Palliative care I Dyspnea

Introduction

Dyspnea, or shortness of breath, is a serious symptom in palliative medicine. It is a deeply subjective sensation that, like pain, is associated with a significant reduction in the quality of life. Dyspnea can be associated with the experience of an existential threat and fear of death. Difficulty in breathing is not measurable or quantifiable and must not be confused with objectifiable parameters such as pulse-oxymetrically measured hypoxia.

Shortness of breath is a common symptom of the terminal and final phase of life and it affects more than 50% of palliative care patients. It has a significant impact on the perceptions of the people caring for the patient. Shortness of breath is easily transmitted to the people in the immediate vicinity and can trigger feelings of threat and fear in them too. It especially causes feelings of helplessness in helpers.

Apart from the psychosocial strain of overwhelmed relatives, shortness of breath is the most common reason for admitting a patient to hospital at the end of their life (1).

The fourfold human being in dyspnea

In dyspnea, changes occur in the patient’s fourfold nature. Physical causes of dyspnea are,
in tumor patients: lung metastases or tumors, tumor-related upper respiratory tract congestion, pleural carcinoma, lymphangiosis carcinomatosa, pleural effusion, pericardial effusion, (recurrent) pulmonary embolism, general physical weakness, anemia, pneumonia, ascites, etc.
in non-tumor patients: bronchial obstruction in COPD, pulmonary congestion in terminal heart failure, abnormally viscous mucus, e.g., in cystic fibrosis, insufficiency of the respiratory muscles in amyotrophic lateral sclerosis, etc.

As a result of hypoxia and hypercapnia, the patient’s life organization is close to “suffocation” and is therefore limited in its regenerative, constructive capacities. The dyspnea itself points to the patient’s sensory or astral organization: dyspnea is a sensation often associated with changes in breathing (tachypnea, prolonged expiration) and tachycardia. Increased mental tension is expressed in the activation of the autonomic nervous system and leads to increased sympathetic tone accompanied by restlessness. The experience of shortness of breath almost never occurs in isolation but is almost always associated with another cardinal symptom in palliative medicine: fear. The sentient organization (astral organization) is the carrier of the human soul. Accordingly, the breathlessness and fear experienced in the astral organization can form such a close connection that their causes can no longer be separated. Fear of suffocation touches a primal human fear and symbolizes an agonizing death. Fantasies of drowning often go hand in hand with this kind of fear. This clearly shows the existential threat of dyspnea: the patient experiences herself endangered and threatened as an individual being, as an “I”.

Therapeutic aspects

Breathlessness can be experienced with different degrees of severity and can therefore also be evaluated by the patient in more than one way. Some patients have been accustomed to breathlessness for many years and are not worried by a lack of air after minimal physical exertion, while others find this restriction threatening if they were still able to exert themselves a short time ago.

It is important for the therapist and palliative care physician to recognize and understand the threat to the patient and to refrain from imposing their own subjective assessments.

Shortness of breath must not be trivialized, and it should be treated and alleviated immediately! Its treatment consists of multimodal therapy based on the underlying disease processes. The therapy is oriented towards the different dimensions of dyspnea and includes—in addition to medicinal therapy—external applications, rhythmical massage therapy, eurythmy therapy, art therapy and talk therapy to support the patient.