151
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Gradalski T. Multicomponent Compression Bandaging Combined with Diuretic Therapy of Anasarca Secondary to Palliative Chemotherapy: A Case Report. J Palliat Med 2020; 24:144-147. [PMID: 32181697 DOI: 10.1089/jpm.2019.0691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Although decongestive physiotherapy combined with diuretics may be efficient in limb edemas, no such therapy has been described in the context of anasarca. Case Description: A bedbound 62-year-old man with stage IV pancreatic cancer, presenting with progressing severe dyspnea at rest and anasarca, was admitted to the free-standing hospice 3 weeks after receiving nab-paclitaxel with gemcitabine. Two weeks before admission, oral loop and potassium-sparing diuretics were started for bilateral lower limb edema, which progressed to anasarca even though the drug dose was increased. Hypotension hindered further dose escalation of diuretics. Supportive multicomponent bandage compression on both legs with concurrent intravenous furosemide in hypersaline infusion was implemented with good clinical toleration. Afterward, the loop diuretic dose was increased, and supplemented with dexamethasone. A spectacular edema decrease and marked dyspnea improvement with 19 kg body weight reduction were observed within 7 days. Furosemide was switched to oral route and the patient was discharged needing only occasional assistance in daily living. Conclusion: Compression bandaging with diuretic therapy may be considered even in advanced generalized edemas; however, further studies are needed to determine the adequate therapeutic regime.
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Ferreira DH, Louw S, McCloud P, Fazekas B, McDonald CF, Agar MR, Clark K, McCaffrey N, Ekström M, Currow DC. Controlled-Release Oxycodone vs. Placebo in the Treatment of Chronic Breathlessness-A Multisite Randomized Placebo Controlled Trial. J Pain Symptom Manage 2020; 59:581-589. [PMID: 31655189 DOI: 10.1016/j.jpainsymman.2019.10.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 10/14/2019] [Accepted: 10/16/2019] [Indexed: 11/12/2022]
Abstract
CONTEXT Chronic breathlessness is a clinical syndrome that results in significant distress and disability. Morphine can reduce chronic breathlessness when the contributing etiologies are optimally treated. OBJECTIVES Does oxycodone reduce chronic breathlessness compared with placebo? METHODS A multisite, randomized, placebo-controlled, double-blind, parallel-arm, fixed-dose trial of oral controlled-release oxycodone 15 mg (5 mg, eight hourly) or placebo (ACTRN12609000806268 at www.anzctr.org.au). As-needed immediate-release morphine (2.5 mg per dose; six and less doses/day) was available for both arms as required by one ethics committee overseeing the trial. Recruitment occurred from 2010 to 2014 in 14 inpatient and outpatient respiratory, cardiology, and palliative care services across Australia. Participants were adults, with chronic breathlessness (modified Medical Research Council Scale 3 or 4), who were opioid naive. The primary end point was the proportion of people with greater than 15% reduction from baseline in the intensity of breathlessness now (0-100 mm visual analogue scale) comparing arms Days 5-7. Secondary end points were average and worst breathlessness, quality of life, function, and harms. RESULTS Of 157 participants randomized, 155 were included (74 oxycodone and 81 placebo), but the study did not reach target recruitment. There was difference in neither between groups for the primary outcome (P = 0.489) nor any of the prespecified secondary outcomes. Placebo participants used more as-needed morphine (mean 7.0 vs. 4.2 doses; P ≤ 0.001). Oxycodone participants reported more nausea (P < 0.001). CONCLUSION There was no signal of benefit from oxycodone over placebo. Future research should focus on investigating the existence of an opioid class effect on the reduction of chronic breathlessness.
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Affiliation(s)
- Diana H Ferreira
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Sandra Louw
- McCloud Consulting Group, Narabang Way, Belrose, New South Wales, Australia
| | - Philip McCloud
- McCloud Consulting Group, Narabang Way, Belrose, New South Wales, Australia
| | - Belinda Fazekas
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia; IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Christine F McDonald
- Austin Health, Heidelberg, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia
| | - Meera R Agar
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Katherine Clark
- Northern Sydney Local Health District, St Leonards, New South Wales, Australia; University of Sydney, Glebe, New South Wales, Australia
| | - Nikki McCaffrey
- Deakin Health Economics, School of Health and Social Development, Deakin University, Melbourne, Victoria, Australia
| | - Magnus Ekström
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia; Department of Clinical Sciences Lund, Lund University, Faculty of Medicine, Respiratory Medicine and Allergology, Lund, Sweden
| | - David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia; IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.
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153
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Elliott-Button HL, Johnson MJ, Nwulu U, Clark J. Identification and Assessment of Breathlessness in Clinical Practice: A Systematic Review and Narrative Synthesis. J Pain Symptom Manage 2020; 59:724-733.e19. [PMID: 31655187 DOI: 10.1016/j.jpainsymman.2019.10.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/11/2019] [Accepted: 10/11/2019] [Indexed: 01/09/2023]
Abstract
CONTEXT Breathlessness is common in chronic conditions but often goes unidentified by clinicians. It is important to understand how identification and assessment of breathlessness occurs across health care settings, to promote routine outcome assessment and access to treatment. OBJECTIVE The objective of this study was to summarize how breathlessness is identified and assessed in adults with chronic conditions across different health care settings. METHODS This is a systematic review and descriptive narrative synthesis (PROSPERO registration: CRD42018089782). Searches were conducted on Medline, PsycINFO, Cochrane Library, Embase, and CINAHL (2000-2018) and reference lists. Screening was conducted by two independent reviewers, with access to a third, against inclusion criteria. Data were extracted using a bespoke proforma. RESULTS Ninety-seven studies were included, conducted in primary care (n = 9), secondary care (n = 53), and specialist palliative care (n = 35). Twenty-five measures of identification and 41 measures of assessment of breathlessness were used. Primary and secondary care used a range of measures to assess breathlessness severity, cause, and impact for people with chronic obstructive pulmonary disease. Specialist palliative care used measures assessing broader symptom severity and function with less focus on overall quality of life. Few studies were identified from primary care. CONCLUSION Various measures were identified, reflective of the setting's purpose. However, this highlights missed opportunities for breathlessness management across settings; primary care is particularly well placed to diagnose and support breathlessness. The chronic obstructive pulmonary disease approach (where symptoms and quality of life are part of disease management) could apply to other conditions. Better documentation of holistic patient-reported measures may drive service improvement in specialist palliative care.
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Affiliation(s)
- Helene L Elliott-Button
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom.
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Ugochinyere Nwulu
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Joseph Clark
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
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154
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Slev VN, Molenkamp CM, Eeltink CM, Roeline W Pasman H, Verdonck-de Leeuw IM, Francke AL, van Uden-Kraan CF. A nurse-led self-management support intervention for patients and informal caregivers facing incurable cancer: A feasibility study from the perspective of nurses. Eur J Oncol Nurs 2020; 45:101716. [PMID: 32023503 DOI: 10.1016/j.ejon.2019.101716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 12/09/2019] [Accepted: 12/19/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Investigation of the feasibility of recruitment through nurses of patients with incurable cancer, and the feasibility (adoption, usage) and nurses' evaluation of a nurse-led self-management support intervention, integrated in continuity home visits and based on the 5 A's Behavior Change Model. METHOD Questionnaire, registrations, evaluation forms, and interviews. RESULTS Recruitment was complicated; many patients were ineligible for participation, nurses appeared protective of their patients (gatekeeping), and recruitment during the first continuity home visit appeared to be a barrier as a lot of other issues had to be discussed. The adoption rate was 81%, meaning that 18 out of 22 nurses recruited were willing to use the intervention. The usage rate at the nurse level was 56%, meaning that 10 nurses applied the intervention in full (having applied all five A's) in at least one patient. Nurses used the intervention in full in 21 out of the 36 patients included, implying a usage rate at the patient level of 58%. Nurses' mean general satisfaction score for the intervention was 7.57 (range 0-10). Nurse were especially positive about the 5 A's model, and considered the continuity home visits to be an appropriate setting for the intervention. CONCLUSIONS Timing of recruitment and gatekeeping complicated recruitment of patients through nurses. Although nurses were positive about the intervention, nurses often did not fully apply the intervention. To improve its usage, it is suggested that nurses should first be trained in using the 5 A's model.
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Affiliation(s)
- Vina N Slev
- Amsterdam UMC, location VU University Medical Center/ Amsterdam Public Health Research Institute, Department of Public and Occupational Health, de Boelelaan, 1117, Amsterdam, the Netherlands; Expertise Center for Palliative Care, Van der Boechorststraat 7, Amsterdam, Netherlands.
| | - Cornelia M Molenkamp
- Evean, Department of Specialised Home Care Nursing, Waterlandplein 5, Purmerend, the Netherlands
| | - Corien M Eeltink
- Amsterdam UMC, location VU University Medical Center Department of Hematology, De Boelelaan, 1117, Amsterdam, Netherlands
| | - H Roeline W Pasman
- Amsterdam UMC, location VU University Medical Center/ Amsterdam Public Health Research Institute, Department of Public and Occupational Health, de Boelelaan, 1117, Amsterdam, the Netherlands; Expertise Center for Palliative Care, Van der Boechorststraat 7, Amsterdam, Netherlands
| | - Irma M Verdonck-de Leeuw
- Amsterdam UMC, location VU University Medical Center Department of Otolaryngology - Head & Neck Surgery, De Boelelaan, 1117, Amsterdam, the Netherlands; Vrije Universiteit, Amsterdam Public Health, Faculty of Behavioral and Movement Sciences, Department of Clinical Psychology, Amsterdam, the Netherlands; Cancer Center Amsterdam (CCA), De Boelelaan, 1117, Amsterdam, the Netherlands
| | - Anneke L Francke
- Amsterdam UMC, location VU University Medical Center/ Amsterdam Public Health Research Institute, Department of Public and Occupational Health, de Boelelaan, 1117, Amsterdam, the Netherlands; Expertise Center for Palliative Care, Van der Boechorststraat 7, Amsterdam, Netherlands; NIVEL, Netherlands Institute for Health Services Research, Otterstraat 118 - 124, Utrecht, the Netherlands
| | - Cornelia F van Uden-Kraan
- Vrije Universiteit, Amsterdam Public Health, Faculty of Behavioral and Movement Sciences, Department of Clinical Psychology, Amsterdam, the Netherlands
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155
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Candy B, Armstrong M, Flemming K, Kupeli N, Stone P, Vickerstaff V, Wilkinson S. The effectiveness of aromatherapy, massage and reflexology in people with palliative care needs: A systematic review. Palliat Med 2020; 34:179-194. [PMID: 31659939 PMCID: PMC7000853 DOI: 10.1177/0269216319884198] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Aromatherapy, massage and reflexology are widely used in palliative care. Despite this, there are questions about their suitability for inclusion in clinical guidelines. The need to understand their benefits is a public priority, especially in light of funding pressures. AIM To synthesise current evidence on the effectiveness of aromatherapy, massage and reflexology in people with palliative care needs. DESIGN A systematic review of randomised controlled trials (PROSPERO CRD42017081409) was undertaken following international standards including Cochrane guidelines. The quality of trials and their pooled evidence were appraised. Primary outcomes on effect were anxiety, pain and quality-of-life. DATA SOURCES Eight citation databases and three trial registries were searched to June 2018. RESULTS Twenty-two trials, involving 1956 participants were identified. Compared with a control, four evaluated aromatherapy, eight massage and six reflexology. A further four evaluated massage compared with aromatherapy. Trials were at an unclear risk of bias. Many had small samples. Heterogeneity prevented meta-analysis. In comparison with usual care, another therapy or an active control, evidence on the effectiveness of massage and aromatherapy in reducing anxiety, pain and improving quality-of-life was inconclusive. There was some evidence (low quality) that compared to an active control, reflexology reduced pain. CONCLUSIONS This review identified a relatively large number of trials, but with poor and heterogeneous evidence. New clinical recommendations cannot be made based on current evidence. To help provide more definitive trial findings, it may be useful first to understand more about the best way to measure the effectiveness of these therapies in palliative care.
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Affiliation(s)
- Bridget Candy
- Marie Curie Palliative Care Research
Department, Division of Psychiatry, University College London, London, UK
| | - Megan Armstrong
- Marie Curie Palliative Care Research
Department, Division of Psychiatry, University College London, London, UK
| | - Kate Flemming
- Department of Health Sciences,
University of York, York, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research
Department, Division of Psychiatry, University College London, London, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research
Department, Division of Psychiatry, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research
Department, Division of Psychiatry, University College London, London, UK
| | - Susie Wilkinson
- Palliative Care Institute Liverpool,
University of Liverpool, Liverpool, UK
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156
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Fröhlich G, Schorn K, Fröhlich H. [Dyspnea : A challenging symptom in the primary care setting]. Internist (Berl) 2020; 61:21-35. [PMID: 31889210 DOI: 10.1007/s00108-019-00720-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Dyspnea is a very common symptom leading to visits to a general physician (GP). Correct differential diagnosis is the major challenge for the GP. There are no guidelines on dyspnea. This review provides an overview of the main causal diseases for dyspnea, presents methods for history taking and differential diagnosis, and specifies the role of GPs in the primary care setting in the case of dyspnea.
