Hsu et al.

BMC Palliative Care (2021) 20:42

https://doi.org/10.1186/s12904-021-00713-6

RESEARCH ARTICLE Open Access

Enhanced home palliative care could

reduce emergency department visits due
to non-organic dyspnea among cancer
patients: a retrospective cohort study
Hua-Shui Hsu1,2,3,4, Tai-Hsien Wu2,4, Chin-Yu Lin5, Ching-Chun Lin1,2,3, Tsung-Po Chen1,2,3 and Wen-Yuan Lin1,2,3*

Abstract
Background: Dyspnea is a common trigger of emergency department visits among terminally ill and cancer
patients. Frequent emergency department (ED) visits at the end of life are an indicator of poor-quality care. We
examined emergency department visit rates due to dyspnea symptoms among palliative patients under enhanced
home palliative care.
Methods: Our home palliative care team is responsible for patient management by palliative care specialists,
residents, home care nurses, social workers, and chaplains. We enhanced home palliative care visits from 5 days a
week to 7 days a week, corresponding to one to two extra visits per week based on patient needs, to develop
team-based medical services and formulate standard operating procedures for dyspnea care.
Results: Our team cared for a total of 762 patients who exhibited 512 ED visits, 178 of which were due to dyspnea
(mean ± SD age, 70.4 ± 13.0 years; 49.4% male). Dyspnea (27.8%) was the most common reason recorded for ED
visits, followed by pain (19.0%), GI symptoms (15.7%), and fever (15.3%). The analysis of Group A versus Group B
revealed that the proportion of nonfamily workers (42.9% vs. 19.4%) and family members (57.1% vs. 80.6%) acting as
caregivers differed significantly (P < 0.05). Compared to the ED visits of the Group A, the risk was decreased by
30.7% in the Group B (P < 0.05).
Conclusions: This study proves that enhanced home palliative care with two additional days per week and
formulated standard operating procedures for dyspnea could significantly reduce the rate of ED visits due to non-
organic dyspnea during the last 6 months of life.
Keywords: Dyspnea, Home palliative care, Emergency department

* Correspondence: [email protected]
1
Department of Family Medicine and Social Medicine, School of Medicine,
College of Medicine, China Medical University, Taichung, Taiwan
2
Department of Family Medicine, China Medical University Hospital,
Taichung, Taiwan
Full list of author information is available at the end of the article

© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
Hsu et al. BMC Palliative Care (2021) 20:42 Page 2 of 7

