Experience of advanced chronic obstructive pulmonary disease: metasynthesis of qualitative research

Death attitudes in Chronic Obstructive Pulmonary Disease (COPD) patients: A mixed-methods study

Research shows the significance of death attitudes for the mental health of somatically ill people, but findings that focus on multidimensionality in processing death are scarce. Patients with Chronic Obstructive Pulmonary Disease (COPD) report shortness of breath, pain and anxiety about suffocation and high mental distress. Utilizing a mixed-methods approach from 64 hospitalized COPD patients, we examined how they cope with mortality. We conducted a narrative interview with two questions. Patients completed the Multidimensional Orientation Toward Dying and Death Inventory (MODDI-F). Findings reveal a spectrum of death-related narratives, with most patients reporting at least 3 different attitudes. The sample showed below average scores in the Rejection of One's Own Death and Dying subscale of the MODDI-F. Assessing death attitudes using two simple questions proved highly applicable in this population and may serve as a potential approach to engage patients in discussions about existential matters, as suggested in the literature.

Factors Associated with Non-Adherence to Self-Management Among Patients with Chronic Obstructive Pulmonary Disease: A Survey Using the Delphi Technique and Analytic Hierarchy Process

Background

The relevant factors and patterns of non-adherence to self-management among patients with chronic obstructive pulmonary disease (COPD) need to be elucidated to improve self-management.

Purpose

This study was a survey to prioritize the relevance of factors associated with non-adherence to COPD self-management using the Delphi technique and analytic hierarchy process (AHP).

Patients and Methods

A total of 15 expert panels were established to determine the priority of relevant factors in a three-round Delphi survey and an AHP. To develop the preliminary conceptual framework for non-adherence to COPD self-management, findings from a systematic literature review, a qualitative study using in-depth interviews with COPD patients, and the first round of the Delphi survey were integrated. Based on the preliminary framework, the content validity ratio (CVR) was analyzed to examine the consensus among expert panels in the second and third rounds of the Delphi survey, and the relative weight was determined by pairwise comparisons between alternative factors in the AHP.

Results

In developing the preliminary conceptual framework, 8 factor categories and 53 factors were identified as relevant to non-adherence to COPD self-management. Of the 53 factors, 22 factors with a CVR of 0.49 or higher were identified in the Delphi survey. A total of 14 of the 53 factors were common to both the Delphi survey and AHP with high weights. The most notable factors were prolonged treatment, experience of treatment failure, and unknown effects of medication.

Conclusion

Through consensus decision-making by experts, 14 factors were identified as relevant factors associated with non-adherence to COPD self-management. A hierarchical and systematic framework incorporating factors associated with non-adherence to COPD self-management was developed in this study. Further research is needed to develop intervention strategies based on factors associated with non-adherence to COPD self-management.

Sex based differences in depression, anxiety, and quality of life and predictors of quality of life among South Asian individuals with chronic obstructive pulmonary disease: A Bayesian analysis

BACKGROUND

COPD can affect both men and women leading to deteriorating impact on general well-being, personal, and family life and decreased quality of life. Anxiety, depression, and self-care behaviours can affect the quality of life of individuals with COPD. There is a dearth of sex-based comparative analyses of anxiety, depression, quality of life, and predictors of quality of life among South Asian individuals with COPD.

PURPOSE

To identify the sex-based differences in depression, anxiety, and quality of life and the predictors of quality of life among South Asian individuals with COPD.

METHODS

A cross-sectional survey of 294 men and 114 women with COPD was conducted in Khyber Pakhtunkhwa, Pakistan. Hospital Anxiety and Depression scale, World Health Organization Quality of Life-brief version, Self-Care of Chronic Obstructive Pulmonary Disease Inventory, the Self-Care Self-Efficacy in COPD Scale were used for data collection. Bayesian independent sample t-test was used to compare mean differences in depression, anxiety, and quality of life among men and women. Two regression models were examined to determine if age, years of living with COPD, anxiety, depression, self-care self-efficacy, self-care monitoring, management, and maintenance were predictors of quality of life among men and women.

FINDINGS

Bayesian analysis showed anecdotal evidence that women had higher levels of depression, but lower levels of anxiety compared to men. Anecdotal evidence indicated that the physical quality of life of men was better than women, but strong evidence that their social relationship and environmental quality of life was better than women. Years of living with COPD, anxiety, depression, self-care self-efficacy, self-care management, self-care monitoring, and self-care maintenance were stronger predictors of women's quality of life. Anxiety and depression only predicted men's psychological quality of life, but predicted women's psychological, social relationships, and environmental quality of life.

CONCLUSIONS

The findings contribute to literature highlighting sex-based differences in anxiety, depression, and quality of life among South Asian men and women with COPD. Men generally reported higher levels of quality of life than women across all domains. Women's social relationships and environmental quality of life were greatly impacted by anxiety and depression. Quality of life interventions for women should be targeted at improving their social relationships and environmental satisfaction and addressing anxiety and depression.

Motivation and preferences for learning of patients with COPD or asthma and their significant others in pulmonary rehabilitation: a qualitative study

Introduction

An in-depth understanding of educational needs from the perspective of learners in pulmonary rehabilitation is lacking. To improve learning in pulmonary rehabilitation, understanding of factors that induce or enhance intrinsic motivation in both patients and their significant others is needed. Therefore, this study aims to gain in-depth understanding of what motivates patients with COPD or asthma referred for pulmonary rehabilitation and their significant others to learn and what their preferences are for education.

Methods

For this qualitative study, a sample was taken from a previous quantitative study. Data was collected through one-time face-to-face semi-structured interviews. The interviews were transcribed and independently analysed by two researchers using thematic analyses.

Results

Twelve patients and four significant others (56% female; age: 63±11 years) were interviewed. Participants expressed a variety of information needs and learning preferences. Subthemes that emerged within the theme of motivation for learning were: 1) curiosity, such as knowledge gaps and hope for new information; and 2) values and goals, such as own health, caring for loved ones and spending time with family.

Discussion

To enhance intrinsic motivation for learning within pulmonary rehabilitation, autonomy of individuals should be supported by offering several learning topics and education adapted to preferences, while curiosity should be fostered by targeting information needs. Moreover, health education programmes should match with the personal values and goals of individuals, such as own health, caring for loved ones and spending time with family.

"You don't want to know just about my lungs, you…want to know more about me". Patients and their caregivers' evaluation of a nurse-led COPD supportive care service

AIM

To evaluate a nurse-led model of supportive care in a COPD outpatient service from patient and caregiver perspectives.

DESIGN

Case study methodology.

METHODS

Data were collected from semi-structured interviews with patients (n = 12) and caregivers (n = 7) conducted between April 2020 and September 2022. A purposive sampling strategy was used. Interviews were transcribed verbatim and analysed using content analysis with an inductive approach. COREQ guidelines informed reporting of this study.

RESULTS

Eight categories were identified from the data evaluating of the model of care relating to the most helpful aspects of COPD supportive care and suggested improvements to the model of care. The categories were: guidance with managing symptoms; participating in advance care planning; home visiting; expert advice; continuity and trust; caring; caregiver support and improvements to the model of care.

CONCLUSION

In a nurse-led model of COPD supportive care, what patients and caregivers valued most was expert advice and guidance with symptom management, flexible home visiting, participation in advance care planning, caring and continuity within an ongoing trusted therapeutic relationship. Understanding what patients and caregivers value most is essential in designing and delivering models of care that meet the needs of patients living with chronic, life-limiting illness.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Nurses can lead effective models of supportive care that offer valuable support to patients living with COPD and their caregivers.

