Table 6.

The step-by-step list describes how emergency clinicians are able to provide quality care for palliative dyspnea management

	Detail
1. The systematic screening can	Facilitated early detection and timely intervention.
2. The measurement for patients’ distress and discomfort related to dyspnea	• The 0–10 numeric rating scale to the intensity of dyspnea is the most valid, reliable, and widely used measurement for patients’ subjective distress and discomfort. • The behavioral approach observed for respiratory distress signs is an option for such a crisis, terminal dyspnea, or patients unable to communicate. The Respiratory Distress Observation Scale (RDOS) consists of 8 variables that are possible to use in the ED but require more studies. • Whenever possible, a comprehensive assessment should be done to determine the severity of dyspnea, potential causes, concomitant symptoms, functional and emotional impacts. • An assessment of family caregiver coping, needs, care participation, and home resources will support and incorporate them into the health care team. Psychoeducational interventions should be provided to caregivers.
3. The treatment for reversible causes and disease-modifying treatments (eg, diuretics, corticosteroids)	Optimized and aligned with patient preferences, goals of care, prognosis, and overall health status. The time-limited trial interventions might be particularly helpful for patients who have uncertain goals of care prior to intubation.
4. A recommended stepwise approach to palliate the suffering of dyspnea	1. Begins with determining potentially reversible causes 2. Using nonpharmacologic (see Table 7) 3. Pharmacologic interventions (see Table 8)
5. The referral of patients with refractory dyspnea, despite receiving appropriate treatments, to a palliative care specialist	Along with treating the patient’s suffering, the goals of care discussion can be facilitated to the patient and their families.
6. Reassessment and adjustment of interventions	Used the same assessment tool for adjustment of dyspnea palliation until the patient’s suffering from dyspnea was relieved.

Data from [Weissman DE. Dyspnea at End-of-Life. Palliative Care Network of Wisconsin. 2015. Available at: www.mypcnow.org/fast-fact/dyspnea-at-end-of-life/. Accessed March 2023.] [Ahmed A, Graber MA. Approach to the adult with dyspnea in the emergency department. UpToDate 2022. Available at: https://www.uptodate.com/contents/approach-to-the-adult-with-dyspnea-in-the-emergency-department. Accessed March 2023.] [Hui D, Bohlke K, Bao T, et al. Management of Dyspnea in Advanced Cancer: ASCO Guideline. J Clin Oncol. 2021;39(12):1389–1411. https://doi.org/10.1200/JCO.20.03465] [Mularski RA, Reinke LF, Carrieri-Kohlman V, et al. An official American Thoracic Society workshop report: assessment and palliative management of dyspnea crisis. Ann Am Thorac Soc. 2013;10(5):S98-S106. https://doi.org/10.1513/AnnalsATS.201306-169ST] [Quest TE, Lamba S. Palliative for adults in the ED: Concepts, presenting complaints, and symptom management. UpToDate 2022. Available at: https://www.uptodate.com/contents/palliative-care-for-adults-in-the-ed-concepts-presenting-complaints-and-symptom-management. Accessed March 2023.]