Background Methods
Home is the most common place of death for advanced Study design
cancer patients and an important site of palliative care This study was a retrospective cohort study conducted
in Taiwan and elsewhere [1]. The aim of palliative home at China Medical University Hospital, Taichung, Taiwan.
care service is to improve the quality of life of patients Our patients who died with a primary diagnosis of can-
with cancer and families without raising the total costs cer were from the linked hospital administrative data-
of care [2, 3]. A palliative care team, including specialist bases during 2016–17.
doctors, nurses, social workers, nutritionists and chap-
lains, gives caregivers indispensable medical and emo- Study setting
tional assistance so that they can smooth the transition Cancer patients were referred from outpatient depart-
of palliative care from the hospital to home [4]. Other- ments, oncology wards, and palliative care wards in
wise, patients often seek urgent medical services for the China Medical University Hospital for consecutive home
emergency department (ED) [5]. palliative care. On referral to home palliative care
Frequent emergency department visits at the end of agency, the case manager recorded basic information of
life are an indicator of poor-quality care [6]. About four- the patient, such as sex, age, medical history, patho-
fifths of palliative care patients with advanced cancer logical condition, medication records, catheter location,
have repeated visits to the emergency department during emotion, family support and medical use location. The
the final 6 months of life [7]. However, nearly one- specialist home palliative care nurses then visited the
fourth of ED visits by palliative care patients may be home to evaluate home care needs, care plan, and visit
avoidable [8]. For family members, because their clinical frequency, caring for patient until death.
judgment abilities are not sufficient, patients tend to Our team members include family physicians, home
have more than one ED visit for the same condition [9]. care nurses, social workers, and chaplains. Our team-
Dyspnea is one of the most common refractory symp- based services provided: a 24-h call line is available for
toms in patients with advanced diseases, including cancer phone consultations in the home care team’s office; ac-
and noncancer populations [10]. Previous studies show cording to the patients’ and family caregivers’ require-
that the prevalence of dyspnea is greater than 50% among ments and clinical conditions, our home care nurse
terminally ill patients and the cancer population [11, 12]. arranged a visit once or twice a week, and family phys-
Dyspnea intensity and prevalence enhanced with disease ician would be arranged a visit with nurse once a month.
progression, especially at the end of life, and it may leave During home visits, our home care nurse would be per-
devastating impacts on family and caregivers [7, 13, 14]. formed consciousness assessment, vital signs measure-
Dyspnea, which is a complex symptom resulting from ment (eg, body temperature, pulse rate, respiration rate,
organic causes and psychologic distress, calls for com- blood pressure and oxygen saturation), pain assessment
prehensive evaluation and management of the condition (eg, visual analog scale and critical care pain observation
[15]. Anxiety and panic are strongly correlated with psy- tool) and adjustment of drug (eg, tramadol, morphine
chological dyspnea [16]. Oxygen therapy and low-dose and fentanyl patch), respiratory tract symptom assess-
sustained-related opioids play some roles in refractory ment (eg, wheeze, gasp, cough, chest tightness and chest
dyspnea, and nonpharmacologic treatment can provide pain), gastrointestinal symptom assessment (eg, abdom-
some benefits [17, 18]. A specialist palliative care team is inal pain, nausea, vomiting, diarrhea and bowel move-
necessary for managing patients with incurable dyspnea. ment frequency), urinary tract symptoms assessment (eg,
In Taiwan, several medical centers have established well- urine color, frequency and volume), nutritional status
trained home palliative care teams to provide medical, and assessed the intravenous fluid supplement, catheter
psychosocial, and spiritual support for terminally ill pa- renewal (eg, endotracheal tube, nasogastric tube and
tients and their families. Early integration of palliative urinary catheter), wound or ostomy nursing, as well as
care could improve quality of life by supporting patients blood test. In addition, we offered formal education in-
through complex physical, psychosocial, and spiritual is- formation sheets on dyspnea management to family
sues [19–21]. caregivers to help them obtain organized content for
However, few studies have focused on strategies for home care (Table 1).
decreasing suffering from dyspnea through home pallia-
tive care. The aim of the present study was to compare Selection criteria
two different approaches for dyspnea relief provided by There are two different home palliative care services in
our home palliative care team. These findings may reveal this study. During 2016, we performed basic home pal-
how the burdens of dyspnea patients can be reduced by liative care service (Group A) for all patients. During
home palliative care at the end of life and help promote 2017, we performed enhanced home palliative care ser-
successful experiences in future clinical practice. vice (Group B) for all patients.
Hsu et al. BMC Palliative Care (2021) 20:42 Page 3 of 7

