Palliative Care for End-Stage Lung Disease Patients

Although the length of survival in end-stage lung disease (ESLD) patients is difficult to predict, it is the physician’s role to initiate end-of-life (EOL) discussions with the patient and to facilitate advance medical planning (AMP). AMP should evolve by continuing communication between physician, patient, and patient’s proxy, and the informed choices that the patient makes should be recorded. Home-based hospice care is an option that should be included in EOL discussions. The goal of palliative care should be to provide the best quality of life (QOL) for the patient by symptom relief through pharmacologic and nonpharmacologic modalities. Dyspnea is a common and distressing symptom for ESLD patients. Opioids (nonnebulized forms), bronchodilators (short-acting beta-2 agonists), oxygen, and pulmonary rehabilitation and inspiratory muscle training provide dyspnea relief and may improve QOL. Neither fear of respiratory depression nor addiction should deter physicians from using opioids to relieve dyspnea in ESLD patients. The dose of opioids needed to relieve dyspnea is less than needed for pain relief, and improvement in breathlessness can be achieved without a significant increase in arterial carbon dioxide level. Although Medicare criteria used for long-term oxygen treatment are based on oxygen saturation or tension measurements, these criteria are waived when oxygen is used for palliation of dyspnea in patients enrolled in a hospice program. Short-acting beta-2 agonists should be tried on all dyspneic ESLD patients and maintained if the patient notes improvement in dyspnea. Additional bronchodilator(s) may help some patients. Cough, anxiety, depression, delirium, and other symptoms must be controlled with appropriate medications. Time spent in an unhurried manner with the ESLD patient and family with sensitivity and responsiveness to their needs is a major contribution that a physician can make.