Living with breathlessness: a survey of caregivers of breathless patients with lung cancer or heart failure

Evaluation of a training program using the SBAR communication tool for caregivers managing acute respiratory distress in lung cancer patients: A pilot randomized controlled trial protocol

Background

Family-based caregivers are increasingly important in the management of non-hospitalized lung cancer patients. However, lack of training can negatively impact care including diagnostic errors that can lead to delays in providing appropriate medical treatment. Acute respiratory failure (ARF) is common symptom of lung cancer and requires urgent intervention as well as adequate communication with healthcare professionals (HCPs) to enable appropriate decision-making and improve patient outcomes. Standardized tools such as the Situation, Background, Assessment, Recommendation (SBAR) tool and its French adaptation SAED, standing for Situation, Antécédent, Évaluation et Demande, are designed to facilitate communication among (HCPs).Additionally, digital interventions, such as serious games, are increasingly used to train HCPs though its use for caregivers has not been studied. This pilot study aims to assess an innovative serious game training using the SAED tool combined with standard instructions on self-efficacy for family-based caregivers of lung cancer patients when facing a simulated situation of ARF. The study also aims to examine caregivers' emotional state, quality of life, satisfaction and knowledge about the SBAR tool.

Methods

A monocentric, randomized, controlled, open-label, superiority, parallel-arm trial will be conducted for 18 months with 3 mid-study assessments (NCT05839353). Family caregivers of lung cancer patients will be recruited at the University Hospital Center of Saint Pierre, Reunion Island, France. Participants will be randomized (1:1) into two groups: the experimental group receiving training using the SBAR/SAED tool and standard instructions for managing respiratory distress/dyspnea, and the control group, receiving standard instructions only. The primary outcome will be to determine perceived self-efficacy as measured by the Generalized Self-Efficacy Scale.

Discussion

This study will present a preliminary assessment of training family caregivers in using the SBAR/SAED tool in simulated episodes of ARF in lung cancer patients. Our findings may provide valuable insights into effective training methods for caregivers in critical home care situations and could be widely used for lung cancer management.

The Effectiveness of Lifestyle Interventions in Heart Failure With Preserved Ejection Fraction: A Systematic Review and Network Meta-Analysis

OBJECTIVES

To perform a network meta-analysis to determine the effectiveness of lifestyle interventions in exercise tolerance and quality of life (QoL) in people with HFpEF.

METHODS

Ten databases were searched for randomized controlled trials that evaluated a diet and/or exercise intervention in people with heart failure with preserved ejection fraction until May 2022. The co-primary outcomes were peak oxygen uptake (V̇O2peak) and Quality of Life as assessed by the Minnesota Living with Heart Failure Questionnaire (MLHFQ). We synthesized data using network meta-analysis.

RESULTS

We identified 13 trials, including a total of 869 participants, and we incorporated 6 different interventions. Improvements in V̇O2peak compared to controls were seen for all exercise interventions (2.88 [95% CI: 1.36; 4.39] mL/kg/min) for high-intensity interval training (HIIT); 2.37 [95% CI: 1.02; 3.71] mL/kg/min for low-intensity exercise (LIT) combined with a hypocaloric diet; 2.05 [95% CI: 0.81; 3.29] mL/kg/min for moderate-intensity continuous training (MICT); 1.94 [95% CI: 0.59; 3.29] mL/kg/min for LIT; 1.85 [95% CI: 0.27; 3.44] mL/kg/min for MICT combined with resistance training) but not a hypocaloric diet alone (1.26 [95%CI: -0.08; 2.61] mL/kg/min). Only HIIT (-14.45 [95%CI: -24.81; -4.10] points) and LIT (95% CI: -11.05 [-20.55; -1.54] mL/kg/min) significantly improved MLHFQ scores. Network meta-analysis indicated that HIIT was the most effective intervention for improving both V̇O2peak (mean improvement 2.88 [95% CI: 1.36; 4.39] mL/kg/min, follow-up range, 4 weeks-3 years) and QoL (-14.45 [95% CI: -24.81; -4.10] points, follow-up range, 12-26 weeks) compared to usual care.

CONCLUSIONS

This network meta-analysis indicates that HIIT is the most effective lifestyle intervention studied to improve exercise capacity and QoL, with mean improvements exceeding the minimum clinically meaningful thresholds. HIIT is likely to be an underused management strategy in HFpEF, but further studies are needed to confirm long-term improvements in symptoms and clinical outcomes.

Experiences of relatives caring for psychiatric patients in the Greater Accra Region of Ghana

PURPOSE

The study aimed at examining the lived experiences of relatives caring for family members with mental illness in Ghana.

METHODS

Interpretative Phenomenological Analysis (IPA) was adopted to explore caregivers' in-depth experiences. Fifteen caregivers were purposefully selected from four hospitals within the Greater Accra Region of Ghana, and they were engaged in face-to-face interview sessions through the semi-structured guided interviews. Interviews were transcribed into text formats and analysed using the IPA approach.

RESULTS

Three superordinate themes and their respective sub-themes were identified. Theme 1: Being with the mentally ill (time consuming; financial burden; healer shopping); Theme 2: Psychosocial effect (stigmatization; stress and depression; changes in social/work life); Theme3: Coping resources (prayers/spirituality; psychological capital - ignoring, self-encouragement, acceptance, routinization; social/family support; reading).

CONCLUSION

It was recommended that healthcare professionals ought to prepare family members for the emotional challenges by providing them with constant therapeutic service to help reduce their emotional strain associated with the burden of care. Public education should be intensified for people to understand the need for accepting people with mental illness in order to reduce the issue of stigmatization. Again, government should institute policies through its agencies (Ministry of Health, Ghana Health Service) to assist the caregivers in the discharge of responsibilities. This could take the form of reducing cost of drugs, and establishing community mental health care to provide immediate support.

Relationship between dyspnoea and related factors in patients with cancer: a cross-sectional study

OBJECTIVES

Dyspnoea is a common and distressing symptom in patients with cancer. We aimed to analyse the association between dyspnoea and related factors and to estimate their causal relationship.

METHODS

A cross-sectional study was conducted. Patients with cancer with dyspnoea and a mean Numerical Rating Scale (NRS) of ≥3 over 24 hours were enrolled at 10 institutions in Japan from December 2019 to February 2021. The outcomes included dyspnoea, cough and pain NRS over 24 hours, Eastern Cooperative Oncology Group Performance Status, Hospital Anxiety and Depression Scale, Somatosensory Amplification Scale, opioids for dyspnoea and respiratory failure. Path analyses were conducted to estimate the direct and indirect paths with reference to dyspnoea and related factors.

RESULTS

A total of 209 patients were enrolled and 208 patients were included in the analysis. Cough worsened dyspnoea (β=0.136), dyspnoea increased emotional distress (β=1.104), emotional distress increased somatosensory amplification (β=0.249) and somatosensory amplification worsened cough (β=0.053) according to path analysis.

CONCLUSION

There may be a vicious circle among dyspnoea and related factors: cough worsened dyspnoea, dyspnoea increased emotional distress, emotional distress increased somatosensory amplification and somatosensory amplification worsened cough. When treating dyspnoea in patients with cancer, managing these factors aimed at interrupting this vicious circle may be useful.

TRIAL REGISTRATION NUMBER

UMIN Clinical Trials Registry (UMIN000038820).

The impact of regular, low-dose, sustained-release morphine for chronic breathlessness on caregiver burden: An exploratory analysis of the BEAMS trial

BACKGROUND

Chronic breathlessness adversely impacts people with chronic obstructive pulmonary disease and their caregivers (family and friends), who may, in turn, experience significant burden due to their caregiving role. Sustained-release morphine may reduce chronic breathlessness in some patients, which may have an impact on caregivers' perceived burden.

AIM

To explore the impact on caregiver burden of active treatment of people with chronic breathlessness (modified Medical Research Council (mMRC) ⩾ 3) and chronic obstructive pulmonary disease (COPD) with regular, low-dose, sustained-release morphine within a multi-site, double-blind, randomised, placebo-controlled trial.

DESIGN

Exploratory analysis of self-reported caregiver burden at baseline and end of week 3 in a randomised, double-blind, placebo-controlled study. Caregiver measures included: demographics and perceived burden (Zarit Burden Interview 12-item short-form questionnaire). Patient measures included: worst breathlessness and FitBitR-measures.

