The goal of this webinar was to educate healthcare professionals on interventions for cough, dyspnea, hemoptysis, and the “death rattle” in patients with end-of-life respiratory symptoms.

1. Respiratory Symptoms
in the Terminally Ill Patient
Cough, Hemoptysis, and the “Death Rattle”

2. CE Provider
Information
VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and
Nursing Home Administrators through: VITAS Healthcare Corporation of Florida, Inc./CE
Broker Number: 50-2135. Approved By: Florida Board of Nursing/Florida Board of Nursing
Home Administrators/Florida Board of Clinical Social Workers, Marriage and
Family Therapy & Mental Health Counseling.
VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home
Administrators and Respiratory Therapists through: VITAS Healthcare Corporation of
Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA
CE Provider Number: 139000207/RT CE Provider Number: 195000028/Approved By the
Illinois Division of Profession Regulation for: Licensed Nursing Home Administrators and
Illinois Respiratory Care Practitioner.
VITAS Healthcare, #1222, is approved to offer social work continuing education by the
Association of Social Work Boards (ASWB) Approved Continuing Education (ACE)
program. Organizations, not individual courses, are approved as ACE providers. State and
provincial regulatory boards have the final authority to determine whether an individual
course may be accepted for continuing education credit. VITAS Healthcare maintains
responsibility for this course. ACE provider approval period: 06/06/2021 – 06/06/2024.
Social workers completing this course receive 1.0 continuing education credit(s).
Provided By:
VITAS Healthcare Corporation of California, Inc. is an approved provider of this activity
Approved By the California Board of Nursing CEP#10517 Expires January 31, 2023
Provided By:
This program has been pre-approved by The Commission for Case Manager Certification to
provide continuing education credit to CCM® board certified case managers. The course is
approved for (1) CE contact hour(s). Activity code: I00047974 Approval Number:
210003343. To claim these CEs, log into your CCMC Dashboard at
www.ccmcertification.org
Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA:
No NHAs, KS: No NHAs,NJ: No NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No
NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois.

3. Goal
The goal of this presentation is to educate
healthcare professionals on effective and
competent management of respiratory
symptoms so that terminally ill patients and
their families may receive optimal hospice
and palliative care.

4. Therapeutic
Goal
Development of respiratory symptoms,
such as dyspnea, cough, hiccups, and
secretions, is common at end of life and
can often be anticipated.
The optimal therapeutic goal when
confronted with a patient experiencing
respiratory symptoms is to treat the
underlying condition (if possible).

5. Objectives
• Define dyspnea, cough, and hemoptysis
• List palliative treatment options
• Describe pharmacologic and
non-pharmacologic interventions
• Explain the “death rattle” and
effective treatment agents

6. Case of LM
• LM is a 68-year-old male with history of metastatic
non-small cell lung cancer (NSCLC) and chronic
obstructive pulmonary disease (COPD), admitted
to the medical floor with shortness of breath
(SOB), wheeze, and bloody cough (hemoptysis)
• A large inoperable mass in the mediastinum
involves the right main stem bronchus with
post-obstructive pneumonia
• LM has undergone radiation treatment for the
mass and laser ablation to control hemoptysis
• Fever, severe dyspnea, and cough add to his
overall symptom burden
• LM has lost 18% of his body weight in the last
three months, is weak and fatigued, and requires
assistance in 3/6 activities of daily living (ADLs)

7. Dyspnea
• Subjective feeling of SOB
• A common respiratory symptom at the
end of life (EOL)
– Only 11.4% of patients at EOL
report no dyspnea
– Often related to other advanced illnesses:
• Advanced heart failure
• Advanced COPD and pulmonary fibrosis
• Pneumonia, aspiration, and sepsis
• Malignancy
• Pulmonary embolism
– Medical treatments: Chemotherapy,
XRT, other medications
Kamal, A., Maguire, J., Wheeler, J., Currow, D.,& Abernethy, A. (2011). Dyspnea review for the palliative
care professional: assessment, burdens, and etiologies. Journal of Palliative Medicine, 14(10):1167–1172.