Table 1 Patient instructions for family caregiver Table 2 Standard operating procedures for dyspnea and
Phase 1. For restless and anxious individuals with respiration rate less excessive sputum with difficult expectoration in Group B
than 20 times per min, follow the steps below: patients
1. Check if he or she is feeling unwell. Learning Goals
2. Use a fan or open the window to improve air circulation [22]. 1. Being able to list out current medications.
3. Massage the acupuncture points Lu 10 (Yuji), Lu 7 (Lieque) and 2. Assessment of dyspnea, labored breathing, excessive sputum with
ST36 (Zu San Li) or have him or her try to meditate [23, 24]. difficult expectoration, and symptoms of deoxygenation.
4. Refrain from straining when urinating or defecating. 3. Assessment of sputum amount, color, and odor.
Phase 2. For individuals with respiration rate between 20 and 24 times 4. Management of acute dyspnea.
per min, follow the steps below:
5. Management of excessive sputum and difficult expectoration.
1. Check vital signs. Note. A. Lung primary cancer or metastases, compression of tumor mass on
2. Check if he or she has been taking medications as prescribed. the airway, pulmonary infection, failure to clear sputum, heart failure, anemia
and other situations may lead to dyspnea
3. In case of thick sputum, use an ultrasonic nebulizer for steam B. Timely management involves minimizing patient’s fear, easing tension, and
inhalation. using simple yet appropriate methods to regain airway patency
4. If necessary, clear sputum with sputum suction therapy.
bleeding/complications. Dyspnea is a common symptom
5. Breathe air in from the nose and breathe out from the mouth with among the ill and older patients during the last 3 days of
a pursed lip.
life [25]. Patients (> 18 years old) with dyspnea who vis-
6. Prepare to rent a medical oxygen generator in case oxygen therapy
is needed.
ited the ED within 3 days prior to death were excluded
from this study. The following data were extracted for
7. Stay with the patient.
each eligible participant: sex, age, educational status, reli-
8. Sit in a reclined position or lie down with head elevated with gion, place of care, type of caregiver, number of nurse
cushioning at a 30–45 degrees angle.
home visits and calls, major reasons for ED visit, and site
9. Take extra precaution to protect the oral mucosa for mouth
breathers.
of death.
Phase 3. For individuals with respiration rate more than 24–28 times per
min or with sighing respiration (deep breaths), follow the steps below: Statistical analysis
A general linear model was used to compare group dif-
1. Check vital signs.
ferences. All statistical analyses were performed using
2. Check consciousness.
SPSS version 21.0 (SPSS, Inc., IBM Company, Chicago,
3. Check for death rattles. IL, USA). All P-values were based on two-tailed tests
4. Provide oxygen therapy. with statistical significance set at < 0.05.
5. Consider giving medication for management of shortness of
breath. Results
6. Call the palliative home-care nurse. During the study period from January 1, 2016 to December
Please check the box after each step is completed, so the palliative home-care 31, 2017, our home palliative care team served a total of
nurse will have a better understanding of the patient’s conditions 762 patients with cancer: 374 were in Group A, and 388
were in Group B. A total of 440 ED visits were recorded,
Group a among which 106 were attributed to dyspnea (Fig. 1). Of
The basic home palliative care visits occurred 5 days a the 89 patients (106 ED visits), 20 (22%) were classi-
week (Monday to Friday). fied as lung cancer in situ and 21(24%) were lung
metastasis (Supplementary Table 1).
Group B
In addition to basic home palliative care, the enhanced Demographics of ED patients with dyspnea
home palliative care extended the service time (seven Table 3 depicts the characteristics of ED visits attributed
days a week), and trained our home care nurse with for- to dyspnea under our home palliative care services. The
mulated standard operating procedures for dyspnea care total number of ED visits due to dyspnea was 106 (69
(Table 2). from the Group A and 37 from the Group B). The
mean ± SD age of subjects was 70.4 ± 13.0 years, 49.4%
Data source male. The majority of caregivers of patients were mi-
This study used ED clinical data of cancer patients who grant workers, companions, offspring and siblings of the
received home palliative care during the final 6 months patient. Analysis of home palliative care revealed that
of life. The reasons for ED visits were anemia, altered the proportion of nonfamily workers (42.9% vs. 19.4%)
mental status, catheter-related events, dyspnea, falls, and family members (57.1% vs. 80.6%) acting as care-
fever, N/V or other GI symptoms, pain, and tumor givers was significantly different between Group A and B
Hsu et al. BMC Palliative Care (2021) 20:42 Page 4 of 7

