Checked: 05-04-2018 by
vicky.ryan Next Review: 06-09-2019
EOL Respiratory symptoms NS MOM
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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
Information for this care map has been adapted from the Adult Palliative Care Guidelines (April 2014) available here
· csci = continuous subcutaneous infusion (via a syringe driver)
1.1 Who is eligible for care by St Peter’s Hospice?
· Anyone over the age of 18 with an active and advanced life limiting disease such as cancer, heart and/or lung disease and neurological diseases;
· Patients referred to St Peter’s Hospice may be close to the end of active treatment when a doctor has advised either that no further treatment will be of benefit or that further treatment is purely for the relief of difficult symptoms;
· The patient may be near the end of their life and may have chosen to die in a hospice. The patient (or their chosen representative i.e. next of kin) must agree to the referral;
· St Peter’s Hospice provides care to the people of Bristol, South Gloucestershire, North Somerset and part of B&NES.
1.2 Who can make a referral to St Peter’s Hospice?
Anyone can make a referral but usually patients are referred by a health or social care professional such as their GP, District Nurse or Hospital Palliative Care Team. The patient’s GP must be in agreement with the referral.
Once a patient has been accepted by St Peter’s Hospice they will be contacted by a triage nurse to let them know what will happen next. For the majority of patients the first contact they will receive will be a telephone call from the triage nurse to introduce the service and assess any urgent issues. This will often be followed by a visit from a Community Nurse Specialist or perhaps an invitation to an outpatient appointment.
Hard copies of the Drug chart and patient information leaflet are available in GP Practices and with Community Nursing teams. The version attached below is provided as a last resort as these are not designed to be printed locally.
Service commissioned by NHS England on behalf of NS CCG
Breathlessness or dyspnoea is a subjective experience of breathing discomfort that varies in intensity. Breathlessness should not be mistaken for tachypnoea and its severity can only be judged by the patient. Breathlessness is frightening for both patients and their carers.
The neurophysiology of breathlessness is complex and not well understood. Normal breathing is maintained by regular rhythmical activity in the respiratory centre in the brain stem. This is stimulated by mechanical receptors (stretch receptors in the airways, intercostal muscles and diaphragm) and by hypoxia and hypercapnia (detected by chemoreceptors in the aortic and carotid bodies and in the medulla). In malignant lung disease breathlessness is usually due to distortion and stimulation of the mechanical receptors, and blood gases are often normal.
Breathlessness occurs in 50% of hospice patients, most commonly in cancers of the lung, breast, prostate, colon and rectum, yet in 25% of these patients there may be no evidence of lung or pleural involvement.
Consider Causes of breathlessness
Cancer related causes
•Primary or secondary tumour causing airway obstruction (always look for stridor), lung infiltration/lymphangitis carcinomatosis
Physiotherapists can teach patients and carers techniques to reduce the work of breathing, to encourage relaxation, to aid expectoration of secretions, and coping strategies to improve breathing control. Occupational Therapists can provide advice on pacing activities, relaxation and the provision of aids to help functional activities which have been limited due to breathlessness. Explanation to carers is also vital and carers can be involved in ensuring that patients use the “tripod” sitting position, using a stream of air from a fan or window across the face, in reassurance and in reminding the patient of breathing techniques. The introduction of breathlessness management clinics where a multi-professional team approach is used to assess and teach patients and carers to cope with breathlessness have been shown to be of value.
For breathlessness, BNSSG Formulary advise the following pharmacotherapies:
Oral morphine solution - to relieve sensation of breathlessness (TLS Green)
Lorazepam- for anxiety associated with shortness of breath (TLS Green)
Oxygen- trial if SaO2 < 90% (TLS Green)
Alternatives: (TLS Blue)
Oxycodone liquid – (TLS Blue- if morphine intolerant)
Fentanyl sc injection- (TLS Blue- if eGFR < 30mls/min)
Specific indications: (TLS Blue)
Dexamethasone –(TLS Blue- for Superior Vena Cava Obstruction (SVCO) or major airway obstruction)
Antibiotics – (TLS Blue- for infection)
Furosemide – (TLS Blue- for pulmonary oedema)
Salbutamol – (TLS Blue- for nebuliser for bronchospasm).
Even in the absence of obvious wheeze, there may be an element of reversible bronchoconstriction which will benefit from a trial of salbutamol. Nebulized salbutamol can cause tachycardia, tremor and anxiety.
