Cough in palliative care

Overview
Clinicians
Clinicians

A cough is an automatic reaction to clear your airways if they are blocked by something, such as phlegm (mucus), smoke, dust or a piece of food. This page focuses on cough in people living with a terminal illness.

Key points

A cough is common symptom if you have a terminal illness, especially if it is related to a lung disorder such as lung cancer.
A cough can be caused by the terminal illness itself or by any pre-existing lung conditions you may have, such as COPD or interstitial lung disease.
A cough may be productive (moist) or unproductive (dry).
A productive cough produces phlegm (mucus from the back of your throat, nose, sinuses or up from your lungs). An unproductive cough is a dry, often hacking, cough.
Treatment aims to relieve your cough and make you feel better.

If you have a cough and you’re short of breath, cough up blood or have unexplained problems like weight loss or a high temperature (fever), you should see your GP urgently.

What causes a cough?

There are many causes that can contribute to a cough if you have a terminal illness. It may come and go quickly (acute) or may come on slowly and last for a longer time (chronic). Your cough may also have associated symptoms such as shortness of breath, wheeze or chest tightness.

It can be caused by the terminal illness you are living with, eg, lung cancer, or other medical conditions that happen at the same time. It can also be caused by a combination of possible causes. Sometimes, it's not possible to find out an exact cause.

Common causes of a cough in people living with a terminal illness include:

cancer and its complications, such as pulmonary oedema, pulmonary embolism, pleural effusion or airway obstruction
conditions affecting your lungs, such as asthma, COPD or interstitial lung disease
heart conditions such as heart failure
GI conditions such as gastroesophageal reflux
infection such as pneumonia, common cold or bronchiectasis
side effect of medicines or treatment, eg, if you are on ACE inhibitor or radiotherapy.

How is the cause of a cough diagnosed?

Your doctor may ask you some questions to find out the possible causes of your cough. These include the following:

Did it start suddenly or develop over time? Did anything trigger it? How long has it lasted?
When do you cough? Is it worse at night?
Are you breathless even when you're not coughing? Have you got any pain in your chest?
Are you coughing up phlegm (mucus)? What colour is it? Is there any blood?
Do you feel ill? Do you have a high temperature (fever), weight loss or sweats?
Have you been in contact with anyone with tuberculosis (TB) or travelled overseas recently?
Do you smoke?
Have you started any new medicine recently?
Do you have any pre-existing lung conditions such as COPD or asthma?
Is there anything that you have found helps with your cough?

They may also listen to your chest, take a sample of any mucus you might be coughing up or order an x-ray or test to see how well your lungs work.

How is a cough treated?

In palliative care, treatment aims to relieve your cough and make you feel better. You may have many healthcare professionals such as doctors, nurses, a physiotherapist, an occupational therapist, a palliative care specialist or a cancer specialist involved in your care, as it requires treatment from a multidisciplinary team.

If you have a medical condition, or any obvious causes of your cough are found, treatment will focus on the condition or cause.

The treatment of cough also depends on whether it is a dry or moist cough.

Dry cough (unproductive cough)

Some of the medicines that may be used to treat dry cough include:

nebulised saline
codeine
pholcodine linctus
morphine
steroids.

Moist cough (productive cough)

Treatment for a moist cough may include:

chest physiotherapy
nebulised saline
bronchodilators such as salbutamol or ipratropium
steroids
antibiotics if infection is suspected
proton pump inhibitors such as omeprazole for reflux.

Nearing the end of life, some of these medicines may be given to you via subcutaneous injection (under your skin) or a syringe driver. Read more about syringe drivers.

You may receive both non-medicine and medicine treatment together, depending on your condition.

You may also be referred to a chest physiotherapist, an occupational therapist, a psychologist, or a complementary therapist as part of your treatment. Sometimes, non-medicine measures may be useful, such as position changes (especially overnight), or sips of warm fluids may be soothing for a persistent cough.

What support is available with a cough?

Living with a cough can be frustrating. It can also make it challenging to do things physically. Talk through your feelings with your family/whānau and friends to get the support you need.

If you need extra help in daily activities such as washing, dressing or cooking, your doctor may be able to arrange this for you.

Below are some support services and information for people affected by cancer and their family/whānau:

Emotions & cancer Cancer Society, NZ
How we can help Cancer Society, NZ
Cancer services – find a hospital/service near you Healthpoint, NZ
More cancer support groups

Learn more

The following links have more information about cough. Be aware that websites from other countries may have information that differs from New Zealand recommendations.

Managing the symptoms of cancer Macmillan Cancer Support, UK
Cough Ministry of Health, NZ
Cough NHS, UK
Cough Health Direct, Australia

References

Cough in palliative care Auckland Regional HealthPathways, NZ
Cough Scottish Palliative Care Guidelines, UK
Palliative care pain & symptom control guidelines for adults Greater Manchester and Eastern Cheshire Strategic Clinical Networks, UK

Credits: Health Navigator Editorial Team. Reviewed By: Jarna Standen, Registered Nurse, Mercy Hospice, Auckland Last reviewed: 03 Jul 2020 Page last updated: 03 Jul 2020

Information for healthcare providers on palliative care - cough

The content on this page will be of most use to clinicians, such as nurses, doctors, pharmacists, specialists and other healthcare providers.

The following information on cough in palliative care is taken form Auckland Regional HealthPathways, accessed May 2020:

About cough in palliative care

Cough is a common symptom, particularly in respiratory disorders such as primary or metastatic lung cancer, and lymphangitis
Many patients have underlying diseases such as COPD or interstitial lung disease that may contribute to cough. Identify any reversible causes.
In palliative care, cough may be multi‑factorial.
Cough can be stimulated by reflux oesophagitis.
When patients are dying and are no longer able to clear sputum, it may be appropriate to suppress the cough.
Antibiotics may be a useful palliative treatment.

Assessment

Identify the possible cause of the cough by checking:
• precipitating factors, and diurnal variation, especially nocturnal cough.
• volume, and colour, of sputum.
• any associated symptoms e.g., dyspnoea, wheeze, chest tightness.
• any underlying diseases e.g., COPD, interstitial lung disease.
• symptoms related to GORD, rhinosinusitis, asthma.
• drug cause e.g., ACE inhibitors.
See also Chronic Cough.

Management

Treating the cough, rather than the cause, may be more appropriate for some patients as some treatments may take several weeks to take effect e.g., proton pump inhibitor (PPI) or inhaled steroid.
If lung malignancy is suspected as the primary cause of cough, consider non-acute oncology assessment for advice about radiotherapy or chemotherapy.
Treat the cause as appropriate.
Treat the cough depending on whether it is dry or moist.

Regional HealthPathways NZ

Access to the following regional pathways is localised for each region and access is limited to health providers. If you do not know the login details, contact your DHB or PHO for more information: