Morphine for dyspnea control in terminal cancer patients: is it appropriate in Taiwan?

Morphine for dyspnea control usually arouses ethical controversy in terminal cancer care. This study prospectively assessed the use of morphine for dyspnea control in terminal cancer patients in terms of two characteristics: the extent to which medical staff, family, and patients found morphine to be ethically acceptable and efficacious, and the influence of morphine on survival. One hundred and thirty-six palliative care patients meeting specific eligibility criteria were enrolled. A structured data collection form was used daily to evaluate clinical conditions, which were analyzed at the time of admission and 48 h before death. Sixty-six (48.6%) of the 136 patients had dyspnea on admission. The intensity was mild in 14.0% and moderate or severe in 34.6%. The intensity of dyspnea became worse 48 h before death (4.29+/-2.55 vs. 4.94+/-2.60, P < 0.001, range 0-10). Twenty-seven (40.9%) of 66 patients with dyspnea received morphine on admission for the control of dyspnea; the routes of administration were oral (59.3%) and subcutaneous (40.7%). Fewer than two-thirds (59.3%) of the patients were given morphine with the consent of both patient and family. More than one-third (40.7%) on admission and about one-half (52.8%) in the 48 h before death had the consent of family alone. Positive ethical acceptability and satisfaction with using morphine for dyspnea control were found in both medical staff and family in this study. Multiple Cox regression analysis showed that using morphine for dyspnea, both on admission and in the 48 h before death, did not significantly influence the patients' survival (HR: 0.015, 95% CI: 0.00-4.23; HR: 1.76, 95% CI: 0.73-4.24). In this population, the use of morphine for dyspnea control in the terminal phase of cancer was effective and ethically validated in the study. Research efforts to find the most appropriate route and dosage of morphine for dyspnea, based on the patient's situation, remain worthwhile.

Ensuring competency in end-of-life care: controlling symptoms

BACKGROUND: Palliative medicine is assuming an increasingly important role in patient care. The Education for Physicians in End-of-life Care (EPEC) Project is an ambitious program to increase core palliative care skills for all physicians. It is not intended to transmit specialty level competencies in palliative care. METHOD: The EPEC Curriculum was developed to be a comprehensive syllabus including trainer notes, multiple approaches to teaching the material, slides, and videos of clinical encounters to trigger discussion are provided. The content was developed through a combination of expert opinion, participant feedback and selected literature review. Content development was guided by the goal of teaching core competencies not included in the training of generalist and non-palliative medicine specialist physicians. RESULTS: Whole patient assessment forms the basis for good symptom control. Approaches to the medical management of pain, depression, anxiety, breathlessness (dyspnea), nausea/vomiting, constipation, fatigue/weakness and the symptoms common during the last hours of life are described. CONCLUSION: While some physicians will have specialist palliative care services upon which to call, most in the world will need to provide the initial approaches to symptom control at the end-of-life.

Managing dyspnea and cough

Dyspnea, like pain, is a subjective experience that incorporates physical elements and affective components. Management of breathlessness in patients with cancer requires expertise that includes an understanding and assessment of the multidimensional components of the symptom, knowledge of the pathophysiologic mechanisms and clinical syndromes that are common in cancer, and familiarity with the indications and limitations of the available therapeutic approaches. Relief of breathlessness should be the goal of treatment at all stages of cancer. Good control of dyspnea will improve the patient's quality of life.

Nebulized morphine for paroxysmal cough and dyspnea in a nursing home resident with metastatic cancer

Nursing homes continue to be challenged with the task of caring for patients in various stages of disease. Historically, the death of a long-term care patient in this setting is not unusual; however, researchers and clinicians are focusing increasingly on the quality of life at the end of life, regardless of location. The long-term care facility is an ideal setting in which to begin to effectively address these issues, especially as individual patients in need present for care. Although the care of many of our geriatric patients meets the definition of palliative care, no where is the need greater, and more obvious, than in the patient presenting with terminal illness. Aggressive treatment of distressing symptomatology contributes to overall quality of life, and returns to the patient some of the freedom and autonomy usurped by the disease process. It is particularly rewarding for the interdisciplinary team to be successful in controlling symptoms in the patient with limited life expectancy, thus allowing the patient to complete unfinished tasks and enjoy quality time with family and friends. Often the "triumphs" in the nursing home are few and fleeting; abolishing pain, distress, and suffering is both personally and professionally satisfying for everyone involved. We presented a review of the available literature on a technique in palliative medicine which is still evolving. Additional, we presented its practical use in a frail, elderly nursing home resident admitted with end-stage metastatic breast carcinoma. The geriatric adage of "start low, and go slow" was effectively borne out in the management of this resident's most difficult symptoms, shortness of breath and paroxysmal cough leading to symptomatic atrial fibrillation. The key to the management of the frail elderly patient goes beyond " start low and go slow" to "aggressively titrate as needed but no further" in order to meet the needs of the individual patient and avoids unwanted side effects.

Management of dyspnea and cough in patients with cancer

The understanding and treatment of dyspnea in the cancer patient are where the science of pain management was 15 or 20 years ago. Very few studies have examined the pathophysiologic mechanisms that cause dyspnea in cancer patients, and few investigators have evaluated therapeutic strategies to control dyspnea in this patient group. The optimal therapy for dyspnea is treatment of the underlying cause. When this is not possible, opioids and phenothiazines provide effective symptomatic relief in most cases, but many unanswered questions remain. Are these the optimal drugs, and what are their optimal doses? What are the effects of chronic dosing? Which is the best route of administration? How serious are the risks of respiratory depression? A clear consensus supports the aggressive treatment of pain in terminally ill cancer patients, even if death is hastened as an unintended consequence. No such position has yet been reached in the management of dyspnea in the same population. As a result, dyspnea is addressed only very late in the course of the disease, perhaps reducing the patient's quality of life and function at earlier stages and resulting in a very small "therapeutic window" in the terminal phase. Clearly, a need exists for more research to determine the most effective management of this common and very distressing symptom.