Randomized controlled trials have shown both air and oxygen reduce breathlessness in patients with cancer. Oxygen can be helpful with or without hypoxia but the costs of using oxygen therapy are considerable in financial, patient and family anxiety, as well as logistical and safety terms. Oxygen therapy should not be undertaken lightly and only after a full discussion of the benefits and burdens. Offer to teach the patient to use a fan before a trial of oxygen even in patients with hypoxia. Patients may prefer to use oxygen in short bursts around exercise or mealtimes. Local supplementary oxygen guidelines should be consulted particularly for COPD patients.
In a 2010 study of 239 patients with life-limiting illness assessed as ineligible for long term oxygen therapy, a randomised trial showed no symptomatic benefit of oxygen over air delivered through nasal cannula.
It is very important to discuss the rationale for the above with patient and/or family.
Oxygen therapy should be administered according to current guidance attached
•Lymphangitis carcinomatosis - steroids or anti-cancer treatment
•Deconditioning - rehabilitation
•Depression - antidepressants
•Panic attacks - non-pharmacological approaches and benzodiazepines
Cough is a forced expulsive manoeuvre usually against a closed glottis and is associated with a characteristic sound. Cough may be present in up to 50% of patients with terminal cancer and up to 80% of patients with lung cancer. It occurs as a result of mechanical and chemical irritation of receptors in the respiratory tract.
The causes are similar to those causing shortness of breath. Prolonged bouts of coughing are exhausting, and can be associated with breathlessness, haemoptysis, pain, incontinence, insomnia and social isolation.
Assess type and severity of the cough and associated symptoms
Look for a cause or precipitant and treat reversible causes
Establish if the cough is productive or not
Dry cough may need suppression
Moist cough - the phlegm may need loosening to encourage expectoration or suppressing depending on prognosis
Terminal cough may need suppression
Simple measures such as increasing the humidity of the room should be considered
Reversible causes of cough
•Irritants and smoking
•Rhinitis/post nasal drip
•Gastro-oesophageal reflux disease
Chest infections commonly occur in the last few days of life. It may be inappropriate to treat relatively asymptomatic pneumonia. However, infected chest secretions may be copious and more effectively treated with antibiotics than by symptomatic measures alone such as antimuscarinics. Frequently patients have had several prior courses of antibiotics, in which case a short course of a broad spectrum antibiotic may be justified. See BNSSG Antimicrobial guidelines for more information.
Mucoloytics reduce sputum viscosity.
Steam inhalations or nebulized saline may liquidise tenacious sputum to allow a more productive cough.
Normal saline 2.5-5ml q.d.s. via nebulizer
Patients who are not immediately dying may benefit from active cycle breathing techniques and postural drainage to help clear sputum.
Demulcent cough preparations containing soothing substances such as syrup and glycerol taste good and are harmless and inexpensive.
Simple linctus 5mL (with 5mL warm water) q.d.s.
Cough sweets and over the counter preparations of the patient’s choice
Opioids act on the medulla suppressing the cough reflex
Codeine linctus 15mg/5mL at 5-10ml q.d.s.
Morphine solution 2.5-5mg may be given every 4 hours
Methadone 2mg/5ml linctus (specialist use) has a long half life and maybe more effective than morphine. Laxatives and anti-emetics should be considered.
Increased respiratory secretions (Bronchorrhoea)
Bronchorrhoea is defined as more than 100ml of sputum a day and is associated with bronchoalveolar cell carcinoma. Glucocorticoids may help reduce tumoral oedema thereby relieving cough. Ipratropium, antisecretory medications and nebulized indometacin may help.
These guidelines are for patients who are imminently dying and develop 'rattling' or 'bubbly' breathing (the death-rattle).
The following guidelines should not be used as they stand if the patient is still aware enough to be distressed by the dry mouth that will result from treatment.
1.Acute pulmonary oedema should be excluded, or treated with furosemide.
2.Try repositioning the patient on different sides.
3.Explain to any relatives present:
◦the noise is present because the patient is not coughing or clearing their throat as they normally would
Explanation and reassurance to the relatives are important, as medication will only stop the rattle in half of the patients.
◦if the patient is deeply asleep or unconscious, he/she will not be distressed by the rattling even though it may sound as though the breathing is difficult
◦despite best attempts at treating the rattle with medication, this does not always work
See Palliative Care Guidelines for specific dosage ranges for hyoscine hydrobromide and hyoscine butylbromide (TLS Green) subcutaneously and via CSCI. Doses above 1.6mg/24hr via CSCI can be sedating although the BNF states upto 2mg/24h is possible.
Glycopyrronium (TLS Blue) may also be used for the death rattle. It does not cause sedation or confusion, but lacks antiemetic effect, and sedation is often either required or irrelevant in the terminal stage. It is useful for the patient who is still conscious and wishes to remain as alert as possible. Equivalent doses are given in the links below: