Cancer nursing practice development: understanding breathlessness

Experiences of non-specialist nurses caring for patients and their significant others undergoing transitions during palliative end-of-life cancer care: a systematic review

BACKGROUND

Non-specialist nurses, who are providing palliative end-of-life cancer care to patients and significant others undergoing psychosocial and existential transitions, may experience dissatisfaction, frustration and sorrow. On the other hand, they may also experience happiness, increased knowledge and personal growth.

OBJECTIVE/QUESTION

What are non-specialist nurses' experiences when providing palliative end-of-life cancer care that involves the psychosocial and existential transitions of their patients and significant others?

INCLUSION CRITERIA TYPES OF PARTICIPANTS

The current review considered studies that included a description of the experiences of non-specialist trained registered nurses (RNs) working in non-specialist wards.

PHENOMENA OF INTEREST

The current review considered studies that investigated experiences of RNs when providing palliative end-of-life cancer care that involves the psychosocial and existential transitions of their patients and significant others.

CONTEXT

The contact and care for patients and their significant others during palliative end-of-life cancer care.

TYPES OF STUDIES

The current review considered studies that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.

SEARCH STRATEGY

The search aimed at finding both published and unpublished studies in English, Danish, Norwegian, Swedish and German, and was unrestricted by time. Eleven electronic databases and seven websites were searched.

METHODOLOGICAL QUALITY

Methodological validity of the qualitative papers was assessed independently by two reviewers using the standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI).

DATA EXTRACTION

Data were extracted from papers included in the review using the standardized data extraction tool from the JBI-QARI.

DATA SYNTHESIS

Qualitative research findings were synthesized using the JBI-QARI.

RESULTS

A total of 81 findings were extracted from the three studies and allocated to five categories and merged into a meta-synthesis with the overarching synthesized finding related to the challenges that non-specialist nurses faced when providing palliative end-of-life cancer care. The summary of findings is illustrated below.

CONCLUSION

The studies in this review provided useful and credible statements from non-specialist nurses working in non-specialist wards about their challenges when providing palliative end-of-life cancer care to patients and their significant others undergoing psychosocial and existential transitions.

Dissemination and utilization of an intervention to manage breathlessness: Letting go or letting down?

The relationship between research and practice development has not always been a close one. Researchers focus upon the production of new knowledge to create the evidence base upon which the development of practice is taken forward, usually by other people within the clinical area. Work being undertaken at the Macmillan Practice Development Unit (MPDU) in London about the dissemination and utilisation of evidence concerning the management of breathlessness has raised a number of issues. These concern the confidence of practitioners to take on new approaches within the practice sphere, their desire for accredited education, and questions about responsibility for, and ownership of, the dissemination process. Different values about the nature of learning are explored here, which may explain the dissonance between practitioner and researcher expectations about the dissemination and utilisation process.

[Changes in quality of life and anxiety of lung cancer patients underwent chemotherapy]

背景与目的

通过观察肺癌患者化疗前后生活质量及焦虑情绪的改变，探讨化疗对肺癌患者生活质量及焦虑情绪的影响。

方法

随机抽取住院化疗的肺癌患者58例，分别于化疗前、化疗后2周期1星期内、化疗后4周期1星期内评估临床疗效，并进行肺癌患者生活质量量表（QLQ-C30）和ZUNG焦虑自评量表（SAS）评分。

结果

化疗前，生活质量功能领域、疲乏、呼吸困难条目得分较高，有焦虑情绪的占56%，SAS得分为49.54±5.64；焦虑症状与失眠轻度相关（P < 0.05）；化疗后2周期，呼吸困难得分下降，失眠、食欲丧失得分上升，较化疗前相比差异有统计学意义（P < 0.05）；有焦虑情绪的占80%，SAS得分为52.48±6.10，较化疗前相比差异有统计学意义（P < 0.05）；有基础病患者SAS得分高于无基础病患者，差异有统计学意义（P < 0.05）；焦虑症状与疲乏、呼吸困难轻度相关（P < 0.05）。化疗后4周期，躯体、角色、情绪、社会功能得分下降明显，恶心呕心、食欲不振、便秘、经济困难条目得分上升，较化疗后2周期相比差异有统计学意义（P < 0.05）；有焦虑情绪的占72%，SAS得分为54.82±6.55，较化疗后2周期相比无统计学差异；SAS得分与KPS呈负相关（P < 0.05）；焦虑症状与疲乏、失眠相关（P < 0.01），与便秘轻度相关（P < 0.05）。

结论

化疗过程中，部分肺癌患者躯体症状得到缓解，焦虑情绪明显增加，生活质量有所下降，医务工作者应及时评价患者生活质量及情绪改变，提高患者生活质量，积极地对患者进行心理疏导治疗。

The lived experience of breathlessness and its implications for care: a qualitative comparison in cancer, COPD, heart failure and MND

BACKGROUND

Breathlessness is one of the core symptoms, particularly persistent and frequent, towards the end of life. There is no evidence of how the experience of breathlessness differs across conditions. This paper compares the experience of breathlessness in cancer, COPD, heart failure and MND, four conditions sharing heavy symptom burdens, poor prognoses, high breathlessness rates and palliative care needs.

METHODS

For this qualitative study a purposive sample of 48 patients was included with a diagnosis of cancer (10), COPD (18), heart failure (10) or MND (10) and experiencing daily problems of breathlessness. Patients were recruited from the respective clinics at the hospital; specialist nurses' ward rounds and consultations, and "Breathe Easy" service users meetings in the community. Data were collected through semi-structured, in-depth interviews and participant observation. Breathlessness was compared according to six components derived from explanatory models and symptom schemata, first within groups and then across groups. Frequency counts were conducted to check the qualitative findings.

RESULTS

All conditions shared the disabling effects of breathlessness. However there were differences between the four conditions, in the specific constraints of the illness and patients' experiences with the health care context and social environment. In cancer, breathlessness signalled the (possible) presence of cancer, and functioned as a reminder of patients' mortality despite the hopes they put in surgery, therapies and new drugs. For COPD patients, breathlessness was perceived as a self-inflicted symptom. Its insidious nature and response from services disaffirmed their experience and gradually led to greater disability in the course of illness. Patients with heart failure perceived breathlessness as a contributing factor to the negative effects of other symptoms. In MND breathlessness meant that the illness was a dangerous threat to patients' lives. COPD and heart failure had similar experiences.

CONCLUSION

Integrated palliative care is needed, that makes use of all appropriate therapeutic options, collaborative efforts from health, social care professionals, patients and caregivers, and therapies that acknowledge the dynamic interrelation of the body, mind and spirit.

The lived experience of breathlessness and its implications for care: a qualitative comparison in cancer, COPD, heart failure and MND

BACKGROUND

Breathlessness is one of the core symptoms, particularly persistent and frequent, towards the end of life. There is no evidence of how the experience of breathlessness differs across conditions. This paper compares the experience of breathlessness in cancer, COPD, heart failure and MND, four conditions sharing heavy symptom burdens, poor prognoses, high breathlessness rates and palliative care needs.

METHODS

For this qualitative study a purposive sample of 48 patients was included with a diagnosis of cancer (10), COPD (18), heart failure (10) or MND (10) and experiencing daily problems of breathlessness. Patients were recruited from the respective clinics at the hospital; specialist nurses' ward rounds and consultations, and "Breathe Easy" service users meetings in the community. Data were collected through semi-structured, in-depth interviews and participant observation. Breathlessness was compared according to six components derived from explanatory models and symptom schemata, first within groups and then across groups. Frequency counts were conducted to check the qualitative findings.

RESULTS

All conditions shared the disabling effects of breathlessness. However there were differences between the four conditions, in the specific constraints of the illness and patients' experiences with the health care context and social environment. In cancer, breathlessness signalled the (possible) presence of cancer, and functioned as a reminder of patients' mortality despite the hopes they put in surgery, therapies and new drugs. For COPD patients, breathlessness was perceived as a self-inflicted symptom. Its insidious nature and response from services disaffirmed their experience and gradually led to greater disability in the course of illness. Patients with heart failure perceived breathlessness as a contributing factor to the negative effects of other symptoms. In MND breathlessness meant that the illness was a dangerous threat to patients' lives. COPD and heart failure had similar experiences.

CONCLUSION

Integrated palliative care is needed, that makes use of all appropriate therapeutic options, collaborative efforts from health, social care professionals, patients and caregivers, and therapies that acknowledge the dynamic interrelation of the body, mind and spirit.

