What are the appropriate steps to manage symptoms of pain, fatigue, and difficulty breathing?

Managing Pain, Fatigue, and Difficulty Breathing

Physicians should routinely assess these three symptoms using brief standardized tools (visual analog or numeric rating scales) at every encounter and initiate evidence-based treatments immediately, as inadequate symptom control represents poor quality of care. 1

Systematic Assessment Approach

Begin by determining the underlying context and life expectancy, as this fundamentally changes management strategy—whether the patient has years, months-to-weeks, or weeks-to-days to live guides the aggressiveness and goals of intervention. 1, 2

Initial Symptom Evaluation

• Assess pain intensity using numeric rating scales (0-10) at every visit, as lack of awareness of patient pain is a major barrier to adequate management. 1
• Screen for fatigue systematically, recognizing it is often the most prevalent symptom but frequently goes unrecognized and undertreated. 1
• Evaluate dyspnea severity using validated scales, and in non-communicative patients, assess physical signs like labored breathing as indicators of respiratory distress. 1, 2
• Screen concurrently for depression, as pain, fatigue, and dyspnea often cluster together, and treating depression may improve other symptoms. 1

Pain Management Algorithm

Follow the WHO three-step analgesic ladder, which provides adequate relief for the majority of patients. 1

Step 1: Mild Pain

• Start with NSAIDs (e.g., ibuprofen 400-800mg every 6-8 hours) for mild pain, using the lowest effective dose for the shortest duration necessary. 1, 3
• Monitor for gastrointestinal bleeding risk, particularly in patients with prior ulcer history, those taking corticosteroids/anticoagulants, older age, or alcohol use. 3

Step 2: Moderate Pain

• Add a weak opioid to the NSAID when pain persists or increases. 1

Step 3: Severe Pain

• Substitute a strong opioid for moderate-to-severe pain. 1
• For opioid-naïve patients, start morphine 2-10mg PO every 2 hours as needed or 1-3mg IV every 2 hours as needed, adjusting for patient size, age, and organ dysfunction. 1, 2
• Use around-the-clock dosing rather than as-needed to improve adherence and outcomes. 1
• Titrate opioids to symptoms with no specified dose limit, as concerns about respiratory depression should not prevent adequate pain control. 1, 2
• If patients receive two bolus doses in one hour, double the infusion rate; for patients already on opioid infusions, give bolus doses equal to two times the hourly rate for breakthrough pain. 1

Adjuvant Therapies

• Add adjuvants for neuropathic pain and to manage opioid side effects. 1
• Consider external beam radiotherapy for localized pain and bisphosphonates for bone metastases pain. 1
• Order anti-nausea medications PRN with all opioid prescriptions. 1

Dyspnea Management Algorithm

For Patients with Years of Life Expectancy

• Treat underlying causes first: consider radiation/chemotherapy for malignancies, therapeutic drainage for cardiac/pleural/abdominal fluid, bronchoscopic therapy, bronchodilators, diuretics, steroids, antibiotics, or transfusions as indicated. 2
• Provide oxygen therapy only for hypoxemia (target saturation >94%) or when patients report subjective relief, as oxygen is ineffective in non-hypoxemic patients. 1, 2
• Implement nonpharmacologic interventions: fans directed at the face, cooler room temperatures, stress management, and relaxation therapy. 2

For Patients with Months-to-Weeks of Life Expectancy

• Administer morphine 2.5-10mg PO every 2 hours as needed or 1-3mg IV every 2 hours as needed for opioid-naïve patients experiencing dyspnea. 2
• Increase opioid doses by 25% for patients already on chronic opioids when dyspnea develops. 2
• Add benzodiazepines specifically for dyspnea associated with anxiety: start lorazepam 0.5-1mg PO every 4 hours as needed. 1, 2
• Consider noninvasive positive-pressure ventilation (CPAP/BiPAP) for severe but potentially reversible conditions. 2
• Manage fluid overload by decreasing or discontinuing enteral/parenteral fluids and consider low-dose diuretics. 2
• Treat excessive secretions with scopolamine 0.4mg subcutaneous every 4 hours as needed or 1.5mg patches (1-3 patches every 3 days), or alternatives like atropine 1% ophthalmic solution or glycopyrrolate 0.2-0.4mg IV/subcutaneous every 4 hours. 2

For Acute Heart Failure with Dyspnea

• Administer sublingual/IV nitrates titrated to blood pressure in the absence of cardiogenic shock. 1
• Give IV diuretics (furosemide) for volume overload. 1
• Initiate non-invasive ventilation (CPAP) promptly if respiratory distress is detected. 1

Fatigue Management

Recognize that fatigue has limited proven treatment options, but addressing contributing factors is essential. 1

• Treat underlying depression with adequate doses and duration of antidepressants, as this may improve fatigue. 1
• Consider cognitive-behavioral and psychosocial interventions, which show modest benefit. 1
• Reassess regularly, as fatigue management requires ongoing evaluation and adjustment. 1

Critical Implementation Strategies

• Develop and utilize institutional protocols for systematic symptom assessment and management. 1
• Educate both physicians and patients about symptom management expectations and treatment algorithms. 1
• Perform continuous quality-improvement interventions with regular reassessment and follow-up of symptom scores. 1
• Ensure all opioid prescriptions are refillable with proper verification to maximize convenience and compliance. 1

Common Pitfalls to Avoid

• Do not undertitrate opioids due to unfounded fears of respiratory depression—when appropriately dosed for symptoms, opioids are safe and effective. 1, 2
• Do not reduce opioid doses solely for decreased blood pressure, respiration rate, or level of consciousness when opioids are necessary for adequate dyspnea and pain management in dying patients. 1
• Do not overlook depression screening, as patients may associate stigma with psychiatric diagnosis and be reluctant to report symptoms. 1
• Do not delay palliative interventions until the very end of life, as early implementation improves quality of life. 2
• Do not rely on oxygen therapy alone for non-hypoxemic patients with dyspnea, as it provides no benefit. 2
• Do not fail to address the psychological and emotional components of these symptoms, which can significantly amplify their intensity. 2