8. Dyspnea
(cont.)
• Unmanaged dyspnea and other respiratory
symptoms are key drivers of emergency
department (ED) utilization and
hospitalization in patients with life-limiting
and advanced illness
• Evidence shows that 50% of solid tumor
cancer patients with dyspnea who present
to the ED die within 6 months
Koelwyn, G., Jones, L., Hornsby, W., & Eves, N. (2012). Exercise therapy in the management of dyspnea in patients
with cancer. Current Opinion in Supportive and Palliative Care, 6(2):129–137. doi:10.1097/SPC.0b013e32835391dc

9. Dyspnea
(cont.)
• Frequently associated with
other symptoms:
– Asthenia
– Anxiety
– Insomnia
– Pain
• Recognized to be more difficult
to evaluate and treat than pain
• Median length of stay for patients
experiencing dyspnea was longer
than those without the symptom
Guirimand, F., Sahut d'izarn, M., Laporte, L., Francillard, M., Richard J.,& Aegerter P. (2015). Sequential occurrence of dyspnea
at the end of life in palliative care, according to the underlying cancer. Cancer Medicine, 4(4):532–539. dx.doi:10.1002/cam4.419

10. Types of
Dyspnea
Continuous Dyspnea: Dyspnea that
is always present
– Reported by 39% of patients
Breakthrough Dyspnea: Short periods
of dyspnea interspersed with periods of
no breathlessness throughout the day
– Reported by 80% of patients with SOB
– 5-6 episodes per day lasting 5 minutes
or less
Reddy, S., Parsons, H., Elsayem, A., Palmer, J., & Bruera, E. (2009). Characteristics and correlates
of dyspnea in patients with advanced cancer. Journal of Palliative Medicine, 12(1):29-36.

11. Assessment
of Dyspnea
Dyspnea is highly subjective and often
based on patient-reported severity,
similar to pain.
Kamal A., Maguire J., Wheeler J., Currow D., & Abernethy A. (2011). Dyspnea review for the palliative
care professional: assessment, burdens, and etiologies. Journal of Palliative Medicine, 14(10):1167–1172.
Patient Descriptors of Dyspnea
I feel… My… I cannot…
That I am smothering Breathing requires effort Take a full breath
That my breath stops Chest feels tight Get enough air
That I am suffocating Breathing is fast
Stop thinking about
my breathing

12. Assessment
of Dyspnea
(cont.)
Conduct a careful history and
physical examination.
• Note the presence or
absence of:
– Wheeze
– Crackles
– Lung sounds
– Peripheral edema
– Cyanosis
• Note patient’s use of
accessory muscles

13. Dyspnea Management
Kamal A., Maguire J., Wheeler J., Currow D., & Abernethy, A. (2011). Dyspnea review for the palliative
care professional: assessment, burdens, and etiologies. Journal of Palliative Medicine, 14(10):1167–1172.
Biopsychosocial Model of Dyspnea Management

14. Treatments
for Dyspnea
Understand underlying cause to
optimize treatment:
• Hypoxemia: Oxygen therapy
• Asthma/COPD: Bronchodilators, oral
steroids, occasional antibiotics, and
occasional surgical interventions
• Pneumonia and URI: Antibiotics,
bronchodilators, steroids (sometimes)
• Heart failure and edema: Diuretics,
optimal medical management, and
inotropes (sometimes)
• Pleural effusions: Thoracentesis
• Solid tumors: XRT, surgical interventions

15. • Opioids are highly effective in managing the
symptoms of SOB in advanced illness patients
– Intermittent and/or continuous dosing can be
used depending on underlying cause, other
symptoms, and type of dyspnea
• Opioids’ effects are due to ventilatory response
to carbon dioxide, hypoxia, inspiratory flow-
resistive loading, vasodilatory effect on pulmonary
vascular pressures, and decreased oxygen
consumption with exercise
• Multiple studies have shown that opioids are
safe in this population
• When anxiety is present with dyspnea,
benzodiazepines or SSRI can be added as
adjuvant therapy
Opioids for
Patients With
Dyspnea
Nearing End
of Life

16. Case of LM
(cont.)
LM receives 5 mg of IV morphine
in ED along with nebulizers, oxygen,
Tylenol, and first-dose antibiotics.
• 3 days later:
– Fever and chills have subsided
– LM is weaker, has SOB at rest, and
requires continuous oxygen and
frequent doses of opioids
– He continues to have persistent
cough and occasional hemoptysis
After LM’s goals-of-care (GOC) conversation
with the hospitalist, a hospice consultation
is recommended.

17. Cough
• A normal physiologic function designed
to protect the airways by removing
mucus and foreign materials
• Cough is under both involuntary and
voluntary control
• Cough reflex is mediated by the
vagus nerve in the airways and the
glossopharyngeal nerve in the pharynx
• Cough is stimulated by mechanical
or chemical irritation of the trachea
or bronchi, or by pressure from
adjacent structures

18. Cough
(cont.)
• Cough occurs in 30%-50% of all
patients at the end of life
• Approximately 80% of lung cancer
patients and patients whose death
is imminent will have cough as a
major symptom
• Ineffective cough is common in
advanced illness such as COPD and
cancer, leading to pooling of
secretions and even dyspnea
• Refractory cough can also be present
– Requires aggressive management
to prevent complications

19. Causes of
Cough in
Advanced
Illness
Non-Cancer Related:
• End-stage (ES)
cardiac disease
• ES pulmonary disease
• ES renal disease
• Neuromuscular
(MS, ALS)
• Late-stage dementias
• GERD
• Cerebrovascular disease
• Medications (ACEi)
Bonneau, A. (2009). Cough in the palliative care setting. Canadian Family Physician. 55(6):600–602.
Cancer Related:
• Pulmonary mass
or involvement
• Intrinsic/extrinsic
airway obstruction
• SVC syndrome
• Aspiration
• PE
• Chemotherapy-
induced

20. Symptoms
Caused by
Cough
• Loss of appetite
• Headache
• Dizziness
• Sleep disturbance
• Fatigue
• Infections/pneumonia
Bonneau, A. (2009). Cough in the palliative care setting. Canadian Family Physician. 55(6):600–602.

21. Evaluation
of Cough
Thorough history and physical exam
help define cause and most appropriate
plan of care.
• Understanding underlying etiology
determines appropriate intervention:
– Non-pharmacologic
– Pharmacologic
• Determination of severity of cough:
mild, moderate, or severe

22. Non-
Pharmacologic
Treatment
• Proper positioning of patient to
promote drainage of secretions and
minimize gastric reflux or aspiration
• Chest physical therapy/percussion
therapy to help mobilize
difficult secretions
• Air humidifiers
• Saline nebulizers to minimize
airway irritation and dryness
• Minimize exposure to perfumes and
aromas that can trigger cough
• Lozenges and hard candies

23. Pharmacologic
Treatment
Many medications can be used to
help manage cough in patients with
life-limiting and advanced illness.
• Main categories:
– Peripherally acting agents
– Centrally acting agents
– Other and mixed agents
Medications are utilized to suppress
cough directly, mobilize secretions,
or treat secondary causes of cough.

24. Mild Cough
• Non-pharmacologic interventions
are preferred
• Benzonatate is a stretch receptor
anesthetic agent
• Nebulizers in those with COPD
or asthma
• Dextromethorphan
• Guaifenesin to help thin secretions

25. Moderate
to Severe
Cough
• Opioids are first-line therapy
– Morphine 5 mg q4H
• Gabapentin and pregabalin can be
tried in those who cannot tolerate
opioid therapy; more frequently
used in chronic cough situations
• Nebulized anesthetic agents
(e.g., lidocaine, bupivacaine)
can offer some relief
Yancy Jr, W. S., McCrory, D. C., Coeytaux, R. R., Schmit, K. M., Kemper, A. R., Goode, A., ... &
Sanders, G. D. (2013). Efficacy and tolerability of treatments for chronic cough. Chest, 144(6):1827-1838.

26. Severe
Refractory
Cough
• May require a multifocal approach
combining non-pharmacologic and
pharmacologic approaches
• Opioids with inhaled anesthetics to
gain control of refractory cough with
addition of gabapentinoids to suppress
the neuroexcitatory component

27. Cough
Suppressants
• Elixirs/cough drops
• Dextromethorphan
• Opioids
• Inhaled anesthetics
• Gabapentinoids

28. Other
Pharmacological
Measures
• Expectorants
• Antihistamines
• Decongestants
• Oral corticosteroid
• Bronchodilators
• Antacid medications

29. Case of LM
(cont.)
• LM is started on low-dose methadone and
gabapentin for his cough, and morphine
(as needed) for breakthrough episodes
of cough and pain
• During his GOC conversation, he reports
a desire to return home and stay at home
• He and his family elect home hospice
as his disposition plan; 5 days following
his admission, he is discharged home
on hospice
• 1 week after discharge, he begins to
have significant worsening of cough and
hemoptysis; an on-call hospice nurse
is dispatched to his home