Fig. 1 Flowchart of study subjects

(P < 0.05). In multivariable logistic regression analysis no significant associations between home palliative care
adjusted for each covariate, the types of caregivers was service group and site of death (Supplementary Table 2).
an independent factor (OR = 3.29. 95%CI = 1.01–10.78,
P < 0.05) in enhanced home palliative care service (Sup- Association between improved care quality and ED visits
plementary Table 2). There was no significant difference Figure 2a summarizes the numbers and major reasons
in the proportion of patient deaths at home in Group A for ED visits. The total ED visits in Group A and Group
and Group B (24.5% vs 33.3%, P = 0.39). In unadjusted B were 248 and 192, respectively. In Group A, dyspnea
and adjusted logistic regression analysis, there were also (27.8%) was the most common reason recorded for ED

Table 3 Characteristics of ED patients with dyspnea attributed to the home palliative care patients with cancer
Characteristic All sample Group A Group B P-value*
Patients, No. 89 57 32
ED visits 106 69 37
Man, No (%) 44 (49.4) 27 (47.4) 17 (53.1) 0.60
Age, mean ± SD, yr 70.4 ± 13.0 69.3 ± 13.1 72.6 ± 12.7 0.31
Grade of school completed, yr 8 ± 4.8 8.4 ± 4.4 7.3 ± 5.5 0.32
Home care services
Telephone nurse per weeks 1.3 ± 1.2 1.4 ± 0.8 1.4 ± 2.0 0.95
Visiting nurse per weeks 0.77 ± 0.89 0.75 ± 0.4 0.98 ± 1.8 0.32
Types of Caregivers
Family 57 (65.5) 32 (57.1) 25 (80.6) 0.027
Nonfamily 30 (34.5) 24 (42.9) 6 (19.4)
Site of death
Home 23 (27.7) 13 (24.5) 10 (33.3) 0.39
Hospital 60 (72.3) 40 (75.5) 20 (66.7)
* General linear model for continuous variables, Chi-square test for categorical variables for the different palliative home care methods
Hsu et al. BMC Palliative Care (2021) 20:42 Page 5 of 7

Fig. 2 Reasons for visits to the emergency department (ED) by home palliative care patients with cancer. a all reasons of ED visits b dyspnea of
ED visits

visits, followed by pain (19.0%), GI symptoms (15.7%), In addition to the differences in the pathophysiology
and fever (15.3%). Through improved home palliative of various diseases, dyspnea is strongly correlated with
care intervention, the percentage of ED visits for dys- mood distresses, such as anxiety, panic, and fear of suf-
pnea was reduced in Group B compared the Group A. focation, which may increase respiratory effort. In 2009,
As shown in Fig. 2b, the risk was significantly reduced the American Thoracic Society indicated that palliative
by 30.7% in Group B (P < 0.05). management of dyspnea crisis most commonly occurs in
unprepared and overwhelmed family-caregivers and in
Discussion chaotic settings [26]. Because dyspnea should be
During the last 6 months of life in cancer patients re- assessed by the individual experiencing it, the medical
ceiving palliative home care, when additional home pal- care team must understand the expectations and appre-
liative care team interventions on the weekend were hensions of the patients and caregivers [27–29]. Given
considered, ED visits were significantly reduced by that dyspnea is multifactorial, a beneficial treatment
30.7% (P < 0.05) compared to standard palliative care. strategy should include interventions to reduce anxiety
This study indicates that effective home palliative care and other types of psychological distress [30]. In this
reduced ED visits related to controllable dyspnea. study, detailed education sheets without bedside
Hsu et al. BMC Palliative Care (2021) 20:42 Page 6 of 7