SETTING/PARTICIPANTS

All consenting caregivers of trial patient participants in a multi-site study recruiting from palliative care and respiratory services.

RESULTS

Caregivers (n = 49; 59% women; median age 68 years [IQR 50-75]) reported median baseline caregiver burden 12 [IQR 5-17], with 53% reporting high burden (⩾13). Eighty-four percent of caregivers reported no change in burden. In people whose worst breathlessness improved, caregiver burden moved in the same direction, though the correlation was not significant (rs = 0.25, p = 0.17). Conversely, caregiver burden worsened as patients' minutes lightly active increased, with the correlation being significant (rs = 0.56, p = 0.04).

CONCLUSIONS

Caregivers reported high levels of caregiver burden, but patients' response to treatment in terms of their symptom and function may influence change in caregiver burden over a three-week period.

What factors are associated with informal carers' psychological morbidity during end-of-life home care? A systematic review and thematic synthesis of observational quantitative studies

Background

Family carers are central in supporting patients nearing end of life. As a consequence, they often suffer detrimental impacts on their own mental health. Understanding what factors may affect carers' mental health is important in developing strategies to maintain their psychological well-being during caregiving.

Aim

To conduct a systematic review and thematic evidence synthesis of factors related to carers' mental health during end-of-life caregiving.

Method

Searches of MEDLINE, CINAHL, PsychINFO, Social Sciences Citation Index, EMBASE, Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effects 1 January 2009-24 November 2019. We included observational quantitative studies focusing on adult informal/family carers for adult patients at end of life cared for at home considering any factor related to carer mental health (anxiety, depression, distress and quality of life) pre-bereavement. Newcastle-Ottawa Quality Assessment Scale was used. Thematic analysis with box score presentation, and meta-analysis were done where data permitted.

Results

Findings from 63 included studies underpinned seven emergent themes. Patient condition (31 studies): worse patient psychological symptoms and quality of life were generally associated with worse carer mental health. Patient depression was associated with higher depression in carers (standardised mean difference = 0.59, 95% confidence interval 0.32 to 0.87, I2 = 77%). Patients' other symptoms and functional impairment may relate to carer mental health, but findings were unclear. Impact of caring responsibilities (14 studies): impact on carers' lives, task difficulty and general burden had clear associations with worse carer mental health. Relationships (8 studies): family dynamics and the quality of the carer-patient relationship may be important for carer mental health and are worthy of further investigation. Finance (6 studies): insufficient resources may relate to carers' mental health and warrant further study. Carers' psychological processes (13 studies): self-efficacy and preparedness were related to better mental health. However, findings regarding coping strategies were mixed. Support (18 studies): informal support given by family and friends may relate to better carer mental health, but evidence on formal support is limited. Having unmet needs was related to worse mental health, while satisfaction with care was related to better mental health. Contextual factors (16 studies): older age was generally associated with better carer mental health and being female was associated with worse mental health.

Limitations

Studies were mainly cross-sectional (56) rather than longitudinal (7) which raises questions about the likely causal direction of relationships. One-third of studies had samples < 100, so many had limited statistical power to identify existing relationships.

Conclusions and future work

Future work must adopt a comprehensive approach to improving carers' mental health because factors relating to carer mental health cover a broad spectrum. The literature on this topic is diverse and difficult to summarise, and the field would benefit from a clearer direction of enquiry guided by explanatory models. Future research should (1) further investigate quality of relationships and finances; (2) better define factors under investigation; (3) establish, through quantitative causal analyses, why factors might relate to mental health; and (4) utilise longitudinal designs more to aid understanding of likely causal direction of associations.

Study registration

This study is registered as PROSPERO registration 2019 CRD42019130279 at https://www.crd.york.ac.uk/prospero/.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme HSDR 18/01/01 and is published in full in Health and Social Care Delivery Research. See the NIHR Funding and Awards website for further award information.

A novel opportunity to improve heart failure care: focusing on subcutaneous furosemide

The prevalence of heart failure (HF) continues to rise in developed nations. Symptomatic congestion is the most common reason for patients to seek medical attention, and management often requires intravenous (IV) diuretic administration in the hospital setting. Typically, the number of admissions increases as the disease progresses, not only impacting patient survival and quality of life but also driving up healthcare expenditures. pH-neutral furosemide delivered subcutaneously using a proprietary, single-use infusor system (Furoscix) has a tremendous potential to transition in-hospital decongestive therapy to the outpatient setting or to the patient's home. This review is aimed at providing an overview of the pharmacodynamic and pharmacokinetic profile of the novel pH-neutral furosemide in addition to the most recent clinical trials demonstrating its benefit when used in the home setting. Given the newest data and approval by the Food and Drug Administration in the US, it has the potential to revolutionize the care of patients with decompensated HF. Undoubtedly, it will lead to improved quality of life as well as significantly reduced healthcare costs related to hospital admissions.

Postdischarge Caregiver Burden Among Family Caregivers of Older Trauma Patients

Importance

Caregiver burden, characterized by psychological distress and physical morbidity, affects more than 50 million family caregivers of older adults in the United States. Risk factors for caregiver burden among caregivers of older trauma patients have not been well characterized.

Objective

To characterize postdischarge caregiver burden among caregivers of older trauma patients and identify targets that can inform interventions to improve their experience.

Design, Setting, and Participants

This study used a repeated cross-sectional design. Participants were family caregivers for adults 65 years or older with traumatic injury who were discharged from 1 of 2 level I trauma centers. Telephone interviews were conducted at 1 month and 3 months postdischarge with family caregivers (identified by the patient as family or friends who provided unpaid care). Admissions occurred between December 2019 and May 2021, and data were analyzed from June 2021 to May 2022.

Exposure

Hospital admission for geriatric trauma.

Main Outcome and Measures

High caregiver burden was defined by a score of 17 or higher on the 12-item Zarit Burden Interview. Caregiver self-efficacy and preparedness for caregiving were assessed via the Revised Scale for Caregiving Self-Efficacy and Preparedness for Caregiving Scale, respectively. Associations between caregiver self-efficacy, preparedness for caregiving, and caregiver burden were tested via mixed-effect logistic regression.

Results

There were 154 family caregivers enrolled in the study. Their mean (SD) age was 60.6 (13.0) years (range, 18-92 years), 108 of 154 were female (70.6%). The proportion of caregivers experiencing high burden (Zarit Burden Interview score ≥17) was unchanged over time (1 month, 38 caregivers [30.9%]; 3 months, 37 caregivers [31.4%]). Participants with lower caregiver self-efficacy and preparedness for caregiving were more likely to experience greater caregiver burden (odds ratio [OR], 7.79; 95% CI, 2.54-23.82; P < .001; and OR, 5.76; 95% CI, 1.86-17.88; P = .003, respectively).

Conclusion and Relevance

This study found that nearly a third of family caregivers of older trauma patients experience high caregiver burden up to 3 months after the patients' discharge. Targeted interventions to increase caregiver self-efficacy and preparedness may reduce caregiver burden in geriatric trauma.

Effect of listening to breathing recordings on self-reported breathlessness: a public experiment

Breathlessness is a common and persistent symptom for those living with chronic lung conditions and advanced disease [1]. It can be distressing for those who experience it, and often results in anxiety, physical inactivity and a poorer quality of life [2, 3]. Additionally, it impacts significantly on those who are close, including friends and family, and is associated with a considerable care burden [4].

This public experiment – a collaboration between the Cicely Saunders Institute and Science Gallery London – found that listening to audio recordings of breathlessness resulted in a noticeable increase in self-reported breathlessness. https://bit.ly/3o8py2Q

Optimising breathlessness triggered services for older people with advanced diseases: a multicentre economic study (OPTBreathe)

BACKGROUND

In advanced disease, breathlessness becomes severe, increasing health services use. Breathlessness triggered services demonstrate effectiveness in trials and meta-analyses but lack health economic assessment.

METHODS

Our economic study included a discrete choice experiment (DCE), followed by a cost-effectiveness analysis modelling. The DCE comprised face-to-face interviews with older patients with chronic breathlessness and their carers across nine UK centres. Conditional logistic regression analysis of DCE data determined the preferences (or not, indicated by negative β coefficients) for service attributes. Economic modelling estimated the costs and quality-adjusted life years (QALYs) over 5 years.