[Experiences of Burden and Coping Strategies and their Associations with Mental Health and Well-Being in COPD - a Mixed Methods Study]

Understanding trigger and maintaining factors regarding psychiatric comorbidities in COPD is of great importance. In the presented mixed-methods study, qualitative interview data on burden experience and coping were related to psychiatric comorbidity (using PHQ-D) and quality of live (Positive Affect Negative Affect Schedulde, PANAS and Satisfaction with Life Scale, SWLS) and extended by the Freiburg Questionnaire on Coping with Illness (FKV-LIS). The two interview questions prompting narrative were 1.) "What is currently bothering you most?"; 2.) "How do you cope with your chronic disease in everyday life?" A total of 62 patients who were hospitalized due to COPD participated. The severity of physical impairment was assessed using GOLD stage and the Charlson Comorbidity Index (CCI). The interviews conducted were content analyzed and then quantified. The collected data were then compared between two groups with regard to mental distress. 13 themes of burden and 11 coping strategies were identified by content analysis. A total of 42 patients showed signs of mental distress, while 20 patients did not show signs of distress. There were no significant differences between the two groups in terms of sociodemographic characteristics and the severity of their physical symptoms. In the first interview question, the stressed group more frequently addressed issues related to death (35.7% versus 15.0%) and social stress (21.4% versus 0.0%). With respect to the second interview question, the nonstressed group was significantly more likely to mention strategies for consciously emphasizing positive emotions (70.0% versus 31.0%). In addition, higher scores on the FKV scales for depressive coping and trivialization and wishful thinking were evident in the stressed group. Quality of life and mental distress should be considered in clinical care for COPD. Interventions to influence illness perception and related coping styles are important, especially with regard to the development of a realistic and optimistic perspective on life and disease burden, as well as the inclusion of group and family therapeutic interventions.

Perspectives from patients with chronic lung disease on a telehealth-facilitated integrated palliative care model: a qualitative content analysis study

BACKGROUND

Chronic lung disease affects nearly 37 million Americans and often results in significant quality of life impairment and healthcare burden. Despite guidelines calling for palliative care (PC) integration into pulmonary care as a vital part of chronic lung disease management, existing PC models have limited access and lack scalability. Use of telehealth to provide PC offers a potential solution to these barriers. This study explored perceptions of patients with chronic lung disease regarding a telehealth integrated palliative care (TIPC) model, with plans to use findings to inform development of an intervention protocol for future testing.

METHODS

For this qualitative study, we conducted semi-structured interviews between June 2021- December 2021 with patients with advanced chronic lung disease. Interviews explored experiences with chronic lung disease, understanding of PC, and perceived acceptability of the proposed model along with anticipated facilitators and barriers of the TIPC model. We analyzed findings with a content analysis approach.

RESULTS

We completed 20 interviews, with two that included both a patient and caregiver together due to patient preference. Perceptions were primarily related to three categories: burden of chronic lung disease, pre-conceived understanding of PC, and perspective on the proposed TIPC model. Analysis revealed a high level of disease burden related to chronic lung disease and its impact on day-to-day functioning. Although PC was not well understood, the TIPC model using a shared care planning approach via telehealth was seen by most as an acceptable addition to their chronic lung disease care.

CONCLUSIONS

These findings emphasize the need for a patient-centered, shared care planning approach in chronic lung disease. The TIPC model may be one option that may be acceptable to individuals with chronic lung disease. Future work includes using findings to refine our TIPC model and conducting pilot testing to assess acceptability and utility of the model.

Partnership-based nursing practice framework for patients with advanced chronic obstructive pulmonary disease and their families-A discursive paper

AIM

The increase in the number of people with chronic obstructive pulmonary disease (COPD) and the disease burden, has prompted concerted efforts to improve healthcare, particularly outpatient services. In line with these attempts the Partnership-Based Nursing Practice Theoretical Framework for People with COPD was developed to guide outpatient nursing care. The principal approach of the framework is a 'Dialogue' with the patients, which has four components: 'Establishing family involvement', 'Assisting living with symptoms' and 'Facilitating access to healthcare', with the primary goal being 'Enhancement of the health experience'. With new knowledge, research on the framework, and extensive experience in using it, a need arose to modify the framework to maximize its clinical utility.

DESIGN

Discursive paper.

METHODS

A narrative review and critical reflection was conducted to revise the nursing practice framework via selected literature search from 2012 to 2022, research on the framework, and the authors' reflections on the clinical experience of using the framework.

RESULTS

The nursing practice framework highlights capacities and possibilities that lie in the nurse-patient relationship. The overarching dialogue in the revised framework includes both patients and families. The action-related component 'Assisting living with the disease' was added to the framework to underscore the significance of attempting to understand what may lie ahead for patients and families. The other action-related components are as follows: 'Assisting living with symptoms' and 'Facilitating access to healthcare'. The primary goal remains unchanged: enhancing the 'Health experience'.

CONCLUSION

Using the revised nursing practice framework in outpatient care may help to enhance the lives of people with COPD and their families, particularly at advanced stages of the disease. It may have transferability to other groups of people living with progressive diseases dealing with complicated health problems, and to reduce the usage of costly healthcare resources such as hospital care.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The partnership-based nursing practice framework assumes an extension of conventional specialized respiratory service and embraces a comprehensive account for that which may influence the patient's health problems. This guidance, which holistically attends to patient-family needs of living with complicated and progressive health predicaments, is fundamental. It contributes to strengthening the disciplinary focus of nursing, interdisciplinary collaboration, person-family-centred quality nursing care and inspires research initiatives. Critical reflections and updates on nursing practice frameworks, such as this revision, are essential to advance nursing and healthcare.

PATIENT OR PUBLIC CONTRIBUTION

There is no direct patient- or public contribution.

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.

Development of pictogram-based content of self-management health information for Korean patients with chronic obstructive pulmonary disease

BACKGROUND

Adherence to self-management greatly impacts patients with chronic obstructive pulmonary disease (COPD) patients. However, most patients with COPD have a limitation in understanding text-based self-management plans owing to low health literacy. Thus, strategies to improve self-management in patients with COPD should be developed.

OBJECTIVES

This study aimed to develop pictogram-based content comprising self-management health information for patients with COPD.

METHODS

Items for COPD self-management health information were selected based on in-depth interviews with patients and text network analysis conducted in our previous study and a systematic literature review to develop preliminary pictogram-based content. Then, 30 patients with COPD and 10 healthcare professionals (HCPs) were recruited to evaluate the preliminary content using a client satisfaction questionnaire with a maximum score of 32.

RESULTS

Content was developed with one item related to disease knowledge while the other 20 concerned self-management. Patients (28.70 ± 2.94) and HCPs (27.40 ± 2.84) evaluated the content as high quality with adjustments made to increase the size of the letters and shorten the number of items for readability. Twenty-one items were collated in the final booklet, while 14 of the 21 items were incorporated into a poster.

CONCLUSIONS

This study indicates that the pictogram-based content was sufficiently well designed and received good evaluations from both patients with COPD and HCPs. Therefore, it may have prospects for enhancing self-management in patients with COPD. However, the effect of the content on the outcomes of older patients with COPD and low health literacy will need to be validated in future research.

Service Level Characteristics of Rural Palliative Care for People with Chronic Disease

CONTEXT

Despite clear benefit from palliative care in end-stage chronic, non-malignant disease, access for rural patients is often limited due to workforce gaps and geographical barriers.

OBJECTIVES

This study aimed to understand existing rural service structures regarding the availability and provision of palliative care for people with chronic conditions.

METHODS

A cross-sectional online survey was distributed by email to rural health service leaders. Nominal and categorical data were analyzed descriptively, with free-text questions on barriers and facilitators in chronic disease analyzed using qualitative content analysis.

RESULTS

Of 42 (61.7%) health services, most were public (88.1%) and operated in acute (19, 45.2%) or community (16, 38.1%) settings. A total of 17 (41.5%) reported an on-site specialist palliative care team, primarily nurses (19, 59.5%). Nearly all services (41, 95.3%) reported off-site specialist palliative care access, including: established external relationships (38, 92.7%); visiting consultancy (26, 63.4%); and telehealth (18, 43.9%). Perceived barriers in chronic disease included: lack of specific referral pathways (18; 62.1%); negative patient expectations (18; 62.1%); and availability of trained staff (17; 58.6%). Structures identified to support palliative care in chronic disease included: increased staff/funding (20, 75.0%); formalized referral pathways (n = 18, 64.3%); professional development (16, 57.1%); and community health promotion (14, 50%).

CONCLUSION

Palliative care service structure and capacity varies across rural areas, and relies on a complex, at times ad hoc, network of onsite and external supports. Services for people with chronic, non-malignant disease are sparse and largely unknown, with a call for the development of specific referral pathways to improve patient care.

Embedding nurse-led supportive care in an outpatient service for patients with Chronic Obstructive Pulmonary Disease

AIM

To describe a small multidisciplinary team's experience of the process of embedding nurse-led supportive care into an existing Chronic Obstructive Pulmonary Disease outpatient service.

