Palliative care in chronic obstructive pulmonary disease

Non-invasive ventilation in the care of patients with chronic obstructive pulmonary disease with palliative care needs: a scoping review

BACKGROUND

Patients with severe chronic obstructive pulmonary disease (COPD) could have palliative care (PC) needs because of unmet needs such as dyspnoea. This may lead to anxiety and may have an impact on patients' ability to perform daily activities of living. PC can be started when patients with COPD have unmet needs and can be provided alongside disease-modifying therapies. Non-invasive ventilation (NIV) could be an important measure to manage dyspnoea in patients with COPD in need of PC. A scoping review was conducted to gain an overview of the existing research and to identify knowledge gaps. The aim of this scoping review was to systematically map published studies on the use of NIV in patients with COPD with PC needs, including the perspectives and experiences of patients, families, and healthcare professionals (HCPs).

METHODS

This review was conducted following the framework of Arksey and O'Malley. The reporting of the review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. The review protocol was published. AMED, CINAHL, Embase, MEDLINE, PEDro, and PsycInfo were searched from inception to November 14, 2022. The included studies had to report the perspectives and experiences of COPD patients, relatives, and HCPs regarding NIV in the care of patients with COPD with PC needs. In pairs, the authors independently assessed studies' eligibility and extracted data. The data were organised thematically. The results were discussed in a consultation exercise.

RESULTS

This review included 33 papers from 32 studies. Four thematic groupings were identified: preferences and attitudes towards the use of NIV; patient participation in the decision-making process of NIV treatment; conflicting results on the perceived benefits and burdens of treatment; and heterogenous clinical outcomes in experimental studies. Patients perceived NIV as a 'life buoy' to keep them alive. Many patients wanted to take part in the decision-making process regarding NIV treatment but expressed varying degrees of inclusion by HCPs in such decision-making. Conflicting findings were identified regarding the perceived benefits and burdens of NIV treatment. Diversity in heterogeneous clinical outcomes were reported in experimental studies.

CONCLUSIONS

There is a need for more studies designed to investigate the effectiveness of NIV as a palliative measure for patients with COPD with PC needs using comprehensive outcomes. It is especially important to gain more knowledge on the experiences of all stakeholders in the use of home-based NIV treatment to these patients.

Non-invasive ventilation in the palliative care of patients with chronic obstructive pulmonary disease: a scoping review protocol

INTRODUCTION

Patients with advanced chronic obstructive pulmonary disease (COPD) experience a great symptom burden. Breathlessness is a very frequently reported symptom that negatively affects all aspects of daily life and could lead to fear of dying. Non-invasive ventilation (NIV) could be an important palliative measure to manage breathlessness in patients with advanced COPD. We decided to conduct a scoping review to attain an overview of the existing research and to identify knowledge gaps. This scoping review aims to systematically map published studies on the use of NIV in the palliative care of COPD patients, including the perspectives and experiences of patients, families and healthcare professionals.

METHODS AND ANALYSIS

This scoping review will employ the framework of Arksey and O'Malley. The reporting will be guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. A comprehensive and systematic search strategy will be developed in cooperation with an experienced librarian. Database searches will be conducted in AMED, PEDro, Embase, CINAHL, PsycInfo and MEDLINE in February 2021. Pairs of authors will independently assess studies' eligibility and extract data using a standardised data-charting form. The data will be inductively summarised and organised thematically. The results will be discussed with an advisory board consisting of nurses and physicians from respiratory and intensive care units.