Non-invasive interventions for improving well-being and quality of life in patients with lung cancer

BACKGROUND

This is an updated version of the original review published in Issue 4, 2004 of The Cochrane Library. Lung cancer is one of the leading causes of death globally. Despite advances in treatment, the outlook for the majority of patients remains grim and most face a pessimistic future accompanied by sometimes devastating effects on emotional and psychological health. Although chemotherapy is accepted as an effective treatment for advanced lung cancer, the high prevalence of treatment-related side effects as well the symptoms of disease progression highlight the need for high-quality palliative and supportive care to minimise symptom distress and to promote quality of life.

OBJECTIVES

To assess the effectiveness of non-invasive interventions delivered by healthcare professionals in improving symptoms, psychological functioning and quality of life in patients with lung cancer.

SEARCH STRATEGY

We ran a search in February 2011 to update the original completed review. We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 2), MEDLINE (accessed through PubMed), EMBASE, PsycINFO, AMED, British Nursing Index and Archive (accessed through Ovid) and reference lists of relevant articles; we also contacted authors.

SELECTION CRITERIA

Randomised or quasi-randomised clinical trials assessing the effects of non-invasive interventions in improving well-being and quality of life in patients diagnosed with lung cancer.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed relevant studies for inclusion. Data extraction and risk of bias assessment of relevant studies was performed by one author and checked by a second author.

MAIN RESULTS

Fifteen trials were included, six of which were added in this update. Three trials of a nursing intervention to manage breathlessness showed benefit in terms of symptom experience, performance status and emotional functioning. Four trials assessed structured nursing programmes and found positive effects on delay in clinical deterioration, dependency and symptom distress, and improvements in emotional functioning and satisfaction with care.Three trials assessed the effect of different psychotherapeutic, psychosocial and educational interventions in patients with lung cancer. One trial assessing counselling showed benefit for some emotional components of the illness but findings were not conclusive. One trial examined the effects of coaching sensory self monitoring and reporting on pain-related variables and found that although coaching increases the amount of pain data communicated to providers by patients with lung cancer, the magnitude of the effect is small and does not lead to improved efficacy of analgesics prescribed for each patient's pain level. One trial compared telephone-based sessions of either caregiver-assisted coping skills training (CST) or education/support involving the caregiver and found that patients in both treatment conditions showed improvements in pain, depression, quality of life and self efficacy.Two trials assessed exercise programmes; one found a beneficial effect on self empowerment and the other study showed an increase in quadriceps strength but no significant changes for any measure of quality of life. One trial of nutritional interventions found positive effects for increasing energy intake, but no improvement in quality of life. Two small trials of reflexology showed some positive but short-lasting effects on anxiety and pain intensity.The main limitations of the studies included were the variability of the interventions assessed and the approaches to measuring the considered outcomes, and the lack of data reported in the trials regarding allocation of patients to treatment groups and blinding.

AUTHORS' CONCLUSIONS

Nurse follow-up programmes and interventions to manage breathlessness may produce beneficial effects. Counselling may help patients cope more effectively with emotional symptoms, but the evidence is not conclusive. Other psychotherapeutic, psychosocial and educational interventions can play some role in improving patients' quality of life. Exercise programmes and nutritional interventions have not shown relevant and lasting improvements of quality of life. Reflexology may have some beneficial effects in the short term.

Dyspnea experience and management strategies in patients with lung cancer

OBJECTIVE

The aim of this paper was to describe lung cancer patients' experience of dyspnea and their strategies for managing the dyspnea.

METHODS

Semi-structured interviews with two main questions about dyspnea experiences and management were conducted with 20 patients with lung cancer, not amenable to curative treatment, who had completed life prolonging treatments. Data analysis was made with a descriptive, qualitative content analysis.

RESULTS

The two questions resulted in two domains with 7 categories and subcategories. The experience of dyspnea included four categories: 'Triggering factors' included circumstances contributing to dyspnea, which comprised physical, psychosocial and environmental triggers. Bodily manifestations were considered to be the core of the experience. 'Immediate reactions' concerned physical and psychological impact. The long-term reactions included limitations, increased dependence and existential impact concerning hope, hopelessness and thoughts of death. The experience of managing dyspnea included three categories: 'Bodily strategies', 'psychological strategies' and 'medical strategies'.