DESIGN

Case study methodology METHODS: Data were collected from multiple sources including key documents and semi-structured interviews with healthcare professionals (n = 6) conducted between June and July 2021. A purposive sampling strategy was used. Content analysis was applied to key documents. Interviews were transcribed verbatim and analysed using an inductive approach.

RESULTS

Subcategories under the four-stage process were identified from the data.

ASSESSMENT

evidence of needs of patients with Chronic Obstructive Pulmonary Disease; gaps in care and evidence of other models of supportive care. Planning: setting the supportive care service structure and intention; resources and funding; leadership, specialization and respiratory/palliative care roles.

IMPLEMENTATION

relationships and trust; embedding supportive care and communication.

EVALUATION

benefits and positive outcomes for staff and patients, and, improvements and future considerations for supportive care in the COPD service.

CONCLUSION

A collaboration between respiratory and palliative care services resulted in successfully embedding nurse-led supportive care in a small outpatient service for patients with Chronic Obstructive Pulmonary Disease. Nurses are well placed to lead new models of care that aim to address unmet biopsychosocial-spiritual needs of patients. More research is needed to evaluate nurse-led supportive care in Chronic Obstructive Pulmonary Disease and other chronic illness settings; the effectiveness of nurse-led supportive care from the perspective of patients and caregivers and the impact of nurse-led supportive care on health service usage.

PATIENT OR PUBLIC CONTRIBUTION

The development of the model of care is informed by ongoing discussions with patients with COPD and their caregivers. Data availability statement: Research data are not shared (due to ethical restrictions).

IMPACT

Embedding nurse-led supportive care in an existing Chronic Obstructive Pulmonary Disease outpatient service is achievable. Nurses with clinical expertise can lead innovative models of care that address the unmet biopsychosocial-spiritual needs of patients with conditions such as Chronic Obstructive Pulmonary Disease. Nurse-led supportive care may have utility and relevance in other chronic disease contexts.

Using a person-centered approach in clinical care for patients with complex chronic conditions: Perspectives from healthcare professionals caring for Veterans with COPD in the U.S. Veterans Health Administration's Whole Health System of Care

BACKGROUND

The largest nationally integrated health system in the United States, the Veterans Health Administration (VHA), has been undergoing a transformation toward a Whole Health (WH) System of Care. WH Clinical Care, a component of this system, includes holistically assessing the Veteran's life context, identifying what really matters to the Veteran, collaboratively setting and monitoring personal health and well-being goals, and equipping the Veteran with access to conventional and complementary and integrative health resources. Implementation of WH Clinical Care has been challenging. Understanding healthcare professionals' perspectives on the value of and barriers and facilitators to practicing WH Clinical Care holds relevance for not only VHA's efforts but also other health systems, in the U.S. and internationally, that are engaged in person-centered care implementation.

OBJECTIVES

We sought to understand perspectives of healthcare professionals at VHA on providing WH Clinical Care to Veterans with COPD, as a lens to understand the broader issue of WH Clinical Care for Veterans living with complex chronic conditions.

DESIGN

We interviewed 25 healthcare professionals across disciplines and services at a VA Medical Center in 2020-2021, including primary care providers, pulmonologists, palliative care providers, and chaplains. Interview transcripts were analyzed using qualitative content analysis.

KEY RESULTS

Each element of WH Clinical Care raised complex questions and/or concerns, including: (1) the appropriate depth/breadth of inquiry in person-centered assessment; (2) the rationale for elicitation of what really matters; (3) the feasibility and appropriate division of labor in personal health goal setting and planning; and (4) challenges related to referring Veterans to a broad spectrum of supportive services.

CONCLUSIONS

Efforts to promote person-centered care must account for healthcare professionals' existing comfort with its elements, advocate for a team-based approach, and continue to grapple with the conflicting structural conditions and organizational imperatives.

The experience of hospitalization in people with advanced chronic obstructive pulmonary disease: A qualitative, phenomenological study

OBJECTIVES

People with advanced chronic obstructive pulmonary disease (COPD) are frequently hospitalized, reporting high physical, psychological and spiritual suffering. Existing research focused on discrete aspects of hospitalization, such as care or treatment, yet lacks a complete picture of the phenomenon. The aim of this study is to understand the lived experience of hospitalization in people with advanced COPD.

METHODS

A qualitative, descriptive phenomenological approach was employed to study the phenomenon of hospitalization for people with advanced COPD. Unstructured interviews were conducted during hospitalization at a tertiary care hospital in India, in 2017, audio-recorded, and then transcribed. Giorgi's descriptive phenomenological analysis method guided the analysis.

RESULTS

Fifteen people with advanced COPD participated. Emergency admissions were common because of acute breathlessness, leading to repeated hospitalizations. Hospitalization gave a sense of safety but, despite this, people preferred to avoid hospitalization. Care influenced trust in hospitalization and both shaped the experience of hospitalization. Multi-dimensional suffering was central to the experience and was described across physical, psychological and spiritual domains.

DISCUSSION

Hospitalization was identified largely as a negative experience due to the perception of continued suffering. Integrating palliative care into the routine care of people with advanced COPD may enable improvements in care.

Nonpharmacological management of psychological distress in people with COPD

Psychological distress is prevalent in people with COPD and relates to a worse course of disease. It often remains unrecognised and untreated, intensifying the burden on patients, carers and healthcare systems. Nonpharmacological management strategies have been suggested as important elements to manage psychological distress in COPD. Therefore, this review presents instruments for detecting psychological distress in COPD and provides an overview of available nonpharmacological management strategies together with available scientific evidence for their presumed benefits in COPD. Several instruments are available for detecting psychological distress in COPD, including simple questions, questionnaires and clinical diagnostic interviews, but their implementation in clinical practice is limited and heterogeneous. Moreover, various nonpharmacological management options are available for COPD, ranging from specific cognitive behavioural therapy (CBT) to multi-component pulmonary rehabilitation (PR) programmes. These interventions vary substantially in their specific content, intensity and duration across studies. Similarly, available evidence regarding their efficacy varies significantly, with the strongest evidence currently for CBT or PR. Further randomised controlled trials are needed with larger, culturally diverse samples and long-term follow-ups. Moreover, effective nonpharmacological interventions should be implemented more in the clinical routine. Respective barriers for patients, caregivers, clinicians, healthcare systems and research need to be overcome.

Caring for patients with advanced COPD: beyond the inhalers…

COPD affects millions of people worldwide. Patients with advanced COPD have a high symptom burden. Breathlessness, cough and fatigue are frequent daily symptoms. Guidelines often focus on pharmacological treatment, especially inhaler therapy, but other approaches in combination with medications offer symptomatic benefit. In this review, we take a multidisciplinary approach with contributions from pulmonary physicians, cardiothoracic surgeons and a physiotherapist. The following areas are addressed: oxygen therapy and noninvasive ventilation (NIV), dyspnoea management, surgical and bronchoscopic options, lung transplantation and palliative care. Oxygen therapy prescribed within guidelines improves mortality in patients with COPD. NIV guidelines offer only low-certainty instruction on the use of this therapy on the basis of the limited available evidence. Dyspnoea management can take place through pulmonary rehabilitation. Specific criteria aid decisions on referral for lung volume reduction treatments through surgical or bronchoscopic approaches. Lung transplantation requires precise disease severity assessment to determine which patients have the most urgent need for lung transplantation and are likely to have the longest survival. The palliative approach runs in parallel with these other treatments, focusing on symptoms and aiming to improve the quality of life of patients and their families facing the problems associated with life-threatening illness. In combination with appropriate medication and an individual approach to symptom management, patients' experiences can be optimised.

Educational aims

To understand the multidisciplinary approach to management of patients with advanced COPD.To recognise the parallel approaches to oxygen, NIV and dyspnoea management with consideration of more interventional options with lung volume reduction therapy or lung transplantation.To understand the high level of symptomatology present in advanced COPD and the relevance of palliative care alongside optimal medical management.

"Dignity as a Small Candle Flame That Doesn't Go Out!": An Interpretative Phenomenological Study with Patients Living with Advanced Chronic Obstructive Pulmonary Disease

Long-term illness, such as chronic obstructive pulmonary disease (COPD), can expose people to existential suffering that threatens their dignity. This qualitative study explored the lived experiences of patients with advanced COPD in relation to dignity. An interpretative phenomenological approach based on lifeworld existentials was conducted to explore and understand the world of the lived experience. Twenty individuals with advanced COPD (GOLD [Global Initiative for Chronic Obstructive Lung Disease] stages III and IV) were selected using a purposive sampling strategy. In-depth interviews were used to collect data, which were then analysed using Van Manen's phenomenology of practice. The existential experience of dignity was understood, in essence, as "a small candle flame that doesn't go out!". Four intertwined constituents illuminated the phenomenon: "Lived body-balancing between sick body and willingness to continue"; "Lived relations-balancing between self-control and belongingness"; "Lived Time-balancing between past, present and a limited future"; and "Lived space-balancing between safe places and non-compassionate places". This study explains how existential life phenomena are experienced during the final phases of the COPD trajectory and provides ethical awareness of how dignity is lived. More research is needed to investigate innovative approaches to manage complex care in advanced COPD, in order to assist patients in discovering their inner resources to develop and promote dignity.

Social dimensions of chronic respiratory disease: stigma, isolation, and loneliness

PURPOSE OF REVIEW

Social wellbeing is a core component of heath. However, people with chronic respiratory disease report unmet social needs, particularly in relation to stigma, social isolation, and loneliness. This review considers recent advances in understanding these social concepts within the context of chronic respiratory disease.

RECENT FINDINGS

A growing body of qualitative work illustrates the detrimental impacts of stigma in chronic respiratory disease, contributing towards poorer psychological health and self-management, and reduced engagement with professional support. Stigma, alongside physical limitations stemming from respiratory symptoms, can also contribute to social isolation and loneliness. Social isolation and loneliness are associated with poorer mental health and quality of life, declines in function, and in some cases, increased hospital admissions. Although close or cohabiting relationships can ameliorate some social challenges, isolation and loneliness can also impact informal carers of people with chronic respiratory disease.

SUMMARY

Increasing evidence illustrates the direct and indirect influences of social dimensions on health outcomes for people living with chronic respiratory disease. Although there is increased understanding of the lived experiences of stigma, less is understood about the complexities of social isolation and loneliness in chronic respiratory disease, and optimal interventions to address social challenges.

A survey of hospice day services in the United Kingdom & Republic of Ireland : how did hospices offer social support to palliative care patients, pre-pandemic?

INTRODUCTION

Social support is described by patients and other stakeholders to be a valuable component of palliative day care. Less is known about the range of hospice services that have been used in practice that facilitate social support. An online survey aimed to gain an overview of all hospice day services that facilitated social support for adults outside of their own homes.

METHODS

An online survey was distributed via email to people involved in managing hospice day services. Questions were asked on hospice characteristics, including staff and volunteer roles. Respondents were asked to identify services they felt offered social support to patients. Data collection took place between August 2017 and May 2018.

RESULTS

Responses were received from 103 hospices in the UK and ROI (response rate 49.5%). Results provide an overview of hospice day and outpatient services that offer social support to patients. These are: multi-component interventions, activity groups, formal support groups, befriending, and informal social activities. Multi-component interventions, such as palliative day care, were the most commonly reported. Their stated aims tend to focus on clinical aspects, but many survey respondents considered these multicomponent interventions to be the 'most social' service at their hospice. The survey also identified a huge variety of activity groups, as well as formal therapeutic support groups. Informal 'social-only' activities were present, but less common. Over a third of all the services were described as 'drop in'. Most responding hospices did not routinely use patient reported outcome measures in their 'most social' services.

CONCLUSIONS

The survey documents hospice activity in facilitating social support to be diverse and evolving. At the time of data collection, many hospices offered multiple different services by which a patient might obtain social support outside of their own home and in the presence of other patients.

Experiences of fatigue among people with chronic obstructive pulmonary disease: a qualitative systematic review protocol

OBJECTIVE

The objective of this review is to explore the experiences of adults with chronic obstructive pulmonary disease living with fatigue.

INTRODUCTION

Chronic obstructive pulmonary disease is an incurable disease that causes multiple physical, social, and psychological burdens to those affected as well as their caregivers. One symptom that affects the quality of life of people with chronic obstructive pulmonary disease is fatigue. However, the experiences of fatigue disclosed by people with chronic obstructive pulmonary disease have not been widely documented in previous reviews. The findings of this review will provide insights into how people with chronic obstructive pulmonary disease experience fatigue, which will be useful for developing, targeting, and implementing needs-based counseling interventions to help them deal with fatigue and maintain functioning.

INCLUSION CRITERIA

This review will consider studies that include adults (>18 years) with chronic obstructive pulmonary disease at any stage, and that focus on the experiences of fatigue in any context, including health services (in- and out-patient), community, work, leisure, and home.

METHODS

MEDLINE, CINAHL, PsycINFO, Academic Search Premier, Web of Science, Medic, OpenGrey, and ProQuest Dissertation and Theses will be searched for relevant published and unpublished literature with no restrictions on publication date. Study selection, quality appraisal, and data extraction will be conducted by 2 independent reviewers. Eligible studies will be evaluated using the JBI critical appraisal tool for qualitative research. Findings will be pooled using the JBI method of meta-aggregation, and a level of credibility will be assigned to the findings. The findings will be graded according to the ConQual approach for establishing confidence in findings.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021242227.

Exploring patients' and health professionals' perspectives on health literacy needs in the context of chronic obstructive pulmonary disease

OBJECTIVE

Persons with chronic obstructive pulmonary disease (COPD) require complex follow-up by healthcare professionals (HCPs) and may experience several health literacy (HL) needs. This study aimed to explore such needs in people with COPD and the HCPs who care for them.

METHODS

From October 2016 to August 2017 a qualitative study with four focus groups (FG) were performed in people with COPD (n = 14) and three in multidisciplinary HCPs (n = 21). An inductive thematic analysis was used to investigate HL needs.

RESULTS

Four HL needs emerged: 1) strengthening the feeling of security; 2) combating the burden of insufficient knowledge on COPD and lack of informational flow; 3) supporting motivation for endurance and self-management; and 4) strengthening dignity.

DISCUSSION

This study highlights a gap between people with COPD who express important HL needs and HCPs' capabilities to care for these needs. For HCPs to increase HL in such cases, HCPs need to improve their own HL. It is essential to find solutions on how to improve HL in HCPs who care for people with COPD and to increase the availability of interventions that increase HL in COPD. Education programs, health organizations, and governments should be aware of HL needs in such situations.

Qualitative Review on Domains of Quality of Life Important for Patients, Social Care Users, and Informal Carers to Inform the Development of the EQ-HWB

OBJECTIVES

To identify the themes to inform the content of a new generic measure, the EQ-HWB (EQ Health and Wellbeing), that can be used in economic evaluation across health, social care, and public health, based on the views of users and beneficiaries of these services including informal carers.

METHODS

A qualitative review was undertaken. Systematic and citation searches were undertaken focusing on qualitative evidence of the impact on quality of life from reviews for selected health conditions, informal carers, social care users, and primary qualitative work used in the development of selected measures. A subset of studies was included in the review. Framework analysis and synthesis were undertaken based on a conceptual model.

RESULTS

A total of 42 reviews and 24 primary studies were selected for inclusion in the review. Extraction and synthesis resulted in 7 high-level themes (with subthemes): (1) feelings and emotions (sadness, anxiety, hope, frustration, safety, guilt/shame); (2) cognition (concentration, memory, confusion, thinking clearly); (3) self-identity (dignity/respect, self-esteem); (4) "coping, autonomy, and control" relationships; (5) social connections (loneliness, social engagement, stigma, support, friendship, belonging, burden); (6) physical sensations (pain, discomfort, sleep, fatigue); and (7) activity (self-care, meaningful activities, mobility, communication, hearing, vision). Apart from physical sensations, most of the other themes and subthemes were relevant across both health and social care, including for informal carers.

CONCLUSIONS

The findings from this broad review identified themes that go beyond health and that are relevant to patients, informal carers, and social care users. The themes and subthemes informed the domains for the EQ-HWB.

Existential suffering in the day to day lives of those living with palliative care needs arising from chronic obstructive pulmonary disease (COPD): A systematic integrative literature review

BACKGROUND

The impact of living with palliative care needs arising from COPD disrupts an individual's existential situation. However, no comprehensive synthesis of existing research has been published to determine the presentation and impact of existential suffering.