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Affiliation(s)
- Georg Fröhlich
- Internistisch-hausärztliche Praxis mit Schwerpunkt Diabetes, Vorhonig 5, 65620, Waldbrunn, Deutschland.
| | - Kai Schorn
- Hausärztliche Gemeinschaftspraxis, Berlin, Deutschland
| | - Heike Fröhlich
- Internistisch-hausärztliche Praxis mit Schwerpunkt Diabetes, Vorhonig 5, 65620, Waldbrunn, Deutschland
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157
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Eisenmann Y, Golla H, Schmidt H, Voltz R, Perrar KM. Palliative Care in Advanced Dementia. Front Psychiatry 2020; 11:699. [PMID: 32792997 PMCID: PMC7394698 DOI: 10.3389/fpsyt.2020.00699] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/02/2020] [Indexed: 12/20/2022] Open
Abstract
Dementia syndrome is common and expected to increase significantly among older people and characterized by the loss of cognitive, psychological and physical functions. Palliative care is applicable for people with dementia, however they are less likely to have access to palliative care. This narrative review summarizes specifics of palliative care in advanced dementia. Most people with advanced dementia live and die in institutional care and they suffer a range of burdensome symptoms and complications. Shortly before dying people with advanced dementia suffer symptoms as pain, eating problems, breathlessness, neuropsychiatric symptoms, and complications as respiratory or urinary infections and frequently experience burdensome transitions. Pharmacological and nonpharmacological interventions may reduce symptom burden. Sensitive observation and appropriate assessment tools enable health professionals to assess symptoms and needs and to evaluate interventions. Due to lack of decisional capacity, proxy decision making is often necessary. Advanced care planning is an opportunity establishing values and preferences and is associated with comfort and decrease of burdensome interventions. Family carers are important for people with advanced dementia they also experience distress and are in need for support. Recommendations refer to early integration of palliative care, recognizing signs of approaching death, symptom assessment and management, advanced care planning, person-centered care, continuity of care, and collaboration of health care providers.
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Affiliation(s)
- Yvonne Eisenmann
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Heidrun Golla
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Holger Schmidt
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Clinical Trials Center (ZKS), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Center for Health Services Research, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Klaus Maria Perrar
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
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158
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Guthrie DM, Harman LE, Barbera L, Burge F, Lawson B, McGrail K, Sutradhar R, Seow H. Quality Indicator Rates for Seriously Ill Home Care Clients: Analysis of Resident Assessment Instrument for Home Care Data in Six Canadian Provinces. J Palliat Med 2019; 22:1346-1356. [DOI: 10.1089/jpm.2019.0022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Dawn M. Guthrie
- Department of Kinesiology and Physical Education and Wilfrid Laurier University, Waterloo, Ontario, Canada
- Department of Health Sciences, Wilfrid Laurier University, Waterloo, Ontario, Canada
| | - Lisa E. Harman
- Department of Kinesiology and Physical Education and Wilfrid Laurier University, Waterloo, Ontario, Canada
| | - Lisa Barbera
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Fred Burge
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Beverley Lawson
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kimberlyn McGrail
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Center for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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159
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Currow D, Louw S, McCloud P, Fazekas B, Plummer J, McDonald CF, Agar M, Clark K, McCaffrey N, Ekström MP. Regular, sustained-release morphine for chronic breathlessness: a multicentre, double-blind, randomised, placebo-controlled trial. Thorax 2019; 75:50-56. [PMID: 31558624 DOI: 10.1136/thoraxjnl-2019-213681] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/08/2019] [Accepted: 08/20/2019] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Morphine may decrease the intensity of chronic breathlessness but data from a large randomised controlled trial (RCT) are lacking. This first, large, parallel-group trial aimed to test the efficacy and safety of regular, low-dose, sustained-release (SR) morphine compared with placebo for chronic breathlessness. METHODS Multisite (14 inpatient and outpatient cardiorespiratory and palliative care services in Australia), parallel-arm, double-blind RCT. Adults with chronic breathlessness (modified Medical Research Council≥2) were randomised to 20 mg daily oral SR morphine and laxative (intervention) or placebo and placebo laxative (control) for 7 days. Both groups could take ≤6 doses of 2.5 mg, 'as needed', immediate-release morphine (≤15 mg/24 hours) as required by the ethics review board. The primary endpoint was change from baseline in intensity of breathlessness now (0-100 mm visual analogue scale; two times per day diary) between groups. Secondary endpoints included: worst, best and average breathlessness; unpleasantness of breathlessness now, fatigue; quality of life; function; and harms. RESULTS Analysed by intention-to-treat, 284 participants were randomised to morphine (n=145) or placebo (n=139). There was no difference between arms for the primary endpoint (mean difference -0.15 mm (95% CI -4.59 to 4.29; p=0.95)), nor secondary endpoints. The placebo group used more doses of oral morphine solution during the treatment period (mean 8.7 vs 5.8 doses; p=0.001). The morphine group had more constipation and nausea/vomiting. There were no cases of respiratory depression nor obtundation. CONCLUSION No differences were observed between arms for breathlessness, but the intervention arm used less rescue immediate-release morphine. TRIAL REGISTRATION NUMBER ACTRN12609000806268.
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Affiliation(s)
- David Currow
- IMPACCT, Faculty of Heath, University of Technology Sydney, Sydney, New South Wales, Australia .,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Sandra Louw
- McCloud Consulting Group, Sydney, New South Wales, Australia
| | - Philip McCloud
- McCloud Consulting Group, Sydney, New South Wales, Australia
| | - Belinda Fazekas
- IMPACCT, Faculty of Heath, University of Technology Sydney, Sydney, New South Wales, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - John Plummer
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Christine F McDonald
- Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Meera Agar
- IMPACCT, Faculty of Heath, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Katherine Clark
- Northern Sydney Local Health District, Saint Leonards, New South Wales, Australia.,Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nikki McCaffrey
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Deakin Health Economics, Deakin University Faculty of Health, Burwood, Victoria, Australia
| | - Magnus Pär Ekström
- IMPACCT, Faculty of Heath, University of Technology Sydney, Sydney, New South Wales, Australia.,Department of Clinical Sciences, Division of Respiratory Medicine & Allergology, Lund University, Lund, Sweden
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160
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Roper L, Donnellan W, Hanratty B, Bennett K. Exploring dimensions of social support and resilience when providing care at the end of life: a qualitative study. Aging Ment Health 2019; 23:1139-1145. [PMID: 30522340 DOI: 10.1080/13607863.2018.1484886] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Research shows that formal and informal social support can facilitate resilience in carers. There is a paucity of research exploring social support and resilience amongst recently bereaved informal carers. Aim: To examine how the presence or absence of distinct dimensions of social support facilitate or hinder resilience in recently bereaved informal carers. Participants: 44 bereaved carers, who had been identified by GP as 'main carer' of someone recently deceased (3-12 months), aged between 38 and 87 years old (mean= 67). Methods: Thematic analysis then the Ecological Framework of Resilience as an organisational tool to develop overarching themes in the data. We used the Sherbourne and Stewart model to identify social support that was lacking as well as social support that was present. Results: A range of social support types were identified. There was an emphasis on the importance of relationships with both health professionals and family members, including the care recipient. However, social support was not necessary for resilience if the participant had other resources. Conclusions: Social support for carers providing end of life care is almost exclusively based around end of life care 'work'. In comparison to other research our study suggests that relationships with family and health professionals are paramount. Multidimensional support is needed for carers to enhance their resilience.
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Affiliation(s)
- Louise Roper
- a Department of Health Service Research , University of Liverpool , Liverpool , UK
| | - Warren Donnellan
- b School of Psychology , University of Liverpool , Liverpool , UK
| | - Barbara Hanratty
- c Institute of Health & Society , Newcastle University , Newcastle , UK
| | - Kate Bennett
- b School of Psychology , University of Liverpool , Liverpool , UK
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161
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Lovell N, Etkind SN, Bajwah S, Maddocks M, Higginson IJ. 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. J Pain Symptom Manage 2019; 58:369-381.e7. [PMID: 31201877 DOI: 10.1016/j.jpainsymman.2019.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/04/2019] [Accepted: 06/05/2019] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Natasha Lovell
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom.
| | - Simon Noah Etkind
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
| | - Irene Julie Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
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162
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Abstract
Aim Millions of new cancer cases are diagnosed each year. Patients often become hopeless during the disease. This study aimed to develop a short-intervention instrument targeted to raise hope in cancer patients. Methods Using a panel of experts, an instrument was developed, which consisted of 11 counseling items. The instrument was applied to a sample of 153 palliative care cancer patients randomized into three groups (G1: instrument applied by Rater 1, G2: control, and G3: instrument applied by Rater 2). Application of the instrument required 20-30 minutes. Using the Herth Hope Index (HHI) scores as the main outcome, changes over time (baseline, 1-hour, and one-week) were evaluated. Results The mean baseline HHI scores were 41.38±4.46. The HHI scores were statistically similar at the baseline (p>0.05) but significantly different at one hour and one week in favor of the G1 and G3 groups (p<0.001). In G1, the HHI significantly increased from baseline to one-hour measurements (t=-12.413, p<0.001) and remained unchanged at one week (t=1.088, p=0.282). Similarly, there was a significant increase in the HHI scores from baseline to one-hour measurements in G3 (t=-9.144, p<0.001), which remained unchanged between one hour and one week (t=-0.099, p=0.921). Conclusion This study demonstrated the effectiveness of a structured, short counseling intervention in increasing hope among palliative care cancer patients.
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Affiliation(s)
- Yusuf Adnan Guclu
- Family Medicine, Izmir Health Sciences University, Tepecik Education and Research Hospital, Izmir, TUR
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163
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Edwards H, Bennett M. Access to Opioids for Patients with Advanced Disease. Curr Pharm Des 2019; 25:3203-3208. [PMID: 31333089 DOI: 10.2174/1381612825666190716095337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/11/2019] [Indexed: 12/14/2022]
Abstract
Pain at the end of life is common in both malignant and non-malignant disease. It is feared by patients, their families and careers, and professionals. Effective pain control can be achieved for the majority of patients at the end of life using a multimodal approach. Pharmacological management relies predominantly on strong opioids. In spite of this, evidence suggests that under treatment of pain is common resulting in unnecessary suffering. Multiple barriers to use of opioids have been identified. Patient barriers include reluctance to report pain and to take analgesics. Professional barriers include inadequate pain assessment and lack of specialist knowledge and confidence in opioid therapy. Fear of side effects including respiratory depression affects patients and professionals alike. The impact of the "opioid epidemic", with increasing prescribed and illicit opioid use around the world, has also led to increasingly stringent regulation and concern about under prescribing in palliative care. System barriers to use of opioids at the end of life result from limited opioid availability in some countries and also inconsistent and limited access to palliative care. Multiple interventions have been developed to address these barriers, targeted at patients, professionals and systems. There is increasing evidence to suggest that complex interventions combining a number of different approaches are most effective in optimising pain outcomes for patients at the end of life.
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Affiliation(s)
- Helen Edwards
- Academic Unit of Palliative Care, University of Leeds, Leeds, United Kingdom
| | - Michael Bennett
- Academic Unit of Palliative Care, University of Leeds, Leeds, United Kingdom
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164
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Which symptoms and problems do advanced cancer patients admitted to specialized palliative care report in addition to those included in the EORTC QLQ-C15-PAL? A register-based national study. Support Care Cancer 2019; 28:1725-1735. [DOI: 10.1007/s00520-019-04976-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/28/2019] [Indexed: 11/12/2022]
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165
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Gryschek G, Machado DDA, Otuyama LJ, Goodwin C, Lima MCP. Spiritual coping and psychological symptoms as the end approaches: a closer look on ambulatory palliative care patients. PSYCHOL HEALTH MED 2019; 25:426-433. [PMID: 31284732 DOI: 10.1080/13548506.2019.1640887] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Palliative care providers must seek to improve quality of life despite their patients' life-threating diseases, based on the concept of total pain, which includes physical, psychological and spiritual pain. Understanding the relationship between spiritual coping and psychological symptoms (especially depressive symptoms) could help healthcare teams better address patients' needs. Across-sectional survey with aconvenient sample of ambulatory palliative care patients investigated their psychological pain through the Hospital Anxiety and Depressive (HAD) scale and their use of spirituality using the Brief Religious/spiritual coping (BriefRCOPE) scale. Alinear regression model, using the HADS-depression as outcome variable and the BriefRCOPE as the independent variable, adjusting for confounding variables, investigated the possible association between these variables. Due to methodological limitations, just 40 out 130 potential participants were assessed, with 40percent showing depressive symptoms. In regression model, depressive and anxiety symptoms were significantly associated with each other (p = 0.037 and 0.015, respectively) and negative religious/spiritual coping was associated with depressive symptoms (p = 0.033). This study found asignificant relationship between psychological pain and negative spiritual coping mechanisms. Palliative care professionals should be trained to address patients' total pain and spiritual needs, supporting their ability to cope with their suffering.