ETHICS AND DISSEMINATION

Approval for the workshop with the advisory board has been attained from the Norwegian Centre for Research Data (480222), and approval will be attained from the Personal Data Protection Officers of the participating hospitals. All advisory board participants will sign an informed written consent before participation. The results could contribute to developing the body of evidence on the use of NIV in the palliative care of COPD patients and serve to identify directions for future research.

lncRNA TUG1 regulates human pulmonary microvascular endothelial cell apoptosis via sponging of the miR-9a-5p/BCL2L11 axis in chronic obstructive pulmonary disease

The aim of the present study was to investigate the function of long non-coding RNA taurine-upregulated gene 1 (lncRNA TUG1) in chronic obstructive pulmonary disease and further assess the underlying molecular mechanisms. Flow cytometry analysis was performed to detect cell apoptosis of human pulmonary microvascular endothelial cells (HPMECs) treated with 1% cigarette smoke extract (CSE). The activity of caspase-3 was measured using a Caspase-3 Activity assay kit and the protein expression of cleaved caspase-3, caspase-3 and Bcl-2 like 11 (BCL2L11) were measured using western blotting. Reverse transcription-quantitative PCR (RT-qPCR) was performed to measure the expression of TUG1 mRNA levels in the treated cells. The association between TUG1, the miR-9a-5p/BCL2L11 axis and with miR-9a-5p were predicted and verified using a dual luciferase reporter assay system. The mRNA expression of miR-9a-5p and BCL2L11, and the transfection efficiency were measured by RT-qPCR. The results showed that CSE induced cell apoptosis and increased lncRNA TUG1 expression in HPMECs. CSE significantly reduced the expression of miR-9a-5p in HPMECs compared with the control group. TUG1-short hairpin RNA relieved cell apoptosis induced by CSE by upregulating miR-9a-5p in HPMECs. The present study predicted and verified that BCL2L11 is a direct target of miR-9a-5p. The mRNA expression of BCL2L11 was increased in HPMECs following CSE treatment compared with the control group. miR-9a-5p mimic and BCL2L11-plasmid markedly increased the expression of miR-9a-5p and BCL2L11, respectively. miR-9a-5p mimic reversed the increase in cell apoptosis induced by CSE by inhibiting BCL2L11 expression in HPMECs. To conclude, the present study demonstrated that lncRNA TUG1 exerted roles in cell apoptosis induced by CSE through modulating the miR-9a-5p/BCL2L11 axis.

Ten minutes to midnight: a narrative inquiry of people living with dying with advanced copd and their family members

Purpose: To explore how people with end stage chronic obstructive pulmonary disease and their family members describe living in the face of impending death.

Methods: A narrative inquiry was undertaken using a social constructionist perspective. Data were collected in 2017–18 in two in-depth interviews, lasting 90 to 120 minutes approximately 3–4 months apart, with a telephone follow-up 2–3 months later. Thematic analysis was conducted including analysis within and across participants.

Results: Sixteen people with advanced chronic obstructive pulmonary disease and seven family members participated. For both people with the disease and family members, six key themes/storylines emerged including missing life, being vigilant, hope and realism, avoiding death talk, the scary dying process, and need to prepare.

Conclusion: This study highlighted six key storylines about death and dying with advanced chronic obstructive pulmonary disease for people with the illness and their family members. The participants with the illness and their family members held similar perceptions about end of life. More supports are needed for people with advanced chronic obstructive pulmonary disease and their family members in living with their illness while ensuring that they experience a “good death.”

A systematic review and meta-analysis of studies comparing burden from lung cancer and chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease and lung cancer are both life-limiting diseases that confer burden in the form of symptoms and affect functioning and quality of life. Comparing burden between these diseases is of interest to determine whether people with chronic obstructive pulmonary disease require improved access to Specialist Palliative Care. Access should be based on needs rather than diagnosis or prognosis but is limited for people with chronic obstructive pulmonary disease compared to lung cancer.

AIM

The aim of this study was to synthesise research comparing burden from chronic obstructive pulmonary disease and lung cancer to estimate relative need for Specialist Palliative Care.

DESIGN

A systematic review was conducted of observational quantitative studies published in English peer-reviewed journals comparing burden from chronic obstructive pulmonary disease and lung cancer (PROSPERO CRD42018108819). No limits were placed on disease stage. Meta-analyses were performed where studies used the same measure; otherwise, synthesis used a narrative approach. Risk of bias was assessed using the Agency for Healthcare Research and Quality tool.

DATA SOURCES

Electronic databases were searched in September 2019.

RESULTS

Of 790 articles returned, 13 were included, reporting 11 studies. Risk of bias was generally moderate. Except for pain, burden tended to be at least as substantial from chronic obstructive pulmonary disease as from lung cancer, with breathlessness and impacts on functioning being significantly worse. Longitudinal studies suggest that people with chronic obstructive pulmonary disease live with burden for longer.

CONCLUSION

Efforts should be made to ensure that access to Specialist Palliative Care is commensurate with chronic obstructive pulmonary disease's substantial and long-lasting burden. Future research should clarify whether managing burden in chronic obstructive pulmonary disease and lung cancer requires different approaches.

Hardware Prototype for Wrist-Worn Simultaneous Monitoring of Environmental, Behavioral, and Physiological Parameters

We designed a low-cost wrist-worn prototype for simultaneously measuring environmental, behavioral, and physiological domains of influencing factors in healthcare. Our prototype continuously monitors ambient elements (sound level, toxic gases, ultraviolet radiation, air pressure, temperature, and humidity), personal activity (motion tracking and body positioning using gyroscope, magnetometer, and accelerometer), and vital signs (skin temperature and heart rate). An innovative three-dimensional hardware, based on the multi-physical-layer approach is introduced. Using board-to-board connectors, several physical hardware layers are stacked on top of each other. All of these layers consist of integrated and/or add-on sensors to measure certain domain (environmental, behavioral, or physiological). The prototype includes centralized data processing, transmission, and visualization. Bi-directional communication is based on Bluetooth Low Energy (BLE) and can connect to smartphones as well as smart cars and smart homes for data analytic and adverse-event alerts. This study aims to develop a prototype for simultaneous monitoring of the all three areas for monitoring of workplaces and chronic obstructive pulmonary disease (COPD) patients with a concentration on technical development and validation rather than clinical investigation. We have implemented 6 prototypes which have been tested by 5 volunteers. We have asked the subjects to test the prototype in a daily routine in both indoor (workplaces and laboratories) and outdoor. We have not imposed any specific conditions for the tests. All presented data in this work are from the same prototype. Eleven sensors measure fifteen parameters from three domains. The prototype delivers the resolutions of 0.1 part per million (PPM) for air quality parameters, 1 dB, 1 index, and 1 °C for sound pressure level, UV, and skin temperature, respectively. The battery operates for 12.5 h under the maximum sampling rates of sensors without recharging. The final expense does not exceed 133€. We validated all layers and tested the entire device with a 75 min recording. The results show the appropriate functionalities of the prototype for further development and investigations.

Palliative Care Initiation in Chronic Obstructive Pulmonary Disease: Prognosis-Based, Symptoms-Based or Needs-Based?

The absence or late initiation of palliative care (PC) in chronic obstructive pulmonary disease (COPD) is multidimensional. To provide palliative care from the moment of COPD diagnosis remains utopic. Even the advanced forms or the end-of-life stages benefit late or never from these services. In this context, the research questions for the present systematic review were focused on the prognosis variables or multicomponent indices in COPD patients alongside the symptoms and unmet needs, which may be useful for the palliative care initiation. The aim was to help clinicians to identify not only the tools reliable to predict poor survival in COPD patients but also to identify the criteria for appropriateness for early palliative care onset. The search included systematic reviews and reviews published in English in the PUBMED database from Jan 1, 2015 to Jan 6, 2020. From a total of 202 findings, after applying filters, using additional sources, and eliminating duplicates, the search strategy screened 16 articles, out of which 10 were selected and included. A Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) flow diagram was constructed. The main domains identified as barriers in providing palliative care in COPD patients were complex: from the prognosis difficulties to the prognostic variables and scores proposed for initiating PC; from the troublesome symptoms or the unidimensional symptom tools to the unmet needs of COPD patients. The review concluded that none of the existing prognostic variables and multicomponent indices are reliable enough to exclusively predict poor survival in COPD patients and the decision to initiate PC should be rather based on the presence of refractory symptoms and patients’ unmet needs and preferences. Despite the current advances, the ideal model to initiate palliative care from the moment COPD is diagnosed is a goal for clinicians trained in, and capable of providing palliative care in any COPD patient.