30. Hemoptysis
Hemoptysis is the expectoration of
blood, usually derived from the lungs
or bronchial tubes as a result of
pulmonary or bronchial hemorrhage.
• Several sources exist:
– Tracheobronchial
– Non-lower respiratory
– Pulmonary parenchymal
– Primary vascular

31. Hemoptysis
(cont.)
Lung cancer patients present with
hemoptysis 30%-50% of the time.
• Common causes
– Pneumonia
– Lung cancer
– Acute/chronic bronchitis
– Pulmonary embolus
– Tuberculosis
Jacob, L., Bidwell, M., Pachner, M. (2005). Hemoptysis: Diagnosis and
Management. American Family Physician, 72(7): 1253-1260.

32. Evaluation
Careful history and physical are
important to distinguish hemoptysis
from hematemesis and upper
respiratory sites of bleeding.
• Hematemesis is the spitting up
or vomiting of blood; it is often
confused with hemoptysis
– Source is the esophagus,
stomach, and upper GI
Ruling out hematemesis allows for
accurate diagnosis of hemoptysis
etiology and drives the treatment plan.

33. Determining
Severity of
Bleeding
Non-Massive Hemoptysis:
• Minimal blood production
• Normal vital signs
• No abnormal gas exchange
Massive Hemoptysis:
• Hemodynamic instability and
abnormal gas exchange present
• Tachycardia
• Hypotension
• Tachypnea
• Hypoxemia

34. Hemoptysis
Evaluation
American College of Radiology
Appropriateness Criteria for Imaging
in Patients With Hemoptysis:
• Initial evaluation of patients with hemoptysis
should include chest radiography
• In patients at high risk of malignancy with
normal findings on chest radiography,
CT, and bronchoscopy:
– Observation for 3 years may
be considered
– Radiography and CT should be performed at
follow-up based on the patient’s risk factors
– Bronchoscopy may be performed in addition
to imaging during the observation period
Earwood, J., Thompson, T. (2015). Hemoptysis: Diagnosis and Management. American Family Physician, 15;91(4):243-249.

35. Hemoptysis
Evaluation
(cont.)
• CT should be considered:
– For initial evaluation in patients at high
risk of malignancy or suspicious findings
on chest radiography
– In current/former smokers with normal
findings on chest radiography
• Massive hemoptysis can be treated with:
– Surgery or percutaneous embolization
– Multidetector CT before embolization or
surgery can define the source of hemoptysis
– Percutaneous embolization may be
used initially to halt hemorrhage before
definitive surgery
Earwood, J., Thompson, T. (2015). Hemoptysis: Diagnosis and Management. American Family Physician, 15;91(4):243-249.

36. Non-Massive Hemoptysis
Earwood, J., Thompson, T. (2015). Hemoptysis: Diagnosis and Management. American Family Physician, 15;91(4):243-249.

37. Non-Massive Hemoptysis Management
Earwood, J., Thompson, T. (2015). Hemoptysis: Diagnosis and Management. American Family Physician, 15;91(4):243-249.

38. Etiology
Tracheobronchial sources:
• Bronchitis, trauma, or foreign bod
Parenchymal sources:
• Infections (abscess, PNA, TB),
vasculitis, and trauma
Primary vascular sources:
• AVM, PE, elevated PAP, pulmonary
artery rupture from procedure
Other causes to consider:
• Medications, particularly anticoagulation

39. Treatment for
Hemoptysis
• Cough suppressants
• Saline nebulizers for airway irritation
• Visualization and therapy
via bronchoscopy
• Interventional radiology for large bleeding
• CT-guided embolization
• Bronchial arteriogram with embolization
• Supportive care
• Psychosocial support
• Patient and family education about
possibilities of massive hemoptysis

40. Alternative
Therapies
Alternative therapies to radiation:
• Bronchial artery embolization
• Laser coagulation
• Cryotherapy

41. Massive
Hemoptysis
• Massive hemoptysis is a rare condition
occurring in about 1%-4% of all patients
• Death may occur very suddenly
• Patients will cough up massive
amounts of blood
• Rapid and physically
painless exsanguination
• Exceedingly traumatic for the family
− Recommendation: have dark-colored
towels available