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Affiliation(s)
- Guilherme Gryschek
- Internal Medicine/Medical Education Post-Graduation Program, School of Medical Sciences, UNICAMP, Campinas-SP, Brazil.,Palliative Care Institute Liverpool, University of Liverpool, Liverpool, UK
| | | | - Leonardo Jun Otuyama
- Division of Pharmacy, Hospital of Clinics, School of Medicine, University of São Paulo, São Paulo-SP, Brazil
| | - Christian Goodwin
- Palliative Care Institute Liverpool, University of Liverpool, Liverpool, UK
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166
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White N, Reid F, Harries P, Harris AJL, Minton O, McGowan C, Lodge P, Tookman A, Stone P. The (un)availability of prognostic information in the last days of life: a prospective observational study. BMJ Open 2019; 9:e030736. [PMID: 31292186 PMCID: PMC6624101 DOI: 10.1136/bmjopen-2019-030736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES The aims of this study were (1) to document the clinical condition of patients considered to be in the last 2 weeks of life and (2) to compare patients who did or did not survive for 72 hours. DESIGN A prospective observational study. SETTING Two sites in London, UK (a hospice and a hospital palliative care team). PARTICIPANTS Any inpatient, over 18 years old, English speaking, who was identified by the palliative care team as at risk of dying within the next 2 weeks was eligible. OUTCOME MEASURES Prognostic signs and symptoms were documented at a one off assessment and patients were followed up 7 days later to determine whether or not they had died. RESULTS Fifty participants were recruited and 24/50 (48%) died within 72 hours of assessment. The most prevalent prognostic features observed were a decrease in oral food intake (60%) and a rapid decline of the participant's global health status (56%). Participants who died within 72 hours had a lower level of consciousness and had more care needs than those who lived longer. A large portion of data was unavailable, particularly that relating to the psychological and spiritual well-being of the patient, due to the decreased consciousness of the patient. CONCLUSIONS The prevalence of prognostic signs and symptoms in the final days of life has been documented between those predicted to die and those who did not. How doctors make decisions with missing information is an area for future research, in addition to understanding the best way to use the available information to make more accurate predictions.
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Affiliation(s)
- Nicola White
- Marie Curie Palliative Care Research Department, University College London, London, London, UK
| | - Fiona Reid
- Department of Primary Care & Public Health Sciences, King’s College London, London, London, UK
| | - Priscilla Harries
- Centre for Applied Health and Social Care Research (CAHSCR), Kingston University & St George’s, University of London, London, UK
- Department of Clinical Sciences, Brunel University London, London, UK
| | - Adam J L Harris
- Experimental Psychology, University College London, London, London, UK
| | - Ollie Minton
- Palliative Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, Brighton and Hove, UK
| | - Catherine McGowan
- Palliative Medicine, St. Georges University Hospitals NHS Foundation Trust, London, UK
| | - Philip Lodge
- Palliative Medicine, Royal Free London NHS Foundation Trust, London, London, UK
- Marie Curie Hospice Hampstead, London, UK
| | - Adrian Tookman
- Palliative Medicine, Royal Free London NHS Foundation Trust, London, London, UK
- Marie Curie Hospice Hampstead, London, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, University College London, London, London, UK
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167
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Blomberg K, Lindqvist O, Harstäde CW, Söderman A, Östlund U. Translating the Patient Dignity Inventory. Int J Palliat Nurs 2019; 25:334-343. [DOI: 10.12968/ijpn.2019.25.7.334] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: The Patient Dignity Inventory (PDI) is based on an empirically-driven dignity model that has been developed and used for clinically assessing the various sources of dignity-related distress. In a recent review, it received the highest score as a useful instrument in both practice and research in palliative care. The PDI has been adapted to and validated for use in various countries, but not yet Sweden. Aims: To translate the PDI into Swedish, including cultural adaptation for clinical use. Methods: A multi-step process of translation, negotiated consensus, expert group discussion (n=7: four invited experts and three researchers) and cognitive interviewing (n=7: persons with palliative care needs). Findings: Discussion, by the expert reviewers, of both linguistic and cultural issues regarding the content and readability of the translated Swedish version resulted in revisions of items and response alternatives, focusing mainly on semantic, conceptual, and experiential equivalence. A pilot version for cognitive interviews was produced. The analysis of data showed that most of the items were judged to be relevant by the persons with palliative care needs. Conclusion: The process of translation and adaptation added clarity and consistency. The Swedish version of the PDI can be used in assessing dignity-related distress. The next step will be to test this Swedish version for psychometric properties in a larger group of patients with palliative care needs before use in research.
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Affiliation(s)
- Karin Blomberg
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | | | - Carina Werkander Harstäde
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, Kalmar/Växjö, Sweden
| | - Annika Söderman
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Ulrika Östlund
- Center for Research & Development, Uppsala University/Region Gävleborg, Gävle, Sweden Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
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169
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Garcia MV, Luckett T, Johnson M, Hutchinson A, Lal S, Phillips JL. The roles of dispositional coping style and social support in helping people with respiratory disease cope with a breathlessness crisis. J Adv Nurs 2019; 75:1953-1965. [PMID: 31012133 DOI: 10.1111/jan.14039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 02/12/2019] [Accepted: 03/28/2019] [Indexed: 12/01/2022]
Abstract
AIM To explore the role of coping moderators in self-management of breathlessness crises by people with advanced respiratory disease. DESIGN A secondary analysis of semi-structured interview data. METHODS Interviews with patients who had advanced respiratory disease, chronic breathlessness and at least one experience where they considered presenting to Emergency but self-managed instead (a "near miss"). Participants were recruited from New South Wales, Queensland, Victoria, South Australia or Tasmania. Eligible caregivers were those who contributed to Emergency-related decision-making. Interviews were coded inductively and then deductively against the coping moderators social support and dispositional coping style, defined by the Transactional Model of Stress and Coping. RESULTS Interviews were conducted between October 2015 - April 2016 with 20 patients and three caregivers. Social networks offered emotional and practical support but also had potential for conflict with patients' 'hardy' coping style. Patient hardiness (characterized by a sense of 'commitment' and 'challenge') promoted a proactive approach to self-management but made some patients less willing to accept support. Information-seeking tendencies varied between patients and were sometimes shared with caregivers. An optimistic coping style appeared to be less equivocally beneficial. CONCLUSION This study shows that social support and coping style may influence how people self-manage through their breathlessness crises and identified ways coping moderators can facilitate or hinder effective self-management. IMPACT This study confers insights into how social-support and coping style can be supported and optimized to facilitate breathlessness self-management. Acknowledging coping moderator interactions is beneficial for developing resources and strategies that recognise patient mastery.
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Affiliation(s)
- Maja Villanueva Garcia
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Tim Luckett
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Miriam Johnson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, UK
| | - Ann Hutchinson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, UK
| | - Sara Lal
- School of Life Sciences, University of Technology, Sydney, New South Wales, Australia
| | - Jane L Phillips
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
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170
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Maddocks M, Brighton LJ, Farquhar M, Booth S, Miller S, Klass L, Tunnard I, Yi D, Gao W, Bajwah S, Man WDC, Higginson IJ. Holistic services for people with advanced disease and chronic or refractory breathlessness: a mixed-methods evidence synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Lisa Jane Brighton
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Morag Farquhar
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Sara Booth
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Sophie Miller
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Lara Klass
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - India Tunnard
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - William D-C Man
- National Heart and Lung Institute, Imperial College London, London, UK
- Harefield Pulmonary Rehabilitation and Muscle Research Laboratory, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
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171
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Sleeman KE, de Brito M, Etkind S, Nkhoma K, Guo P, Higginson IJ, Gomes B, Harding R. The escalating global burden of serious health-related suffering: projections to 2060 by world regions, age groups, and health conditions. LANCET GLOBAL HEALTH 2019; 7:e883-e892. [PMID: 31129125 PMCID: PMC6560023 DOI: 10.1016/s2214-109x(19)30172-x] [Citation(s) in RCA: 357] [Impact Index Per Article: 71.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/08/2019] [Accepted: 03/22/2019] [Indexed: 01/17/2023]
Abstract
Background Serious life-threatening and life-limiting illnesses place an enormous burden on society and health systems. Understanding how this burden will evolve in the future is essential to inform policies that alleviate suffering and prevent health system weakening. We aimed to project the global burden of serious health-related suffering requiring palliative care until 2060 by world regions, age groups, and health conditions. Methods We projected the future burden of serious health-related suffering as defined by the Lancet Commission on Palliative Care and Pain Relief, by combining WHO mortality projections (2016–60) with estimates of physical and psychological symptom prevalence in 20 conditions most often associated with symptoms requiring palliative care. Projections were described in terms of absolute numbers and proportional change compared with the 2016 baseline data. Results were stratified by World Bank income regions and WHO geographical regions. Findings By 2060, an estimated 48 million people (47% of all deaths globally) will die with serious health-related suffering, which represents an 87% increase from 26 million people in 2016. 83% of these deaths will occur in low-income and middle-income countries. Serious health-related suffering will increase in all regions, with the largest proportional rise in low-income countries (155% increase between 2016 and 2060). Globally, serious health-related suffering will increase most rapidly among people aged 70 years or older (183% increase between 2016 and 2060). In absolute terms, it will be driven by rises in cancer deaths (16 million people, 109% increase between 2016 and 2060). The condition with the highest proportional increase in serious-related suffering will be dementia (6 million people, 264% increase between 2016 and 2060). Interpretation The burden of serious health-related suffering will almost double by 2060, with the fastest increases occurring in low-income countries, among older people, and people with dementia. Immediate global action to integrate palliative care into health systems is an ethical and economic imperative. Funding Research Challenge Fund, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London.
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Affiliation(s)
- Katherine E Sleeman
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK.
| | - Maja de Brito
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK; Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Simon Etkind
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Kennedy Nkhoma
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Ping Guo
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Barbara Gomes
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK; Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Richard Harding
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
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Barnes-Harris M, Allgar V, Booth S, Currow D, Hart S, Phillips J, Swan F, Johnson MJ. Battery operated fan and chronic breathlessness: does it help? BMJ Support Palliat Care 2019; 9:478-481. [PMID: 31068332 DOI: 10.1136/bmjspcare-2018-001749] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 04/03/2019] [Accepted: 04/23/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To examine whether use of a hand-held fan ('fan') improves breathlessness and increases physical activity. METHODS A secondary exploratory analysis using pooled data from the fan arms of two feasibility randomised controlled trials in people with chronic breathlessness: (1) fan and activity advice vs activity advice, (2) activity advice alone or with the addition or the 'calming hand', or the fan, or both. Descriptive statistics and regression analysis to explore patient characteristics associated with benefit (eg age, sex, diagnosis, general self-efficacy). RESULTS Forty-one participants were allocated the fan (73 years (IQR 65-76, range 46-88), 59% male, 20 (49%) chronic obstructive pulmonary disease (COPD), three (7%) heart failure, three (7%) cancer). Thirty-five (85%) reported that the fan helped breathing, and 22 (54%) reported increased physical activity.Breathlessness benefit was more likely in older people, those with COPD and those with a carer. However, due to the small sample size none of these findings were statistically significant. Those with COPD were more likely to use the fan than people with other diagnoses (OR 5.94 (95% CI 0.63 to 56.21, p=0.120)). CONCLUSIONS These exploratory data support that the fan helps chronic breathlessness in most people and adds new data to indicate that the fan is perceived to increase people's physical activity. There is also a signal of possible particular benefits in people with COPD which is worthy of further study.
