Breathlessness, or dyspnoea, is an unpleasant sensation defined as ‘a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity’ (Parshall et al. [114], p.435). Some of the causes of breathlessness are listed in Box 11.4.

Approximately 70% of patients experience dyspnoea in the last 6 weeks of life and the distress associated with this symptom increases as death approaches (Ben‐Aharon et al. [10], Kamal et al. [72]). The causes of dyspnoea are often multifactorial (Ekstrom et al. [43]). In a prospective study, 50–65% of almost 600 patients attending a specialized palliative care unit had more frequent incidence of dyspnoea during the last 3 months of life (Ekstrom et al. [43]). Both patients and their families and carers report breathlessness to be a distressing symptom that can result in reduced quality of life, largely due to measures taken to manage this symptom (such as undertaking less physical activity), increased anxiety and depression, and the increased likelihood of hospital admissions (Simon et al. [138]). As death approaches, it still may be appropriate to try to manage reversible causes of breathlessness to manage the distress of this symptom, but dyspnoea can become refractory to intervention (Lacey [77]).

Pharmacological management with oral or parenteral opioids has been shown to help with the sensation of dyspnoea (Ben‐Aharon et al. [10], Chin and Booth [25], Dudgeon [42], Ekstrom et al. [43], Jennings et al. [70]). Benzodiazepines may be useful for reducing panic and anxiety but have not been evidenced to show an improvement in breathing (Simon et al. [138]). Oxygen therapy has been found to improve dyspnoea in patients who have been found to be hypoxic. In one study, approximately 10% of patients used oxygen therapy to help them with the distress of dyspnoea (Campbell et al. [19]).

Any reversible causes should be treated initially; however, if symptomatic relief is the aim of treatment, combining both pharmacological (Table 11.3) and non‐pharmacological interventions will improve symptom burden and quality of life (Currow et al. [32]). In patients who have low haemoglobin, a blood transfusion can help with the symptom of breathlessness. However, in some instances receiving a blood transfusion does not make the patient feel any better. Any ongoing interventions (such as blood transfusions) should only be considered if they are providing symptom relief and/or improving quality of life.

It is useful to explore the extent of their breathlessness with the patient; how this is impacting them physically and psychologically; and how this is affecting their quality of life. Assessing previous effective methods used to control dyspnoea is useful as these can be implemented.

For patients with refractory dyspnoea and severe distress in the terminal phase, sedation may need to be considered as an option to adequately control the symptom and to relieve suffering (Lacey [77]). Terminal sedition is explored further below.