Nebulized morphine for paroxysmal cough and dyspnea in a nursing home resident with metastatic cancer.

Nursing homes continue to be challenged with the task of caring for patients in various stages of disease. Historically, the death of a long-term care patient in this setting is not unusual; however, researchers and clinicians are focusing increasingly on the quality of life at the end of life, regardless of location. The long-term care facility is an ideal setting in which to begin to effectively address these issues, especially as individual patients in need present for care. Although the care of many of our geriatric patients meets the definition of palliative care, no where is the need greater, and more obvious, than in the patient presenting with terminal illness. Aggressive treatment of distressing symptomatology contributes to overall quality of life, and returns to the patient some of the freedom and autonomy usurped by the disease process. It is particularly rewarding for the interdisciplinary team to be successful in controlling symptoms in the patient with limited life expectancy, thus allowing the patient to complete unfinished tasks and enjoy quality time with family and friends. Often the "triumphs" in the nursing home are few and fleeting; abolishing pain, distress, and suffering is both personally and professionally satisfying for everyone involved. We presented a review of the available literature on a technique in palliative medicine which is still evolving. Additional, we presented its practical use in a frail, elderly nursing home resident admitted with end-stage metastatic breast carcinoma. The geriatric adage of "start low, and go slow" was effectively borne out in the management of this resident's most difficult symptoms, shortness of breath and paroxysmal cough leading to symptomatic atrial fibrillation. The key to the management of the frail elderly patient goes beyond " start low and go slow" to "aggressively titrate as needed but no further" in order to meet the needs of the individual patient and avoids unwanted side effects.