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Affiliation(s)
| | | | - Sara Booth
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - David Currow
- Faculty of Heath, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Simon Hart
- Wolfson Palliative Care, Hull York Medical School, Hull, UK
| | - Jane Phillips
- School of Nursing and Midwifery, University of Technology, Sydney, New South Wales, Australia
| | - Flavia Swan
- Wolfson Palliative Care, Hull York Medical School, Hull, UK
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173
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Pommer W, Wagner S, Thumfart J. Conservative Care, Dialysis Withdrawal, and Palliative Care: Results from a Survey of a Non-Profit Dialysis Provider in Germany. Kidney Blood Press Res 2019; 44:158-169. [PMID: 31048581 DOI: 10.1159/000498994] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 01/16/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In Germany, practice patterns of conservative renal care (CRC), dialysis withdrawal (DW), and concomitant palliative care in patients who choose these options are unknown. METHOD A survey was designed including 13 structured and one open questions on the management and frequency of CRC and DW, local palliative care structure, and fundamentals of the decision-making process, and addressed to the head physicians of all renal centers (n = 193) of a non-profit renal care provider (KfH - Kuratorium für Dialyse und Nierentransplantation, Neu-Isenburg, Germany). RESULTS Response rate was 62.2% (n = 122 centers) comprising 14,197 prevalent dialysis patients and 159,652 renal outpatients. Two-thirds of the respondents were men (85% in the age group between 45 and 64 years). Mean time of experience in renal medicine was 22.2 years in men, 20.8 years in women. 94% of all centers provided CRC with a different frequency and proportion of patients (mean 8.4% of the center population, median 5%, range 0-50%). Mean proportion of DW was 2.85% per year (median 2%, range 1-15%). Physicians and center features were not significantly associated with utilization of CRC or DW. Palliative care management varied including local palliative teams, support by general physicians, or by the renal team itself. Hospice care was only established in patients undergoing CRC. Fundamentals of the decision-making process were the desire of the patient (90% in CRC, 67% in DW). Patients undergoing CRC changed their opinion towards treatment modality "frequently" in 18% of the cases, "occasionally" in 73%. Physicians' decisions were mostly driven by presumed fatal prognosis and poor physical or mental conditions of the individual patient. Different barriers to provide palliative care for the renal population like lack of education in palliative medicine, shortness of staff, lack of financial resources, and local palliative care structures were reported. CONCLUSION Compared to international numbers, in Germany, proportion of CRC and DW reported by non-profit renal centers is in the lower range. Center practice of palliative care management varies and is driven by availability of local palliative care resources and presumably by attitudes of the renal teams. Quality of palliative care and the decision-making process need further evaluation.
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Affiliation(s)
- Wolfgang Pommer
- KfH - Kuratorium für Dialyse und Nierentransplantation, Neu-Isenburg, Germany,
| | | | - Julia Thumfart
- Charité Universitätsmedizin Berlin, Clinic for Pediatric, Gastroenterology, Nephrology, and Metabolic Diseases, Berlin, Germany
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174
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Ekström M, Williams M, Johnson MJ, Huang C, Currow DC. Agreement Between Breathlessness Severity and Unpleasantness in People With Chronic Breathlessness: A Longitudinal Clinical Study. J Pain Symptom Manage 2019; 57:715-723.e5. [PMID: 30639756 DOI: 10.1016/j.jpainsymman.2019.01.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 12/31/2018] [Accepted: 01/02/2019] [Indexed: 11/25/2022]
Abstract
CONTEXT Chronic breathlessness is a cardinal symptom in cardiopulmonary disease where both overall intensity or severity (S) and unpleasantness (U) are commonly quantified. OBJECTIVE We aimed to evaluate agreement between breathlessness severity and unpleasantness over eight days in patients with chronic breathlessness. METHODS Longitudinal analysis of 265 patients with chronic breathlessness who rated current overall breathlessness severity and unpleasantness on a 0-100 mm visual analogue scale (VAS) in the morning and evening over eight days. A total of 3630 paired overall severity-unpleasantness (S-U) differences were analyzed; median 15 (IQR 13-16) per patient. Agreement was evaluated using Bland-Altman plots. Associations of the difference between severity and unpleasantness (S-U difference) with clinical factors and perceived quality of life were analyzed using multilevel linear regression adjusted for confounders. RESULTS Over eight days, severity and unpleasantness scores were highly correlated, had similar variability, and varied more between patients than within patients. The mean S-U difference was small at 2.1 mm. Agreement between overall severity and unpleasantness was similar or higher than expected from the variability in individual scores. The S-U difference was similar across evaluated factors including age, sex, diagnosis, morning/evening assessment, modified Medical Research Council breathlessness score, morphine treatment, and presence of different sensory qualities of breathlessness. Higher overall severity and unpleasantness associated with worse perceived quality of life in a similar way. CONCLUSION In patients with chronic breathlessness over eight days, overall severity and unpleasantness of breathlessness were comparable and associated to other clinical factors in a similar manner.
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Affiliation(s)
- Magnus Ekström
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden; ImPaCCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.
| | - Marie Williams
- School of Health Sciences, University of South Australia, Adelaide, Australia
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, UK
| | - Chao Huang
- Hull York Medical School, Institute for Clinical and Applied Health Research, University of Hull, UK
| | - David C Currow
- ImPaCCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
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175
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Tan SB, Liam CK, Pang YK, Leh-Ching Ng D, Wong TS, Wei-Shen Khoo K, Ooi CY, Chai CS. The Effect of 20-Minute Mindful Breathing on the Rapid Reduction of Dyspnea at Rest in Patients With Lung Diseases: A Randomized Controlled Trial. J Pain Symptom Manage 2019; 57:802-808. [PMID: 30684635 DOI: 10.1016/j.jpainsymman.2019.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/13/2019] [Accepted: 01/14/2019] [Indexed: 12/13/2022]
Abstract
CONTEXT Dyspnea is a common and distressing symptom in respiratory diseases. Despite advances in the treatment of various lung diseases, the treatment modalities for dyspnea remain limited. OBJECTIVES This study aims to examine the effect of 20-minute mindful breathing on the rapid reduction of dyspnea at rest in patients with lung cancer, chronic obstructive pulmonary disease, and asthma. METHODS We conducted a parallel-group, nonblinded, randomized controlled trial of standard care plus 20-minute mindful breathing vs. standard care alone for patients with moderate to severe dyspnea due to lung disease, named previously, at the respiratory unit of University Malaya Medical Centre in Malaysia, from August 1, 2017, to March 31, 2018. RESULTS Sixty-three participants were randomly assigned to standard care plus a 20-minute mindful breathing session (n = 32) or standard care alone (n = 31), with no difference in their demographic and clinical characteristics. There was statistically significant reduction in dyspnea in the mindful breathing group compared with the control group at minute 5 (U = 233.5, n1 = 32, n2 = 31, mean rank1 = 23.28, mean rank2 = 37.72, z = -3.574, P < 0.001) and minute 20 (U = 232.0, n1 = 32, n2 = 31, mean rank1 = 23.00, mean rank2 = 36.77, z = -3.285, P = 0.001). CONCLUSION Our results provide evidence that a single session of 20-minute mindful breathing is effective in reducing dyspnea rapidly for patients with lung cancer, chronic obstructive pulmonary disease, and asthma.
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Affiliation(s)
- Seng-Beng Tan
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chong-Kin Liam
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Yong-Kek Pang
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Diana Leh-Ching Ng
- Department of Medicine, Faculty of Medicine and Health Science, University Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia
| | - Tat-Seng Wong
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kelvin Wei-Shen Khoo
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chieh-Yin Ooi
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chee-Shee Chai
- Department of Medicine, Faculty of Medicine and Health Science, University Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia.
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176
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ElMokhallalati Y, Woodhouse N, Farragher T, Bennett MI. Specialist palliative care support is associated with improved pain relief at home during the last 3 months of life in patients with advanced disease: analysis of 5-year data from the national survey of bereaved people (VOICES). BMC Med 2019; 17:50. [PMID: 30898162 PMCID: PMC6429790 DOI: 10.1186/s12916-019-1287-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 02/11/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Studies have shown that more than half of patients with advanced progressive diseases approaching the end-of-life report pain and that pain relief for these patients is poorest at home compared to other care settings such as acute care facilities and hospice. Although home is the most common preferred place of death, the majority of deaths occur outside the home. Specialist palliative care is associated with improved quality of life, but systematic reviews of RCTs have failed to show a consistent association with better pain relief. The aim of this study was to examine the factors associated with good pain relief at home in the last 3 months of life for people with advanced progressive disease. METHODS Data were obtained from the National Bereavement Survey in England, a cross-sectional post-bereavement survey of a stratified random sample of 246,763 deaths which were registered in England from 2011 to 2015. From 110,311 completed surveys (45% response rate), the analysis was based on individual-level data from 43,509 decedents who were cared for at home before death. RESULTS Decedents who experienced good pain relief at home before death were significantly more likely to have received specialist palliative care (adjusted OR = 2.67; 95% CI, 2.62 to 2.72) and to have a recorded preferred place of death (adjusted OR = 1.87; 95% CI, 1.84 to 1.90) compared to those who did not. Good pain relief was more likely to be reported by a spouse or partner of the decedents compared to reports from their son or daughter (adjusted OR = 1.50, 95% CI, 1.47 to 1.53). CONCLUSION This study indicates that patients at home who are approaching the end-of-life experience substantially better pain relief if they receive specialist palliative care and their preferred place of death is recorded regardless of their disease aetiology.
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Affiliation(s)
- Yousuf ElMokhallalati
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences (LIHS), School of Medicine, University of Leeds, Room 10.39, Level 10, Worsley Building, Clarendon Way, Leeds, LS2 9NL, UK.
| | - Natalie Woodhouse
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences (LIHS), School of Medicine, University of Leeds, Room 10.39, Level 10, Worsley Building, Clarendon Way, Leeds, LS2 9NL, UK
| | - Tracey Farragher
- Academic Unit of Public Health, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Michael I Bennett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences (LIHS), School of Medicine, University of Leeds, Room 10.39, Level 10, Worsley Building, Clarendon Way, Leeds, LS2 9NL, UK
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177
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van der Steen JT, Lennaerts H, Hommel D, Augustijn B, Groot M, Hasselaar J, Bloem BR, Koopmans RTCM. Dementia and Parkinson's Disease: Similar and Divergent Challenges in Providing Palliative Care. Front Neurol 2019; 10:54. [PMID: 30915012 PMCID: PMC6421983 DOI: 10.3389/fneur.2019.00054] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 01/16/2019] [Indexed: 12/29/2022] Open
Abstract
Dementia and Parkinson's disease are incurable neurological conditions. Patients often experience specific, complex, and varying needs along their disease trajectory. Current management typically employs a multidisciplinary team approach. Recognition is growing that this team approach should also address palliative care issues to optimize quality of life for patient and family caregivers, but it remains unclear how palliative care is best delivered. To inspire future service development and research, we compare the trajectories and conceptualization of palliative care between dementia and Parkinson's disease. Both Parkinson's disease and dementia are characterized by a protracted course, with progressive but fairly insidious development of disability. However, patients with Parkinson's disease may experience relatively stable periods initially but with time, a wide range of debilitating symptoms develops, many of which do not respond well to treatment. Eventually, dementia develops in most Parkinson patients, while motor disability develops in many dementia patients. In both diseases, symptoms such as pain, apathy, sleeping problems, falls, and a high caregiver burden are prevalent. Advance care planning has benefits in terms of being prepared before the disease progresses into a stage with communication problems or severe cognitive impairment. However, for both conditions, the protracted disease trajectories complicate conceptualization of palliative care through different stages of the disease, with pertinent questions such as when to offer what interventions pro-actively. Given the similarities and differences, we should develop palliative approaches that are partially generic and partially disease-specific. These should be integrated seamlessly with disease-specific care. Substantial research is already being performed on dementia palliative care. This may also inform the further development of palliative care for Parkinson's disease, including an evaluation of palliative interventions and services.
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Affiliation(s)
- Jenny T. van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, Netherlands
| | - Herma Lennaerts
- Departments of Neurology and Anesthesiology, Pain and Palliative Care, Radboud university medical center, Nijmegen, Netherlands
| | - Danny Hommel
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud university medical center, Nijmegen, Netherlands
- Groenhuysen Organisation, Roosendaal, Netherlands
| | | | - Marieke Groot
- Department of Anesthesiology, Pain and Palliative Care/Expertise Center for Palliative Care, Radboud university medical center, Nijmegen, Netherlands
| | - Jeroen Hasselaar
- Department of Anesthesiology, Pain and Palliative Care/Expertise Center for Palliative Care, Radboud university medical center, Nijmegen, Netherlands
| | - Bastiaan R. Bloem
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud university medical center, Nijmegen, Netherlands
| | - Raymond T. C. M. Koopmans
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, Netherlands
- Radboudumc Alzheimer Center, Nijmegen, Netherlands
- De Waalboog “Joachim en Anna, ” Center for Specialized Geriatric Care, Nijmegen, Netherlands
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178
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Heydari A, Sharifi H, Bagheri Moghaddam A. The Provision of Palliative Care for Noncancer Patients With Advanced Disease: Equity Does Matter. Am J Hosp Palliat Care 2019; 36:932-933. [PMID: 30836767 DOI: 10.1177/1049909119835225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
According to the World Health Organization, the main mission of palliative care is to optimize the quality of life of patients with serious chronic disease, as well as their caregivers, by providing biopsychosociospiritual care. However, historically, the primary focus of palliative care is on providing care only for cancer diseases. Based on the current literature, it is assumed that palliative care is not provided for many chronic diseases on a regular basis and in many cases, a clinical guideline does not exist for providing palliative care.