FINDINGS

The DCE recruited 190 patients and 68 carers. Offering breathlessness services in person from general practitioner (GP) surgeries was not preferred (β=-0.30, 95% CI -0.40 to -0.21); hospital outpatient clinics (0.16, 0.06 to 0.25) or via home visits (0.15, 0.06 to 0.24) were preferred. Inperson services with comprehensive treatment review (0.15, 0.07 to 0.21) and holistic support (0.19, 0.07 to 0.31) were preferred to those without. Cost-effectiveness analysis found the most and the least preferred models of breathlessness services were cost-effective compared with usual care. The most preferred service had £5719 lower costs (95% CI -6043 to 5395), with 0.004 (95% CI -0.003 to 0.011) QALY benefits per patient. Uptake was higher when attributes were tailored to individual preferences (86% vs 40%).

CONCLUSION

Breathlessness services are cost-effective compared with usual care for health and social care, giving cost savings and better quality of life. Uptake of breathlessness services is higher when service attributes are individually tailored.

Palliative Care Early in the Care Continuum among Patients with Serious Respiratory Illness: An Official ATS/AAHPM/HPNA/SWHPN Policy Statement

Background: Patients with serious respiratory illness and their caregivers suffer considerable burdens, and palliative care is a fundamental right for anyone who needs it. However, the overwhelming majority of patients do not receive timely palliative care before the end of life, despite robust evidence for improved outcomes. Goals: This policy statement by the American Thoracic Society (ATS) and partnering societies advocates for improved integration of high-quality palliative care early in the care continuum for patients with serious respiratory illness and their caregivers and provides clinicians and policymakers with a framework to accomplish this. Methods: An international and interprofessional expert committee, including patients and caregivers, achieved consensus across a diverse working group representing pulmonary-critical care, palliative care, bioethics, health law and policy, geriatrics, nursing, physiotherapy, social work, pharmacy, patient advocacy, psychology, and sociology. Results: The committee developed fundamental values, principles, and policy recommendations for integrating palliative care in serious respiratory illness care across seven domains: 1) delivery models, 2) comprehensive symptom assessment and management, 3) advance care planning and goals of care discussions, 4) caregiver support, 5) health disparities, 6) mass casualty events and emergency preparedness, and 7) research priorities. The recommendations encourage timely integration of palliative care, promote innovative primary and secondary or specialist palliative care delivery models, and advocate for research and policy initiatives to improve the availability and quality of palliative care for patients and their caregivers. Conclusions: This multisociety policy statement establishes a framework for early palliative care in serious respiratory illness and provides guidance for pulmonary-critical care clinicians and policymakers for its proactive integration.

Feasibility of telepsychology support for patients with advanced cardiorespiratory diseases and their caregivers

Objective

The aim of this study was to test the feasibility of telepsychology support for patients with severe cardiorespiratory disease and their caregivers. A secondary objective was to explore pre-post relationships between patients' and caregivers' clinical measures.

Methods

A telehealth program incorporating telepsychology support, i.e., an “on-demand” phone service with a psychologist, was provided to consecutive cardiorespiratory patients at discharge from inpatient rehabilitation and to their caregivers. At the start and end of the 1-year program, participants were interviewed “face-to-face,” and their anxiety/depression level, patients' quality of life (MRF-28, SF-36, and MQOL), and caregivers' (n = 18) family strain (FSQ) and needs (CNA) were assessed: we analyzed the correlations and evaluated customer satisfaction.

Results

Of 80 eligible individuals, 40 took part in this study: 22 patients (FVC = 39 ± 14%; EF = 39 ± 13%) and 18 caregivers. Eleven (28%, 6 patients and 5 caregivers) requested tele-psychological support, resulting in 51 consultations focused on anxiety, difficulty in patient management, worry about the patient's emotional state, and need for emotional support; 3 participants underwent a tailored psychotherapy program. All participants expressed high satisfaction with the service. At enrolment, anxiety was less evident in patients (73% men) than in caregivers, while depressive symptoms were more evident (6.5 ± 3.1), and correlated with MRF-28 and MQOL. Caregivers' (94% women) FSQ showed a “strongly recommended” need for support; at enrolment, high levels of anxiety/depression were correlated with high FSQ (for both, p < 0.05); depressive symptoms correlated negatively with age (p = 0.025) and positively with emotional needs (p = 0.025); anxiety was positively correlated with education level (p = 0.048). At follow-up, patients' perception of support (n = 13/22) tended to increase (p = 0.089), while caregivers' strain (n = 10/18) tended to decline (to within the “range of attention”). At enrolment, caregivers' anxiety/depression and strain correlated with patients' quality of life (for both; p < 0.05). At follow-up, caregivers' strain correlated with patients' quality of life (p = 0.028) and cognitive performance (p = 0.048).

Conclusion

Telepsychology support associated with a telehealth service is feasible and satisfying for both participants and psychological management. A suitable support program can benefit both patients and caregivers, particularly those at higher risk of depressive symptoms (younger caregivers) and anxiety (all caregivers).

Instruments to assess the burden of care for family caregivers of adult palliative care patients

BACKGROUND

A primary caregiver shares the illness experience of the patient and undertakes vital care work, alongside managing the patient's emotions, and is actively involved in care process without being paid. When faced with the palliative care patient's needs, caregivers are affected on multiple levels (physical, psychological and socio-economic), thereby experiencing a moderate or severe burden of care.

AIM

To identify assessment instruments for the burden of care for family caregivers that are suitable to be used in clinical practice.

METHOD

A narrative review was conducted using an electronic search in Pubmed, PsychINFO, CINAHL of articles published in English between 2009-2019, using the search terms: 'caregiver/family, caregiver/carer and burden and palliative care/hospice/end of life'. An assessment grid was developed to appraise the clinical use of identified instruments.

RESULTS

Of the 568 articles identified, 40 quantitative studies were selected using 31 instruments to measure the caregiver burden of cancer, noncancer and terminally ill patients. Most instruments 23 (74.11%) evaluate the psycho-emotional and, 22 (70.96%) the social domain, 12 instruments (38.7%) focused on the physical domain, three (9.67%) on the spiritual field and six instruments (19.35%) on economic aspects. For the multidimensional instruments, the assessment grid scored highest for the Burden Scale for Family Caregiver (BSFC).

CONCLUSION

The BSFC is the tool that seems to meet the most requirements, being potentially the most useful tool in clinical practice.

Heart Failure Caregiver Burden and Outcomes: A Systematic Review

Introduction/Objective:

This review aimed to summarize articles describing caregiver burden and the relationship between health outcomes as well as describing interventions focusing on this population.

Methods:

The review used the PRISMA statement and Whittemore and Knafl guidelines. The search engines Scopus, PubMed, Ovid (PsycINFO), and CINAHL were searched for articles published in English.

Results:

This review included 30 studies that met the criteria. Physical, psychological, and social factors were associated with HF caregiver burden. HF caregiver interventions included health education, post-discharge home visits, phone calls, counseling, and support groups that demonstrated some potential to reduce the caregivers’ burden.

Discussion:

Healthcare provider team should screen for caregiver burden and promote healthy behaviors, and strategies to improve quality of life. Further studies should include caregivers as care team members and embed social networking in the interventions for reducing HF caregiver burden. The caregivers’ burden could influence the poor outcomes of care, including physical, psychological, societal, and functional dimensions. Future interventions should develop to alleviate HF caregiver burden.

Intensity of care and perceived burden among informal caregivers to persons with chronic medical conditions: a systematic review and meta-analysis

PURPOSE

Informal caregivers provide ongoing assistance to a loved one with a health condition. No studies have compared caregiving intensity and perception of burden across chronic medical conditions.

MATERIALS AND METHODS

Databases were searched from inception through 11 September 2020 to identify studies that included the Level of Care Index or the Zarit Burden Inventory (ZBI) among caregivers for people with chronic diseases. Pooled mean ZBI scores and 95% confidence intervals by medical condition were calculated using a random effects model and heterogeneity with I².

RESULTS

Ninety-seven included articles reported on 98 unique samples across 21 chronic diseases. No study used the Level of Care Index. Among 12 disease groups with more than one study, heterogeneity was too high (I² range: 0-99.6%, ≥76.5% in 11 groups) to confidently estimate burden. The percent of studies rated high risk of bias ranged from 0% to 98%, but all external validity items were rated as high-risk in >50% of studies.

CONCLUSIONS

Findings highlight the need for studies on caregiver burden to improve sampling techniques; better report sampling procedures and caregiver and care recipient characteristics; and develop a standard set of outcomes, including a measure of caregiving intensity. Systematic Review Registration: CRD42017080962IMPLICATIONS FOR REHABILITATIONThe amount of burden reported by caregivers to loved ones is associated with reduced physical and mental health.We found considerable heterogeneity in perceived burden reported by informal caregivers across different studies within disease groups, which is likely related to methodological issues, including sampling techniques.Health care providers who use research on caregiver burden should assess how representative study samples may be and exercise caution in drawing conclusions.

Referral Practices of Cardiologists to Specialist Palliative Care in Canada

BACKGROUND

Patients with heart failure have palliative care needs that can be effectively addressed by specialist palliative care (SPC). Despite this, SPC utilization by this patient population is low, suggesting barriers to SPC referral. We sought to determine the referral practices of cardiologists to SPC.

METHODS

Cardiologists across Canada were invited to participate in a survey about their referral practices to SPC. Associations between referral practices and demographic, professional, and attitudinal factors were analyzed using multiple and logistic regression.

RESULTS

The response rate was 51% (551 of 1082). Between 35.1% and 64.2% of respondents were unaware of referral criteria to local SPC services. Of the respondents, 29% delayed SPC referral because of prognostic uncertainty, and 46.8% believed that SPC prioritizes patients with cancer. In actual practice, nearly three-fourths of cardiologists referred late. Referral frequency was associated with greater availability of SPC services for patients with nonmalignant diseases (P = 0.008), a higher number of palliative care settings accepting patients receiving continuous infusions or pursuing acute care management (P < 0.001), satisfaction with services (P < 0.001), and less equation of palliative care with end-of-life care (P < 0.001). Early timing of referral was associated with greater availability of SPC services for patients with nonmalignant diseases and less equation of palliative care with end-of-life care.

CONCLUSIONS

The findings suggest that barriers to timely SPC referral include an insufficiency of services for patients with nonmalignant diseases especially in the outpatient setting, the perception that SPC services do not accept patients receiving cardiology-specific treatments, and a misperception about the identity of palliative care.

Palliative Care for People Living With Heart Disease-Does Sex Make a Difference?

The distribution of individual heart disease differs among women and men and, parallel to this, among particular age groups. Women are usually affected by cardiovascular disease at an older age than men, and as the prevalence of comorbidities (like diabetes or chronic pain syndromes) grows with age, women suffer from a higher number of symptoms (such as pain and breathlessness) than men. Women live longer, and after a husband or partner's death, they suffer from a stronger sense of loneliness, are more dependent on institutionalized care and have more unaddressed needs than men. Heart failure (HF) is a common end-stage pathway of many cardiovascular diseases and causes substantial symptom burden and suffering despite optimal cardiologic treatment. Modern, personalized medicine makes every effort, including close cooperation between disciplines, to alleviate them as efficiently as possible. Palliative Care (PC) interventions include symptom management, psychosocial and spiritual support. In complex situations they are provided by a specialized multiprofessional team, but usually the application of PC principles by the healthcare team responsible for the person is sufficient. PC should be involved in usual care to improve the quality of life of patients and their relatives as soon as appropriate needs emerge. Even at less advanced stages of disease, PC is an additional layer of support added to disease modifying management, not only at the end-of-life. The relatively scarce data suggest sex-specific differences in symptom pathophysiology, distribution and the requisite management needed for their successful alleviation. This paper summarizes the sex-related differences in PC needs and in the wide range of interventions (from medical treatment to spiritual support) that can be considered to optimally address them.

Associations between informal care costs, care quality, carer rewards, burden and subsequent grief: the international, access, rights and empowerment mortality follow-back study of the last 3 months of life (IARE I study)

BACKGROUND

At the end of life, formal care costs are high. Informal care (IC) costs, and their effects on outcomes, are not known. This study aimed to determine the IC costs for older adults in the last 3 months of life, and their relationships with outcomes, adjusting for care quality.

METHODS

Mortality follow-back postal survey.

SETTING

Palliative care services in England (London), Ireland (Dublin) and the USA (New York, San Francisco).

PARTICIPANTS

Informal carers (ICrs) of decedents who had received palliative care.

DATA

ICrs reported hours and activities, care quality, positive aspects and burdens of caregiving, and completed the Texas Revised Inventory of Grief (TRIG).

ANALYSIS

All costs (formal, informal) were calculated by multiplying reported hours of activities by country-specific costs for that activity. IC costs used country-specific shadow prices, e.g. average hourly wages and unit costs for nursing care. Multivariable logistic regression analysis explored the association of potential explanatory variables, including IC costs and care quality, on three outcomes: positive aspects and burdens of caregiving, and subsequent grief.

RESULTS

We received 767 completed surveys, 245 from London, 282 Dublin, 131 New York and 109 San Francisco. Most respondents were women (70%); average age was 60 years. On average, patients received 66-76 h per week from ICrs for 'being on call', 52-55 h for ICrs being with them, 19-21 h for personal care, 17-21 h for household tasks, 15-18 h for medical procedures and 7-10 h for appointments. Mean (SD) IC costs were as follows: USA $32,468 (28,578), England $36,170 (31,104) and Ireland $43,760 (36,930). IC costs accounted for 58% of total (formal plus informal) costs. Higher IC costs were associated with less grief and more positive perspectives of caregiving. Poor home care was associated with greater caregiver burden.

CONCLUSIONS

Costs to informal carers are larger than those to formal care services for people in the last three months of life. If well supported ICrs can play a role in providing care, and this can be done without detriment to them, providing that they are helped. Improving community palliative care and informal carer support should be a focus for future investment.

Home-Based Educational Programs for Management of Dyspnea: A Systematic Literature Review

Dyspnea or breathlessness is a symptom of a plethora of diseases; despite that its management poses a challenge, it leads to frequent hospitalizations and a poor quality of life. In lung cancer, dyspnea may appear at any time of the disease but mainly during the end-of-life period. This article aims to explore the effectiveness of home-based educational programs for the management of dyspnea. This is a systematic review. The inclusion criteria were studies published between 2000 and 2018, and structured nurse-led home educational programs for the management of dyspnea due to cancer. The search via PUBMED, COCHRANE, EBSCO, and Google Scholar was worldwide for English- and Greek-language articles. The keywords included “education, program, intervention, patient, dyspnea, breathlessness, cancer, home, nurse.” The review was expanded to dyspnea being due to any chronic disease as it gave only one research article for lung cancer. The review identified seven research articles evaluating the effectiveness of various home-based educational programs for dyspnea management due to chronic obstructive pulmonary disease, heart failure, and lung cancer. They showed that a structured home-based educational program is of benefit for the patients by improving their dyspnea levels and their quality of life. There is the need to evaluate the benefits of home-based educational programs for cancer patients with dyspnea at home either as part of a symptom alone support program or as part of the general support given to cancer patients at home.

Developing and Assessing the Effectiveness of a Nurse-Led Home-Based Educational Programme for Managing Breathlessness in Lung Cancer Patients. A Feasibility Study

Introduction: Breathlessness is the most common and refractory symptom in lung cancer patients. Even though various educational programmes have been developed, only a few were intended for implementation in the home setting for its management.

Aim: Feasibility of a study for implementing a nurse-led educational programme for breathlessness management of lung cancer patients at home.

Method: A randomized feasibility study was undertaken between February 2017 and October 2018. Patients were recruited through referral from oncologists from two oncology centers in Cyprus under certain inclusion and exclusion criteria. Patients were randomized in the intervention or control group via a computer programme, and their named family caregivers (f.c.) were allocated in the same group. Participants were not blinded to group assignment. The intervention consisted of a PowerPoint presentation and implementation of three non-pharmacological interventions. The control group received usual care. Patients were assessed for breathlessness, anxiety, and depression levels, whereas f.c. were assessed for anxiety, depression, and burden levels. F.c. also assessed patients' dyspnea level. The duration of the study process for both the intervention and control group was over a period of 4 weeks.

Results: Twenty-four patients and their f.c. (n = 24) were allocated equally in the intervention and control group. Five patients withdrew, and the final sample entered analysis was 19 patients and 19 family caregivers. In the intervention group n = 11 + 11, and in the control group n = 8 + 8. In the intervention group patients' breathlessness and anxiety levels showed improvement and their f.c.s in the anxiety and burden levels. Major consideration was the sample size and the recruitment of the patients by the referring oncologists. Attrition was minor during the study process. No harm was recorded by the participants of the study.

Conclusions: The study provided evidence of the feasibility of the implementation of the educational programme. For the future definitive study major consideration should be patients' recruitment method in order to achieve adequate sample size. Moreover, qualitative data should be collected in relation to the intervention and the involvement of f.c. The feasibility study was registered to the Cyprus Bioethics Committee with the registration number 2016/16. There was no funding of the study.

Long-Term Socioeconomic Impact of Informal Care Provided to Patients with Pacemakers: Remote vs. Conventional Monitoring

The impact of informal care immediately after pacemaker (PM) implantation has been well established; however, not much is known about its long-term effects. The present study compared personal characteristics, associated problems, workloads, time, and costs related to informal care provided to patients with PM under remote monitoring (RM) vs. conventional monitoring (CM) in the hospital, five years after implantation. The PONIENTE study was a controlled, non-randomized or masked clinical trial conducted with information obtained from the perspective of informal caregivers. Data were collected at 12 and 60 months after PM implantation. The patients in the study were assigned to two different groups: remote monitoring (RM) and conventional monitoring (CM). The “Disability, personal autonomy, and dependency situations survey” (EDAD) was administered to collect information on sociodemographic characteristics, time, care difficulties, health status, professional aspects, and impact on economic, family, or leisure aspects of the main caregivers providing care to patients with pacemakers. After five years, 55 patients completed the study (RM = 21; CM = 34). The average age was 63.14 years (SD = 14.90), 96% of them were women, and the most predominant marital status was married (72%). Informal caregivers lived in the homes of the patients in 70% of cases, and 88% indicated that they had to provide care six to seven days a week. The average cost per patient during the monitoring period studied was 13.17% lower in the RM group than in the CM group, and these differences were not statistically significant (p = 0.35). This study found similar results in the two groups under study with respect to sociodemographic characteristics, workload, time, and problems associated with health, leisure and family members. The costs associated with care were higher in the CM group; however, these differences were not statistically significant.

Utility of the integrated palliative care outcome scale (IPOS): a cross-sectional study in hospitalised patients with heart failure

AIM

The aim of this study was to evaluate the suitability and comprehensibility of the integrated palliative care outcome scale for the evaluation of palliative care needs in patients with heart failure.

METHODS AND RESULTS

This cross-sectional study investigated 100 heart failure patients (40 women, 60 men; median age 79 years) within the first few days of their hospitalisation by applying the integrated palliative care outcome scale (3-day recall period) and two additional self-developed questions about the suitability and comprehensibility of the integrated palliative care outcome scale. Clinically relevant somatic and psycho-emotional symptoms were reported very frequently (approximately 75% each), followed by communicational needs or practical issues. Ninety-five per cent of patients thought the integrated palliative care outcome scale very easy to understand, and 91% judged the integrated palliative care outcome scale suitable to assess palliative care needs.

CONCLUSION

The integrated palliative care outcome scale was well accepted by hospitalised patients with heart failure and identified a high burden of both physical and psycho-emotional symptoms. Screening for palliative care has to consider patients and their relatives alike, and should be part of a comprehensive care concept jointly integrated into clinical routine by primary and specialised palliative care teams.

Effect of lower extremity amputation on caregiving burden in caregivers of patients with diabetic foot: Prospective cohort study

Lower extremity amputation as a treatment of diabetic foot ulcer is probably a major burden for the patient's family and friends, who typically act as caregivers and support the patient in coping with the physical disabilities and emotional distress. In the present prospective study, we investigated the effects of different lower extremity amputation levels for diabetic foot ulcer treatment on caregivers of patients with diabetes using the Zarit Burden Interview (ZBI-12) scale. Patients with diabetic foot ulcers who underwent unilateral major amputation (above-below knee) and minor amputation of foot (heel sparing) and their caregivers were requested to volunteer to participate in this study from June 2016 to December 2018. The ZBI-12 form was completed immediately preoperatively and 3 and 6 months after postoperatively. In the minor amputation group, the mean age of the 51 patients was 72.1 years. In the major amputation group, the mean age of the 88 patients was 73.7 years. Both groups of caregivers of patients with minor amputation and major amputations showed a significant improvement in ZBI-12 score when compared preoperatively and at 3- and 6-month follow-up visits. The mean ZBI-12 score was significantly higher in the major than in the minor amputation group in preoperative and all postoperative visits. The absence of the ankle joint in the below- or above-knee amputation renders it more difficult for the amputee to quickly learn the use of prosthesis, thereby increasing the burden of the patient and caregivers. We found that lower extremity amputation for the treatment of chronic diabetic foot ulcers has significantly favourable effect on the caregiver burden, and thereby heel sparing was considerably more effective for the caregiver burden.

Palliative Care and the Management of Common Distressing Symptoms in Advanced Cancer: Pain, Breathlessness, Nausea and Vomiting, and Fatigue

Good symptom management in oncology is associated with improved patient and family quality of life, greater treatment compliance, and may even offer survival advantages. With population growth and aging, the proportion of patients with multiple symptoms-both related and unrelated to their cancer-is anticipated to increase, supporting calls for a more routine and integrated approach to symptom management. This article presents a summary of the literature for the use of symptom assessment tools and reviews the management of four common and distressing symptoms commonly experienced by people with advanced cancer: pain, breathlessness, nausea and vomiting, and fatigue. We also discuss the role of palliative care in supporting a holistic approach to symptom management throughout the cancer trajectory.

To What Extent Do the NRS and CRQ Capture Change in Patients' Experience of Breathlessness in Advanced Disease? Findings From a Mixed-Methods Double-Blind Randomized Feasibility Trial

CONTEXT

Chronic or refractory breathlessness is common and distressing. To evaluate new treatments, outcome measures that capture change in patients' experience are needed.

OBJECTIVES

To explore the extent to which the numerical rating scale (NRS) worst and average, and the Chronic Respiratory Questionnaire capture change in patients' experience during a trial of mirtazapine for refractory breathlessness.

METHODS

Convergent mixed-methods design embedded within a randomized trial comprising 1) semi-structured qualitative interviews (considered to be the gold standard) and 2) outcome measure data collected pre- and post-intervention. Data were integrated, exploring examples where findings agreed and disagreed. Adults with advanced cancer, chronic obstructive pulmonary disease, interstitial lung disease, or chronic heart failure, with a modified Medical Research Council dyspnea scale grade 3 or 4 were recruited from three U.K. sites.

RESULTS

Data were collected for 22 participants. Eleven had a diagnosis of chronic obstructive pulmonary disease, eight interstitial lung disease, two chronic heart failure, and one cancer. Median age was 71 (56-84) years. Sixteen participants were men. Changes in the qualitative data were commonly captured in the NRS (worst and average) and the Chronic Respiratory Questionnaire. The NRS worst captured change most frequently. Improvement in the emotional domain was associated with physical changes, improved confidence, and control.

CONCLUSION

This study found that the NRS using the question "How bad has your breathlessness felt at its worst over the past 24 hours?" captured change across multiple domains, and therefore may be an appropriate primary outcome measure in trials in this population. Future work should confirm the construct validity of this question.

Depressive symptoms in the family caregivers of patients with heart failure: an integrative review

AIMS

Identify the occurrence of depressive symptoms in family caregivers of patients with heart failure and the correlation of other variables with depressive symptoms.

DESIGN/METHOD

The literature review was conducted in the Web of Science, Medline, LILACS and PubMed databases in March 2017. Papers published between 2004 and 2016, written in English, Spanish or Portuguese were included. The descriptors used were health, heart failure, depression, caregivers, and family.

RESULTS

26 papers were selected. 6% to 64% reported depressive symptoms. Depressive symptoms were associated with patients' and caregivers' characteristics. In most cases, depressive symptoms were greater among family caregivers than in the general population and were mainly associated with care burden and quality of life.

CONCLUSIONS

The studies report depressive symptoms in caregivers of patients with heart failure.

Holistic services for people with advanced disease and chronic or refractory breathlessness: a mixed-methods evidence synthesis

Background

Breathlessness is a common and distressing symptom of many advanced diseases, affecting around 2 million people in the UK. Breathlessness increases with disease progression and often becomes chronic or refractory. Breathlessness-triggered services that integrate holistic assessment and specialist palliative care input as part of a multiprofessional approach have been developed for this group, offering tailored interventions to support self-management and reduce distress.

Objectives

The aim was to synthesise evidence on holistic breathlessness services for people with advanced disease and chronic or refractory breathlessness. The objectives were to describe the structure, organisation and delivery of services, determine clinical effectiveness, cost-effectiveness and acceptability, identify predictors of treatment response, and elicit stakeholders’ evidence-based priorities for clinical practice, policy and research.

Design

The mixed-methods evidence synthesis comprised three components: (1) a systematic review to determine the clinical effectiveness, cost-effectiveness and acceptability of holistic breathlessness services; (2) a secondary analysis of pooled individual data from three trials to determine predictors of clinical response; and (3) a transparent expert consultation (TEC), comprising a stakeholder workshop and an online consensus survey, to identify stakeholders’ priorities.

Results

Thirty-seven papers reporting on 18 holistic breathlessness services were included in the systematic review. Most studies enrolled people with thoracic cancer, were delivered over 4–6 weeks, and included breathing training, relaxation techniques and psychological support. Meta-analysis demonstrated significant reductions in the Numeric Rating Scale (NRS) distress due to breathlessness, significant reductions in the Hospital Anxiety and Depressions Scale (HADS) depression scores, and non-significant reductions in the Chronic Respiratory Disease Questionnaire (CRQ) mastery and HADS anxiety, favouring the intervention. Recipients valued education, self-management interventions, and expertise of the staff in breathlessness and person-centred care. Evidence for cost-effectiveness was limited and inconclusive. The responder analysis (n = 259) revealed baseline CRQ mastery and NRS distress to be strong predictors of the response to breathlessness services assessed by these same measures, and no significant influence from baseline breathlessness intensity, patient diagnosis, lung function, health status, anxiety or depression. The TEC elicited 34 priorities from stakeholders. Seven priorities received high agreement and consensus, reflecting stakeholders’ (n = 74) views that services should be person-centred and multiprofessional, share their breathlessness management skills with others, and recognise the roles and support needs of informal carers.

Limitations

The evidence synthesis draws predominantly from UK services and may not be generalisable to other settings. Some meta-analyses were restricted by reporting biases and statistical heterogeneity.

Conclusions

Despite heterogeneity in composition and delivery, holistic breathlessness services are highly valued by recipients and can lead to significant improvements in the distress caused by breathlessness and depression. Outcomes of improved mastery and reduced distress caused by breathlessness are not influenced by patient diagnosis, lung function or health status. Stakeholders highlighted the need for improved access to person-centred, multiprofessional breathlessness services and support for informal carers.

Future work

Our research suggests that key therapeutic components of holistic breathlessness services be considered in clinical practice and models of delivery and educational strategies to address stakeholders’ priorities tested.

Study registration

This study is registered as PROSPERO CRD42017057508.

Funding

The National Institute for Health Research (NIHR) Health Services and Delivery programme. Matthew Maddocks, Wei Gao and Irene J Higginson are supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London; Matthew Maddocks is supported by a NIHR Career Development Fellowship (CDF-2017-009), William D-C Man is supported by the NIHR CLAHRC Northwest London and Irene J Higginson holds a NIHR Emeritus Senior Investigator Award.

Impact of a Graded Exercise Program on V˙O2peak and Survival in Heart Failure Patients

INTRODUCTION

Although exercise therapy has the potential to improve health outcomes of patients with chronic heart failure (CHF), less than 50% of patients adhere to prescribed physical activity guidelines 1 yr after cardiac rehabilitation. We aimed to assess the effects of an extended cardiac rehabilitation program with 12 months of graded exercise therapy (GET) and resistance exercise training (RT) on exercise capacity and long-term survival in patients with CHF.

METHODS

This prospective cohort study included 60 CHF patients between 2009 and 2010. The GET-RT program consisted of exercise sessions at 6 d·wk. Total training time of aerobic exercises increased incrementally every other week without changing exercise intensity. Resistance exercise training consisted of 8 exercises with a durable resistance band. Guidance consisted of a step-down approach from in-hospital to home-based training. Cardiopulmonary exercise tests were performed at baseline, 3, 6, and 12 months. Subsequently, patients were propensity score matched on a 1:2 ratio with controls (n = 117) from a CHF registry of patients from the same clinic receiving usual out-patient care and the incidence of all-cause mortality was compared between both groups.

RESULTS

Baseline V˙O2 peak was 15.0 mL·min·kg and significantly elevated at 3 months (+1.1 mL·min·kg (95% CI, 0.4-1.8), 6 months (+2.9 mL·min·kg (95% CI, 1.1-2.9) and 12 months (+2.6 mL·min·kg (95% CI, 1.4-3.8). During 8 yr of follow-up 23 (38.3%) patients of the GET-RT program died versus 63 (53.8%) patients of the control group (P = 0.063).

CONCLUSIONS

The 12-month GET-RT program was associated with an improved fitness during 1-yr follow-up, whereas a tendency toward better survival rates was observed during long-term follow-up.

Influence of preparedness on anxiety, depression, and quality of life in caregivers of heart failure patients: Testing a model of path analysis

OBJECTIVES

Testing the influence of heart failure (HF) caregiver preparedness on anxiety and depression, and the influence of HF caregiver anxiety and depression on caregiver physical and mental QOL.

METHODS

In this cross-sectional study, we used the Caregiver Preparedness Scale (CPS), the Hospital Anxiety and Depression Scale (HADS) with the anxiety (HADS-A) and depression (HADS-D) subscales, and the Short-Form 12 (SF-12) measuring the physical component summary (PCS) and the mental component summary (MCS) of QOL. Socio-demographic data and patients' clinic data were also collected. Data analysis was conducted with descriptive statistics, correlations, and path analysis.

RESULTS

A total of 366 HF caregiver and patient dyads were enrolled. Caregivers were mostly females (73.3%) with a mean age of 58.61 (SD = 15.66) years. The tested model showed excellent fit indices with the following significant paths: CPS scores predicted HADS-D scores; HADS-A scores predicted MCS scores; and HADS-D scores predicted both PCS and MCS scores. Also, HADS-D mediated the relationship between CPS and MCS scores.

CONCLUSION

Preparedness influences HF caregiver depression and depression influences caregiver physical and mental QOL. Depression mediates between preparedness and HF caregiver mental QOL.

PRACTICE IMPLICATIONS

Interventions focused on improving HF caregiver preparedness may improve caregivers' depression and QOL.

Brief version of Zarit Burden Interview (ZBI) for burden assessment in older caregivers

The degree of burden related to the demands of daily care provided to a dependent older adult is important to evaluate due to the negative influence exerted on caregivers’ physical and psychological health.

Lung Cancer App (LuCApp) study protocol: a randomised controlled trial to evaluate a mobile supportive care app for patients with metastatic lung cancer

INTRODUCTION

Mobile health technologies may enhance patient empowerment and data integration along the whole care continuum. However, these interventions pose relatively new regulatory, organisational and technological challenges that limit appropriate evaluation. Lung Cancer App (LuCApp) is a mobile application developed by researchers and clinicians to promote real-time monitoring and management of patients' symptoms. This protocol illustrates a clinical trial designed to evaluate the usability, effectiveness and cost-effectiveness of LuCApp versus standard of care.

METHODS AND ANALYSIS

This is a 24-week two-arm non-blinded multicentre parallel randomised controlled trial. A total of 120 adult patients diagnosed with small or non-small cell lung cancer and eligible for pharmaceutical treatments will be allocated 1:1 to receiving either standard care or LuCApp in addition to standard care at three oncology sites in Northern Italy. During the treatment period, LuCApp allows daily monitoring and grading of a list of symptoms, which trigger alerts to the physicians in case predefined severity thresholds are met. Patients will complete a baseline assessment and a set of valid and reliable patient-reported outcome measures every 3±1 weeks, and up to 24 weeks. The primary outcome is the change in the score of the Trial Outcome Index in the Functional Assessment of Cancer Therapy (Lung) questionnaire from baseline to 12 weeks. Secondary outcomes are the Lung Cancer Subscale, the EuroQoL 5D-5L questionnaire, the Hospital Anxiety and Depression Scale, the Supportive Care Needs Survey Short Form, the app usability questionnaire and the Zarit Burden Interview for the main caregiver.

ETHICS AND DISSEMINATION

The trial received ethical approval from the three clinical sites. Trial results will be disseminated through peer-reviewed publications and conference presentations.

CONCLUSIONS

This trial makes a timely contribution to test a mobile application designed to improve the quality of life and delivery of care for patients with lung cancer.

TRIAL REGISTRATION NUMBER

NCT03512015; Pre-results.

Recommendations for services for people living with chronic breathlessness in advanced disease: Results of a transparent expert consultation

Chronic breathlessness is highly distressing for people with advanced disease and their informal carers, yet health services for this group remain highly heterogeneous. We aimed to generate evidence-based stakeholder-endorsed recommendations for practice, policy and research concerning services for people with advanced disease and chronic breathlessness. We used transparent expert consultation, comprising modified nominal group technique during a stakeholder workshop, and an online consensus survey. Stakeholders, representing multiple specialities and professions, and patient/carers were invited to participate. Thirty-seven participants attended the stakeholder workshop and generated 34 separate recommendations, rated by 74 online survey respondents. Seven recommendations had strong agreement and high levels of consensus. Stakeholders agreed services should be person-centred and flexible, should cut across multiple disciplines and providers and should prioritize breathlessness management in its own right. They advocated for wide geographical coverage and access to expert care, supported through skills-sharing among professionals. They also recommended recognition of informal carers and their role by clinicians and policymakers. Overall, stakeholders' recommendations reflect the need for improved access to person-centred, multi-professional care and support for carers to provide or access breathlessness management interventions. Future research should test the optimal models of care and educational strategies to meet these recommendations.

Managing chronic breathlessness in the community

Breathlessness or dyspnoea is a subjective experience that can be described as an unpleasant or uncomfortable awareness of breathing. It is a subjective experience for patients and often they learn to adapt to the limitations caused by their condition, which makes their breathlessness less apparent to others. Breathlessness can be subdivided in the context of chronic refractory breathlessness, such as acute breathlessness, which is either an episodic breathlessness or breathlessness crisis. Chronic refractory breathlessness is defined as breathlessness at rest or on minimal exertion that will persist chronically despite optimal treatment of the underlying causative factors. The role of the community nurse in managing the breathless patient should involve differentiating between different types of breathlessness and knowing how to effectively manage it in a holistic manner.

Symptom burden in heart failure: assessment, impact on outcomes, and management

Evidence-based management has improved long-term survival in patients with heart failure (HF). However, an unintended consequence of increased longevity is that patients with HF are exposed to a greater symptom burden over time. In addition to classic symptoms such as dyspnea and edema, patients with HF frequently suffer additional symptoms such as pain, depression, gastrointestinal distress, and fatigue. In addition to obvious effects on quality of life, untreated symptoms increase clinical events including emergency department visits, hospitalizations, and long-term mortality in a dose-dependent fashion. Symptom management in patients with HF consists of two key components: comprehensive symptom assessment and sufficient knowledge of available approaches to alleviate the symptoms. Successful treatment addresses not just the physical but also the emotional, social, and spiritual aspects of suffering. Despite a lack of formal experience during cardiovascular training, symptom management in HF can be learned and implemented effectively by cardiology providers. Co-management with palliative medicine specialists can add significant value across the spectrum and throughout the course of HF.

Problems experienced by informal caregivers of individuals with heart failure: An integrative review

OBJECTIVES

The purpose of this review was to examine and synthesize recent literature regarding problems experienced by informal caregivers when providing care for individuals with heart failure in the home.

DESIGN

Integrative literature review.

DATA SOURCES

A review of current empirical literature was conducted utilizing PubMed, CINAHL, Embase, Sociological Abstracts, Social Sciences Full Text, PsycARTICLES, PsycINFO, Health Source: Nursing/Academic Edition, and Cochrane computerized databases. 19 qualitative, 16 quantitative, and 2 mixed methods studies met the inclusion criteria for review.

REVIEW METHODS

Computerized databases were searched for a combination of subject terms (i.e., MeSH) and keywords related to informal caregivers, problems, and heart failure. The title and abstract of identified articles and reference lists were reviewed. Studies were included if they were published in English between January 2000 and December 2016 and examined problems experienced by informal caregivers in providing care for individuals with heart failure in the home. Studies were excluded if not written in English or if elements of caregiving in heart failure were not present in the title, abstract, or text. Unpublished and duplicate empirical literature as well as articles related to specific end-stage heart failure populations also were excluded. Methodology described by Cooper and others for integrative reviews of quantitative and qualitative research was used. Quality appraisal of the included studies was evaluated using the Joanna Briggs Institute critical appraisal tools for cross-sectional quantitative and qualitative studies.

RESULTS

Informal caregivers experienced four key problems when providing care for individuals with heart failure in the home, including performing multifaceted activities and roles that evolve around daily heart failure demands; maintaining caregiver physical, emotional, social, spiritual, and financial well-being; having insufficient caregiver support; and performing caregiving with uncertainty and inadequate knowledge.

CONCLUSIONS

Informal caregivers of individuals with heart failure experience complex problems in the home when providing care which impact all aspects of their lives. Incorporating advice from informal caregivers of individuals with heart failure will assist in the development of interventions to reduce negative caregiver outcomes. Given the complex roles in caring for individuals with heart failure, multicomponent interventions are potentially promising in assisting informal caregivers in performing these roles.

Understanding how a palliative-specific patient-reported outcome intervention works to facilitate patient-centred care in advanced heart failure: A qualitative study

BACKGROUND

Palliative care needs of patients with chronic heart failure are poorly recognised. Policy makers advise a patient-centred approach to holistically assess patients' needs and care goals. Patient-reported outcome measures are proposed to facilitate patient-centred care.

AIM

To explore whether and how a palliative care-specific patient-reported outcome intervention involving the Integrated Palliative care Outcome Scale influences patients' experience of patient-centred care in nurse-led chronic heart failure disease management clinics.

DESIGN

A feasibility study using a parallel mixed-methods embedded design was undertaken. The qualitative component which examined patients and nurses experience of the intervention is reported here. Semi-structured interviews were conducted and analysed using framework analysis.

SETTING/PARTICIPANTS

Eligible patients attended nurse-led chronic heart failure disease management clinics in two tertiary referral centres in Ireland with New York Heart Association functional class II-IV. Nurses who led these clinics were eligible for inclusion.

RESULTS

In all, 18 patients and all 4 nurses involved in the nurse-led clinics were interviewed. Three key themes were identified: identification of unmet needs, holistic assessment and patient empowerment. The intervention impacted on processes of care by enabling a shared understanding of patients' symptoms and concerns, facilitating patient-nurse communication by focusing on these unmet needs and empowering patients to become more involved in clinical discussions.

CONCLUSION

This Integrated Palliative care Outcome Scale-based intervention empowered patients to become more engaged in the clinical consultation and to highlight their unmet needs. This study adds to the evidence for the mechanism of action of patient-reported outcome measures to improve patient-centred care and will help inform outcome selection for future patient-reported outcome measure research.

Feasibility and acceptability of a patient-reported outcome intervention in chronic heart failure

Patients with chronic heart failure (CHF) have symptoms and concerns which are inadequately addressed. Patient-reported outcome measures (PROMs) can potentially improve the identification and management of advanced symptoms and palliative concerns. However, these have not been used in CHF.

OBJECTIVES

To examine the feasibility and acceptability of using a PROM-the Integrated Palliative care Outcome Scale (IPOS)-together with heart failure nurse education and training to improve the identification and management of symptoms and concerns among patients with CHF.

METHODS

A parallel, mixed methods design with an embedded qualitative component was used to examine the feasibility of recruitment, retention, intervention adherence/compliance and follow-up assessment completion (symptom burden, quality of life, psychological well-being). Patient and nurse qualitative semistructured interviews explored intervention and study design feasibility and its acceptability.

RESULTS

Conversion to consent was 46.9% (372 screened, 81 approached, 38 recruited). 66% of patient participants completed the IPOS; 6% of IPOS questionnaire items were missing (non-response). Over two-thirds (65.6%) of these missing items related to three patients. No item was consistently missing; appetite was the most frequent missing item (1.4%). 92% of participants who completed the IPOS completed all follow-up assessments (1-2 days, 1-2 weeks and 4-6 weeks post-IPOS completion) with no missing data. The a priori feasibility objectives were met. Patients and nurses reported the intervention and study design feasible and acceptable.

CONCLUSIONS

A palliative-specific PROM-based intervention is feasible and acceptable to both patients with CHF and nurses in nurse-led disease management clinics for the purposes of both clinical care and research.

Family caregiving for persons with heart failure at the intersection of heart failure and palliative care: a state-of-the-science review

Many of the 23 million individuals with heart failure (HF) worldwide receive daily, unpaid support from a family member or friend. Although HF and palliative care practice guidelines stipulate that support be provided to family caregivers, the evidence base to guide care for this population has not been comprehensively assessed. In order to appraise the state-of-the-science of HF family caregiving and recommend areas for future research, the aims of this review were to summarize (1) how caregivers influence patients, (2) the consequences of HF for caregivers, and (3) interventions directed at HF caregivers. We reviewed all literature to December 2015 in PubMed and CINAHL using the search terms "heart failure" AND "caregiver." Inclusion criteria dictated that studies report original research of HF family caregiving. Articles focused on children or instrument development or aggregated HF with other illnesses were excluded. We identified 120 studies, representing 5700 caregivers. Research on this population indicates that (1) caregiving situations vary widely with equally wide-ranging tasks for patients to help facilitate their health behaviors, psychological health and relationships, and quality of life (QoL); (2) caregivers have numerous unmet needs that fluctuate with patients' unpredictable medical status, are felt to be ignored by the formal healthcare system, and can lead to distress, burden, and reduced QoL; and (3) relatively few interventions have been developed and tested that effectively support HF family caregivers. We provide recommendations to progress the science forward in each of these areas that moves beyond descriptive work to intervention development and clinical trials testing.

The Experience of Essential Tremor Caregivers: Burden and Its Correlates

Background

Essential tremor (ET) is associated with physical and cognitive impairments, as well as embarrassment, avoidance of social settings, and related difficulties that negatively impact the lives of patients. In similar disease contexts, burden on friends and relatives acting as caregivers has been noted and has well-documented implications. There has been no study examining caregiver burden related to ET.

Methods

Data were gathered from 55 ET participants enrolled in a clinical study and their caregivers. The Zarit Burden Interview was used to assess caregiver burden. To assess clinical features that may be associated with burden, we collected several variables including the Montreal Cognitive Assessment, self-reported tremor disability, a videotaped neurological examination, questionnaires assessing ET participants’ suffering, caregivers’ perceptions of that suffering, and both caregiver and ET participant depressive symptoms. Spearman’s correlations were performed between caregiver burden and clinical features, and we created a multivariate linear regression model predicting caregiver burden.

Results

Many ET caregivers provide little to no care and experience little to no burden. However, some caregivers (11%) provide over 25 h of care/week, and 13% experience high levels of burden. Caregivers most commonly provided assistance with writing and cooking. Increased burden was associated with the ET participants’ decreased cognition, more caregiving tasks, more hours/week of caregiving activities, a longer duration of care, more ET participant falls/year, more medications taken by the ET participant, and more depressive symptoms in both the ET participant and the caregiver (all p < 0.05). ET participants’ suffering and their caregivers’ perceptions of suffering were both associated with increased burden. Neither tremor severity score nor self-reported tremor disability score was associated with increased caregiver burden. Using a multivariate linear regression model, we found that caregivers’ increased perception of their partners’ suffering was the best predictor of caregiver burden.

Conclusion

While not all relatives and friends of ET patients provide extensive care or experience high burden, there is a group reporting high levels of caregiver burden that requires the attention and counseling of clinicians. This burden is associated with primarily non-tremor symptoms of ET and with caregivers’ perception that their partners are suffering.

Six key topics informal carers of patients with breathlessness in advanced disease want to learn about and why: MRC phase I study to inform an educational intervention

INTRODUCTION

Breathlessness is a common symptom of advanced disease placing a huge burden on patients, health systems and informal carers (families and friends providing daily help and support). It causes distress and isolation. Carers provide complex personal, practical and emotional support yet often feel ill-prepared to care. They lack knowledge and confidence in their caring role. The need to educate carers and families about breathlessness is established, yet we lack robustly developed carer-targeted educational interventions to meet their needs.

METHODS

We conducted a qualitative interview study with twenty five purposively-sampled patient-carer dyads living with breathlessness in advanced disease (half living with advanced cancer and half with advanced chronic obstructive pulmonary disease (COPD). We sought to identify carers' educational needs (including what they wanted to learn about) and explore differences by diagnostic group in order to inform an educational intervention for carers of patients with breathlessness in advanced disease.

RESULTS

There was a strong desire among carers for an educational intervention on breathlessness. Six key topics emerged as salient for them: 1) understanding breathlessness, 2) managing anxiety, panic and breathlessness, 3) managing infections, 4) keeping active, 5) living positively and 6) knowing what to expect in the future. A cross-cutting theme was relationship management: there were tensions within dyads resulting from mismatched expectations related to most topics. Carers felt that knowledge-gains would not only help them to support the patient better, but also help them to manage their own frustrations, anxieties, and quality of life. Different drivers for education need were identified by diagnostic group, possibly related to differences in caring role duration and resulting impacts.

CONCLUSION

Meeting the educational needs of carers requires robustly developed and evaluated interventions. This study provides the evidence-base for the content of an educational intervention for carers of patients with breathlessness in advanced disease.

Caregivers' Perspectives on the Use of Long-Term Oxygen Therapy for the Treatment of Refractory Breathlessness: A Qualitative Study

CONTEXT

Despite limited clinical evidence, long-term oxygen therapy (LTOT) is used for the management of refractory breathlessness in people with life-limiting illnesses who are not necessarily hypoxemic.

OBJECTIVES

The aim of this study was to understand caregiver factors associated with caring for someone with LTOT from the perspectives and experiences of caregivers themselves.

METHODS

The qualitative study used semistructured interviews. The study was conducted in two states in Australia. Participants (n = 20) were self-nominated caregivers of people receiving LTOT for refractory breathlessness in the palliative setting.

RESULTS

Data analyses established one overarching theme titled: "Oxygen giveth (something to help caregivers relieve breathlessness) and oxygen taketh away (from patients who lose some autonomy)." The theme captured caregivers' feelings of extreme distress in response to witnessing refractory breathlessness, and oxygen fulfilling several critical and beneficial roles in this context. In parallel, caregivers also explicitly and implicitly articulated several downsides to the use of LTOT.

CONCLUSION

Caregivers find caring for someone with refractory breathlessness extremely distressing. The benefits of LTOT are often overestimated, whereas its potential harms are underestimated. As significant stakeholders of people receiving LTOT, caregivers should be provided with opportunities to collaborate with clinicians in evidence-based decision making, efforts should be made to provide them with information and education about the most effective pharmacological and nonpharmacological strategies to manage refractory breathlessness in a palliative care setting including the appropriate use of LTOT to enable them to do so.

Comparing the symptom experience of cancer patients and non-cancer patients

PURPOSE

Symptom burden is an established concept in oncology encompassing the presence and severity of symptoms experienced by cancer patients. Few studies have examined differences in symptom burden between cancer patients and non-cancer patients. This study seeks to examine the differences in symptom burden between cancer patients (CP) and non-cancer patients (NCP) in order to better understand symptom burden in both populations.

METHODS

Two groups of patients completed the Memorial Symptom Assessment Scale: 301 patients from a general medical clinic and 558 cancer patients from a cancer tumor registry. Participants provided demographic information-age, race/ethnicity, and sex and completed the Memorial Symptom Assessment Scale. Medical comorbidity was also measured.

RESULTS

Most symptoms were more common in CP, except for pain, which was more prevalent in the NCP (45% of CP vs. 54% of NCP, p < .05). There was no difference in prevalence for the following symptoms: dry mouth, mouth sores, feeling nervous, worry, cough, and dizziness. The CP had greater mean MSAS Total scores (0.53 vs. 0.43, p < .01), number of symptoms (9.11 vs. 6.13, p < .01), and psychological subscale scores (0.77 vs. 0.64, p < .05). There was no difference by group in the physical nor the GDI subscale scores.

CONCLUSION

The results of this study support the perception that cancer patients have greater symptom burden. There were some unexpected results, particularly in terms of pain, which was more common in NCP and other symptoms that were experienced equally in both patient populations.