AIM

To provide a synthesis of existing evidence on existential suffering for those living with palliative care needs arising from COPD.

DESIGN

This is an integrative review paper, undertaken using the methodological approach developed by Soares and reported in accordance with PRISMA guidelines. Data analysis was undertaking using an integrated convergent synthesis approach.

DATA SOURCES

Nine electronic databases were searched from April 2019 to December 2019. A second search was undertaken in January 2021 to identify recently published papers meeting the inclusion and exclusion criteria. No date restrictions were imposed. Only papers published in the English Language were considered for inclusion. Empirical research papers employing qualitative and/or quantitative methodologies and systematic literature reviews were included. Articles were accepted for inclusion if they discussed any component of existential suffering when living with COPD and palliative care needs.

RESULTS

Thirty-five papers were included within this review comprising of seven systematic reviews, 10 quantitative studies and 18 qualitative studies. The following themes relating to existential suffering were found: Liminality, Lamented Life, Loss of Personal Liberty, Life meaning and Existential isolation. The absence of life meaning, and purpose was of most importance to participants.

CONCLUSIONS

This review suggests existential suffering is present and of significant impact within the daily lives of those living with palliative care needs arising from COPD. The absence of life meaning has the most significant impact. Further research is required to understand the essential components of an intervention to address existential suffering for this patient group, to ensure holistic palliative care delivery.

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.

The Perspectives of Patients with Chronic Diseases and Their Caregivers on Self-Management Interventions: A Scoping Review of Reviews

BACKGROUND

Self-management (SM) interventions are supportive interventions systematically provided by healthcare professionals, peers, or laypersons to increase the skills and confidence of patients in their ability to manage chronic diseases. We had two objectives: (1) to summarise the preferences and experiences of patients and their caregivers (informal caregivers and healthcare professionals) with SM in four chronic diseases and (2) to identify and describe the relevant outcomes for SM interventions from these perspectives.

METHODS

We conducted a mixed-methods scoping review of reviews. We searched three databases until December 2020 for quantitative, qualitative, or mixed-methods reviews exploring patients' and caregivers' preferences or experiences with SM in type 2 diabetes mellitus (T2DM), obesity, chronic obstructive pulmonary disease (COPD), and heart failure (HF). Quantitative data were narratively synthesised, and qualitative data followed a three-step descriptive thematic synthesis. Identified themes were categorised into outcomes or modifiable factors of SM interventions.

RESULTS

We included 148 reviews covering T2DM (n = 53 [35.8%]), obesity (n = 20 [13.5%]), COPD (n = 32 [21.6%]), HF (n = 38 [25.7%]), and those with more than one disease (n = 5 [3.4%]). We identified 12 main themes. Eight described the process of SM (disease progression, SM behaviours, social support, interaction with healthcare professionals, access to healthcare, costs for patients, culturally defined roles and perceptions, and health knowledge), and four described their experiences with SM interventions (the perceived benefit of the intervention, individualised care, sense of community with peers, and usability of equipment). Most themes and subthemes were categorised as outcomes of SM interventions.

CONCLUSION

The process of SM shaped the perspectives of patients and their caregivers on SM interventions. Their perspectives were influenced by the perceived benefit of the intervention, the sense of community with peers, the intervention's usability, and the level of individualised care. Our findings can inform the selection of patient-important outcomes, decision-making processes, including the formulation of recommendations, and the design and implementation of SM interventions.

Palliative Care For Patients with Advanced COPD in Primary Care

Patients with advanced COPD have a high symptom burden that is often multidimensional. Identification of patients who might benefit from palliative care through validated identification tools, multidimensional symptom management, and timely discussion of advance planning are elements of a palliative care approach for these patients and their families. Coordination among stakeholders providing care and support to these patients is central to ensuring high-quality care and meeting all of their needs.

Effect of therapeutic touch on sleep quality and anxiety in individuals with chronic obstructive pulmonary disease: A randomized controlled trial

PURPOSE

The purpose is to determine the effect of therapeutic touch (TT) on the sleep quality and anxiety of individuals with chronic obstructive pulmonary (COPD) disease.

METHODS

103 patients were randomized in to the two groups: the experimental group, and the control group. In this randomized control study, the patients with COPD in the experimental group were given TT for 10 min between 18:00 and 20:00, one session every day for three consecutive days.

RESULTS

When the experimental group was compared to control group following the intervention, the decrease in the levels of anxiety (p < 0.001) and increase in the sleep quality (p < 0.001) were found to be significant.

CONCLUSION

As a result of the study, it was determined that TT reduced anxiety level and improved sleep quality in individuals with chronic obstructive pulmonary disease. The Clinical Trial Registration Number: NCT04842903.

The information needs of people with COPD-The holistic approach with special reference to gender and time since diagnosis

AIMS

The aim of this study was to determine what kinds of unmet information needs people with COPD have and whether there are differences in information needs between genders or based on the time since COPD diagnosis.

DESIGN

A descriptive cross-sectional study.

METHODS

Data on people with COPD (N = 169) were collected from a two-part questionnaire distributed via website. On the first part, information needs concerning the medical aspects of self-management were measured by the Lung Information Needs Questionnaire (LINQ). On the second part, which was developed specifically for this study, a more holistic view of self-management counselling was sought. Statistical methods were used to analyse the data.

RESULTS

The respondents had wide-ranging information needs in many areas of COPD self-management. The most often reported areas of unmet information needs included exacerbations, diet, fatigue, stress and anxiety, palliative care and sexual life. The information needs varied by gender and time since COPD diagnosis.

Functional decline in emergency department patients with dyspnea: a register-based cohort

BACKGROUND

Functional decline is associated with frequent hospital admissions and elevated risk of death. Presumably, patients acutely admitted to hospital with dyspnea have a high risk of functional decline.

OBJECTIVE

The aim of this study was to describe patient characteristics, hospital trajectory and use of physiotherapy services by dyspneic patients in an emergency department. The study also wanted to compare readmission and death among patients with and without a functional decline and to identify predictors of functional decline.

METHODS

Data originated from a historic cohort of patients admitted to a Danish Emergency Department using prospectively collected electronic patient record data from a Business Intelligence Registry of the Central Denmark Region. The study included adult patients who were treated at the emergency department (ED) for dyspnea in 2015. The main outcome measures were readmission, death and functional decline.

RESULTS

In total, 2048 dyspneic emergency treatments were registered. Within 30 days after discharge, 20% was readmitted and 3.9% had died. Patients with functional decline had a higher rate of 30-day readmission (31.2% vs. 19.1%, P < 0.001) and mortality (9.3% vs. 3.6%, P = 0.009) as well as mortality within 1 year (36.1% vs. 13.4%, P < 0.001). Predictors of functional decline were age ≥60 years and hospital stay ≥6 days.

CONCLUSION

Patients suffering from acute dyspnea are seen at the ED at all hours. In total, one in five patients were readmitted and 3.9% died within 30 days. Patients with a functional decline at discharge seem to be particularly vulnerable.

Impact of patients' attitudes and dynamics in needs and life experiences during their journey in COPD: an ethnographic study

OBJECTIVES

Despite its importance in determining coping behaviors, few studies have assessed the reality of chronic obstructive pulmonary disease (COPD) and its management perceived by patients. This study aimed at an in-depth understanding of this reality to identify COPD patients' attitudes, COPD-shaped experiences, and overlooked needs during their journey.

METHODS

Qualitative ethnographic study including 28 adult patients with moderate and severe COPD and 20 healthcare professionals. Study phases were (1) in-depth individual and (2) ethnographic interviews (qualitative), and (3) online questionnaires (quantitative), including 400 patients. Qualitative data were collected using audio, video, and observation notes. Three ethnographers analyzed data using a template covering different themes: attitudes of COPD patients, COPD-shaped experiences, and overlooked needs.

RESULTS

We identified four attitudinal profiles of COPD patients: 'active controller,' 'naïve minimizer,' 'defeated sufferer,' and 'struggling bon vivant,' which were validated in 400 COPD patients, as well as five stages in the COPD patient journey and overlookedneeds. The 'active controller' profile was associated with slower disease progression compared with the 'defeated sufferer' and 'struggling bon vivant' profiles.

CONCLUSION

Four attitudinal profiles were distinguished and validated in a large sample of COPD patients. Patients' attitudes impacted in COPD-associated experiences, limitations, and unmet needs, which differed among profiles.