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Affiliation(s)
- Abbas Heydari
- 1 Nursing and Midwifery care research center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hassan Sharifi
- 2 Department of Medical-Surgical Nursing, Faculty of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ahmad Bagheri Moghaddam
- 3 Department of Anesthesiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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179
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Siouta N, Heylen A, Aertgeerts B, Clement P, Van Cleemput J, Janssens W, Menten J. Early integrated palliative care in chronic heart failure and chronic obstructive pulmonary disease: protocol of a feasibility before-after intervention study. Pilot Feasibility Stud 2019; 5:31. [PMID: 30834140 PMCID: PMC6385452 DOI: 10.1186/s40814-019-0420-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 02/17/2019] [Indexed: 12/02/2022] Open
Abstract
Background Patients with chronic heart failure (CHF) and patients with chronic obstructive pulmonary disease (COPD) are amenable to integrated palliative care (PC); however, despite the recommendation by various healthcare organizations, these patients have limited access to integrated PC services. In this study, we present the protocol of a feasibility prospective study that aims to explore if an “early integrated PC” intervention can be performed in an acute setting (cardiology and pulmonology wards) and whether it will have an effect on (i) the satisfaction of care and (ii) the quality of life and the level of symptom control of CHF/COPD patients and their informal caregivers. Methods A before-after intervention study with three phases, (i) baseline phase where the control group receives standard care, (ii) training phase where the personnel is trained on the application of the intervention, and (iii) intervention phase where the intervention is applied, will be carried out in cardiology and pulmonology wards in the University Hospital Leuven for patients with advanced CHF/COPD and their informal caregivers. Eligible patients (both control and intervention group) and their informal caregivers will be asked to complete the Palliative Outcome Scale, the CANHELP Lite, and the Advance Care Planning Questionnaire at the inclusion moment and 3 months after hospital discharge. Discussion The present study will assess the feasibility of carrying out PC-focused studies in acute wards for CHF/COPD patients and draw lessons for the further integration of PC alongside standard treatment. Further, it will measure the quality of life and quality of care of patients and thus shed light on the care needs of this population. Finally, it will evaluate the potential efficacy of the “early integrated palliative care” by comparing against existing practices. Trial registration Current Controlled Trials ISRCTN24796028 (date of registration August 30, 2018).
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Affiliation(s)
- N Siouta
- 1Laboratory of Experimental Radiotherapy-Palliative Care, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - A Heylen
- 2Palliative Support Team, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - B Aertgeerts
- 3Academic Center for General Practice, KU Leuven, Kapucijnenvoer 33, 3000 Leuven, Belgium
| | - P Clement
- 4Department of Oncology, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - J Van Cleemput
- 5Department of Cardiology, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - W Janssens
- 6Department of Pneumology, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - J Menten
- 1Laboratory of Experimental Radiotherapy-Palliative Care, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
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Bove DG, Jellington MO, Lavesen M, Marså K, Herling SF. Assigned nurses and a professional relationship: a qualitative study of COPD patients' perspective on a new palliative outpatient structure named CAPTAIN. BMC Palliat Care 2019; 18:24. [PMID: 30825878 PMCID: PMC6397743 DOI: 10.1186/s12904-019-0410-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 02/26/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little is known of how to organize non-malign palliative care, and existing knowledge show that patients with COPD live with unmet palliative needs and low quality of life. With the intent to improve palliative care for patients with COPD, we changed the structure of our outpatient clinic from routine visits by a pulmonary specialist to a structure where each patient was assigned a nurse, offered annual advance care planning dialogues, and ad hoc pulmonary specialist visits. The aim of this study was to explore COPD patients' experiences with a new and altered palliative organization. METHODS The design was interpretive description as described by Thorne. We conducted ten semi-structured interviews with patients with severe COPD from January 2017 to December 2017. RESULTS Patients described how the professional relationship and the availability of their nurse was considered as the most important and positive change. It made the patients feel safe, in control, and subsequently influenced their ability to self-manage their life and prevent being hospitalized. The patients did not emphasize the advanced care planning dialogues as something special or troublesome. CONCLUSION We showed that it is relevant and meaningful to establish a structure that supports professional relationships between patient, nurse and physician based on patients needs. The new way of structuring the outpatient care was highly appreciated by COPD patients and made them feel safe which brought confidence in self-management abilities.
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Affiliation(s)
- D. G. Bove
- Emergency Department, Copenhagen University Hospital, Nordsjælland, Dyrehavevej 29, 3400 Hillerød, Denmark
- Department of Pulmonary & Infectious Diseases, Copenhagen University Hospital, Nordsjælland, Dyrehavevej 29, 3400 Hillerød, Denmark
| | - M. O. Jellington
- Department of Pulmonary & Infectious Diseases, Copenhagen University Hospital, Nordsjælland, Dyrehavevej 29, 3400 Hillerød, Denmark
| | - M. Lavesen
- Department of Pulmonary & Infectious Diseases, Copenhagen University Hospital, Nordsjælland, Dyrehavevej 29, 3400 Hillerød, Denmark
| | - K. Marså
- Department of Palliative Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev Ringvej 75, 2730 Herlev, Denmark
| | - S. F. Herling
- Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Section 2091, Inge Lehmanns Vej 7, 2100 Copenhagen Ø, Denmark
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181
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Jhamb M, Abdel-Kader K, Yabes J, Wang Y, Weisbord SD, Unruh M, Steel JL. Comparison of Fatigue, Pain, and Depression in Patients With Advanced Kidney Disease and Cancer-Symptom Burden and Clusters. J Pain Symptom Manage 2019; 57:566-575.e3. [PMID: 30552961 PMCID: PMC6382584 DOI: 10.1016/j.jpainsymman.2018.12.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/04/2018] [Accepted: 12/05/2018] [Indexed: 12/21/2022]
Abstract
CONTEXT Although symptom clusters have been studied in the context of cancer, few data exist in chronic and end-stage kidney disease (CKD/ESKD) patients. OBJECTIVES The objectives of this study were to 1) characterize and compare symptom cluster phenotypes in patients with advanced CKD, ESKD, and cancer and 2) explore predictors of symptom clusters. METHODS We conducted secondary data analysis of three prospective studies in which pain, depression, and fatigue were assessed in patients with Stage 4-5 CKD, ESKD, and gastrointestinal cancer. Tetrachoric correlations between these symptoms were quantified, and partitioning around medoids algorithm was used for symptom cluster analysis. RESULTS In the 82 CKD, 149 ESKD, and 606 cancer patients, no differences in the average fatigue (P = 0.17) or pain levels (P = 0.21) were observed. Over 80% of patients in each group had at least one symptom. Moderate or severe depressive symptoms were more common in patients with cancer (31% vs. 19% in ESKD vs. 9% in CKD; P < 0.001). Mild-moderate correlations were observed between the three symptoms in ESKD and cancer patients. Three distinct clusters were observed in each group. In ESKD, the HIGH cluster (with high probability of pain, depression, and fatigue) had higher body mass index (P < 0.001) and antidepressant use (P = 0.01). In cancer patients, the HIGH cluster patients were more likely to be female (P = 0.04), use antidepressants (P = 0.04), and have lower serum albumin (P < 0.001) and hemoglobin (P = 0.03) compared to the other two clusters. CONCLUSION Although the burden of fatigue, pain, and depressive symptoms for CKD and ESKD patients is similar to patients with gastrointestinal cancer, symptom cluster phenotypes differed between the groups as did the predictors of symptom clusters.
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Affiliation(s)
- Manisha Jhamb
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan Yabes
- Center for Research on Heath Care, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yisi Wang
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steven D Weisbord
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Renal Section, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Mark Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Jennifer L Steel
- Department of Surgery, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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EVANS CATHERINEJ, ISON LUCY, ELLIS‐SMITH CLARE, NICHOLSON CAROLINE, COSTA ALESSIA, OLUYASE ADEJOKEO, NAMISANGO EVE, BONE ANNAE, BRIGHTON LISAJANE, YI DEOKHEE, COMBES SARAH, BAJWAH SABRINA, GAO WEI, HARDING RICHARD, ONG PAUL, HIGGINSON IRENEJ, MADDOCKS MATTHEW. Service Delivery Models to Maximize Quality of Life for Older People at the End of Life: A Rapid Review. Milbank Q 2019; 97:113-175. [PMID: 30883956 PMCID: PMC6422603 DOI: 10.1111/1468-0009.12373] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Policy Points We identified two overarching classifications of integrated geriatric and palliative care to maximize older people's quality of life at the end of life. Both are oriented to person-centered care, but with differing emphasis on either function or symptoms and concerns. Policymakers should both improve access to palliative care beyond just the last months of life and increase geriatric care provision to maintain and optimize function. This would ensure that continuity and coordination for potentially complex care needs across the continuum of late life would be maintained, where the demarcation of boundaries between healthy aging and healthy dying become increasingly blurred. Our findings highlight the urgent need for health system change to improve end-of-life care as part of universal health coverage. The use of health services should be informed by the likelihood of benefits and intended outcomes rather than on prognosis. CONTEXT In an era of unprecedented global aging, a key priority is to align health and social services for older populations in order to support the dual priorities of living well while adapting to a gradual decline in function. We aimed to provide a comprehensive synthesis of evidence regarding service delivery models that optimize the quality of life (QoL) for older people at the end of life across health, social, and welfare services worldwide. METHODS We conducted a rapid scoping review of systematic reviews. We searched MEDLINE, CINAHL, EMBASE, and CDSR databases from 2000 to 2017 for reviews reporting the effectiveness of service models aimed at optimizing QoL for older people, more than 50% of whom were older than 60 and in the last one or two years of life. We assessed the quality of these included reviews using AMSTAR and synthesized the findings narratively. RESULTS Of the 2,238 reviews identified, we included 72, with 20 reporting meta-analysis. Although all the World Health Organization (WHO) regions were represented, most of the reviews reported data from the Americas (52 of 72), Europe (46 of 72), and/or the Western Pacific (28 of 72). We identified two overarching classifications of service models but with different target outcomes: Integrated Geriatric Care, emphasizing physical function, and Integrated Palliative Care, focusing mainly on symptoms and concerns. Areas of synergy across the overarching classifications included person-centered care, education, and a multiprofessional workforce. The reviews assessed 117 separate outcomes. A meta-analysis demonstrated effectiveness for both classifications on QoL, including symptoms such as pain, depression, and psychological well-being. Economic analysis and its implications were poorly considered. CONCLUSIONS Despite their different target outcomes, those service models classified as Integrated Geriatric Care or Integrated Palliative Care were effective in improving QoL for older people nearing the end of life. Both approaches highlight the imperative for integrating services across the care continuum, with service involvement triggered by the patient's needs and likelihood of benefits. To inform the sustainability of health system change we encourage economic analyses that span health and social care and examine all sources of finance to understand contextual inequalities.
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Affiliation(s)
- CATHERINE J. EVANS
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
- Sussex Community NHS Foundation TrustBrighton General Hospital
| | - LUCY ISON
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - CLARE ELLIS‐SMITH
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - CAROLINE NICHOLSON
- King's College London, Florence Nightingale Faculty of NursingMidwifery & Palliative Care
- St Christopher's Hospice
| | - ALESSIA COSTA
- King's College London, Florence Nightingale Faculty of NursingMidwifery & Palliative Care
| | - ADEJOKE O. OLUYASE
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - EVE NAMISANGO
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - ANNA E. BONE
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - LISA JANE BRIGHTON
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - DEOKHEE YI
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - SARAH COMBES
- King's College London, Florence Nightingale Faculty of NursingMidwifery & Palliative Care
| | - SABRINA BAJWAH
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - WEI GAO
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - RICHARD HARDING
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - PAUL ONG
- World Health Organisation Centre for Health Development
| | - IRENE J. HIGGINSON
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - MATTHEW MADDOCKS
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
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183
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Bannon M, Ernecoff NC, Dionne-Odom JN, Zimmermann C, Corbelli J, Klein-Fedyshin M, Arnold RM, Schenker Y, Kavalieratos D. Comparison of Palliative Care Interventions for Cancer versus Heart Failure Patients: A Secondary Analysis of a Systematic Review. J Palliat Med 2019; 22:966-969. [PMID: 30762462 DOI: 10.1089/jpm.2018.0513] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: In 2016, Kavalieratos and colleagues performed a systematic review of randomized clinical trials (RCTs) of palliative care (PC) interventions. The majority of RCTs included focused on oncology, with fewer in heart failure (HF). Cancer patients' often predictable decline differs from the variable illness trajectories of HF; however, both groups experience similar palliative needs, and accordingly, PC in HF continues to grow. Objective: To investigate if PC interventions differ between cancer and HF patients. Design: In this secondary analysis, we compare PC interventions for cancer and HF patients evaluated in the 2016 systematic review. Settings/Subjects: We included a total of 25 trials, 19 of which included 3730 cancer patients, and 6 of which included 1049 HF patients (mean age, 67 years). Measurements: We compared the following five characteristics among included trials: PC domains addressed, duration, location, provider specialization, and measured outcomes. Results: The content of the cancer and HF interventions was similar. HF interventions tended to include more home-based (50% vs. 37%) and specialty PC interventions (67% vs. 47%), although these results did not reach statistical significance. Both cancer and HF interventions favored longer durations (i.e., more than one month; 79% and 67%). No HF intervention RCTs included caregiver outcomes, whereas 32% of cancer interventions did. Conclusions: There were no substantial differences in content of cancer and HF interventions, although the latter tended to be delivered by PC specialists at home. There is a need for scalable interventions that incorporate the needs and preferences of individual patients, regardless of diagnosis.
