Lung cancer is a disease with a high death rate, despite advances in prevention, diagnosis and treatment. The end of life brings physical, psychological, social and spiritual challenges for patients, families and caregivers. Advance planning can improve comfort and lessen anxiety. This may be done more effectively with some knowledge of what to expect.
Difficulty Breathing
Dyspnea is the medical term for breathlessness. A study of dying patients at five teaching hospitals throughout the United States revealed that severe dyspnea occurred in 32 percent of patients with lung cancer. The research was conducted as part of the Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment (SUPPORT) and published in the May 2000 "Journal of the American Geriatrics Society." Patients may be more comfortable when oxygen or room air is provided by nasal cannula; even the breeze of a fan can provide some relief. At the American Thoracic Society's 2008 International Conference in Toronto on May 20, 2008, it was announced that the use of non-invasive ventilation (NIV), reduces the need for morphine in dying patients and improves comfort better than standard oxygen therapy. NIV helps reduce the work of breathing by delivering air pressure through a mask that aids inflation of the lungs and helps them remain open. The mask can be removed and replaced easily as desired by the patient.
Pain
The SUPPORT study also determined that 28 percent of lung cancer patients experience severe end-of-life pain. Management of pain is complex. A graduated step and multifaceted approach generally follows a course of non-narcotic medications for mild discomfort and opioid drugs for moderate-to-severe pain. By beginning with low doses and increasing narcotic tolerance gradually, side effects such as respiratory depression can be avoided in lung cancer patients.
Delirium
Visual and tactile hallucinations, delusions, incoherent speech and anxiety are characteristic of delirium. Patients may be disoriented, not knowing where they are or what is happening to them. The symptoms are common in up to 85 percent of patients at the end of life, according to research conducted at Cornell University, New York. Published in the December 2008 issue of the "Journal of the American Medical Association," the study highlights the case of a man with lung cancer and states that delirium with or without agitation may be caused by organ failure, infection or side effects of medications. Accurate diagnosis is vital to appropriate treatment.
Noisy Breathing
Also known as the death rattle, noisy breathing in patients dying of lung cancer and other conditions is thought to be the result of increased oral and respiratory secretions. Nurses generally try position changes and suction to alleviate this distressing symptom and doctors may order medications, the side effects of which may cause dry mouth or agitation. A 2008 Cochrane Review of these interventions found none of them to be more effective than placebo and suggested that explanation, reassurance and a discussion of fears and concerns would be more helpful to family members.
References
- "Journal of The American Geriatrics Society", Dying with Lung Cancer or Chronic Obstructive Pulmonary Disease: Insights from SUPPORT. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments, Claessens MT, et. al., May 2000, 48(5Suppl)
- American Thoracic Society's 2008 International Conference in Toronto, Canada, Noninvasive Oxygen Therapy Eases Final Hours, Days for Lung Cancer Patients, Press Release May 20, 2008
- "JAMA", Agitation and Delirium at the End of Life: "We Couldn't Manage Him", Breitbart W, Dec. 24, 2008, 300(24)
- "Cochrane Database of Systematic Reviews", Interventions for Noisy Breathing in Patients Near to Death, Wee B, Hillier R, 2008, 1
