JOURNAL OF PALLIATIVE MEDICINE Volume 18, Number 9, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2015.0109

Journal of Palliative Medicine 2015.18:805-806. Downloaded from by University Of Pittsburgh e-journal package on 11/13/15. For personal use only.

Subjective Dyspnea Paul B. Bascom, MD


he palliative medicine physician sat at the bedside, chair pulled up close, and explored with Anne her deepest concerns. The consult request had arrived mid-afternoon. ‘‘66-yearold woman with metastatic cancer, admitted last night with dyspnea. Expresses desire to die.’’ ‘‘Anne. What is it that most bothers you?’’ ‘‘I feel like I am having trouble breathing.’’ ‘‘And what does this mean to you?’’ he probed gently. ‘‘I worry that this means I can’t go home. I live by myself, and doing even simple things makes me so breathless that I don’t think I can care for myself anymore. I don’t think I will ever get home.’’ ‘‘And how does that make you feel?’’ ‘‘I feel hopeless. I feel despair.’’ Her words hung heavy in the silence. Anne had always been a fighter. Fierce and independent, she had always wanted more treatment, always willing to try something new for her slowly advancing malignancy. Now her spirit seemed broken. There was more to discuss, of course. But it was the end of yet another busy day. The palliative medicine physician decided further conversations could wait until morning. At home late that evening, the palliative medicine physician sat at his computer composing his consult note. He reflected on her words and entered his assessment: Subjective Dyspnea and Existential Suffering. He pondered how this could be palliated. After some consideration, he entered a recommendation for methylphenidate, which has been shown effective for severe depression at the end of life. He prepared to enter his note into the electronic medical record (EHR). Just at that moment, back at the hospital, events began to unfold in a direction the palliative medicine physician had not foreseen. As it turned out, Anne was actually having trouble breathing. Her respiratory system was failing. Her dyspnea was, in fact, objective. As the evening progressed, Anne eventually reached the point where she could no longer breathe enough to sustain her life. She lost consciousness. Her breathing became agonal. She began to die. The bedside nurse noted the abrupt change in Anne’s condition, noted further that Anne’s Code Status was listed as FULL, and initiated a Code 99. Anne was emergently intubated and transferred to the ICU. Review of the EHR

revealed her goal of ‘‘living as long as I can.’’ The ICU team noted the generous doses of morphine on Anne’s medication list, and initiated a naloxone infusion. Anne awoke abruptly in ICU, her peaceful CO2 narcosis replaced with acute opiate withdrawal, adding a cruel overlay to the immediate and excruciating return of her metastatic bone pain. Her prompt wakefulness in response to naloxone confirmed for the ICU team their diagnosis of respiratory arrest from opiate intoxication. The ICU team administered benzodiazepines, but only in judicious doses, lest they again compromise her respiratory function. Had they stopped to do a spontaneous breathing trial, however, the ICU team might have noted that the naloxone had not improved Anne’s ventilatory function to anywhere near levels sufficient to sustain life. The unsuspecting palliative medicine physician was greeted in the morning by an urgent phone call, summoning him to the ICU, and updating him on the previous evening’s events. Embarrassed and chagrined, he encountered the ICU in an uproar. Now beyond despair, Anne was furious, adamant that the breathing tube be removed. ‘‘RIGHT NOW,’’ her lips wordlessly but unmistakably demanded. Her hands gesticulated wildly, drawing her fingers across her neck, or pantomiming using scissors to cut the tube. Only when she promised not to take matters into her own hands, by pulling the tube out herself, was the threat of wrist restraints withdrawn. The palliative medicine physician knew he had the tools to calm the roiling waters. He again pulled his chair up close to the bedside. ‘‘Anne. What matters most to you now?’’ ‘‘I want to die. I’m ready.’’ ‘‘We will keep you comfortable,’’ he assured her. And so the naloxone was discontinued and the morphine reinitiated in a high-dose infusion. And when Anne’s closest friends had gathered at the bedside, and she was again calm, and she had bid her friends ‘‘good-bye,’’ she mouthed the words ‘‘thank you’’ and closed her eyes. The palliative medicine physician held her hand as the tube was removed, and she slipped away swiftly, peacefully. And later that night, not at all peaceful, the palliative medicine physician stared at the ceiling and wondered . Why had Anne developed respiratory failure? Had her slowly progressive malignancy suddenly become more aggressive?

Palliative Medicine Physician, Portland, Oregon.


Journal of Palliative Medicine 2015.18:805-806. Downloaded from by University Of Pittsburgh e-journal package on 11/13/15. For personal use only.


Could it have been something reversible? Cardiogenic pulmonary edema from her experimental chemotherapy? Noncardiogenic edema from her experimental chemotherapy? Bronchospasm, pneumonia, pulmonary embolism, pneumonitis . Had her expressed wish to die led her treating team to stop looking for a treatable etiology? And more troubling questions rose to the surface with uncomfortable persistence. Should he have foreseen this the night before? Had his failure to anticipate her swift decline caused Anne needless suffering? And yet more questions: some shallow and selfish: Should he, could he, revise his original consult note? And some profound and troubling: Can someone in the midst of iatrogenic acute opiate withdrawal be considered to have decision making capacity, particularly when they insist that they want to die? Should he have acceded so quickly to Anne’s request? Or should he have explored the request further, allowing Anne to


grapple with her fears, providing an opportunity for transcendence at the end of life? Had his own emotional distress led him to seek the most expedient solution? Had Anne’s death been hastened? Or . Was this the best possible outcome, a fierce, tumultuous, and swift exit, fully consistent with Anne’s truest self? Something she probably preferred to an agonized slow dribble off the table of life? Through the night, the palliative medicine physician posed these questions to the ceiling. The ceiling remained mute.

Address correspondence to: Paul B. Bascom, MD 3439 NE Sandy Boulevard #601 Portland, OR 97232 E-mail: [email protected]

Subjective Dyspnea.

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