Macro and meso level influences on distributed integrated COPD care delivery: a social network perspective

Background

Care guidelines for people with chronic obstructive pulmonary disease (COPD) recommend an integrated approach for holistic, flexible, and tailored interventions. Continuity of care is also emphasised. However, many patients with COPD experience fragmented care. Discontinuities in healthcare and related social services are likely to result in disjointed rather than integrated care which can negatively affect patient health outcomes. The purpose of this qualitative study was to improve our understanding of, and how, contextual features pertaining to structures and processes of COPD integrated care influence delivery of care within patients’ healthcare networks.

Methods

We conducted individual interviews with 28 participants (9 patients, 16 healthcare professionals, and 3 spousal caregivers). Participants were recruited through the lung clinic at a city hospital in western Canada. We employed a social network paradigm to analyse and interpret the data.

Results

The analysis revealed an overarching theme of fragmented COPD care with two sub-themes: (1) Funding shortfalls and availability of resources, and (2) Dis(mis)connected communication pathways. The overarching theme depicts variations, delays, and discontinuities in patient care. The sub-themes describe how macro level influences and meso level shortfalls were perceived to influence the availability of respiratory care resources that contributed to fragmented COPD care.

Conclusions

Employing a social network lens drew particular attention to family physicians’ pivotal role in delivering community-based COPD care. While an integrated approach to care is recommended by care guidelines, institutional and organizational structures and processes, such as financial and communication structures, may inhibit delivery of integrated care. Thus, macro and meso level structures and processes have the potential to shape patient care by constraining family physicians’ purposive and communication actions necessary for facilitating an integrated distributed approach to care. We propose a context of care which fosters a context for family physicians’ delivery of patient-centered care. Integrated care delivery may improve patients’ wellbeing and alleviate financial constraints on the healthcare system.

Mirror of shame: Patients experiences of late-stage COPD. A qualitative study

AIMS AND OBJECTIVES

This study aims to shed light on patients with late-stage COPD and their experiences of shame.

BACKGROUND

Patients with COPD often experience shame for bringing the disease into their lives due to smoking. Knowledge about patients with COPD and their feelings of shame is crucial, but limited, however.

DESIGN

The study has a qualitative and explorative design. We interviewed twelve patients with late-stage COPD. The data were analysed using Kvale and Brinkmann's three interpretative contexts. The COREQ checklist was used.

RESULTS

Three main themes were defined; the body as a mirror of shame; a sense of being unworthy, invisible and powerless; and that sharing the burden is too difficult. The participants experienced that the disease defined their value as human beings and that made them feel vulnerable, ashamed and more socially isolated.

CONCLUSIONS

The participants experienced feelings of shame, guilt and self-blame due to their own perceptions of themselves. They were in doubt about whether they were worthy to receive care and comfort from both health professionals and, their family and friends. The participants seemed to have internalised the moral norms of contemporary society and the understanding that the disease, and especially a 'self-inflicted' disease, is a personal weakness.

RELEVANCE FOR CLINICAL PRACTICE

Findings from this study show that patients struggle with feelings such as shame and misery. The nurses who work bedside are in continuous contact with the patients and have an opportunity to gain knowledge of these feelings in order to meet the patients' needs for comfort and care. They have an obligation to ask patients about their feelings and meet them with empathy and respect. Moreover, it is necessary to have interdisciplinary fora in clinical practice where health professionals reflect, discuss and challenge themselves according to attitudes towards patients with so-called 'self-inflicted' diseases.

Pulmonary hypertension due to interstitial lung disease or chronic obstructive pulmonary disease: a patient experience study of symptoms and their impact on quality of life

Pulmonary hypertension resulting from chronic lung disease such as chronic obstructive pulmonary disease and interstitial lung disease is categorized by the World Health Organization as Group 3 pulmonary hypertension. To identify the symptoms and impacts of World Health Organization Group 3 pulmonary hypertension and to capture data related to the patient experience of this disease, qualitative research interviews were undertaken with 3 clinical experts and 14 individuals with pulmonary hypertension secondary to chronic obstructive pulmonary disease or interstitial lung disease. Shortness of breath, fatigue, cough, and swelling were the most frequently reported symptoms of pulmonary hypertension due to chronic obstructive pulmonary disease or interstitial lung disease, and shortness of breath was further identified as the single most bothersome symptom for most patients (71.4%). Interview participants also described experiencing a number of impacts related to pulmonary hypertension and pulmonary hypertension symptoms, including limitations in the ability to perform activities of daily living and impacts on physical functioning, family life, and social life as well as emotional impacts, which included frustration, depression, anxiety, isolation, and sadness. Results of these qualitative interviews offer an understanding of the patient experience of pulmonary hypertension due to chronic obstructive pulmonary disease or interstitial lung disease, including insight into the symptoms and impacts that are most important to patients in this population. As such, these results may help guide priorities in clinical treatment and assist researchers in their selection of patient-reported outcome measures for clinical trials in patients with pulmonary hypertension due to chronic obstructive pulmonary disease or interstitial lung disease.

Research and Healthcare Priorities of Individuals Living with COPD

This study describes the research and healthcare priorities of individuals living with COPD. On an online survey, individuals living with COPD assigned a percentage of funding to 22 research priorities and a percentage of time spent communicating with a healthcare provider to 24 healthcare priorities, indicating which topics were most important. For each research and healthcare priority, we examined the selection frequency of the priority and used chi-square analyses to examine differences in priority selection by quartiles of airflow obstruction (percent predicted forced expiratory volume in 1-sec (FEV₁%predicted)) and breathlessness burden and exacerbation risk. Based on participants' responses (N = 148, 47% women; Mean ± Standard Deviation age = 68 ± 9 yrs) relief of breathlessness was the most often selected research (76% of respondents) and healthcare priority (61% of respondents). It was selected most often, regardless of disease severity or breathlessness burden and exacerbation risk. We found differences for disease severity and breathlessness burden and exacerbation risk in some research priorities (e.g., to improve the maximal amount of exercise of adults living with COPD in and out of the home (χ²₍₃₎ = 9.97, Cramer's V =.28) and healthcare priorities (e.g., increase your ability to exercise (χ²₍₃₎ = 9.72, Cramer's V =.27)). This study provides empirical evidence that relief of breathlessness is a top research and healthcare priority for individuals living with COPD. Future healthcare and research activities should align with the priorities of individuals with COPD to improve their care by minimizing disease/symptom burden and optimizing health-related quality of life.

Frailty in Korean patients with chronic obstructive pulmonary disease, using data from the Korea National Health and Nutrition Examination Survey, 2015 and 2016

AIM

To describe frailty, to identify its determinants, and to examine how it affected functioning in Korean patients with chronic obstructive pulmonary disease (COPD). This analysis was based on datasets from the Korea National Health and Nutrition Examination Survey (KNHANES).

BACKGROUND

Most of what is known about the prevalence and determinants of frailty in patients with COPD has come from countries other than Korea. Examining this issue with a representative sample of COPD patients in Korea will shed light on frailty in this population.

METHODS

This cross-sectional study, a secondary data analysis, used datasets from the KNHANES VI (2015) and VII (2016) to understand frailty in 417 patients with COPD (mean age = 65.36; FEV1%predicted value = 78.91). Demographic and clinical data, symptoms, self-rated health, frailty, and functioning were collected in health interviews and health examinations. Descriptive and inferential statistics were used to analyze the data.

RESULTS

One hundred forty-eight participants (35.5%) were frail, 156 (37.4%) were pre-frail, and 113 (27.1%) exhibited no frailty. Multivariate logistic regression showed that self-rated health, stage of COPD based on the Global Initiative for Chronic Obstructive Lung Disease, pain/discomfort, and arthritis were significant predictors of frailty. Multivariate logistic regression also showed that frail participants were more likely to experience limitations in usual activities, after controlling for other covariates.

CONCLUSION

Health care providers who know the determinants of frailty and its relationship with poor functioning will be better prepared to identify at-risk patients with COPD who might benefit from pulmonary rehabilitation.