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Affiliation(s)
- Megan Bannon
- 1Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Natalie C Ernecoff
- 2Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Camilla Zimmermann
- 4Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Corbelli
- 1Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Robert M Arnold
- 6Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yael Schenker
- 6Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dio Kavalieratos
- 2Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,6Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Turrillas P, Teixeira MJ, Maddocks M. A Systematic Review of Training in Symptom Management in Palliative Care Within Postgraduate Medical Curriculums. J Pain Symptom Manage 2019; 57:156-170.e4. [PMID: 30287198 DOI: 10.1016/j.jpainsymman.2018.09.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/18/2018] [Accepted: 09/20/2018] [Indexed: 11/23/2022]
Abstract
CONTEXT Symptom management is a priority area within palliative care core competencies for generalist providers. Although several educational initiatives exist, a comprehensive evidence synthesis on the effectiveness of symptom management training on trainees' learning and patient-reported outcomes is lacking. OBJECTIVES The objective of this study was to determine the effectiveness of training in symptom management in palliative care providers in nonpalliative specialties. METHODS This is a systematic review following Best Evidence Medical Education methods from searches of MEDLINE, EMBASE, ERIC, CINAHL, PsycINFO, Cochrane database of systematic, Clinical Trials.gov, and ISRCTN databases to September 2017. Prospective controlled studies testing the impact of symptom management educational interventions on physicians in training in nonpalliative specialties were included. Data were summarized narratively, grouped by curriculum description, and effectiveness on trainees' learning or patient-reported outcomes. RESULTS Of 5062 records identified, six studies met the inclusion criteria: two randomized controlled trials and four quasi-experimental. Pain management and use of opioids and their side effects were most frequently covered. Clinical decision support tools, Web-based teaching, palliative care rotation, and mixed educational methods were used. Most studies used self-reported, original, or modified evaluation instruments, although psychometric properties were seldom reported. Despite methodological considerations, all educational methods improved trainees' learning outcomes. However, the effects on trainees' behavior and patient-related outcomes were not evaluated. CONCLUSION Current educational training programs in symptom management appear to improve trainees' comfort, preparedness, and knowledge in assessing and managing patients' symptoms at the end of life. More rigorous research to evaluate the impact of this training on residents and organizational performance is now required.
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Affiliation(s)
- Pamela Turrillas
- Department of Palliative Care, Policy, and Rehabilitation, King's College London, Cicely Saunders Institute, London, UK.
| | - Maria Joao Teixeira
- Department of Palliative Care, Policy, and Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
| | - Matthew Maddocks
- Department of Palliative Care, Policy, and Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
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185
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Lovell N, Etkind SN, Bajwah S, Maddocks M, Higginson IJ. Control and Context Are Central for People With Advanced Illness Experiencing Breathlessness: A Systematic Review and Thematic Synthesis. J Pain Symptom Manage 2019; 57:140-155.e2. [PMID: 30291949 DOI: 10.1016/j.jpainsymman.2018.09.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/24/2018] [Accepted: 09/26/2018] [Indexed: 12/01/2022]
Abstract
CONTEXT Breathlessness is common and distressing in advanced illness. It is a challenge to assess, with few effective treatment options. To evaluate new treatments, appropriate outcome measures that reflect the concerns of people experiencing breathlessness are needed. OBJECTIVES The objective of this study was to systematically review and synthesize the main concerns of people with advanced illness experiencing breathlessness to guide comprehensive clinical assessment and inform future outcome measurement in clinical practice and research. METHODS This is a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. MEDLINE (1946-2017), PsycINFO (1806-2017), and EMBASE (1974-2017), as well as key journals, gray literature, reference lists, and citation searches, identified qualitative studies exploring the concerns of people living with breathlessness. Included studies were quality-assessed using the Critical Appraisal Skills Program checklist and analyzed using thematic synthesis. RESULTS We included 38 studies with 672 participants. Concerns were identified across six domains of "total" breathlessness: physical, emotional, spiritual, social, control, and context (chronic and episodic breathlessness). Four of these have been previously identified in the concept of "total dyspnea." Control and context have been newly identified as important, particularly in their influence on coping and help-seeking behavior. The importance of social participation, impact on relationships, and loss of perceived role within social and spiritual domains also emerged as being significant to individuals. CONCLUSION People with advanced illness living with breathlessness have concerns in multiple domains, supporting a concept of "total breathlessness." This adapted model can help to guide comprehensive clinical assessment and inform future outcome measurement in clinical practice and research.
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Affiliation(s)
- Natasha Lovell
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom.
| | - Simon N Etkind
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
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186
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Lovell N, Wilcock A, Bajwah S, Etkind SN, Jolley CJ, Maddocks M, Higginson IJ. Mirtazapine for chronic breathlessness? A review of mechanistic insights and therapeutic potential. Expert Rev Respir Med 2019; 13:173-180. [PMID: 30596298 DOI: 10.1080/17476348.2019.1563486] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Chronic breathlessness is a common and distressing symptom of advanced disease with few effective treatments. Central nervous system mechanisms are important in respiratory sensation and control. Consequently, drugs which may modify processing and perception of afferent information in the brain may have a role. Antidepressants have been proposed; however, current evidence is limited. Of potentially suitable antidepressants, mirtazapine is an attractive option given its tolerability profile, low cost, and wide availability, along with additional potential benefits. Areas covered: The paper provides an overview of the physiology of breathlessness, with an emphasis on central mechanisms, particularly the role of fear circuits and the associated neurotransmitters. It provides a potential rationale for how mirtazapine may improve chronic breathlessness and quality of life in patients with advanced disease. The evidence was identified by a literature search performed in PubMed through to October 2018. Expert opinion: Currently, there is insufficient evidence to support the routine use of antidepressants for chronic breathlessness in advanced disease. Mirtazapine is a promising candidate to pursue, with definitive randomized controlled trials required to determine its efficacy and safety in this setting.
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Affiliation(s)
- N Lovell
- a Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation , King's College London , London , UK
| | - A Wilcock
- b University of Nottingham, Palliative Medicine, Hayward House Specialist Palliative Care Unit , Nottingham University Hospitals NHS Trust , Nottingham , UK
| | - S Bajwah
- a Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation , King's College London , London , UK
| | - S N Etkind
- a Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation , King's College London , London , UK
| | - C J Jolley
- c Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine , King's College London , UK
| | - M Maddocks
- a Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation , King's College London , London , UK
| | - I J Higginson
- a Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation , King's College London , London , UK
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187
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Peng JK, Hepgul N, Higginson IJ, Gao W. Symptom prevalence and quality of life of patients with end-stage liver disease: A systematic review and meta-analysis. Palliat Med 2019; 33:24-36. [PMID: 30345878 PMCID: PMC6291907 DOI: 10.1177/0269216318807051] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND: End-stage liver disease is a common cause of morbidity and mortality worldwide, yet little is known about its symptomatology and impact on health-related quality of life. AIM: To describe symptom prevalence and health-related quality of life of patients with end-stage liver disease to improve care. DESIGN: Systematic review. DATA SOURCES: We searched eight electronic databases from January 1980 to June 2018 for studies investigating symptom prevalence or health-related quality of life of adult patients with end-stage liver disease. No language restrictions were applied. Meta-analyses were performed where appropriate. RESULTS: We included 80 studies: 35 assessing symptom prevalence, 41 assessing health-related quality of life, and 4 both. The instruments assessing symptoms varied across studies. The most frequently reported symptoms were as follows: pain (prevalence range 30%–79%), breathlessness (20%–88%), muscle cramps (56%–68%), sleep disturbance (insomnia 26%–77%, daytime sleepiness 29.5%–71%), and psychological symptoms (depression 4.5%–64%, anxiety 14%–45%). Erectile dysfunction was prevalent (53%–93%) in men. The health-related quality of life of patients with end-stage liver disease was significantly impaired when compared to healthy controls or patients with chronic liver disease. Compared with compensated cirrhosis, decompensation led to significant worsening of both components of the 36-Item Short Form Survey although to a larger degree for the Physical Component Summary score (decrease from average 6.4 (95% confidence interval: 4.0–8.8); p < 0.001) than for the Mental Component Summary score (4.5 (95% confidence interval: 2.4–6.6); p < 0.001). CONCLUSION: The symptom prevalence of patients with end-stage liver disease resembled that of patients with other advanced conditions. Given the diversity of symptoms and significantly impaired health-related quality of life, multidisciplinary approach and timely intervention are crucial.
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Affiliation(s)
- Jen-Kuei Peng
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK.,2 Department of Family Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,3 Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Nilay Hepgul
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Irene J Higginson
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Wei Gao
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
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Abstract
Palliative care is an approach to the care of patients, affected by serious illness, and their families that aims to reduce suffering through the management of medical symptoms, psychosocial issues, spiritual well-being, and setting goals of care. Patients and families affected by a neurodegenerative illness have significant palliative care needs beginning at the time of diagnosis and extending through end-of-life care and bereavement. We advocate an approach to addressing these needs where the patient's primary care provider or neurologist plays a central role. Key skills in providing effective palliative care to this population include providing the diagnosis with compassion, setting goals of care, anticipating safety concerns, caregiver assessment, advance care planning, addressing psychosocial concerns, and timely referral to a hospice. Managing distressing medical and psychiatric symptoms is critical to improving quality of life throughout the disease course as well as at end-of-life. Many symptoms are common across illnesses; however, there are issues that are specific to the most common classes of neurodegenerative illness, namely dementia, parkinsonism, and motor neuron disease. Incorporating a palliative approach to care, although challenging in many ways, empowers physicians to provide greater support and guidance to patients and families in making the difficult journey through a neurodegenerative illness.
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189
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A Systematic Approach to Comfort Care Transitions in the Emergency Department. J Emerg Med 2018; 56:267-274. [PMID: 30600110 DOI: 10.1016/j.jemermed.2018.10.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 10/12/2018] [Accepted: 10/18/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Approximately 25-30% of Americans die within hospitals. An increasingly geriatric and chronically ill population arrive at emergency departments (EDs) for their terminal presentation. Many patients will not choose, nor are EDs obligated to deliver, futile care. Instead, aggressive comfort care may alleviate patient, family, and clinician distress. OBJECTIVES To discuss best practice through a systematic approach to comfort care transitions for the dying ED patient. METHODS Authors utilized a structured literature search conducted via PubMed (MEDLINE), Embase, and CINAHL databases, including studies from 1998 onward focusing on symptom palliation and coordination of care for acutely dying patients. DISCUSSION Comfort care begins with the language used to introduce the transition. Frame choices to avoid creating feelings of familial abandonment. Prognostication in the dying process helps guide treatment planning and stewarding families. Symptom management in the actively dying patient involves diligent titration of medications as well as thoughtful ordering in de-escalation of life-support modalities. Compassionate extubation necessitates anticipation of postextubation dyspnea or airway loss, and therefore may require step-wise weaning of pulmonary support. Suffering at the end of life for patients and families is multidimensional, and is best approached with an interdisciplinary effort involving clinicians, social work, and chaplaincy. CONCLUSION Comfort care deaths are a daily occurrence in the ED. A systematic approach to these transitions ensures optimal care for patients in their final hours and families' experience of these events.