CONCLUSION

Dyspnea experience is a complex experience which influences the life of the patients both with immediate reactions and long-term reactions concerning physical, emotional and existential issues in life and patients address this experience with managing strategies in order to take control of their situation, although they do not seem to be able to meet the existential distress they experience.

Perceptions of Dyspnea and Helpful Interventions During the Advanced Stage of Lung Cancer

Dyspnea is a distressful but neglected symptom in oncology practice and research. The aim of this study was to describe the experience of dyspnea and helpful interventions in Chinese patients with advanced lung cancer admitted in the palliative care unit in 1 region in Hong Kong. A qualitative description approach using in-depth interviews was used to guide this study. Eleven participants agreed to be interviewed with age ranging from 51 to 80 years. They have been diagnosed with lung cancer from 1 to 12 months, and all required oxygen therapy from dyspnea. The results of content analysis revealed 4 main themes: (1) characteristics of dyspnea, (2) impact of dyspnea, (3) strategies used to manage dyspnea, and (4) nurses' role in managing dyspnea. Patients in this study found no Chinese words to adequately define and describe dyspnea and relied on sensations they experienced during the dyspnea episode. The impact of dyspnea was multidimensional, and patients used various strategies to manage dyspnea, including avoiding triggers and utilizing traditional Chinese medicine. Healthcare professionals were perceived to play a very inadequate role in assisting patients with dyspnea, and participants suggested that they should take a more active role in educating and supporting patients with dyspnea.

End of life care: a discursive analysis of specialist palliative care nursing

AIM

The aim of this paper is to consider alternative approaches to service delivery for patients with chronic life-limiting illnesses other than cancer. It will also discuss the issues that arise when considering specialist palliative care services within a broader public health context in the United Kingdom.

BACKGROUND

Contemporary specialist palliative care in the United Kingdom can be said to have two main client groups: the majority are people with a diagnosis of cancer, and a minority are those with a number of other chronic illnesses. From the evidence to date, patients dying from chronic, non-malignant disease experience a considerable number of unmet needs in terms of symptom control and psychosocial support. Although debates in the literature over the last decade have challenged the focus of specialist palliative care services on patients with a cancer diagnosis, only a minority of those with other chronic illnesses receive specialist palliative care services.

DISCUSSION

Current models of specialist palliative care may not be the most appropriate for addressing the complex problems experienced by the many patients with a non-cancer diagnosis. We suggest that care should be structured around patient problems, viewing specialist palliative care as a service for those with complex end of life symptoms or problems. A role for innovative nurse-led care is proposed.

CONCLUSION

Reframing the approach to specialist palliative care in the United Kingdom will require great effort on the part of all health and social care professionals, not least nurses. Critical and creative thinking are prerequisites to the development of new models of working. We suggest that a more coherent approach to research and education is required, in particular strategies that explore how patients and nurses can work together in exploring experiences of illness in order to develop more proactive approaches to care.

Symptoms in patients with lung carcinoma

BACKGROUND

The patient perspective on distress associated with lung carcinoma is important, yet understudied. Previous research on symptom experience generally had not differentiated the dimension symptom intensity/frequency from which symptoms are associated with most distress. The objective of the current study was to determine whether patterns of symptom intensity were similar to patterns of symptom distress, whether patterns were consistent at different time points, whether patterns varied by subgroups, and whether high symptom intensity was equivalent to distress.

METHODS

Four hundred adults who were newly diagnosed with inoperable lung carcinoma completed a measure of symptom intensity/frequency and a new measure of distress associated with symptoms at six time points during the first year after diagnosis. These data were supplemented by field notes by research nurses and by less structured, qualitative interviews.

RESULTS

The mean ranking of distress in the total group and in all subgroups remained constant at all time points, with breathing, pain, and fatigue associated with the most distress. In contrast, the pattern of mean rank order of symptom intensity showed little consistency; however, fatigue had the highest intensity scores at all time points.

CONCLUSIONS

The current data challenged the uncritical use of summated scores of different symptom items in the context of lung carcinoma. Breathing and pain appeared to function as icons representing threats associated with lung carcinoma, with distress described as related to the past and the present and to expectations for the future. One of the most promising implications of these data was in fostering a preventive paradigm for symptom palliation.