Perspectives on palliative oxygen for breathlessness: systematic review and meta-synthesis

Oxygen therapy is frequently prescribed for the palliation of breathlessness, despite lack of evidence for its effectiveness in people who are not hypoxaemic. This study aimed to compare and contrast patients', caregivers' and clinicians' experiences of palliative oxygen use for the relief of chronic breathlessness in people with advanced life-limiting illnesses, and how this shapes prescribing.A systematic review and meta-synthesis of qualitative data was conducted. MEDLINE, CINAHL and PsycINFO were searched for peer-reviewed studies in English (2000-April 2019) reporting perspectives on palliative oxygen use for reducing breathlessness in people with advanced illnesses in any healthcare setting. After data extraction, thematic synthesis used line-by-line coding of raw data (quotes) to generate descriptive and analytical themes.Of 457 articles identified, 22 met the inclusion criteria by reporting perspectives of patients (n=337), caregivers (n=91) or clinicians (n=616). Themes common to these perspectives were: 1) benefits and burdens of palliative oxygen use, 2) knowledge and perceptions of palliative oxygen use beyond the guidelines, and 3) longitudinal trajectories of palliative oxygen use.There are differing perceptions regarding the benefits and burdens of using palliative oxygen. Clinicians should be aware that oxygen use may generate differing goals of therapy for patients and caregivers. These perceptions should be taken into consideration when prescribing oxygen for the symptomatic relief of chronic breathlessness in patients who do not quality for long-term oxygen therapy.

Self-management interventions for adults living with Chronic Obstructive Pulmonary Disease (COPD): The development of a Core Outcome Set for COMPAR-EU project

BACKGROUND

A large body of evidence suggests that self-management interventions (SMIs) may improve outcomes in chronic obstructive pulmonary disease (COPD). However, accurate comparisons of the relative effectiveness of SMIs are challenging, partly due to heterogeneity of outcomes across trials and uncertainty about the importance of these outcomes for patients. We aimed to develop a core set of patient-relevant outcomes (COS) for SMIs trials to enhance comparability of interventions and ensure person-centred care.

METHODS

We undertook an innovative approach consisting of four interlinked stages: i) Development of an initial catalogue of outcomes from previous EU-funded projects and/or published studies, ii) Scoping review of reviews on patients and caregivers' perspectives to identify outcomes of interest, iii) Two-round Delphi online survey with patients and patient representatives to rate the importance of outcomes, and iv) Face-to-face consensus workshop with patients, patient representatives, health professionals and researchers to develop the COS.

RESULTS

From an initial list of 79 potential outcomes, 16 were included in the COS plus one supplementary outcome relevant to all participants. These were related to patient and caregiver knowledge/competence, self-efficacy, patient activation, self-monitoring, adherence, smoking cessation, COPD symptoms, physical activity, sleep quality, caregiver quality of life, activities of daily living, coping with the disease, participation and decision-making, emergency room visits/admissions and cost effectiveness.

CONCLUSION

The development of the COPD COS for the evaluation of SMIs will increase consistency in the measurement and reporting of outcomes across trials. It will also contribute to more personalized health care and more informed health decisions in clinical practice as patients' preferences regarding COPD outcomes are more systematically included.

Exploring health literacy needs in Chronic obstructive pulmonary disease (COPD): Associations between demographic, clinical variables, psychological well-being and health literacy

BACKGROUND

The World Health Organization (WHO) points to health literacy as an important factor in prevention and control of non-communicable diseases (NCDs), including COPD.

OBJECTIVE

To investigate associations between selected demographic and clinical variables, psychological well-being and health literacy.

METHODS

Health literacy was measured using the nine domain Health Literacy Questionnaire (HLQ) and one domain from the eHealth Literacy Questionnaire (eHLQ). Using data from a cross-sectional sample of 158 people with COPD, recruited from a hospital-based patient list period (2014-2016), multiple regression analyses were performed.

RESULTS

The strongest associated variables with health literacy were psychological well-being, measured by the WHO-5 well-being index and education, indicating that higher psychological well-being and educational level are associated with higher levels of health literacy.

CONCLUSION

The present study highlights the importance of specifically looking to psychological factors in determining potentially health literacy needs among people with COPD.

Prioritization and Refinement of Patient-Informed Value Elements as Attributes for Chronic Obstructive Pulmonary Disease Treatment Preferences

BACKGROUND AND OBJECTIVE

Formative research studies can inform stated-preference instrument development to quantify the importance of various attributes of healthcare treatments. The objective of this study was to elicit from patients with chronic obstructive pulmonary disease the prioritization of an established set of patient-informed value elements.

METHODS

Using an iterative mixed-methods study design, we engaged individuals living with chronic obstructive pulmonary disease in Phase 1 value element elicitation and Phase 2 language refinement. Study participants were recruited from March to July 2019. Four guided activities, administered in an online instrument, elicited individual preferences for 40 disease-agnostic value elements that were aligned with treatment, outcomes, or care process. Responses from the guided activities were summarized and then presented to a patient advocate and additional patient participants for further refinement of the value elements and the phrasing.

RESULTS

Twenty-three participants, 18 male and five female, mean age of 66 years (standard deviation = 7) were enrolled in Phase 1. Participant responses informed the selection of eight elements as the key candidates for the Phase 2 language refinement: Side Effects, New Therapeutic Option, Available Treatment, Appropriateness of Care, Predictable Healthcare Needs, Physical Activities: Endurance and Symptom Control, and Explanation of Treatment. With feedback from a patient advocate and additional patient participants, elements were refined, rephrased, or modified and this list was narrowed to six value elements (Side Effects, New Therapeutic Option, Willingness to Pay, Physical Activities, Explanation of Treatment, and Access to Care) to serve as attributes in a conceptual framework for a future quantitative stated-preference instrument.

CONCLUSIONS

This patient-engaged formative work identified patients with chronic obstructive pulmonary disease key attributes of value-based decision making that underpin benefit-risk trade-offs between physical endurance, treatment side effects, care access, and cost. This study illustrates an iterative process for eliciting and refining a comprehensive list of value elements, resulting in a subgroup of elements important to a specific patient population.

Prevalence and burden of obstructive lung disease in the urban poor population of Ottawa, Canada: a community-based mixed-method, observational study

BACKGROUND

Globally the burden of Obstructive Lung Diseases (OLD) is growing, however its effect on urban poor populations with the high prevalence of tobacco dependence is virtually unknown. The purpose of this project is to estimate the prevalence and burden of OLD in the urban, low-income populations of Ottawa, Canada.

METHODS

The study presented in this paper was part of the PROMPT (Management and Point-of-Care for Tobacco Dependence) project; a prospective cohort study in a community-based setting (n = 80) with meaningful Patient Engagement from design to dissemination. Spirometry data, standardized questionnaires and semi-structured interviews from PROMPT were interpreted to understand the lung function, disease burden and social determinants (respectively) in this population.

RESULTS

The prevalence of OLD among those who completed spirometry (N = 64) was 45-59%. Generic and disease-specific quality of life was generally poor in all PROMPT participants, even those without OLD, highlighting the higher disease burden this vulnerable population faces. Quality of life was impacted by two major themes, including i) socioeconomic status and stress and ii) social networks and related experiences of trauma.

CONCLUSION

The prevalence and disease burden of OLD is significantly higher in Ottawa's urban poor population than what is observed in the general Canadian population who smoke, suggesting an etiological role of the social determinants of health. This urges the need for comprehensive care programs addressing up-stream factors leading to OLDs, including poor access and utilization of preventive healthcare addressing the social determinants of health.

TRIAL REGISTRATION

ClinicalTrails.gov - NCT03626064 , Retrospective registered: August 2018.

Palliative Care Needs and Integration of Palliative Care Support in COPD: A Qualitative Study

BACKGROUND

The provision of palliative care for severe COPD remains low, resulting in unmet needs in patients and carers.

RESEARCH QUESTIONS

What are the palliative care needs of patients living with severe COPD and their caregivers? What views of accessing and providing palliative care and factors influence these experiences. To what extent have palliative care and COPD services been integrated?

STUDY DESIGN AND METHODS

A multicentre qualitative study was undertaken in COPD services and specialist palliative care in the United Kingdom involving patients with severe COPD, their carers, and health professionals. Data were collected using semistructured interviews and were analyzed using framework analysis. Themes were integrated using the constant comparison process, enabling systematic data synthesis.