evaluation by professional medical staff could cause anx- study sample size was small. In future work, detailed eval-
iety and confusion among caregivers, resulting in in- uations with prolonged observation are recommended.
creased ED visits.
Some longitudinal surveys observed that over half of Conclusions
all geriatric patients with advanced illness visit the ED This study reveals that enhanced intensity of home pal-
during their last month of life and that repeat visits are liative care visits significantly reduces the number of ED
common [31, 32]. In the enhanced palliative home care visits due to non-organic dyspnea at the end of life. Dys-
of this study, we extended working hours to Saturday pnea is multifactorial, and an integrated treatment strat-
and Sunday (8 am to 6 pm) for palliative home care. egy should include interventions to reduce anxiety and
After we applied more frequent, comprehensive home other psychological distresses.
palliative visits, ED visits due to controllable dyspnea epi-
sodes were significantly reduced by 30.7% (P < 0.05) com-
pared to standard working hours; overall ED visits were Supplementary Information
The online version contains supplementary material available at https://doi.
also significantly decreased. Multiple studies have shown org/10.1186/s12904-021-00713-6.
similar results, i.e., that patients receiving end-of-life nurs-
ing compared to standard nursing exhibited decreased ED Additional file 1: Supplementary Table 1. Cancer types of home
visits during the last 6 months of life [33, 34]. palliative care patients with dyspnea. Supplementary Table 2. Logistic
regression models of home palliative care services in reducing
ED visits can be a source of misery because of the emergency department visits based on each covariate.
crowded environment in hospitals, high patient–nurse
ratios, and long wait times, all of which can exhaust pa-
Abbreviation
tients and their families. When death is imminent, ED is ED: Emergency Department
not the preferred place for the death of patients [35].
Delgado–Guay and colleagues found that nearly one- Acknowledgements
fourth of all ED visits by patients with advanced cancer The authors gratefully acknowledge the staff of the home palliative care in
receiving palliative care could be avoided [8]. the hospital that provided the database for analysis.
Moreover, increased intensity of home palliative care
Authors’ contributions
visits provided not only pharmacological consultation Study concept and design was performed by HSH, THW, CYL, CCL, and TPC.
but also nonpharmacological interventions for dyspnea, Drafting of the manuscript was performed by HSH. THW completed the
such as improved air flow using a fan, use of religious analysis. Critical revision of the manuscript for intellectual content was
performed by HSH, THW, and WTL. All authors have read and approved the
breathing exercises, adoption of a calm, reassuring atti- manuscript.
tude toward patients, comfortable positioning, a humane
environment, and sustained safety to patients and care- Funding
givers. Similar to the findings of Sarmento VP and This study was supported by China Medical University Hospital, Taichung,
colleagues, coaching caregivers and enhancing the expe- Taiwan [grant number DMR-104-071, DMR-105-072, DMR-105-173, and CRS-
108-025]. This funding source had no involvement in study design, data col-
riences of patients and families are key factors in im- lection, analysis, interpretation of data, or writing of this report.
proving home hospice care [22].
In Japan [23] and US [24], the preferred place to die is Availability of data and materials
always home, and accommodating this preference is the Due to privacy and ethical concerns, neither the data nor the source of the
data can be made available.
goal in end-of-life care [31]. In this study, success was
reflected not only by the achievement of the reduced ED
Ethics approval and consent to participate
visits but also by the significant increase in proportion of This study was approved by the research ethics committee of China Medical
families who participated in care responsibilities instead University Hospital (CMUH108-REC3–008).
of nonfamily caregivers (Table 1, P < 0.05).
Consent for publication
Not required.
Limitations
This study has several limitations. First, our hospital, a
Competing interests
medical center, is located in an urban setting, and the None declared.
patients we served lived within the area. Therefore, the
present findings do not reflect the accessibility of home Author details
1
Department of Family Medicine and Social Medicine, School of Medicine,
palliative visits in rural areas. Second, this study was College of Medicine, China Medical University, Taichung, Taiwan.
conducted in only one hospital, and replicating the out- 2
Department of Family Medicine, China Medical University Hospital,
comes in other institutions is important. Finally, further Taichung, Taiwan. 3Department of Palliative Medicine, China Medicinal
University Hospital, Taichung, Taiwan. 4Department of Medical Research,
analysis was not conducted on the causes of dyspnea or China Medical University Hospital, Taichung, Taiwan. 5Department of Nursing,
their relationship with the patients’ cancers because our China Medical University Hospital, Taichung, Taiwan.
Hsu et al. BMC Palliative Care (2021) 20:42 Page 7 of 7

