Breathlessness in the dying phase

NICE (1) state that:

• consider managing breathlessness with:
  • an opioid or
  • a benzodiazepine
  • or a combination of an opioid and benzodiazepine

Breathlessness in the dying phase

• for many patients the fear of dying in a state of marked breathlessness with acute anxiety / panic is their biggest, if unspoken, fear
  
  
• in the last days of life;
  
  
  • consider using an end of life care pathway. Prescribe PRN drugs as described below in anticipation of anxiety or distress caused by breathlessness. Many patients will become unable to take drugs by the oral route so prescribe medication to be given parenterally e.g. subcutaneously. Consider stopping or reducing clinical (artificial) hydration if this is causing fluid overload leading to pulmonary oedema or excessive upper airway secretions
    
    
  • drugs
    • Midazolam 2.5 - 5mg SC hourly PRN
      
      
    • Morphine 2.5 - 5mg SC 1 - 2 hourly PRN (higher doses of morphine may be appropriate in patients who are already receiving regular strong opioids. In patients who need repeated (hourly) doses seek specialist palliative care advice.)

Patients who are persistently breathless and distressed may benefit from a continuous infusion of morphine and/or midazolam - in practice try to ascertain the required dose(s) by observing and titrating according to usage of morphine or midazolam over the previous 24 - 48 hours

For some patients in the dying phase it may be more practical to commence an infusion of morphine or midazolam at an earlier stage alongside the provision of additional PRN medication. The following ranges are usually appropriate:

• morphine 5 - 10mg sub cut infusion over 24 hours
• (higher doses of morphine may be appropriate if the patient is already receiving regular strong opioids for pain)
• combining morphine and midazolam to manage breathlessness in the last days of life is common practice in palliative care.

Reference:

1. NICE (December 2015). Care of dying adults in the last days of life
2. West Midlands Palliative Care Physicians (2012). Palliative care - guidelines for the use of drugs in symptoms control.