In an 89‑year‑old man with end‑stage disease and severe pneumonia receiving 15 L/min oxygen via face mask, what palliative measures can be used to relieve dyspnoea and suffering given a do‑not‑resuscitate decision?

Palliative Management of Severe Dyspnea in End-Stage Disease

Opioids are the first-line pharmacological treatment for palliative relief of dyspnea in this dying patient, with morphine 2.5-5 mg IV every 1-2 hours as needed, titrated to symptom relief, combined with benzodiazepines if anxiety is present. 1, 2

Immediate Pharmacological Interventions

Opioid Therapy (Primary Treatment)

• Start morphine immediately for opioid-naïve patients at 1-3 mg IV every 1 hour as needed, or 2.5-10 mg PO every 2-4 hours if oral route is feasible 1, 2
• Opioids reduce the unpleasantness of dyspnea without causing clinically significant respiratory depression when properly dosed and titrated to symptom relief 1, 2
• Multiple observational studies confirm that appropriate opioid use does not hasten death 1
• The "principle of double effect" provides ethical justification: relief of suffering is the intent, and any life-shortening effect (if it occurs) is morally acceptable when dosing is titrated to symptom control 1
• For acute progressive dyspnea in a dying patient, aggressive titration is required 1, 2

Benzodiazepines (Adjunctive Treatment)

• Add lorazepam 0.5-1 mg IV/PO every 1-4 hours as needed if dyspnea persists despite opioids or if significant anxiety is present 1, 2
• Benzodiazepines are particularly indicated when dyspnea is associated with anxiety or panic 1
• For refractory dyspnea in the dying phase, escalate to terminal sedation using benzodiazepines in combination with opioids 1, 3

Management of Secretions

• Reduce excessive respiratory secretions with scopolamine 0.4 mg SC every 4 hours as needed, or glycopyrrolate 0.2-0.4 mg IV/SC every 4 hours as needed 1
• Note that transdermal scopolamine patches have a 12-hour onset and are inappropriate for imminently dying patients 2

Non-Pharmacological Comfort Measures

Immediate Physical Interventions

• Direct cool air at the patient's face using a handheld fan - this has proven efficacy in randomized trials and provides immediate relief 1, 2, 3
• Position the patient upright with head elevation 30-45 degrees to reduce work of breathing 3
• Open windows, use small ventilators, and maintain cooler room temperature 4, 3

Oxygen Therapy

• Continue the current 15 L/min oxygen via face mask if the patient reports subjective relief 1, 2
• However, recognize that oxygen therapy has limited evidence for dyspnea relief in the absence of hypoxemia 1
• The primary goal is comfort, not oxygen saturation targets 3

Critical Considerations for End-of-Life Care

Ventilation Decisions

• Do not initiate invasive mechanical ventilation given the DNR status, end-stage disease, and advanced age 1
• Non-invasive ventilation (NIV) may be considered only if it provides symptom relief without prolonging the dying process 1
• NIV should be discontinued if it causes distress, respiratory dehydration, or worsens dyspnea 1

Family Support and Communication

• Provide anticipatory guidance to family members about physical reactions during respiratory failure and the dying process 1
• Inform relatives that symptoms of dyspnea and anxiety will be the focus of aggressive symptom relief 1
• Offer emotional and spiritual support to both patient and family 1, 2
• Physicians should personally conduct and accompany symptom management in the dying phase, not delegate this solely to nursing staff 1

Monitoring and Dose Titration

• Titrate opioid doses based on frequent symptom assessment, not on respiratory rate or oxygen saturation 1
• Use a dyspnea scale or observe physical signs of distress in non-communicative patients 1, 2
• Dosages should be adjusted to achieve adequate dyspnea relief while minimizing excessive sedation 1
• Any shortening of life due to unavoidable side effects of symptom control should be tolerated when the intent is symptom relief 1

Common Pitfalls to Avoid

• Do not withhold opioids due to fear of respiratory depression - this concern is not supported by evidence when drugs are properly titrated 1
• Do not rely solely on oxygen therapy - it is insufficient for dyspnea palliation in most dying patients 1
• Do not use nebulized opioids - systematic reviews show they are no more effective than placebo 1
• Do not delay palliative sedation if dyspnea remains refractory to standard opioid and benzodiazepine therapy 1, 3