How is agonal breathing managed in end of life care?

Management of Agonal Breathing in End-of-Life Care

Agonal breathing in end-of-life care should be managed primarily with opioids, specifically morphine, along with benzodiazepines to relieve distress, while providing appropriate family education about this normal dying process.

Understanding Agonal Breathing

Agonal breathing represents the last respiratory pattern before terminal apnea and is characterized by:

• Slow, irregular gasping respirations
• Ineffective ventilation efforts
• Abnormal breathing sounds that may mimic grunting, hiccupping, or gasping 1
• Often distressing for family members to witness

Pharmacological Management

First-Line Medications

1. Opioids:

   • Primary treatment for agonal breathing and dyspnea at end of life 2

   • Dosing recommendations based on opioid status:

     For opioid-naive patients who can swallow:

     • Morphine sulfate immediate-release 2.5-5 mg every 2-4 hours as needed, OR
     • Morphine sulfate modified-release 5 mg twice daily (maximum 30 mg daily) 2

     For patients already taking regular opioids:

     • Morphine sulfate immediate-release 5-10 mg every 2-4 hours as needed, OR
     • One-twelfth of the 24-hour dose for pain 2

     For patients unable to swallow:

     • Morphine sulfate 1-2 mg subcutaneously every 2-4 hours as needed
     • Consider subcutaneous infusion via syringe driver starting with morphine sulfate 10 mg over 24 hours if needed frequently 2

2. Benzodiazepines:

   • Midazolam is preferred due to rapid onset and short half-life 2
   • Should be administered concomitantly with opioids for anxiety and distress

Special Considerations

• If eGFR <30 mL/minute, use equivalent doses of oxycodone instead of morphine 2
• Consider concomitant use of an antiemetic (such as haloperidol) and a regular stimulant laxative (such as senna) 2
• Monitor for respiratory depression but understand that gradual deterioration of respiration is expected as patients near death 2
• Avoid neuromuscular blockade except in rare circumstances of prolonged agonal respiration that causes significant distress despite adequate sedation 3

Non-Pharmacological Approaches

1. Positioning:

   • Sitting upright to increase peak ventilation
   • Leaning forward with arms bracing a chair or knees with upper body supported 2

2. Breathing techniques (if patient is conscious and able):

   • Pursed-lip breathing
   • Relaxing and dropping shoulders to reduce hunched posture 2

Communication with Family

1. Advance preparation:

   • Inform families about agonal breathing before it occurs so they understand it's part of the dying process 1
   • Explain that it does not necessarily indicate suffering 2

2. During agonal breathing:

   • Reassure family that appropriate medications are being given to ensure comfort
   • Explain that this is a normal part of the dying process
   • Provide emotional support and presence

3. Decision-making discussions:

   • Include review of aims, benefits, and risks of palliative sedation
   • Discuss alternatives to its use
   • Include significant family members when possible 2

Monitoring and Assessment

• For imminently dying patients, avoid routine monitoring of vital signs
• Focus only on parameters pertaining to comfort
• Respiratory rate should be monitored primarily to ensure absence of respiratory distress 2
• Do not decrease sedation solely due to gradual deterioration of respiration as patients near death 2

Common Pitfalls to Avoid

1. Inadequate symptom management:

   • Undertreating dyspnea due to fear of respiratory depression
   • Not providing anticipatory medications for breakthrough symptoms

2. Communication errors:

   • Failing to prepare families for the appearance of agonal breathing
   • Not explaining that agonal breathing is part of the natural dying process

3. Monitoring mistakes:

   • Focusing on vital signs rather than comfort in imminently dying patients
   • Decreasing sedation when respiratory rate decreases as part of normal dying process

Studies show that surrogate decision-makers report high satisfaction with end-of-life care when agonal breathing is properly managed with opioids, with 75% feeling the patient suffered minimally before death 4.