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Drury A, Goss J, Afolabi J, McHugh G, O’Leary N, Brady AM. A Mixed Methods Evaluation of a Pilot Multidisciplinary Breathlessness Support Service. EVALUATION REVIEW 2023; 47:820-870. [PMID: 37014066 PMCID: PMC10492442 DOI: 10.1177/0193841x231162402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Breathlessness support services have demonstrated benefits for breathlessness mastery, quality of life and psychosocial outcomes for people living with breathlessness. However, these services have predominantly been implemented in hospital and home care contexts. This study aims to evaluate the adaptation and implementation of a hospice-based outpatient Multidisciplinary Breathlessness Support Service (MBSS) in Ireland. A sequential explanatory mixed methods design guided this study. People with chronic breathlessness participated in longitudinal questionnaires (n = 10), medical record audit (n = 14) and a post-discharge interview (n = 8). Caregivers (n = 1) and healthcare professionals involved in referral to (n = 2) and delivery of (n = 3) the MBSS participated in a cross-sectional interview. Quantitative and qualitative data were integrated deductively via the pillar integration process, guided by the RE-AIM framework. Integration of mixed methods data enhanced understanding of factors influencing the reach, adoption, implementation and maintenance of the MBSS, and the potential outcomes that were most meaningful for service users. Potential threats to the sustainability of the MBSS related to potential preconceptions of hospice care, the lack of standardized discharge pathways from the service and access to primary care services to sustain pharmacological interventions. This study suggests that an adapted multidisciplinary breathlessness support intervention is feasible and acceptable in a hospice context. However, to ensure optimal reach and maintenance of the intervention, activities are required to ensure that misconceptions about the setting do not influence willingness to accept referral to MBSS services and integration of services is needed to enable consistency in referral and discharge processes.
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Affiliation(s)
- Amanda Drury
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
- School of Nursing, Psychotherapy and Community Health, Dublin City University, Dublin, Ireland
| | - Julie Goss
- Our Lady’s Hospice and Care Services, Dublin, Ireland
| | - Jide Afolabi
- Our Lady’s Hospice and Care Services, Dublin, Ireland
| | | | - Norma O’Leary
- Our Lady’s Hospice and Care Services, Dublin, Ireland
| | - Anne-Marie Brady
- Trinity Centre Practice & Healthcare Innovation, School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland
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Obarzanek L, Wu W, Tutag-Lehr V. Opioid Management of Dyspnea at End of Life: A Systematic Review. J Palliat Med 2022; 26:711-726. [PMID: 36453988 DOI: 10.1089/jpm.2022.0311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective: The objective of this systematic review is to consolidate the existing evidence on opioid use, including administration, dosing, and efficacy, for the relief of dyspnea at end of life. The overarching goal is to optimize clinical management of dyspnea by identifying patterns in opioid use, improving opioid management of dyspnea, and to prioritize future research. Background: Opioids are commonly used in the management of dyspnea at end of life, yet specific administration guidelines are limited. A greater understanding of the effectiveness of opioids in relieving end-of-life dyspnea with consideration of study design, patients, and opioids, including dyspnea evaluation tools and outcomes, will leverage development of standardized administration and dosing. Methods: A PRISMA-guided systematic review using six databases identified quality studies of opioid management for patients with dyspnea at end of life. Results: Twenty-three references met review inclusion criteria, which included terminally ill cancer and noncancer patients with various diagnoses. Studies included two randomized controlled trials, and three nonrandomized experimental, three prospective observational, one cross-sectional, and one case series. Thirteen retrospective chart reviews were also included due to the limited rigorous studies rendered by the search. Thirteen studies evaluated morphine, followed by fentanyl (6), oxycodone (5), general opioid use (4), and hydromorphone (2). Routes of administration were parenteral, oral, combination, and nebulization. Dyspnea was evaluated using self-reporting and non-self-reporting evaluation tools. Sedation was the most reported opioid-related adverse effect. Discussion: Challenges persist in conducting end-of-life research, preventing consensus on standardization of opioid treatment for dyspnea within this specific palliative time frame. Future robust prospective trials using specific, accurate assessment with reassessment of dyspnea/respiratory distress, and consideration of opioid tolerance, polypharmacy, and comorbidities are required.