42. Mortality
Prediction in
Hemoptysis
Earwood, J., Thompson, T. (2015). Hemoptysis: Diagnosis and Management. American Family Physician, 15;91(4):243-249.
Predictors of In-Hospital Mortality in Patients With Hemoptysis
Chest radiography on admission shows
involvement of 2 or more quadrants (1 point)
Chronic alcoholism (1 point)
Pulmonary artery involvement (1 point)
Aspergillosis (2 points)
Malignancy (2 points)
Mechanical ventilation
required (2 points)
Score 0 1 2 3 4 5 6 7
Mortality 1% 2% 6% 16% 34% 58% 79% 91%
NOTE: Patients with a score greater than 2 should be admitted to the intensive care unit, and
those with a score greater than 5 may require urgent interventional radiology.
Adapted with permission from Fartoukh M, Khoshnood B, Parrot A, et al. Early pre-diction of
in-hospital mortality of patients with hemoptysis: an approach to defining severe hemoptysis.
Respiration. 2012;83(2):111.

43. Case of LM
(cont.)
• At time of hospice nurse’s visit, LM is found to
have SOB, cough, and moderate hemoptysis
• Hospice nurse contacts hospice physician,
who orders continuous home care to evaluate
and manage symptoms
• LM is now confused, cyanotic, and
minimally responsive
• Oral medications are discontinued; LM is
started on liquid SL methadone and liquid
SL morphine, with doses titrated to manage
cough and shortness of breath
• As his cough improves, his bleeding stops
• 24 hours later, he becomes unresponsive
and develops noisy airway secretions

44. Respiratory
Secretions
• Noisy, moist breathing presents within
several days of death in 60%-90%
of patients
• Caused by air passing through airways
with secretions present (as the patient
is unable to swallow or clear them)
• 2 types:
– Excessive oral secretions
– Excessive bronchial secretions
• Secretions can be thin or thick
in consistency

45. Respiratory
Secretions
(cont.)
• There is limited evidence to support
secretions as a source of discomfort
for patients near the end of life
• Secretions are often associated
with the active dying process and a
prognosis of hours to days
• There is conflicting evidence regarding
effectiveness of pharmacologic therapy
• Simple measures of repositioning
seem to be most effective

46. Management
of Respiratory
Secretions
• Reposition patient to promote secretion
drainage and prevent pooling of secretions
• Educate family that secretions are
normal at end of life
• For thick secretions, saline nebulizers
help to thin and mobilize them
• Anticholinergic medications:
– Atropine
– Hyoscyamine
– Glycopyrrolate
– Scopolamine

47. Similar Medication Effectiveness
Wildiers, H., Dhaenekint, C., Demeulenaere, P., Clement, P. M., Desmet, M., Van Nuffelen, R., ... & Menten, J. (2009). Atropine, hyoscine butylbromide,
or scopolamine are equally effective for the treatment of death rattle in terminal care. Journal of Pain and Symptom Management, 38(1); 124 – 133.
33
42
50
71
76
95
80 80
27
42
54 52
60
56
62
50
28
37
47
57
68
56
100
67
0.0
16.7
33.4
50.1
66.8
83.5
100.2
0.5 1 4 12 24 72 96 120
Percentage
Effective
Hours
Atropine Hyoscine butylbromide Scopolamine
94 94
90
84 83
88
83
75 75
24
38
51
61
68
87
69
79
67
7
17
25
40
57 58
64
75
67
0.0
16.7
33.4
50.1
66.8
83.5
100.2
0.5 1 4 12 24 48 72 96 120
Percentage
Effective
Hours
Baseline Rattle Score 1 Baseline Rattle Score 2 Baseline Rattle Score 3

48. Conflicting
Evidence of
Anticholinergics
• 2013 study by Heisler, et al., looked at
atropine administration vs. placebo in
177 patients with terminal secretions
• Results showed no difference in
severity of terminal secretions between
atropine and placebo groups
• Noise scores improved in both groups,
suggesting a favorable natural course
for this symptom
Heisler, M., Hamilton, G., Abbott, A., Chengalaram, A., Koceja, T., & Gerkin, R. (2013) Randomized double-blind trial of
sublingual atropine vs. placebo in the management of death rattle. Journal of Pain and Symptom Management, 45(1): 14-22.