The Provision of Palliative Care for Noncancer Patients With Advanced Disease: Equity Does Matter

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.

Palliative Care Provision for Patients with Advanced Chronic Obstructive Pulmonary Disease: A Systematic Integrative Literature Review

Although chronic obstructive pulmonary disease (COPD) is recognized as being a life-limiting condition with palliative care needs, palliative care provision is seldom implemented. The disease unpredictability, the misconceptions about palliative care being only for people with cancer, and only relevant in the last days of life, prevent a timely integrated care plan. This systematic review aimed to explore how palliative care is provided in advanced COPD and to identify elements defining integrated palliative care. Eight databases, including MEDLINE, EMBASE and CINAHL, were searched using a comprehensive search strategy to identify studies on palliative care provision in advanced COPD, published from January 1, 1960 to November 30, 2017. Citation tracking and evaluation of trial registers were also performed. Study quality was assessed with a critical appraisal tool for both qualitative and quantitative data. Of the 458 titles, 24 were eligible for inclusion. Experiences about advanced COPD, palliative care timing, service delivery and palliative care integration emerged as main themes, defining a developing taxonomy for palliative care provision in advanced COPD. This taxonomy involves different levels of care provision and integrated care is the last step of this dynamic process. Furthermore, palliative care involvement, holistic needs' assessment and management and advance care planning have been identified as elements of integrated care. This literature review identified elements that could be used to develop a taxonomy of palliative care delivery in advanced COPD. Further research is needed to improve our understanding on palliative care provision in advanced COPD.

Addressing Challenges of Patients With Chronic Pulmonary Disease Using Makerspace Environments

Patients with chronic progressive pulmonary disease suffer from physiological and psychological consequences. These patients experience functional disability, depression and anxiety, and decreased quality of life. Their ability to perform activities of daily living can be severely impaired. Direct patient care nurses are well suited to assist these patients and their caregivers, identifying challenges through interactions and active listening and assisting in the identification of solutions. Even simple solutions to everyday issues can reduce the disease burden for this population. This article describes how direct patient care nurses can address the challenges of these patients through an innovative environment known as a makerspace.

Is the high intensity symptoms experienced by patients admitted with chronic obstructive pulmonary disease documented by health professionals? - a prospective survey with comparison of patient reported outcomes and medical records

Context: Patients with chronic obstructive pulmonary disease (COPD) have a high symptom burden and reduced quality of life. There is an increasing attention on palliation for patients with COPD. Recognition of symptoms is a prerequisite for palliation. Objectives: We aim to investigate the extent to which symptoms in patients with COPD are recognized in the documentation of the health professionals, indicated in 'Doctors Symptom Recognition Rate' (DSR), 'Nurses Symptom Recognition Rate' (NSR) or 'Doctors and/or Nurses Symptom Recognition rates '(DNSR) as a team, respectively. Methods: Patients with COPD (n = 40) admitted in two respiratory units, responded within 48 h on two symptom-screening-tools that access quality of life; COPD assessment test (CAT) used for the treatment of COPD and EORTC-QLQ-C15-PAL used for palliation in patients with cancer. Patient-described symptomatology was compared to the symptoms as recognized in the documentation of doctors and/or nurses. Results: There was a significant discrepancy between the symptomatology indicated by patients with COPD on CAT and EORTC-QLQ-C15-PAL, and the degree by which it was recognized in the medical records indicated in DSR or NSR. In 30 out of 44 items DSR or NSR were < 70%. There was a significant difference between DNSR versus DSR or NSR, respectively, in 19 out of 22 items.Conclusion: A team-based symptom recognition DNSR is superior when compared to DSR or NSR. Team-based systematic screening is suggested as a pathway to increase symptom recognition in patients with COPD. Increased rates of symptom recognition may improve symptom alleviation and thus palliation.