RESULTS

Four themes were generated from interviews with 20 patients, six carers, and 25 health professionals: management of exacerbations, palliative care needs, access to palliative care and pathways, and integration of palliative care support. Uncertainty and fear were common in patients and carers, with identified needs for reassurance, rapid medical access, home care, and finance advice. Timely palliative care was perceived as important by health professionals. Palliative care was integrated into COPD services, although models of working varied across regions. Reliable screening tools and needs assessment, embedded psychological care, and enhanced training in palliative care and communication skills were perceived to be important by health professionals for timely palliative care referrals and optimized management.

INTERPRETATION

Palliative care increasingly is being implemented for nonmalignant diseases including COPD throughout the United Kingdom, although models of working vary. A theoretical model was developed to illustrate the concept and pathway of the integration of palliative care support. A standardized screening and needs assessment tool is required to improve timely palliative care and to address the significant needs of this population.

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.

The clinical effectiveness of the COPDnet integrated care model

RATIONALE

Integrated care models have the potential to improve outcomes for patients with COPD. We therefore designed the COPDnet integrated care model and implemented it in two hospitals and affiliated primary care regions in the Netherlands. The COPDnet model consists of a comprehensive diagnostic trajectory ran in secondary care followed by a non-pharmacological intervention program of both monodisciplinary and multidisciplinary components.

OBJECTIVE

To assess the clinical effectiveness of the COPDnet integrated care model on health status change in patients with COPD.

METHODS

A total of 402 patients with COPD were offered care according to the COPDnet model. At baseline and between 7- and 9-months later health status was measured with the Clinical COPD Questionnaire (CCQ). Primary analysis was carried out for the sample at large. In addition, subgroup analyses were performed after stratification for the type of non-pharmacological intervention where patients had been referred to.

RESULTS

The CCQ total score improved statistically significantly from 1.94 ± 1.04 to 1.73 ± 0.96 (P < 0.01) in the 154 patients with valid follow-up measurements. Subgroup analyses revealed significant improvements in the patients receiving pulmonary rehabilitation only. No change in health status was found in patients receiving pharmacotherapy only, carried out self-treatment or who participated in mono-disciplinary primary care offered by allied healthcare professionals.

CONCLUSIONS

An improved health status was found in patients with COPD who received care according to the COPDnet integrated care model. Subgroups participating in an interdisciplinary pulmonary rehabilitation program predominantly accounted for this effect.

Managing Severe Chronic Breathlessness in Chronic Obstructive Pulmonary Disease Is Challenging for General Practitioners

CONTEXT

Patients with advanced chronic obstructive pulmonary disease (COPD) can develop increasing breathlessness, which can persist despite optimal medical management-refractory breathlessness. Management can be challenging for all clinicians and requires a broad approach that includes optimization of disease directed therapies, non-pharmacological strategies to manage breathlessness and for some patients opioids.

OBJECTIVES

To explore the approaches to breathlessness management and palliative care undertaken by Australian General Practitioners (GP) for patients with severe COPD and refractory breathlessness.

METHODS

A case-vignette based survey was conducted with Australian GPs to determine their approaches to breathlessness management and palliative care in COPD.

RESULTS

Of the 137 GPs, 66% recommended commencing an additional medication to manage refractory breathlessness. Thirty-eight GPs (28%) recommended opioids and 26 (19%) recommended guideline discordant treatments. Two-thirds of GPs had concerns regarding the use of opioids in COPD. Half (55%) of GPs were comfortable providing general palliative care to patients with COPD and 62 (45%) had referred patients with COPD to specialist palliative care services. Most respondents wanted further training to manage severe COPD and severe chronic breathlessness.

CONCLUSION

Most GPs recognized and were willing to add specific treatments for severe chronic breathlessness. However, experience prescribing opioids for severe chronic breathlessness was low, with many practitioners holding significant concerns regarding adverse effects. Many GPs are uncomfortable offering a palliative approach to their COPD patients, yet these patients are not routinely referred to specialist palliative care services despite their immense needs. GPs therefore desire education and support to overcome these barriers.

Description of Participation in Daily and Social Activities for Individuals with COPD

This study described the participation in daily and social activities and the perceived barriers and facilitators to participation of individuals with chronic obstructive pulmonary disease (COPD). Individuals, recruited from outpatient clinics, responded to a survey on their participation in, and barriers and facilitators towards, 26 daily and social activities, divided into 3 categories: (1) physical activity and movement (PAM); (2) self-care; and (3) social engagement. For each activity, chi-square analyses were used to examine participation differences by individuals': quartiles of airflow obstruction [percent predicted forced expiratory volume in 1 second (FEV1%predicted)] and breathlessness burden and exacerbation risk. Of the 200 participants (47% women; mean ± standard deviation age = 68 ± 9 years), most wanted to increase their participation in PAM activities (range 21-75%) and significant differences were found in 5/10 PAM activities for individuals' breathlessness burden and exacerbation risk (e.g., more individuals than expected in group A (modified Medical Research Council breathlessness score <2 and 0-1 exacerbations in past 12 months) participated in regular exercise as much as they wanted (χ₍₉₎²=20.43, Cramer's V=.23)). Regardless of the degree of airflow obstruction or breathlessness burden and exacerbation risk, the most common barrier to participation was breathlessness (p<.001, η²_p=.86) and the most common facilitator was engaging as part of their routine (p<.001, η²_p=.75). Individuals with COPD want to increase their participation in daily and social activities but are limited by breathlessness. Strategies to alleviate breathlessness should be identified/prioritized and incorporated into individuals' daily routines to meet their self-reported participation objectives in daily and social activities.

"So, I try not to go …" Acute-On-Chronic Breathlessness and Presentation to the Emergency Department: In-depth Interviews With Patients, Carers, and Clinicians

CONTEXT

People with acute-on-chronic breathlessness due to cardiorespiratory conditions frequently present to the emergency department (ED) causing burden for the person concerned, their care takers, and emergency services.

OBJECTIVE

To understand the reasons for ED presentation for acute-on-chronic breathlessness and how optimal care might avoid presentations.

METHODS

Qualitative in-depth linked interviews were conducted as part of a mixed-methods study. Transcripts of audio-recordings were subjected to thematic analysis. Consenting patients presenting to a single tertiary hospital ED with acute-on-chronic breathlessness able to be interviewed were eligible. Patient-participants (n = 18) were purposively sampled for maximum variation. Patient-participant-nominated carers (n = 9) and clinicians (n = 8) were recruited.

RESULTS

Theme 1: "The context for the decision to present to the ED" is the experience of acute-on-chronic breathlessness, in which a person faces an existential crisis not knowing where the next breath is coming from, and previous help-seeking experiences. Theme 2 ("Reasons for presentation"): Some were reluctant to seek help until crisis when family carers were often involved in the decision to present. Others had previous poor experiences of help-seeking for breathlessness in the community and turned to the ED by default. Some had supportive primary clinicians and presented to the ED either on their clinician's recommendation or because their clinician was unavailable.

CONCLUSIONS

The decision to present to the ED is made in the context of serious crisis and previous experiences. Discussion of the reason for presentation may enable better management of chronic breathlessness and reduce the need for future emergency presentation.

Living with Advanced Chronic Obstructive Pulmonary Disease: A Qualitative Interview Study with Patients and Informal Carers

The disease trajectory in chronic obstructive pulmonary disease (COPD) is characterised by a progressive decline in overall function, loss of independence and reduction of health-related quality of life. Although the symptom burden is high and care is often demanding, patients' and informal carers' experiences in living with advanced COPD are seldom described. This study sought to explore patients' and informal carers' experiences in living with advanced COPD and to understand their awareness about palliative care provision in advanced COPD. About 20 patients and 20 informal carers were recruited in a respiratory care service in Southern Switzerland. Semistructured individual interviews with participants were conducted on clinic premises and audio-recorded. Interviews lasted between 35 and 45 min. Data were analysed using thematic analysis. Living day to day with COPD, psychosocial dimension of the disease and management of complex care were the main themes identified. Patients and informal carers reported a range of psychological challenges, with feelings of guilt, discrimination and blame. Most of the participants had no knowledge of palliative care and healthcare services did not provide them with any information about palliative care approaches in advanced COPD. The reported psychological challenges may influence the relationship between patients, informal carers and healthcare professionals, adding further complexity to the management of this long-term condition. Further research is needed to explore new ways of managing complex care in advanced COPD and to define how palliative care may be included in this complex care network.