Received: 31 August 2020 Accepted: 11 January 2021 24. Kinoshita H, Maeda I, Morita T, Miyashita M, Yamagishi A, Shirahige Y, et al.
Place of death and the differences in patient quality of death and dying
and caregiver burden. J Clin Oncol. 2015;33(4):357–63.
25. Lynn J, Teno JM, Phillips RS, Wu AW, Desbiens N, Harrold J, et al.
References Perceptions by family members of the dying experience of older and
1. Chen CH, Lin YC, Liu LN, Tang ST. Determinants of preference for home seriously ill patients. SUPPORT investigators. Study to understand prognoses
death among terminally ill patients with cancer in Taiwan: a cross-sectional and preferences for outcomes and risks of treatments. Ann Intern Med.
survey study. J Nurs Res. 2014;22(1):37–44. 1997;126(2):97–106.
2. Gomes B, Calanzani N, Curiale V, McCrone P, Higginson IJ. Effectiveness and 26. Mularski RA, Reinke LF, Carrieri-Kohlman V, Fischer MD, Campbell ML, Rocker
cost-effectiveness of home palliative care services for adults with advanced G, et al. An official American Thoracic Society workshop report: assessment
illness and their caregivers. Cochrane Database Syst Rev. 2013;6:Cd007760. and palliative management of dyspnea crisis. Ann Am Thorac Soc. 2013;
3. Maetens A, Beernaert K, De Schreye R, Faes K, Annemans L, Pardon K, et al. 10(5):S98–106.
Impact of palliative home care support on the quality and costs of care at 27. Bausewein C, Calanzani N, Daveson BA, Simon ST, Ferreira PL, Higginson IJ,
the end of life: a population-level matched cohort study. BMJ Open. 2019; et al. 'Burden to others' as a public concern in advanced cancer: a
9(1):e025180. comparative survey in seven European countries. BMC Cancer. 2013;13:105.
4. National Institution of Aging. What Are Palliative Care and Hospice Care? 28. Grudzen CR, Richardson LD, Morrison M, Cho E, Morrison RS. Palliative care
Bethesda: National Institution of Health; 2017. Available from: https://www. needs of seriously ill, older adults presenting to the emergency department.
nia.nih.gov/health/what-are-palliative-care-and-hospice-care. Acad Emerg Med. 2010;17(11):1253–7.
5. Solberg LM, Hincapie-Echeverri J. Palliative Care in the Emergency 29. Calanzani N, Moens K, Cohen J, Higginson IJ, Harding R, Deliens L, et al.
Department. Crit Care Nurs Clin North Am. 2015;27(3):355–68. Choosing care homes as the least preferred place to die: a cross-national
6. Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block S. Identifying potential survey of public preferences in seven European countries. BMC Palliat Care.
indicators of the quality of end-of-life cancer care from administrative data. 2014;13:48.
J Clin Oncol. 2003;21(6):1133–8. 30. Blinderman CD, Billings JA. Comfort Care for Patients Dying in the hospital.
7. Barbera L, Taylor C, Dudgeon D. Why do patients with cancer visit the N Engl J Med. 2015;373(26):2549–61.
emergency department near the end of life? Cmaj. 2010;182(6):563–8. 31. Mayer DK, Travers D, Wyss A, Leak A, Waller A. Why do patients with cancer
8. Delgado-Guay MO, Kim YJ, Shin SH, Chisholm G, Williams J, Allo J, et al. visit emergency departments? Results of a 2008 population study in North
Avoidable and unavoidable visits to the emergency department among Carolina. J Clin Oncol. 2011;29(19):2683–8.
patients with advanced cancer receiving outpatient palliative care. J Pain 32. Smith AK, McCarthy E, Weber E, Cenzer IS, Boscardin J, Fisher J, et al. Half of
Symptom Manag. 2015;49(3):497–504. older Americans seen in emergency department in last month of life; most