Palliative care for breathless patients in the community

Breathlessness is one of the commonest symptoms experienced by people receiving palliative care. However, misunderstanding of the nature of palliative care may hinder assessment, management and evaluation of care and may contribute to the fear associated with living with breathlessness in the community. Knowledge of related anatomy and physiology of breathlessness is vital in informing nursing care and interventions. Pharmacological interventions have their place, but the focus of nursing care should be on systematic holistic assessment. Using this, nurses should adopt a proactive role in supporting and helping patients to adapt to change by maximizing coping strategies.

Non-invasive interventions for improving well-being and quality of life in patients with lung cancer

BACKGROUND

Lung cancer is one of the leading causes of death globally. Despite advances in treatment, outlook for the majority of patients remains grim and most face a pessimistic outlook accompanied by sometimes devastating effects on emotional and psychological health. Although chemotherapy is accepted as an effective treatment for advanced lung cancer, the high prevalence of treatment-related side effects as well the symptoms of disease progression highlight the need for high quality palliative and supportive care to minimise symptom distress and to promote quality of life.

OBJECTIVES

To assess the effectiveness of non-invasive interventions delivered by healthcare professionals in improving symptoms, psychological functioning and quality of life in patients with lung cancer.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2003), MEDLINE (1966-March 2003), EMBASE (1974-March 2003), CINAHL (1982-September 2002), CancerLit (1975-October 2002), PsycINFO (1873-March 2003), reference lists of relevant articles and contact with authors.

SELECTION CRITERIA

Randomised or quasi-randomised clinical trials assessing the effects of non-invasive interventions in improving well-being and quality of life in patients diagnosed with lung cancer.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed relevant studies for inclusion. Data extraction and quality assessment of relevant studies was performed by one reviewer and checked by a second reviewer.

MAIN RESULTS

Nine trials were included and categorised into six groups. Two trials of a nursing intervention to manage breathlessness showed benefit on symptom experience, performance status and emotional functioning. Three trials assessed structured nursing programmes and found positive effects on delay in clinical deterioration, dependency and symptom distress, and improvements in emotional functioning and satisfaction with care. One trial assessing counselling showed benefit on some emotional components of the illness but findings were not conclusive. One trial assessing an exercise programme, found a beneficial effect on self-empowerment. One trial of nutritional interventions found positive effects for increasing energy intake, but no improvement in quality of life. One trial of reflexology showed some positive, but short-lasting effects on anxiety.

REVIEWERS' CONCLUSIONS

Nurse follow-up programmes and a nurse intervention to manage breathlessness may produce beneficial effects. Psychotherapeutic study indicates that counselling may help patients cope more effectively with emotional symptoms, but the evidence is not conclusive. Findings from the included studies reinforce the necessity for increased training and education of healthcare professionals giving in these interventions. More research, of higher methodological quality is needed in this area to explore possible underlying explanatory mechanisms.

Dyspnea: the continuing challenge of palliative management

The management of dyspnea is a challenge even for the most experienced palliative medicine teams. In the absence of effective treatment for the underlying disease, therapeutic options are limited to the supplementation of oxygen, the use of opioids, and multidisciplinary nonpharmacologic interventions. There is increased research into both the physiology of dyspnea and the correlates of the symptom in advanced disease. Hopefully, this research will lead to improved therapy in the future. This article reviews current literature on dyspnea with a focus on publications in 2001.

Improving the management of breathlessness using a clinical effectiveness programme

Breathlessness represents a significant problem for the person with advanced cancer. Uncontrolled breathlessness ranks highly in terms of uncomfortable symptoms experience, causing pain and distress to the patient and resulting in significant anxiety to their carers. The key to the provision of effective care lies in the informed application of the nursing process, underpinned by a sound knowledge base in relation to the nursing management of breathlessness. Theoretical knowledge enables nursing staff to offer appropriate interventions for the management of breathlessness in collaboration with other members of the multidisciplinary team. This article will discuss the cause and management of breathlessness in the person with advanced cancer; the discussion focuses on the application of research-based interventions and the evaluation of clinical outcomes in a UK clinical governance context.