49. Cautions
Suctioning has been noted to be
ineffective and should be avoided
in the dying patient, in most cases.
Always be prudent when using
anticholinergic medications to avoid
over-utilization and many adverse effects:
– Delirium
– Confusion
– Agitation
– Hyperthermia
– Urinary retention
– Tachycardia
– Dry mouth

50. Types of
Nonmalignant,
Life-Limiting,
Chronic Lung
Diseases
• Chronic obstructive pulmonary
disease (COPD)
• Emphysema
• Chronic bronchitis
• Chronic asthma
• Bronchiectasis
• Pulmonary fibrosis
• Cystic fibrosis
• End-stage tuberculosis

51. Hospice
Eligibility
Guidelines
for Patients
With Advanced
Lung Disease
(ALD)
• Dyspnea at rest or with minimal exertion
• Dyspnea which is unresponsive or poorly
responsive to bronchodilator therapy
• Progression of chronic pulmonary
disease as evidenced by one or more
of the following:
– Frequent use of medical services,
including hospitalizations, ED visits,
and/or physician outpatient visits
due to symptoms of pulmonary disease

52. Hospice
Eligibility
Guidelines
for Patients
With ALD
(cont.)
• Frequent episodes of bronchitis
or pneumonia
• Unintentional weight loss of ≥ 10% body
weight over the preceding 6 months
• Progressive inability to independently
perform various ADLs or an increasing
dependency with ADLs, resulting in a
progressively lower performance status

53. Other
Important
Clinical
Factors
• Cor pulmonale
• Continuous chronic oxygen therapy
• Resting tachycardia, > 100 bpm
• Steroid-dependent
• Cyanosis

54. Abnormal
Lab Findings
While these laboratory studies may be
helpful to the clinician when considering
patient eligibility for hospice, they are not
required for patient admission:
• FEV1 ≤ 30% predicted post-bronchodilator
• Serial decreases in FEV1 of at least
40 mL/year over several years
• PO2 ≤ 55 mmHg on room air
• O2 sat. ≤ 88% on room air
• Persistent hypercarbia (pCO2)
≥ 50 mmHg

55. Conclusion
• Breathing is a gift. Although each breath
comes naturally to most of us, breathing
is a struggle for some patients.
• Offer assistance to patients and families
to help them cope with the respiratory
challenges they may face at the end of life.

56. Questions?

57. References
Bonneau, A. (2009). Cough in the palliative care setting. Canadian Family
Physician. 55(6):600–602.
Earwood, J., Thompson, T. (2015). Hemoptysis: Diagnosis and Management.
American Family Physician, 15;91(4):243-249.
Guirimand, F., Sahut d'izarn, M., Laporte, L., Francillard, M., Richard J.,
& Aegerter P. (2015). Sequential occurrence of dyspnea at the end of life
in palliative care, according to the underlying cancer. Cancer Medicine,
4(4):532–539. dx.doi:10.1002/cam4.419
Heisler, M., Hamilton, G., Abbott, A., Chengalaram, A., Koceja, T., & Gerkin,
R. (2013) Randomized double-blind trial of sublingual atropine vs. placebo
in the management of death rattle. Journal of Pain and Symptom Management,
45(1): 14-22.
Jacob, L., Bidwell, M., & Pachner, M. (2005). Hemoptysis: Diagnosis and
Management. American Family Physician, 72(7): 1253-1260.

58. References
(cont.)
Kamal, A., Maguire, J., Wheeler, J., Currow, D., & Abernethy, A. (2011).
Dyspnea review for the palliative care professional: assessment,
burdens, and etiologies. Journal of Palliative Medicine, 14(10):1167–1172.
Koelwyn, G., Jones, L., Hornsby, W., & Eves, N. (2012). Exercise therapy in the
management of dyspnea in patients with cancer. Current Opinion in Supportive
and Palliative Care, 6(2):129–137. doi:10.1097/SPC.0b013e32835391dc
Reddy, S., Parsons, H., Elsayem, A., Palmer, J., & Bruera, E. (2009).
Characteristics and correlates of dyspnea in patients with advanced cancer.
Journal of Palliative Medicine, 12(1):29-36.
Wildiers, et al. (2009). Atropine, hyoscine butylbromide, or scopolamine
are equally effective for the treatment of death rattle in terminal care.
Journal of Pain and Symptom Management, 38(1); 124 – 133.
Yancy Jr, W. S., McCrory, D. C., Coeytaux, R. R., Schmit, K. M., Kemper, A. R.,
Goode, A., ... & Sanders, G. D. (2013). Efficacy and tolerability of treatments for
chronic cough. (2013). Chest, 144(6):1827-1838.

59. Respiratory Symptoms
in the Terminally Ill Patient
Cough, Hemoptysis, and the “Death Rattle”