Breathlessness (Palliative Care) Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • Patients over 18 years of age
  • Symptomatic treatment of breathlessness in advanced disease

This guidance does not cover:

  • Patients under 18 years of age
  • Treatment of acute reversible breathlessness

Assessment

  • Dyspnoea is a common symptom that can be very frightening and patients may fear that they will suffocate.
    • The pathophysiology of dyspnoea is poorly understood and the cause usually multi­factorial.
    • A careful assessment of the timing of onset and other associated symptoms may be useful.
  • Investigations such as chest x­rays, scans and blood gases are often of limited value in patients with advanced cancer. However, reversible causes should be considered and managed appropriately e.g. pulmonary embolism, congestive cardiac failure, cardiac arrhythmias, pleural effusion, infection, severe anaemia, SVCO.

Management

Non­pharmacological approaches
  • These may include using a fan or draft from an open window, physiotherapy, positioning, breathing techniques, massage, visualisation, CBT and distraction.
  • If patient are mouth breathing then good oral care is important.
  • The relative contribution of non­pharmacological and pharmacological treatments vary according to the stage of the patient's illness i.e. non pharmacological methods are likely to be most useful in patients who are only breathless on exertion, whereas for patients in the last few hours or days of life, pharmacological treatments predominate.
Bronchodilators
  • May be helpful even in the absence of obvious wheeze
  • Salbutamol via nebuliser or spacer
  • Ipratropium bromide via nebuliser or spacer
Opioids
  • Opioids reduce excessive respiratory drive and may make breathing more efficient, reducing the sensation of breathlessness
  • Opioids are useful treatments for breathlessness in patients with cancer and terminal respiratory failure e.g. secondary to COPD
  • There is no evidence that opioids cause respiratory depression if used in appropriate, proportionate doses
  • Oral morphine sulphate modified release 5-10mg BD would be a reasonable starting dose
  • Alternatively oral morphine immediate release 2.5-5mg, up to 4 hourly can be used.
  • Doses of oral morphine above 60mg in 24 hours are unlikely to produce further benefit
  • Morphine modified release seems to be less effective for breathlessness for some patients than immediate release morphine preparations given 4 hourly
  • If patient are already on strong opioids for pain then consider contacting the Specialist Palliative Care team for advice
Benzodiazepines
  • Whilst there is no consistent RCT evidence for the use of benzodiazepines in relieving breathlessness, they may be helpful in patients who feel anxious or panicky when breathless.
  • Lorazepam 0.5-1mg sublingually has a more rapid onset of action than diazepam, making it useful for acute panic
  • Midazolam 2.5mg SC may be useful in the last days of life where the oral/sublingual route is less well tolerated
  • If anxiety is a significant driver it may be appropriate to use and anxiolytic anti-depressant; Mirtazapine 15-30mg ON or Citalopram 10-20mg OD
  • Undesirable effects include drowsiness, falls, and memory and cognitive impairment. Use with appropriate monitoring and caution, particularly in elderly and frail patients.
  • Tolerance and dependence are unlikely to be problematic when used for 4 weeks or less.
Oxygen
  • Most patients will not benefit from oxygen therapy unless there is significant hypoxaemia. Some patients may derive considerable benefit although no change in blood gases can be detected, which may be a result of facial or nasal cooling or placebo. The same benefit may be derived by using a fan. Patients can become dependent on oxygen leading to increased social isolation.
  • If available, assess for hypoxia (may occur post exertion) using a pulse oximeter
  • Offer a trial of oxygen if SaO2 92% or lower on air
  • In patients with COPD SaO2 of 88-92% are accepted as normal.
  • Offer a trial of oxygen for a fixed period e.g. 15 – 30 minutes and assess response
  • Intermittent or continuous domiciliary oxygen can be prescribed. An oxygen concentrator is generally more cost­effective for patients requiring oxygen for more than 8 hours a day.
  • Respiratory Specialist Team – Home Oxygen Service Written or telephone referral to 01977 747437 / Fax 01977 747441

Managing breathlessness in the last few hours or days or life

Patients may be fearful, often unspoken, that they will die with acute, distressing breathlessness or suffocation. It can be helpful to discuss the management of breathlessness in the last few hours or days of life with patients, if appropriate.

A calm, positive and logical approach can do much to alleviate the distress of severe breathlessness in a dying patient. Occasionally breathlessness can be very difficult to control in the terminal phase, and sedation may then be necessary to alleviate distress.

  • Opioids would be the first line medication, if opioid naïve diamorphine 2.5 - 5mg PRN
  • If two or more doses are required within 24 hours consider starting a syringe driver, usually 5-10mg Diamorphine over 24 hours if opioid naive
  • For those already on opioids, PRN dose would be 1/6th of the 24 hourly SC dose.
  • Second line medication would be Midazolam 2.5-5mg PRN

Referral

Referral Criteria

Wakefield CCG
  • Eligibility for referral to specialist palliative care services (including inpatient, community, day hospice or outpatient service provision) is based on patient need not diagnosis:
    • The patient has active, progressive and usually advanced disease for which the prognosis is limited (although this may be several years) and the focus of care is quality of life.
    • The patient has unresolved complex needs that cannot be met by the caring team. These needs may be physical, psychological, social and /or spiritual. Examples may include complicated symptoms, difficult family situations, or ethical issues regarding treatment decisions.
  • Patients who meet the above criteria may be admitted to any part of the specialist palliative care service as required
  • An eConsultation request can also be sent via SystmOne
  • See palliative care contact details and resources for further information
North Kirklees
  • Common eligibility criteria were agreed in 2000 by all providers of SPC (specialist palliative care) working in Calderdale and Kirklees in order to ensure equity of access. The criteria reflects those adopted by other SPC services across the country and was incorporated into the new service agreement with Kirkwood on April 2015
  • There are three elements to the common eligibility criteria:
    • Patients should have active, progressive and potentially life-threatening illness
    • Patients should have unresolved, complex needs that cannot be met by the current caring team, or it is anticipated that the patient will develop such needs in the near future. These needs may be psychological, social, spiritual or physical
    • Patients must have been recently assessed by a member of a SPC team
  • See palliative care contact details for further information


Referral Forms

Wakefield CCG
North Kirklees CCG

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient Information/Public Health/Self Care

Evidence/Supporting Informtation

Useful Links

Hospice information
Other

Assurance & Governance

  • This guidance was developed on: 07.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified:08.2017
  • Publication Date: 08.2017
  • Review Date: 07.2019
  • Ref No: PL2 - 07.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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