021 from: https://www.mypcnow.org/fast-fact/high-flow-nasal-cannula-oxygen-therapy-in-palliative-care/
- Mercadante S, Arcuri E, Santoni A. Opioid-Induced Tolerance and Hyperalgesia. CNS Drugs. 2019. Retrieved October 18, 2021 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6897318/
- Global RPh. Opioid Conversion Calculator Morphine Equivalents – Advanced. Retrieved October 12, 2021 from: https://globalrph.com/medcalcs/opioid-pain-management-converter-advanced/
- Stanford School of Medicine. Opioid Conversion Equivalency Table. Retrieved October 12, 2021 from: https://palliative.stanford.edu/opioid-conversion/equivalency-table/
- Portenoy RK, Mehta Z, Ahmed E. Cancer Pain Management with Opioids: Optimizing Analgesia. In: UpToDate, Post TW, Savarese DMF, Abraham J (Eds.). UpToDate, Waltham, MA. Retrieved September 30, 2021 from: https://www.uptodate.com/contents/cancer-pain-management-with-opioids-optimizing-analgesia
- Shreves, A. (2015, May 4). “I Wish Things Were Different.” Emergency Physicians Monthly. https://epmonthly.com/article/i-wish-things-were-different/
- Thoma, B. (2016, February 25). An Approach to Palliative Care in the ED. CanadiEM. https://canadiem.org/an-approach-to-palliative-care-in-the-ed/
- Harman SM, Amos Bailey F, Walling AM. Palliative Care: The Last Hours and Days of Life. In: UpToDate, Post TW, Givens J, Bruera E (Eds.). UpToDate, Waltham, MA. Retrieved September 30, 2021 from: https://www.uptodate.com/contents/palliative-care-the-last-hours-and-days-of-life
- Weissman DE. (2014). Syndrome of Imminent Death. Palliative Care Network of Wisconsin. Retrieved October 1, 2021 from: https://www.mypcnow.org/fast-fact/syndrome-of-imminent-death/
- Weissman DE, Rosielle DA, Bukowy EA. (2015). Diagnosis and Treatment of Terminal Delirium. Palliative Care Network of Wisconsin. Retrieved October 1, 2021 from: https://www.mypcnow.org/fast-fact/diagnosis-and-treatment-of-terminal-delirium/
- Bickel K, Arnold R. (2015). Death Rattle and Oral Secretions. Palliative Care Network of Wisconsin. Retrieved October 1, 2021 from: https://www.mypcnow.org/fast-fact/death-rattle-and-oral-secretions/
- Protus BM, Grauer PA, Kimbrel JM. Evaluation of atropine 1% ophthalmic solution administered sublingually for the management of terminal respiratory secretions. Am J Hosp Palliat Care. 2013;30(4):388-392.
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