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190
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Penders YW, Onwuteaka-Philipsen B, Moreels S, Donker GA, Miccinesi G, Alonso TV, Deliens L, Van den Block L. Differences in primary palliative care between people with organ failure and people with cancer: An international mortality follow-back study using quality indicators. Palliat Med 2018; 32:1498-1508. [PMID: 30056802 DOI: 10.1177/0269216318790386] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Measuring the quality of palliative care in a systematic way using quality indicators can illuminate differences between patient groups. AIM To investigate differences in the quality of palliative care in primary care between people who died of cancer and people who died of organ failure. DESIGN Mortality follow-back survey among general practitioners in Belgium, the Netherlands, and Spain (2013-2014), and Italy (2013-2015). A standardized registration form was used to construct quality indicators regarding regular pain measurement, acceptance of the approaching end of life, communication about disease-related topics with patient and next-of-kin; repeated multidisciplinary consultations; involvement of specialized palliative care; place of death; and bereavement counseling. SETTING/PARTICIPANTS Patients (18+) who died non-suddenly of cancer, cardiovascular disease, or respiratory disease ( n = 2360). RESULTS In all countries, people who died of cancer scored higher on the quality indicators than people who died of organ failure, particularly with regard to pain measurement (between 17 and 35 percentage-point difference in the different countries), the involvement of specialized palliative care (between 20 and 54 percentage points), and regular multidisciplinary meetings (between 12 and 24 percentage points). The differences between the patient groups varied by country, with Belgium showing most group differences (eight out of nine indicators) and Spain the fewest (two out of nine indicators). CONCLUSION People who died of organ failure are at risk of receiving lower quality palliative care than people who died of cancer, but the differences vary per country. Initiatives to improve palliative care should have different priorities depending on the healthcare and cultural context.
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Affiliation(s)
- Yolanda Wh Penders
- 1 End-of-Life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Bregje Onwuteaka-Philipsen
- 2 Amsterdam Public Health Research Institute, Department of Public and Occupational Health, Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Sarah Moreels
- 3 Scientific Institute of Public Health (Wetenschappelijk Instituut Volksgezondheid, Institut Scientifique de Santé Publique), Unit of Health Services Research, Brussels, Belgium
| | - Gé A Donker
- 4 NIVEL Primary Care Database-Sentinel Practices, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Guido Miccinesi
- 5 Clinical and Descriptive Epidemiology Unit, Cancer Prevention and Research Institute, Florence, Italy
| | - Tomás Vega Alonso
- 6 Public Health Directorate, Regional Ministry of Health (Dirección General de Salud Pública, Consellería de Sanidad), Valladolid, Spain
| | - Luc Deliens
- 1 End-of-Life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,7 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Lieve Van den Block
- 1 End-of-Life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
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191
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Roumelioti ME, Steel JL, Yabes J, Vowles KE, Vodovotz Y, Beach S, Rollman B, Weisbord SD, Unruh ML, Jhamb M. Rationale and design of technology assisted stepped collaborative care intervention to improve patient-centered outcomes in hemodialysis patients (TĀCcare trial). Contemp Clin Trials 2018; 73:81-91. [PMID: 30208343 PMCID: PMC6168366 DOI: 10.1016/j.cct.2018.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/17/2018] [Accepted: 09/07/2018] [Indexed: 01/08/2023]
Abstract
Most hemodialysis (HD) patients experience symptoms of depression, pain and fatigue that impair their health-related quality of life (HRQOL) significantly. These symptoms are associated with increased hospitalization and mortality, mediated by behavioral factors (e.g. non-adherence to medication and dialysis) and biological factors (e.g. inflammatory cytokines). Prior interventions to alleviate symptoms and improve HRQOL showed limited effectiveness in HD patients and their effect on bio-behavioral mediators is lacking evidence. It is imperative to improve patient-centered dialysis care and to address call from Kidney Disease Improving Global Outcomes (KDIGO) guidelines for integration of symptom assessment and management in routine HD-care. Technology-Assisted stepped Collaborative Care (TĀCcare) is a multi-center randomized controlled trial (RCT) of 150 diverse HD patients from Pennsylvania and New Mexico, designed to compare the effectiveness of a 12-week stepped collaborative care intervention (cognitive behavioral therapy, CBT) with an attention control arm of technology-delivered health education. Collaborative care provides an integrated multi-disciplinary structured management plan. Furthermore, a stepped approach to pharmacotherapy and/or CBT allows for individualization of treatment according to patients' clinical status, preferences and treatment response. To simplify the delivery of CBT and to minimize patient and provider burden, we will use live video-conferencing with patients in dialysis units. We will examine the effect of these interventions on patient symptoms, HRQOL, treatment adherence and inflammatory biomarkers. This RCT tests a readily implementable intervention that can be integrated in routine HD-care and will generate novel and meaningful insights on strategies to alleviate common symptoms and improve HRQOL in HD.
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Affiliation(s)
- Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine Albuquerque, NM, United States
| | - Jennifer L Steel
- Department of Surgery, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jonathan Yabes
- Center for Research on Heath Care, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kevin E Vowles
- Department of Psychology, University of New Mexico & Division of Physical Medicine and Rehabilitation, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Yoram Vodovotz
- Department of Immunology and Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Scott Beach
- Department of Psychology, University Center for Social and Urban Research, University of Pittsburgh, Pittsburgh, PA, United States
| | - Bruce Rollman
- Department of Medicine, Psychiatry, Biomedical Informatics, and Clinical and Translational Science, University of Pittsburgh, Pittsburgh, PA, United States
| | - Steven D Weisbord
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Mark L Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine Albuquerque, NM, United States
| | - Manisha Jhamb
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
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192
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Couples affected by dementia and their experiences of advance care planning: a grounded theory study. AGEING & SOCIETY 2018. [DOI: 10.1017/s0144686x1800106x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractGlobal policy places emphasis on the implementation and usage of advance care planning (ACP) to inform decision making at the end of life. For people with dementia, where its use is encouraged at the point of diagnosis, utilisation of ACP is relatively poor, particularly in parts of Europe. Using a constructivist grounded theory methodology, this study explores the ways in which co-residing couples considered ACP. Specifically, it seeks to understand the ways in which people with dementia and their long-term co-residing partners consider and plan, or do not plan, for future medical and social care. Sixteen participants were interviewed. They identified the importance of relationships in the process of planning alongside an absence of formal service support and as a result few engaged in ACP. The study recognises the fundamental challenges for couples in being obliged to consider end-of-life issues whilst making efforts to ‘live well’. Importantly, the paper identifies features of the ACP experience of a relational and biographical nature. The paper challenges the relevance of current global policy and practice, concluding that what is evident is a process of ‘emergent planning’ through which couples build upon their knowledge of dementia, their networks and relationships, and a number of ‘tipping points’ leading them to ACP. The relational and collective nature of future planning is also emphasised.
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193
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Siouta N, Clement P, Aertgeerts B, Van Beek K, Menten J. Professionals' perceptions and current practices of integrated palliative care in chronic heart failure and chronic obstructive pulmonary disease: a qualitative study in Belgium. BMC Palliat Care 2018; 17:103. [PMID: 30143036 PMCID: PMC6109336 DOI: 10.1186/s12904-018-0356-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 08/17/2018] [Indexed: 12/13/2022] Open
Abstract
Background Patients with Chronic Heart Failure (CHF) and patients with Chronic Obstructive Pulmonary Disease (COPD) share similar symptom burden with cancer patients, however, they are unlikely to receive palliative care (PC) services. This article examines the perceptions of health care professionals and the current practices of integrated palliative care (IPC) in Belgium. Methods Cardiologists and pulmonologists, working in primary care hospitals in Belgium, participated in this study with semi-structured interviews based on IPC indicators. One researcher collected, transcribed verbatim the interviews and carried out their thematic analysis. To increase the reliability of the coding, a second researcher coded a random 30% of the interviews. Results A total of 22 CHF/COPD specialists participated in the study. The results show that IPC and its potential benefits are viewed positively. A number of IPC components like the holistic approach (physical, psychological, social, spiritual aspects) via multidisciplinary teams, prognosis discussion and illness limitations, patient goals assessment, continuous goal adjustment, reduction of suffering and advanced care planning are partially implemented in several health centers. However, PC specialists are absent from such implementations and PC is still an end-of-life care. Conclusions Misconceptions about PC and its association to death and end-of-life appear to be decisive factors for the exclusion of PC specialists and the late initiation of PC itself. The implementation of IPC components is not associated to PC, and as such, leads to suboptimal results. Improved education and enhanced communication is expected to alleviate existing challenges and thus improve the quality of life for the patients.
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Affiliation(s)
- N Siouta
- Department of Experimental Radiotherapy and Palliative Care, UZ Leuven, Campus Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium.
| | - P Clement
- Department of Experimental Oncology, UZ Leuven, Campus Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium
| | - B Aertgeerts
- Department of Public Health and Primary Care, Academic Center for General Practice, Kapucijnenvoer 33, 3000, Leuven, Belgium
| | - K Van Beek
- Department of Experimental Radiotherapy and Palliative Care, UZ Leuven, Campus Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium
| | - J Menten
- Department of Experimental Radiotherapy and Palliative Care, UZ Leuven, Campus Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium
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194
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Kurita K, Siegler EL, Reid MC, Maciejewski RC, Prigerson HG. It Is Not What You Think: Associations Between Perceived Cognitive and Physical Status and Prognostic Understanding in Patients With Advanced Cancer. J Pain Symptom Manage 2018; 56:259-263. [PMID: 29753102 PMCID: PMC6050084 DOI: 10.1016/j.jpainsymman.2018.04.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 04/27/2018] [Accepted: 04/29/2018] [Indexed: 11/25/2022]
Abstract
CONTEXT Patients with advanced cancer often overestimate their time left to live. Those who have heightened awareness of their cognitive and physical deficits at the end of life may have a better prognostic understanding. OBJECTIVES We sought to investigate the extent to which patients' self-reports of physical well-being and cognitive function were associated with prognostic understanding. METHODS Logistic regression analyzed data from Coping with Cancer II, a National Cancer Institute-funded study of patients with advanced cancer from nine U.S. cancer clinics. Patients with metastatic cancers who had an oncologist-estimated life expectancy of less than six months and did not have significant cognitive impairment were eligible (N = 300). Trained interviewers administered subsets of the McGill Quality of Life and the Functional Assessment of Cancer Therapy-Cognition, Version 2, to measure physical well-being and cognitive complaints. There were four dichotomous outcomes: acknowledgment of their terminal illness; understanding that their diagnosis was late or end stage; belief that life expectancy was months, not years; and prognostic understanding, which was defined as accurate responses to all three questions. Covariates included age and gender. RESULTS Worse patient-reported physical well-being and cognitive function were independently associated with the patient's acknowledgment of his and/or her terminal illness (adjusted odds ratio 0.91; 95% CI = 0.82, 1.00; P = 0.047 and adjusted odds ratio 1.73; 95% CI = 1.17, 2.55; P = 0.006, respectively). CONCLUSION Patients who reported worse cognitive function and physical well-being were more aware of their terminal illness than those with better cognitive function.
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Affiliation(s)
- Keiko Kurita
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, USA; Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Eugenia L Siegler
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - M Cary Reid
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Renee C Maciejewski
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, USA
| | - Holly G Prigerson
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, USA; Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA.
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195
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Fearon D, Hughes S, Brearley SG. A philosophical critique of the UK's National Institute for Health and Care Excellence guideline 'Palliative care for adults: strong opioids for pain relief'. Br J Pain 2018; 12:183-188. [PMID: 30057763 DOI: 10.1177/2049463717753021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The National Institute for Health and Care Excellence (NICE) promotes evidence-based medicine throughout contemporary health care. Its guidelines are employed in the United Kingdom and elsewhere, influencing the type and quality of health care provided. NICE considers a range of evidence in the process of creating guidelines; however, the research accepted as evidence greatly relies on positivist methodologies. At times, it is unnecessarily restricted to quantitative methods of data collection. Using the Clinical Guideline 140, opioids in palliative care, as an example, it is demonstrated that the research accepted as evidence is unable to provide answers to complex problems. In addition, several inherent biases are discussed, such as age inequality and pharmaceutical company influence. In order to provide coherent and useful guidelines relevant to complex problems in a real world setting, NICE must move away from focusing on data from randomised controlled trials. Its epistemological foundation must be questioned, paving the way for alternative research paradigms to be considered as evidence and thereby enriching subsequent guidelines.