[Characteristics of non-pharmacological interventions in the elderly with COPD. Smoking cessation, pulmonary rehabilitation, nutritional management and patient education]

Chronic obstructive pulmonary disease (COPD) is a respiratory disorder responsible for a high mortality and disability. People older than 65 years are more commonly affected than younger people and tend to present with more symptoms and a greater level of disability. Non-pharmacological interventions play an important role in the management of all patients with COPD and this is particularly true in the elderly. Given the improvement in quality of life and risk of hospitalization, smoking cessation should be promoted to patients of all ages. Increased physical activity is associated with reduced respiratory symptoms. Tests such as the "Short Physical Performance Battery" can be useful in frailer older people with COPD, while walking tests such as the 6-minute walk test are used as an assessment before pulmonary rehabilitation. Increased physical activity should be combined with nutritional management. Screening for undernutrition by questionnaire, body mass index and albumin quantification is recommended in the elderly. In case of undernutrition, oral supplementation seems to reduce the risk of re-admission. All these measures must be included in an education program adapted to the elderly comorbidities (hearing loss, isolation…).

Low uptake of palliative care for COPD patients within primary care in the UK

Mortality and symptom burden from chronic obstructive pulmonary disease (COPD) and lung cancer are similar but there is thought to be an inequality in palliative care support (PCS) between diseases. This nationally representative study assessed PCS for COPD patients within primary care in the UK.This was a cohort study using electronic healthcare records (2004-2015). Factors associated with receiving PCS were assessed using logistic regression for the whole cohort and deceased patients.There were 92 365 eligible COPD patients, of which 26 135 died. Only 7.8% of the whole cohort and 21.4% of deceased patients received PCS. Lung cancer had a strong association with PCS compared with other patient characteristics, including Global Initiative for Chronic Obstructive Lung Disease stage and Medical Research Council Dyspnoea score (whole cohort, lung cancer: OR 14.1, 95% CI 13.1-15; deceased patients, lung cancer: OR 6.5, 95% CI 6-7). Only 16.7% of deceased COPD patients without lung cancer received PCS compared with 56.5% of deceased patients with lung cancer. In patients that received PCS, lung cancer co-diagnosis significantly increased the chances of receiving PCS before the last month of life (1-6 versus ≤1 month pre-death: risk ratio 1.4, 95% CI 1.3-1.7).Provision of PCS for COPD patients in the UK is inadequate. Lung cancer, not COPD, was the dominant driver for COPD patients to receive PCS.

Palliative care in pulmonary arterial hypertension

PURPOSE OF REVIEW

Developments in the management of pulmonary arterial hypertension have significantly improved prognosis changing this from an acute to a chronic disease. Despite optimal treatment many patients still have a high-symptom burden both because of the disease and the side-effects of therapy, consequently there is an increasing need for a palliative care approach to improve the quality of life for this patient group. This review article will outline the need for palliative care support for patients with pulmonary arterial hypertension, discuss the barriers that currently exist and suggest how this may be improved.

RECENT FINDINGS

Studies have been conducted which explore the role of palliative care in pulmonary arterial hypertension including physicians attitudes and the current barriers that exist to prevent its implementation.

SUMMARY

Specialist palliative support is utilized in the minority of patients with pulmonary arterial hypertension despite a need for symptom control. Patients may benefit from the introduction of a palliative care approach as part of their standard care, but to achieve this there needs to be a greater understanding of the role of palliative care by both clinicians and patients and more research into the benefits for patients with pulmonary arterial hypertension.

Palliative Care and Interventional Pulmonology

Since pulmonary pathologies, such as lung cancer and chronic obstructive pulmonary disease (COPD), are some of the leading causes of morbidity and mortality around the world, pulmonologists are likely to encounter patients with unmet palliative care needs. This article focuses on the symptoms and complications encountered by patients with terminal pulmonary conditions, briefly describes the non-interventional palliative strategies, and then discusses more advanced therapies available in the realm of interventional pulmonology. Most of the literature discussed here is derived from patients with lung cancer and COPD.