9. Mierendorf SM, Gidvani V. Palliative care in the emergency department. admitted to hospital, and many die there. Health Aff (Millwood). 2012;31(6):
Perm J. 2014;18(2):77–85. 1277–85.
10. Laribi S, Keijzers G, van Meer O, Klim S, Motiejunaite J, Kuan WS, et al. 33. Bell D, Ruttenberg MB, Chai E. Care of Geriatric Patients with advanced
Epidemiology of patients presenting with dyspnea to emergency illnesses and end-of-life needs in the emergency department. Clin Geriatr
departments in Europe and the Asia-Pacific region. Eur J Emerg Med. 2019; Med. 2018;34(3):453–67.
26(5):345–9. 34. Seow H, Barbera L, Pataky R, Lawson B, O'Leary E, Fassbender K, et al. Does
11. Moens K, Higginson IJ, Harding R. Are there differences in the prevalence of increasing home care nursing reduce emergency department visits at the
palliative care-related problems in people living with advanced cancer and end of life? A population-based cohort study of Cancer decedents. J Pain
eight noncancer conditions? A systematic review. J Pain Symptom Manag. Symptom Manag. 2016;51(2):204–12.
2014;48(4):660–77. 35. Sutradhar R, Barbera L, Seow HY. Palliative homecare is associated with
12. Bruera E, Schmitz B, Pither J, Neumann CM, Hanson J. The frequency and reduced high- and low-acuity emergency department visits at the end of
correlates of dyspnea in patients with advanced cancer. J Pain Symptom life: a population-based cohort study of cancer decedents. Palliat Med. 2017;
Manag. 2000;19(5):357–62. 31(5):448–55.
13. Thomas S, Bausewein C, Higginson I, Booth S. Breathlessness in cancer
patients - implications, management and challenges. Eur J Oncol Nurs.
2011;15(5):459–69. Publisher’s Note
14. Seow H, Barbera L, Sutradhar R, Howell D, Dudgeon D, Atzema C, et al. Springer Nature remains neutral with regard to jurisdictional claims in
Trajectory of performance status and symptom scores for patients with published maps and institutional affiliations.
cancer during the last six months of life. J Clin Oncol. 2011;29(9):1151–8.
15. Abernethy AP, Wheeler JL. Total dyspnoea. Curr Opin Support Palliat Care.
2008;2(2):110–3.
16. De Peuter S, Van Diest I, Lemaigre V, Verleden G, Demedts M, Van den
Bergh O. Dyspnea: the role of psychological processes. Clin Psychol Rev.
2004;24(5):557–81.
17. Pisani L, Hill NS, Pacilli AMG, Polastri M, Nava S. Management of Dyspnea in
the terminally ill. Chest. 2018;154(4):925–34.
18. Nauck F, Alt-Epping B. Crises in palliative care--a comprehensive approach.
Lancet Oncol. 2008;9(11):1086–91.
19. Higginson IJ, Bausewein C, Reilly CC, Gao W, Gysels M, Dzingina M, et al. An
integrated palliative and respiratory care service for patients with advanced
disease and refractory breathlessness: a randomised controlled trial. Lancet
Respir Med. 2014;2(12):979–87.
20. Sorenson HM. Palliative care for lung disease: start early, stay late. Lancet
Respir Med. 2013;1(4):279–80.
21. Ekström M, Allingham SF, Eagar K, Yates P, Johnson C, Currow DC.
Breathlessness during the last week of life in palliative care: an Australian
prospective, Longitudinal Study. J Pain Symptom Manage. 2016;51(5):816–
23.
22. Gisondi MA. A case for education in palliative and end-of-life care in
emergency medicine. Acad Emerg Med. 2009;16(2):181–3.
23. Sarmento VP, Gysels M, Higginson IJ, Gomes B. Home palliative care works:
but how? A meta-ethnography of the experiences of patients and family
caregivers. BMJ Support Palliat Care. 2017;7(4):0.