How to Manage Dyspnea in Dying Patients

Terminally ill patients in hospice or palliative care settings might experience dyspnea (difficulty breathing) as they near the end of their lives. Dyspnea may be related to an underlying disease, such as lung cancer or chronic obstructive pulmonary disease (COPD), or a secondary cause such as pneumonia.

Oxygen therapy is usually the first line of treatment, but other non-medical interventions may help, too.

This article discusses dyspnea at the end of life, what causes it, and how it can be managed.

What Is Dyspnea?

Dyspnea is a shortness of breath or difficult or labored breathing that can sometimes occur suddenly. People experiencing dyspnea often describe it as shortness of breath, tightness in their chest, fighting for air, or feeling smothered. Or they might simply say, "I can't breathe."

In some cases, a patient's respiration rate (how rapidly they breathe in and out) will increase and their chest might constrict as the patient tries to get enough air while breathing.

Normal breathing and the exchange of oxygen for carbon dioxide is a combination of the rate of breathing (breaths per minute) and the volume of air per breath (tidal volume). Patients experiencing dyspnea might try to increase the rate of their breathing or the tidal volume.

If an individual's oxygen levels are severely compromised, discoloration might occur in their nail beds and/or lips, a serious condition called cyanosis.

What Are the Causes of Dyspnea?

There are many causes of dyspnea in end-of-life situations. The cause is sometimes directly related to the patient's underlying disease—especially if the diagnosis involves the respiratory system, such as lung cancer or chronic obstructive pulmonary disease (COPD).

Dyspnea can also occur due to secondary causes, such as pneumonia or chemotherapy, or due to the lungs overcompensating for the failure of another organ, such as the kidney or heart. Typically, several factors can contribute to a terminally ill patient experiencing dyspnea.

Because breathing is something we generally take for granted, individuals experiencing dyspnea often experience heightened anxiety. Anxiety can cause cognitive, emotional, behavioral, and physical manifestations that exacerbate dyspnea, so it's important to manage a patient's anxiety, too.

What Other Breathing Changes Happen Before Death?

Dyspnea isn't the only breathing change you might notice in a person nearing the end of life.

Changes in breathing may come on suddenly and last for only a short period before the person's death, or they may happen over days or hours. Some of the breathing patterns that can occur at the end of life include:

• Terminal respiratory secretions: This is also known as the "death rattle." It is an end-of-life breathing pattern that sounds like wet rattling. It is caused by the dying person's inability to clear their throat. This usually happens in the last stages of the dying process.
• Cheyne-Stokes breathing: This is an abnormal pattern of breathing alternating between slow/deep breathing, fast/shallow breathing, apnea, or moments where breathing stops temporarily. It usually occurs in the last days or hours before death.
• Agonal breathing: This is a breathing pattern that occurs in the last moments of life. Agonal breathing is gasp-like and irregular. It is often associated with an emergency event such as cardiac arrest or severe trauma. Agonal breathing at the end of life only lasts seconds to minutes before death occurs.
  

Medical Treatments for Dyspnea

Because the goal of palliative care and hospice for terminally ill patients is to provide comfort, you most likely should not call 911. In these situations, if your loved one or patient experiences dyspnea, you should contact their treating physician immediately.

The doctor or a nurse will guide you in the best treatment to provide comfort. If your patient is under hospice care, you should call the hospice agency, and a hospice nurse will give you instructions over the phone before possibly sending a nurse out to evaluate the patient's symptoms.

Otherwise, medical treatments/interventions for dyspnea in hospice and palliative-care settings generally focus on relieving the patient's feeling of breathlessness:

• Administering oxygen is usually the first line of treatment.
• If the cause of dyspnea is a chronic illness, such as COPD, medications in use for that illness might be re-evaluated and adjusted, if necessary.
• Morphine is commonly used to relieve breathlessness because it dilates blood vessels in the lungs, reduces the respiration rate, and increases the depth of breathing—all of which can also lower the patient's anxiety level.
• While anti-anxiety medications can reduce a patient's feelings of anxiousness and increase their comfort level, they can also make dyspnea worse.

If a patient experiences dyspnea at the end of life and is awake to feel it, the palliative medicine or hospital provider will be sure to relieve them from this symptom, usually by using certain medications to keep them unconscious.

Non-Medical Treatments for Dyspnea

Non-medical interventions are important in treating dyspnea and can be implemented during medical treatment or while you wait for medical help to arrive. Some things you can do include the following:

• Cool the room and make sure the patient is wearing lightweight clothing.
• Increase the humidity level in the room.
• Use a fan to blow air directly at the patient's face, provided he or she can tolerate this feeling.
• Open a nearby window to provide a breeze and/or fresh air.
• Have the patient sit upright in bed and perform deep-breathing exercises.
• Try a relaxation technique, such as playing relaxing music, applying massage, or some other relaxing touch of the patient's choosing. You might also consider using guided imagery or meditation, which are two techniques that might help.
• Provide emotional support to the patient by listening closely to what he or she says and then providing reassurance.

Summary

Dyspnea describes difficulty breathing and is something that patients may experience at the end of life. It can be caused by their underlying illness or it can happen as a result of a secondary condition such as pneumonia.

Other abnormal breathing patterns such as "death rattle," Cheyne-Stokes breathing, or agonal breathing may also happen in the weeks, hours, or minutes before death.

Dyspnea may be managed with oxygen or with medications that help control the anxiety associated with it.