Dyspnea is an extremely common symptom among cancer patients. Like pain, it is inherently subjective and is best defined as the perception of difficulty in breathing, or an uncomfortable awareness of breathing. Although it may be associated with one or more physiologic disturbances (such as hypercapnia, hypoxia, obstructive or restrictive patterns on pulmonary function tests, or various abnormalities on chest imaging studies), it is not strongly associated with any specific abnormality and may occur in the absence of any. Patient self-report is the gold standard for assessment and may range from mild breathlessness on exertion to a terrifying sense of suffocation.
Drs. Thomas and von Gunten provide a lucid overview of dyspnea and describe the management approach preferred by palliative-care specialists. They make several points that deserve emphasis.
Goals of Care
Effective management of dyspnea is predicated on good communication, a clear understanding of the goals of care, and a comprehensive assessment. A style of communication that is unhurried, calm, and compassionate may itself be therapeutic in the context of a distressing symptom. Ongoing assessment should be linked to education of the patient and family about the symptom and its treatment. A plan for accessing care on an around-the-clock basis is extremely important in addressing this symptom, which may be experienced as a harbinger of death.
The goals of care frame the extent of the evaluation and define the appropriateness of various therapeutic strategies. For patients who appear to have relatively long life expectancies and goals that include functional restoration, the evaluation of potentially treatable primary causes may be extensive, and a full range of primary and symptomatic treatments may be considered. Specialists in pulmonary medicine may be consulted in such cases.
For those with short life expectancies, the goals of care usually stress symptom control over functional gains, and evaluation may be limited to approaches that carry a minimum burden. It is in this population that the role of sedation as a therapeutic approach to address refractory symptoms has gained the strongest support.