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Affiliation(s)
- David Fearon
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK.,Cairdeas International Palliative Care Trust, Mauritania, West Africa
| | - Sean Hughes
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Sarah G Brearley
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
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Basedow-Rajwich B, Montag T, Duckert A, Schulz C, Rajwich G, Kleiter I, Koehler J, Lindena G. Mobile Palliative Care Consultation Service (PCCS): Overview of Hospice and Palliative Care Evaluation (HOPE) Data on In-Patients With End-Stage Cancer, Multiple Sclerosis, and Noncancer, Nonneurological Disease From 4 PCCS Centers in Germany in 2013. Palliat Care 2018; 11:1178224218785139. [PMID: 30038500 PMCID: PMC6053857 DOI: 10.1177/1178224218785139] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 05/04/2018] [Indexed: 11/17/2022] Open
Abstract
Context: During the last decade, numerous in-patient Palliative Care Consultation Service (PCCS) units were established throughout Germany. Objective: To provide an epidemiological overview on a whole year cohort of palliative patients in terms of demography, complaints, and therapy on admission to PCCS and the impact of PCCS treatment, and identify differences and similarities in different palliative patient subgroups. Methods: Chi-square, analysis of variance (ANOVA), Kruskal-Wallis followed by Games-Howell analysis of HOspice and Palliative care Evaluation (HOPE 2013) data on 4 PCCS centers and in total 919 patients, with solid tumors (237), metastatic cancer (397), leukemia and lymphoma (99), neurological (109, mostly multiple sclerosis [MS]), and noncancer, nonneurological disease (NCNND, 77). Results: A mostly uniform block of 3 cancer subgroups in terms of demographics, admission complaints, and initial pharmacological treatment diverged from the neurologic/MS disease subgroup. The “intermediate,” NCNND subgroup coalesced with the cancer or the neurologic/MS subgroups in part of the demographics, complaint, and drug parameters. Tetraparesis, requirement for nursing, and help with daily living were more, and pain, dyspnea, weakness, appetite loss, and fatigue were less frequent in neurologic patients compared with the cancer subgroups. Neurologic patients also showed more common use of coanalgetics and antidepressives, less opiates and nonopiate analgetics, corticosteroids, and antiemetics and antacids. NCNND patients had a particularly high rate of disorientation (48%) and death during PCCS (39%). In the 3 cancer subgroups, dyspnea, weakness, appetite loss, and anxiolytic use were less frequent in solid tumor patients. Palliative Care Consultation Service treatment was associated with reduction in symptom severity independent of subgroup entity. All listed differences were significant at P < .05 level. Conclusion: Despite divergence in demographics, symptoms, and medication, the data underline general usefulness of PCCS care in all end-stage patients and not only the cancer subgroups. Nevertheless, the strong differences revealed in the current study also underscore the need for a carefully tuned, disease-specific therapeutic approach to these subgroups of palliative patients.
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Affiliation(s)
| | - Thomas Montag
- Palliative Care Consultation Service, Department of Palliative Medicine, University Hospital Cologne, Cologne, Germany
| | - Andreas Duckert
- Palliative Care Consultation Service, Klinikum Frankfurt (Oder), Frankfurt, Germany
| | - Christian Schulz
- Interdisciplinary Centre of Palliative Medicine, University Hospital Düsseldorf, Düsseldorf, Germany
| | | | - Ingo Kleiter
- Palliative Care Service, Marianne-Strauss Clinic, Berg, Germany
| | - Jürgen Koehler
- Palliative Care Service, Marianne-Strauss Clinic, Berg, Germany
| | - Gabriele Lindena
- CLARA (CLinical Analysis, Research and Application) Klinische Forschung, Kleinmachnow, Germany
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197
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Harding R. Palliative care as an essential component of the HIV care continuum. Lancet HIV 2018; 5:e524-e530. [PMID: 30025682 DOI: 10.1016/s2352-3018(18)30110-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/11/2018] [Accepted: 05/17/2018] [Indexed: 11/26/2022]
Abstract
Although antiretroviral therapy has reduced mortality among people with HIV, inadequate treatment coverage, ageing, and the increasing incidence of organ failure and malignancies mean that high-quality care should include care at the end of life. This Review summarises the epidemiology of HIV in relation to mortality, and the symptoms and concerns of people with AIDS and those living with HIV who have either related or unrelated advanced comorbidities. In response to the evidence of a need for palliative care, the principles and practice of palliative care are described, and the evidence for its effectiveness and cost-effectiveness is appraised. The core practices of palliative care offer a mechanism to enhance the person-centred nature of HIV care; I identify the gaps in this type of care, and present evidence for effective models of care to address these. I detail the policies that prompt governments and health systems to respond to the palliative care needs of their population. Finally, I conclude this Review with evidence-based recommendations to improve the delivery of, and access to, high-quality HIV care until the end of life, reducing unnecessary suffering while optimising person-centred outcomes.
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Affiliation(s)
- Richard Harding
- Department of Palliative Care, Policy, and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery, and Palliative Care, Cicely Saunders Institute, King's College London, London, UK.
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198
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Odierna DH, Katen MT, Feuz MA, McMahan RD, Ritchie CS, McSpadden S, Burns M, Volow AM, Sudore RL. Symptom Assessment Solutions for In-Home Supportive Services and Diverse Older Adults: A Roadmap for Change. J Palliat Med 2018; 21:1486-1493. [PMID: 29851360 DOI: 10.1089/jpm.2017.0704] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Millions of older adults require Medicaid-funded home care, referred to as In-Home Supportive Services (IHSS). Many of these individuals experience serious illness, disability, and common symptoms such as pain and shortness of breath. OBJECTIVE To explore whether and how to integrate symptom assessment into an IHSS program to identify and manage symptoms in diverse older adults who receive in-home care. DESIGN Qualitative study comprising 10 semistructured focus groups. SETTING AND SUBJECTS Fifty San Francisco IHSS administrators, case managers, providers, and consumers. MEASUREMENTS Two authors double-coded transcripts and conducted thematic analysis. RESULTS Four main themes emerged from the data: (1) Large unmet needs: gaps in understanding, training, standard assessment, and untreated symptoms, including identifying loneliness as a symptom; (2) Potential barriers: misunderstanding of palliative care, consumer reluctance, and the added burden on IHSS workforce; (3) Facilitators: consumer and provider buy-in and perceived benefits of such a symptom assessment program, and the ability to build on current IHSS relationships and infrastructure; and (4) Implementation logistics: taking an individualized, optional approach; consider appropriate messaging about quality of life and not end of life; and creating standardized, easy-to-use procedures, tools, training, and workflow to support providers. CONCLUSIONS An IHSS symptom assessment program is desired, needed, and feasible and can leverage the established IHSS infrastructure and relationships of consumers and IHSS providers to assess symptoms in the home. Acknowledging consumer choice, developing appropriate tools and trainings for IHSS staff, and effective messaging of program goals can contribute to success.
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Affiliation(s)
- Donna H Odierna
- 1 Division of Geriatrics, School of Medicine, University of California , San Francisco, San Francisco, California
| | - Mary T Katen
- 1 Division of Geriatrics, School of Medicine, University of California , San Francisco, San Francisco, California.,2 Geriatrics, Palliative, and Extended Care, San Francisco Veterans Affairs Medical Center , San Francisco, California
| | - Mariko A Feuz
- 1 Division of Geriatrics, School of Medicine, University of California , San Francisco, San Francisco, California.,2 Geriatrics, Palliative, and Extended Care, San Francisco Veterans Affairs Medical Center , San Francisco, California
| | - Ryan D McMahan
- 1 Division of Geriatrics, School of Medicine, University of California , San Francisco, San Francisco, California
| | - Christine S Ritchie
- 1 Division of Geriatrics, School of Medicine, University of California , San Francisco, San Francisco, California.,3 Tideswell at UCSF and the Innovation and Implementation Center on Aging and Palliative Care at the University of California , San Francisco, San Francisco, California
| | - Shireen McSpadden
- 4 San Francisco Department of Aging and Adult Services, City and County of San Francisco, San Francisco, California
| | - Mark Burns
- 5 Homebridge Home Care Agency , San Francisco, California
| | - Aiesha M Volow
- 1 Division of Geriatrics, School of Medicine, University of California , San Francisco, San Francisco, California.,2 Geriatrics, Palliative, and Extended Care, San Francisco Veterans Affairs Medical Center , San Francisco, California
| | - Rebecca L Sudore
- 1 Division of Geriatrics, School of Medicine, University of California , San Francisco, San Francisco, California.,2 Geriatrics, Palliative, and Extended Care, San Francisco Veterans Affairs Medical Center , San Francisco, California.,3 Tideswell at UCSF and the Innovation and Implementation Center on Aging and Palliative Care at the University of California , San Francisco, San Francisco, California
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199
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Andersson S, Årestedt K, Lindqvist O, Fürst CJ, Brännström M. Factors Associated With Symptom Relief in End-of-Life Care in Residential Care Homes: A National Register-Based Study. J Pain Symptom Manage 2018; 55:1304-1312. [PMID: 29305321 DOI: 10.1016/j.jpainsymman.2017.12.489] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 12/22/2017] [Accepted: 12/22/2017] [Indexed: 12/13/2022]
Abstract
CONTEXT Residential care homes (RCHs) are a common place of death. Previous studies have reported a high prevalence of symptoms such as pain and shortness of breath among residents in the last week of life. OBJECTIVES The aim of the study was to explore the presence of symptoms and symptom relief and identify factors associated with symptom relief of pain, nausea, anxiety, and shortness of breath among RCH residents in end-of-life care. METHODS The data consisted of all expected deaths at RCHs registered in the Swedish Register of Palliative Care (N = 22,855). Univariate and multiple logistic regression analyses were conducted. RESULTS Pain was reported as the most frequent symptom of the four symptoms (68.8%) and the one that most often had been totally relieved (84.7%) by care professionals. Factors associated with relief from at least one symptom were gender; age; time in the RCH; use of a validated pain or symptom assessment scale; documented end-of-life discussions with physicians for both the residents and family members; consultations with other units; diseases other than cancer as cause of death; presence of ulcers; assessment of oral health; and prescribed pro re nata injections for pain, nausea, and anxiety. CONCLUSION Our results indicate that use of a validated pain assessment scale, assessment of oral health, and prescribed pro re nata injections for pain, nausea, and anxiety might offer a way to improve symptom relief. These clinical tools and medications should be implemented in the care of the dying in RCHs, and controlled trials should be undertaken to prove the effect.
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Affiliation(s)
| | - Kristofer Årestedt
- Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden; Kalmar County Hospital, Kalmar, Sweden
| | - Olav Lindqvist
- Department of Nursing, Umeå University, Umeå, Sweden; Department of Learning, Informatics, Management and Ethics/MMC, Karolinska Institutet, Stockholm, Sweden
| | - Carl-Johan Fürst
- Department of Clinical Science, Faculty of Medicine, The Institute for Palliative Care, Lund University and Region Skåne, Lund, Sweden
| | - Margareta Brännström
- Department of Nursing, Umeå University, Campus Skellefteå, Umeå, Sweden; The Arctic Research Centre, Umeå University, Umeå, Sweden; Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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200
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Heins M, Hofstede J, Rijken M, Korevaar J, Donker G, Francke A. Palliative care for patients with cancer: do patients receive the care they consider important? A survey study. BMC Palliat Care 2018; 17:61. [PMID: 29665807 PMCID: PMC5905150 DOI: 10.1186/s12904-018-0315-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 04/03/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In many countries, GPs and home care nurses are involved in care for patients with advanced cancer. Given the varied and complex needs of these patients, providing satisfactory care is a major challenge for them. We therefore aimed to study which aspects of care patients, GPs and home care nurses consider important and whether patients receive these aspects. METHODS Seventy-two Dutch patients with advanced cancer, 87 GPs and 26 home care nurses rated the importance of support when experiencing symptoms, respect for patients' autonomy and information provision. Patients also rated whether they received these aspects. Questionnaires were based on the CQ index palliative care. RESULTS Almost all patients rated information provision and respect for their autonomy as important. The majority also rated support when suffering from specific symptoms as important, especially support when in pain. In general, patients received the care they considered important. However, 49% of those who considered it important to receive support when suffering from fatigue and 23% of those who wanted to receive information on the expected course of their illness did not receive this or only did so sometimes. CONCLUSION For most patients with advanced cancer, the palliative care that they receive matches what they consider important. Support for patients experiencing fatigue may need more attention. When symptoms are difficult to control, GPs and nurses may still provide emotional support and practical advice. Furthermore, we recommend that GPs discuss patients' need for information about the expected course of their illness.
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Affiliation(s)
- Marianne Heins
- Netherlands Institute for Health Services Research (NIVEL), P.O Box 1568, 3500 BN, Utrecht, The Netherlands.
| | - Jolien Hofstede
- Netherlands Institute for Health Services Research (NIVEL), P.O Box 1568, 3500 BN, Utrecht, The Netherlands
| | - Mieke Rijken
- Netherlands Institute for Health Services Research (NIVEL), P.O Box 1568, 3500 BN, Utrecht, The Netherlands
| | - Joke Korevaar
- Netherlands Institute for Health Services Research (NIVEL), P.O Box 1568, 3500 BN, Utrecht, The Netherlands
| | - Gé Donker
- Netherlands Institute for Health Services Research (NIVEL), P.O Box 1568, 3500 BN, Utrecht, The Netherlands
| | - Anneke Francke
- Netherlands Institute for Health Services Research (NIVEL), P.O Box 1568, 3500 BN, Utrecht, The Netherlands.,Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, the Netherlands.,Expertise center palliative care, VU University Medical Center, Amsterdam, the Netherlands
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