Palliative and end of life care in solid organ transplantation

Palliative care is an interprofessional approach that focuses on quality of life of patients who are facing life-threatening illness. Palliative care is consistently associated with improvements in advance care planning, patient and caregiver satisfaction, quality of life, symptom burden, and lower healthcare utilization. Most transplant patients have advanced chronic disease, significant symptom burden, and mortality awaiting transplant. Transplantation introduces new risks including perioperative death, organ rejection, infection, renal insufficiency, and malignancy. Numerous publications over the last decade identify that palliative care is well-suited to support these patients and their caregivers, yet access to palliative care and research within this population are lacking. This review describes palliative care and summarizes existing research supporting palliative intervention in advanced organ failure and transplant populations. A proposed model to provide palliative care in parallel with disease-directed therapy in a transplant program has the potential to improve symptom burden, quality of life, and healthcare utilization. Further studies are needed to elucidate specific benefits of palliative care for this population. In addition, there is a tremendous need for education, specifically for clinicians, patients, and families, to improve understanding of palliative care and its benefits for patients with advanced disease.

The potential of palliative care for patients with respiratory diseases

Based on the demonstrated effectiveness of palliative care in the alleviation of symptoms and enhancement of life quality, it is important to incorporate palliative care early in the respiratory disease trajectory. Quality palliative care addresses eight domains that are all patient and family centred. Palliative care interventions in respiratory conditions include management of symptoms such as dyspnoea, cough, haemoptysis, sputum production, fatigue and respiratory secretion management, especially as the end-of-life nears. A practical checklist of activities based on the domains of palliative care can assist clinicians to integrate palliative care into their practice. Clinical management of patients receiving palliative care requires consideration of human factors and related organisational characteristics that involve cultural, educational and motivational aspects of the patient/family and clinicians.

Early palliative care can relieve suffering and provide support for people with respiratory diseaseshttp://ow.ly/z0Hd30jpsb4

Perspectives on advance care planning among patients recently requiring non-invasive ventilation for acute respiratory failure: A qualitative study using thematic analysis

BACKGROUND

Patients requiring non-invasive ventilation for acute-on-chronic respiratory failure due to chronic obstructive pulmonary disease or heart failure exacerbations may have a poor prognosis underscoring the importance of advance care planning.

AIM

We aimed to describe attitudes to, and experiences of, discussing the future among patients recently treated with non-invasive ventilation.

DESIGN

Qualitative research using thematic analysis.

SETTINGS AND PARTICIPANTS

Tertiary teaching hospital. Patients with acute hypercapnic respiratory failure requiring non-invasive ventilation.

RESULTS

Individuals recently treated with non-invasive ventilation describe feeling the future is beyond their control and instead controlled by their illness. Participants often recognised their poor prognosis but avoided discussing some difficult topics. The majority preferred not to undergo cardiopulmonary resuscitation but most had not discussed this with healthcare professionals. When participants voiced concerns about their future health to family members, they were met with polarised responses. Some encountered willingness for further discussion, while others met deflection, deterring further conversation. An overarching narrative of 'Looking through my illness to an uncertain but concerning future' unites these themes.

CONCLUSION

This study suggests opportunities and barriers for advance care planning in individuals with chronic disease. Patients' understanding of their prognosis and their attitudes to cardiopulmonary resuscitation suggests an opportunity for advance care planning. Structuring discussions around patients' preferences for care during future exacerbations may foster a sense of control over the future despite illness. The diversity of familial responses to patients' concerns about their future health has implications for advance care planning. These findings have the potential to improve care for patients with respiratory failure and suggest an important ongoing research agenda.

The Case for Dual Training in Geriatric Medicine and Palliative Care: The Time is Now

The majority of older adults die from chronic illnesses which are preceded by years of progressive decline and increasing symptom burden. Delivery of high-quality care cannot take place without sufficient numbers of health professionals with appropriate training and skills in both geriatric and palliative care medicine. Despite the surge in aging population and the majority of deaths being attributed to patients with multiple comorbidities, very few health-care providers undergo dual training in these areas. Thus, the nation is facing a health-care crisis as the number of geriatric patients with chronic disease increasingly outpaces the number of physicians with adequate skills to manage them. Joint training in palliative care and geriatric medicine could prepare physicians to better manage our aging population by addressing all their health-care needs irrespective of their stage of disease emphasizing patient-directed care.