Management of dyspnea at the end of life

We thank Dr Slawnych for his excellent “Practice” article on dyspnea and agree, “No one should die suffering from breathlessness”. We wish to provide observations on the role of benzodiazepines, antipsychotics and other psychotropics for dyspnea, from our perspective as palliative care providers. Like Dr. Slawnych, we acknowledge the dearth of evidence supporting clinical practice.

Dr Slawnych mentions the use of benzodiazepines as second line agents if symptoms persist despite opioids. We appreciate that there is mention of referral to palliative medicine physicians in these circumstances. However, given limited access to this specialty, we are concerned that this recommendation may lead to increased use of benzodiazepines. A 2016 Cochrane review notes that benzodiazepines have limited efficacy for dyspnea, although they are potentially helpful for anxiety caused by the sensation of dyspnea1. Similarly, the Cancer Care Ontario guidelines suggest use of benzodiazepines for anxiety in patients who have higher PPS and do not recommend them for dyspnea itself2.

The article comments on the role of antipsychotics such as methotrimeprazine for management of agitation related to dyspnea but there is some evidence of benefits for specific antipsychotics for dyspnea itself. As with benzodiazepines there is limited evidence but our experience is they have the potential to alleviate dyspnea, not just agitation, and may be especially relevant later in the course of illness. Additionally, there is emerging evidence that serotonin may play a role in the experience of dyspnea; studies investigating the use of medications that increase serotonin are underway3. Opiates, benzodiazepines, and antipsychotics all have potential for side effects such as confusion, falls, and drowsiness and the choice of second line agents should depend on the nature of symptoms, frailty of the patient, and where they are at in the course of their illness. Finally, there is reasonable-quality evidence for use of non-pharmacological interventions such as a fan on the face, cooler temperatures, and body positioning – and these should certainly be optimized before adding pharmacological agents.

We recognize that the format of the CMAJ paper limits nuance but did want to ensure that it does not lead to excess use of benzodiazepines by physicians with less experience in palliative care or limited opportunities to access clinical support.