How successful are we in relieving terminal dyspnea in cancer patients? A real-world multicenter prospective observational study

Unanswered questions and future direction in the management of terminal breathlessness in patients with cancer

“…A recent systematic review of literature published until 2016 identified only five studies (two RCTs and three prospective cohort studies) that investigated the effectiveness of drug therapy for breathlessness in the last days of life 29. Several new papers have since been published 23 30–32. Below is a summary of available evidence for the main treatment modalities for breathlessness and related conditions in patients with cancer with estimated life expectancy of weeks to days.…”

“…In addition, these studies included only cognitively competent patients with cancer with breathlessness. In clinical practice, morphine is widely used in various forms including continuous intravenous/subcutaneous infusion to ensure timely titration, rapid breathlessness relief and the avoidance of unnecessary adverse events in the setting of clinical deterioration and organ dysfunction during the last weeks to days of life 32 36 37. Thus, it is uncertain whether these results can be applied to patients with cancer who are very close to death.…”

“…This lack of evidence results in a wide variability in the practice of treating patients with terminal breathlessness among palliative care specialists 32 37. A number of important clinical questions have yet to be answered.…”

“…Most patients wish to have symptom relief and remain mentally aware at the end of life 86. However, imminently dying patients tend to show a decline in consciousness associated with organ dysfunction as part of the natural dying process, irrespective of the use of opioids and/or sedatives 6 8 32. In addition, terminal breathlessness may become refractory to standard symptom management, and sometimes require palliative sedation.…”

“…In addition, terminal breathlessness may become refractory to standard symptom management, and sometimes require palliative sedation. Thus, the management of terminal breathlessness needs to take into account a delicate balance of trade-off between breathlessness relief and maintenance of consciousness 32. Best balance of the trade-off highly depends on patients’ goals and preferences.…”