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  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
  • More About:

  • Hospice Care
  • Clergy and Faith Communities
  • Additional Links
    Site Index
    Back to Module 10: Common Physical Symptoms

    Recommended Literature
    Appendix Downloadable Documents and Worksheets

    Recommended Literature

    Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine. 2nd ed. Oxford, England: Oxford University Press; 1998.

    Ferris FD, Flannery JS, McNeal HB, Morissette MR, Cameron R, Bally GA, eds. Module 4: Palliative care. In: A Comprehensive Guide for the Care of Persons with HIV Disease. Toronto, Ontario: Mount Sinai Hospital and Casey House Hospice Inc.; 1995.

    Storey P, Knight CF. UNIPAC Four: Management of Selected Nonpain Symptoms in the Terminally Ill. Hospice/Palliative Care Training for Physicians: A Self-study Program. Gainesville, FL: American Academy of Hospice and Palliative Medicine; 1996.

    Storey P. Primer of Palliative Care. 2nd ed. Gainesville, FL: American Academy of Hospice and Palliative Medicine; 1996.

    Weissman DE. Management of terminal dyspnea. Available at: http://www.grand-rounds.com/mayjune95/5no3terminaldyspnea.html. Accessed December 23, 1998.



    Intended vs. Unintended Consequences

    • Primary intent dictates ethical medical practice
      Many physicians believe that medications used to manage symptoms have an unusually or unacceptably high risk of an adverse event that may shorten a patient’s life, particularly when he or she is frail or close to the end of his or her life. Instead of fully understanding and discussing the potential benefits and risks of these therapies with their patients, taking into account their goals for care, this fear of an adverse unintended consequence often leads clinicians to withhold treatment or dose inadequately, thus leaving their patients suffering unnecessarily. Many physicians inappropriately call this risk of a potentially adverse event, a double effect, when it is in fact a secondary, unintended consequence.
      When offering a therapy, it is the intent in offering a treatment that dictates whether it is ethical medical practice:
    • if the intent in offering a treatment is desirable or helpful to the patient and the potential outcome good (such as relief of suffering), but a potentially adverse secondary effect is undesired and the potential outcome bad (such as death), then the treatment is considered ethical
    • if the intent is not desirable or will harm the patient and the potential outcome bad, the treatment is considered unethical
      Concerns about intended vs. unintended consequences are most commonly invoked around such issues as the treatment of pain or dyspnea with opioids. However, all medical treatments have both intended effects and the risk of unintended, potentially adverse, secondary consequences. Some examples are listed in the following table:

    Intended vs. Unintended Consequences



    Potential Adverse, Secondary Consequences

    TPN for short gut syndrome

    Improved nutritional status

    Sepsis, death


    Cure or reduce the
    burden of cancer

    Immune suppression,
    cytopenias, death


    Prevent arrhythmia

    Promote arrhythmia,

    Epidural administration of analgesia

    Reduce pain

    Sepsis, death

    Stopping all lab tests

    Reduce burden of investigation for patient

    Electrolyte imbalance,

    Operation to repair broken hip

    Reduce pain,
    improve function

    Cardiac arrest,
    death during surgery


    Principle of Double Effect

      The principle of double effect refers to the ethical construct where a physician uses a treatment, or gives medication, for an ethical intended effect where the potential outcome is good (e.g., relief of a symptom), knowing that there will be an undesired secondary effect (such as death). Although this principle of "double effect" is commonly cited in symptom control, in fact, it does not apply, as the secondary adverse consequences are more likely not to occur.
      Euthanasia is not an example of "double effect." The intent in offering the treatment is to end the patient’s life through an active medication (see Module 5: Physician-Assisted Suicide).


    Concerns About Symptom Management

      Concerns that the principle of double effect may be an issue when managing symptoms are raised by the fact that, like other medical treatments, there is a risk that treatments to control symptoms could produce adverse consequences including death, either when improperly used or, very rarely, when properly used. In suffering states of life-threatening illness, death may seem appealing and what is ordinarily intuitive may become complex. For many interventions, such as chemotherapy, TPN for short gut syndrome, surgery, and noninterventions such as stopping all lab tests or avoiding surgery, we make decisions knowing there is a risk of adverse events, in particular, death. As long as (a) the intent is to relieve suffering and not hasten death, (b) death is a possible and not inevitable outcome of the interventions, and (c) there is fully informed consent, there is no ethical concern.
      In contrast, if symptom control involves treatments that are intended to cause death, as the means to relieve suffering, then there is ethical concern. If the patient seeks hastened death by physician-assisted suicide or euthanasia, the clinical and ethical issues are different. In no case should physicians hypocritically and untruthfully call their ministrations palliative or comfort care when, in fact, the intention is to cause death.
      Fortunately, these difficult circumstances need not occur. Adequate symptom management can be achieved without causing death. If the intent in offering a medication such as an opioid is to relieve suffering (e.g., pain, breathlessness) and not cause death, and accepted dosing guidelines are followed:
    • the treatment is considered ethical
    • the risk of a potentially dangerous adverse secondary effects is minimal
    • the risk of respiratory depression is vastly over-estimated. Patients will become drowsy, confused and lose consciousness long before their respiratory rate is compromised


    Providing Palliative Treatment That Might Hasten Death

    • It is the physician’s responsibility to understand to the best of his/her ability the cause of the patient’s suffering, the underlying pathophysiology and psychosocial-spiritual issues, and the possible therapies and pharmacology that could benefit the patient, as well as their potential risks
    • It is the patient’s decision, in consultation with her or his physician(s), to decide either to risk the adverse effects of a particular treatment, or forgo the treatment
    • Likewise, it is the patient’s decision, in consultation with his/her physician(s), to terminate a course of treatment
    • For many patients, the consequences of unrelieved symptoms are worse than the possibility of dying
    • The administration of a medication necessary to ease the pain of a patient who is life-threateningly ill and suffering excruciating pain may be appropriate medical treatment even though the effect of the medication may shorten life

    AMA’s Council on Ethical and Judicial Affairs

    • When physicians provide palliative treatments in an appropriate manner to relieve pain and suffering, they provide a concrete benefit to their patients. For those with advanced illness, the relief will be worth more than the possible risk of death
    • If the patient is not capable of making this decision, efforts should be taken to determine through other means a "substituted judgment" or determination of the "best interests" of the patient


    Treatment of Selected Underlying Causes of Breathlessness


      Although wheezes and/or rhonchi may be present, always look for intercostal retraction on examination (evidence of bronchoconstriction, increased inspiratory pressures). If bronchospasm is suspected, a clinical trial of bronchospasmolytics may be indicated (though careful consideration of the potential of b-adrenergic agents, e.g., albuterol, to cause adverse cardiac effects in patients with cardiac compromise). Frail patients may have difficulties using puffers, even with aerochambers. Nebulized aerosols may be more effective. If adequate doses are ineffective, discontinue therapy to minimize the number of medications, risk of adverse effects, and cost. Possible medications include:
    • steroids to reduce swelling and inflammation
      • dexamethasone 2–20 mg PO, IV, SC q d (long half-life permits once-daily dosing; minimal glucocorticoid effects and edema)
    • albuterol 2–3 puffs q 4–8h (with aerochamber) or albuterol 0.5% 2.5–5.0 mg diluted to 4.0 mL with saline by nebulizer q 4h
    • ipratropium bromide 2–3 puffs q 4–8h prn or 0.125 mg q 4h via nebulizer
    • theophylline and adrenergic agents may cause tremor and anxiety that will exacerbate dyspnea

    Thick Secretions

      Thick secretions can accumulate around tracheostomy appliances and in airways of patients with obstruction or bronchospasm or those who are weak/frail. To minimize secretion buildup, maintain best possible hydration of the patient, keep mucous membranes moist, and increase humidity of inspired air (be careful not to increase risk of respiratory infections). If cough reflex is strong, loosen secretions with nebulized saline and guaifenesin. If cough reflex is weak, dry secretions with:
    • scopolamine 0.1–0.4 mg SC, IV q 4h or 1–3 transdermal patches q 72h or 10–80 mg/h by continuous IV or SC infusion
    • glycopyrrolate 0.4–1.0 mg q d by SC infusion or 0.2 mg SC, IV q 4–6h prn
    • hyoscyamine 0.125 mg po or sl q 8h

    Pleural Effusion

      Pleural effusions can reduce lung volume considerably and cause great distress. Thoracentesis may be effective if fluids are not loculated. If the effusion continues to recur and thoracentesis is ineffective, consider talc, tetracycline, or bleomycin pleurodesis or Tenckhoff catheter insertion to facilitate repeat drainage (drainage can be done at home by visiting nurse).


      Selected patients who are anemic and breathless may benefit from a blood transfusion. A clinical trial is suggested. Transfuse to a hemoglobin level greater than10 g/dL and evaluate over several days (there is an initial placebo effect). If the patient experiences a sustained increase in his or her energy and/or reduced breathlessness, consider following the CBC and transfuse as needed. If there is no benefit, do not follow the CBC or repeat transfusion.
      If the patient has a life expectancy of months or more, consider epoetin alfa 10,000 IU SC 3 times per week (onset of effect takes 4 weeks). Double the dose if the hemoglobin does not increase by more than 1 g/dL within 4 weeks.

    Airway Obstruction

      Airway obstruction can cause considerable distress. High-pitched inspiratory stridor is often audible at a distance. Make sure tracheostomy appliances are cleaned regularly. If the patient is still eating and aspiration is likely, puree solids, thicken liquids with cornstarch or other thickeners, and instruct family members and caregivers on positioning during feeding and suctioning. Surgical management or radiation therapy may be appropriate. Possible medications include:
    • steroids to reduce swelling and inflammation
      • dexamethasone 2–20 mg PO, IV, SC q d (long half-life permits once-daily dosing; minimal mineralocorticoid effect or edema)
    • manage thick secretions
    • racemic epinephrine by inhaler
    • oxygen mixed with helium


    Downloadable Documents and Worksheets