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How successful are we in relieving terminal dyspnea in cancer patients? A real-world multicenter prospective observational study

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Abstract

Purpose

Parenteral morphine is widely used for dyspnea of imminently dying cancer patients, but the outcomes to expect over time remain largely unknown. We examined outcomes after the administration of parenteral morphine infusion over 48 h in cancer patients with a poor performance status.

Methods

This was a multicenter prospective observational study. Inclusion criteria were metastatic/locally advanced cancer, ECOG performance status = 3–4, a dyspnea intensity ≥ 2 on a Support Team Assessment Schedule, Japanese version (STAS-J), and receiving specialized palliative care. After initiating parenteral morphine infusion, we measured dyspnea STAS-J as well as Memorial Delirium Assessment Scale (MDAS), item 9, and Communication Capacity Scale (CCS), item 4, every 6 h over 48 h.

Results

We enrolled 167 patients (median survival = 4 days). The mean age was 70 years, 80 patients (48%) had lung cancer, and 109 (65%) had lung metastases. The mean STAS-J scores decreased from 3.1 (95% confidence interval (CI) = 3.0–3.2) at the baseline to 2.1 (95%CI = 1.9–2.2) at 6 h, and remained 1.6–1.8 over 12–48 h. The proportion of patients with dyspnea relief (STAS-J ≤ 1) increased to 39% at 6 h, and ranged between 49 and 61% over 12–48 h. In contrast, up to 6.6 and 20% of patients showed hyperactive delirium (MDAS item 9 ≥ 2) and an inability to communicate (CCS item 4 = 3), respectively, over 48 h.

Conclusions

Overall, terminal dyspnea was relatively well controlled with parenteral morphine, though a significant number of patients continued to suffer from dyspnea. Future efforts are needed to improve outcomes following standardized dyspnea treatment using patient-reported outcomes for imminently dying patients.

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Funding

This work was funded by a Health Labour Sciences Research Grant from the Ministry of Health, Labour and Welfare. The funding source had no involvement in the study design; collection, analysis, or interpretation of data; writing of the manuscript; or the decision to submit the manuscript for publication.

Author information

Authors and Affiliations

  1. Palliative Care Team, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, Shizuoka, 433-8558, Japan

    Masanori Mori

  2. Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, 3453, Mikatahara-Cho, Kita-Ku, Hamamatsu, Shizuoka, 433-8558, Japan

    Tatsuya Morita

  3. Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Osaka, 591-8555, Japan

    Yoshinobu Matsuda

  4. Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Naka-ku, Hamamatsu, Shizuoka, 430-8558, Japan

    Hirohide Yamada

  5. Department of Palliative Care Unit, JCHO Tokyo Shinjuku Medical Center, 5-1 Tsukudo-cho, Shinjuku, Tokyo, 162-0815, Japan

    Keisuke Kaneishi

  6. Department of Palliative Medicine, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan

    Yoshihisa Matsumoto

  7. Hospice Medical Corporation, Junkei-kai Sotoasahikawa Hospital, 42, Aza-Sangoden, Sotoasahikawa, Akita, 010-0802, Japan

    Naoki Matsuo

  8. Komaki City Hospital, 1-20 Jobushi, Komaki City, Aichi, 485-8520, Japan

    Takuya Odagiri & Hiroaki Watanabe

  9. Department of Palliative Medicine, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi-ku, Tokyo, 173-8605, Japan

    Etsuko Aruga

  10. Osaka City General Hospital, 2-13-22 Miyakojima-hondoori, Miyakojima-ku, Osaka, 534-0021, Japan

    Ryohei Tatara

  11. Department of Palliative Therapy, Cancer Institute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan

    Hiroki Sakurai

  12. Department of Palliative and Supportive Care, Obihiro Kousei General Hospital, 1, Minami-10, Nishi-14, Obihiro, Hokkaidou, 080-0024, Japan

    Akira Kimura

  13. Department of Palliative and Supportive Care, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan

    Hideki Katayama

  14. Department of Palliative Medicine, Shizuoka Saiseikai General Hospital, Oshika, Suruga, Shizuoka, 422-8527, Japan

    Akihiko Suga

  15. Kawasaki Municipal Ida Hospital, Nakahara-ku, Ida 2-27-1, Kawasaki-shi, Kanagawa, Japan

    Tomohiro Nishi

  16. Miyazaki Medical Association Hospital, 738-1 Funato Shinbeppu-cho, Miyazaki, 880-0834, Japan

    Akemi Naito Shirado

  17. Toyama Prefectural Central Hospital, 2-78.2 chome, Nishinagae, Toyama-shi, Toyama, Japan

    Toshio Watanabe

  18. Biostatistics Division, CRAS, National Cancer Center, 5-1-1, Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan

    Aya Kuchiba

  19. Division of Biostatistics, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan

    Takuhiro Yamaguchi

  20. Department of Emergency & Palliative Medicine, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan

    Satoru Iwase

Authors
  1. Masanori Mori
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  2. Tatsuya Morita
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  3. Yoshinobu Matsuda
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  4. Hirohide Yamada
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  5. Keisuke Kaneishi
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  6. Yoshihisa Matsumoto
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  7. Naoki Matsuo
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  17. Akemi Naito Shirado
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  18. Toshio Watanabe
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  19. Aya Kuchiba
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  20. Takuhiro Yamaguchi
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  21. Satoru Iwase
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Corresponding author

Correspondence to Masanori Mori.

Ethics declarations

This study was conducted in accordance with the ethical standards of the Helsinki Declaration and the ethical guidelines for epidemiological research presented by the Ministry of Health, Labour and Welfare in Japan. The study was approved by the Institutional Review Boards (IRBs) of all participating institutions. The IRBs waived the requirement for obtaining written informed consent in this observational study based on the aforementioned ethical guidelines.

Conflict of interest

AK received honoraria for speaking at symposia by Chugai Pharmaceutical Co., Ltd. The other authors declare that they have no conflict of interest.

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Appendix

Appendix

Table 2 The proposed outcomes of terminal dyspnea based on dyspnea intensity and communication capacity
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Mori, M., Morita, T., Matsuda, Y. et al. How successful are we in relieving terminal dyspnea in cancer patients? A real-world multicenter prospective observational study. Support Care Cancer 28, 3051–3060 (2020). https://doi.org/10.1007/s00520-019-05081-9

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