What are the aspects of palliative care in a 75-year-old female with stage 4 adenocarcinoma (lung cancer) on a Non-Rebreather Mask (NRM) at 10 liters of oxygen with pain and respiratory distress?

Palliative Care Management for Stage 4 Lung Adenocarcinoma with Pain and Respiratory Distress

For a 75-year-old female with stage 4 lung adenocarcinoma on NRBM at 10 liters oxygen experiencing pain and respiratory distress, comprehensive palliative care should be introduced immediately with focus on symptom management rather than disease-modifying treatment.

Immediate Management of Respiratory Distress

Pharmacological Interventions

• Opioids are the first-line treatment for dyspnea - if opioid naive, start morphine 2.5-10 mg PO every 2 hours as needed or 1-3 mg IV every 2 hours as needed 1
• For patients already on chronic opioids, consider increasing the dose by 25% to manage acute dyspnea 1
• If dyspnea is associated with anxiety, add benzodiazepines (if benzodiazepine naive, lorazepam 0.5-1 mg PO every 4 hours as needed) 1
• For excessive secretions contributing to respiratory distress, consider scopolamine 0.4 mg subcutaneous every 4 hours, scopolamine patches 1-3 patches every 3 days, atropine 1% ophthalmic solution 1-2 drops sublingual every 4 hours, or glycopyrrolate 0.2-0.4 mg IV/subcutaneous every 4 hours 1

Non-Pharmacological Interventions

• Position the patient upright to ease breathing 2
• Implement interventions to improve breathing efficiency such as pursed lip breathing, diaphragmatic breathing, and pacing techniques 3
• Use fans and maintain cooler room temperatures to reduce the sensation of dyspnea 1
• Provide psychosocial interventions including relaxation techniques and stress management to reduce anxiety associated with dyspnea 1

Pain Management

• Opioids should be titrated aggressively for moderate/severe pain 1
• Important: Do not reduce opioid doses solely for decreased blood pressure, respiration rate, or level of consciousness when necessary for adequate management of dyspnea and pain 1
• For refractory pain, consider palliative sedation after consultation with pain management/palliative care specialists 1

Psychosocial and Spiritual Support

• Implement psychologic interventions including psycho-education, deep breathing, progressive muscle relaxation, guided imagery, cognitive behavioral therapy, and supportive psychotherapy 1
• Provide emotional support to help the patient reshape goals and hopes based on changing reality 2
• Address spiritual concerns and existential distress 2
• Facilitate completion of important personal matters and relationship closure 2

Goals of Care Discussion

• Initiate conversations about the patient's prognosis and goals of care immediately 1
• Discuss the benefits and burdens of continued aggressive interventions versus comfort-focused care 1
• Consider discontinuation of anticancer treatment and focus on best supportive care 1
• Avoid describing palliative care as "giving up," but rather reframe it as "fighting" for better quality of life 1

Care Coordination

• Refer to specialized palliative care services or hospice 1, 2
• Implement a case management approach or nurse-led follow-up program to ensure continuity of care 3
• Consider reducing FiO2 from current levels if possible while maintaining adequate oxygenation, as prolonged use of high-flow oxygen via NRM may be associated with increased mortality in some patients with respiratory failure 4

Common Pitfalls to Avoid

• Avoid delaying palliative care interventions - early introduction of palliative care alongside standard oncology care is recommended for patients with stage IV lung cancer 1, 2
• Do not withhold opioids for fear of respiratory depression when needed for dyspnea management 1
• Avoid focusing solely on disease-modifying treatments at the expense of symptom management 1
• Do not implement overly aggressive nutritional support that may increase suffering in advanced disease 2

Special Considerations for End-of-Life Care

• For patients with weeks to days to live, focus on comfort measures rather than aggressive medical interventions 1
• Provide anticipatory guidance for the patient and family regarding the dying process 1
• Ensure adequate symptom control and preparation for the dying process 1
• Consider sedation for intractable symptoms after appropriate consultation 1