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Affiliation(s)
| | - Wendy Wu
- Shiffman Medical Library, Wayne State University, Detroit, Michigan, USA
| | - Victoria Tutag-Lehr
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
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Schunk M, Berger U, Le L, Rehfuess E, Schwarzkopf L, Streitwieser S, Müller T, Hofmann M, Holle R, Huber RM, Mansmann U, Bausewein C. BreathEase: rationale, design and recruitment of a randomised trial and embedded mixed-methods study of a multiprofessional breathlessness service in early palliative care. ERJ Open Res 2021; 7:00228-2020. [PMID: 34671668 PMCID: PMC8521025 DOI: 10.1183/23120541.00228-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/19/2021] [Indexed: 11/18/2022] Open
Abstract
Background The Munich Breathlessness Service has adapted novel support services to the German context, to reduce burden in patients and carers from breathlessness in advanced disease. It has been evaluated in a pragmatic fast-track randomised controlled trial (BreathEase; NCT02622412) with embedded qualitative interviews and postal survey. The aim of this article is to describe the intervention model and study design, analyse recruitment to the trial and compare sample characteristics with other studies in the field. Methods Analysis of recruitment pathways and enrolment, sociodemographic and clinical characteristics of participants and carers. Results Out of 439 people screened, 253 (58%) were offered enrolment and 183 (42%) participated. n=97 (70%) carers participated. 186 (42%) people did not qualify for inclusion, mostly because breathlessness could not be attributed to an underlying disease. All participants were self-referring; 60% through media sources. Eligibility and willingness to participate were associated to social networks and illness-related activities as recruitment routes. Mean age of participants was 71 years (51% women), with COPD (63%), chronic heart failure (8%), interstitial lung disease (9%), pulmonary hypertension (6%) and cancer (7%) as underlying conditions. Postal survey response rate was 89%. Qualitative interviews were conducted with 16 patients and nine carers. Conclusion The BreathEase study has a larger and more heterogeneous sample compared to other trials. The self-referral-based and prolonged recruitment drawing on media sources approximates real-world conditions of early palliative care. Integrating qualitative and quantitative components will allow a better understanding and interpretation of the results of the main effectiveness study. The BreathEase study, a mixed-methods pragmatic RCT evaluating the Munich Breathlessness Service, included a heterogeneous sample that approximates real-world conditions of early palliative care, and ran qualitative and quantitative trial siblingshttps://bit.ly/375nCMO
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Affiliation(s)
- Michaela Schunk
- Dept of Palliative Medicine, LMU Hospital, LMU Munich, Munich, Germany.,Pettenkofer School of Public Health, Munich, Germany
| | - Ursula Berger
- Pettenkofer School of Public Health, Munich, Germany.,Faculty of Medicine, Institute for Medical Information Processing, Biometry and Epidemiology, LMU Munich, Munich, Germany
| | - Lien Le
- Faculty of Medicine, Institute for Medical Information Processing, Biometry and Epidemiology, LMU Munich, Munich, Germany
| | - Eva Rehfuess
- Pettenkofer School of Public Health, Munich, Germany.,Faculty of Medicine, Institute for Medical Information Processing, Biometry and Epidemiology, LMU Munich, Munich, Germany
| | - Larissa Schwarzkopf
- Health Economics and Health Care Management (IGM), Helmholtz Zentrum München GmbH, German Research Center for Environmental Health, Munich, Germany.,Institut für Therapieforschung, Munich, Germany
| | | | - Thomas Müller
- Faculty of Medicine, Institute for Medical Information Processing, Biometry and Epidemiology, LMU Munich, Munich, Germany
| | - Miriam Hofmann
- Faculty of Medicine, Institute for Medical Information Processing, Biometry and Epidemiology, LMU Munich, Munich, Germany
| | - Rolf Holle
- Pettenkofer School of Public Health, Munich, Germany.,Health Economics and Health Care Management (IGM), Helmholtz Zentrum München GmbH, German Research Center for Environmental Health, Munich, Germany
| | - Rudolf Maria Huber
- Dept of Medicine V, LMU Hospital, LMU Munich, Munich, Germany.,Member of the German Center of Lung Research (DZL, CPC-M), Munich, Germany
| | - Ulrich Mansmann
- Pettenkofer School of Public Health, Munich, Germany.,Faculty of Medicine, Institute for Medical Information Processing, Biometry and Epidemiology, LMU Munich, Munich, Germany
| | - Claudia Bausewein
- Dept of Palliative Medicine, LMU Hospital, LMU Munich, Munich, Germany
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Schunk M, Le L, Syunyaeva Z, Haberland B, Tänzler S, Mansmann U, Schwarzkopf L, Seidl H, Streitwieser S, Hofmann M, Müller T, Weiß T, Morawietz P, Rehfuess EA, Huber RM, Berger U, Bausewein C. Effectiveness of a specialised breathlessness service for patients with advanced disease in Germany: a pragmatic fast-track randomised controlled trial (BreathEase). Eur Respir J 2021; 58:13993003.02139-2020. [PMID: 33509957 DOI: 10.1183/13993003.02139-2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 01/12/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND The effectiveness of the Munich Breathlessness Service (MBS), integrating palliative care, respiratory medicine and physiotherapy, was tested in the BreathEase trial in patients with chronic breathlessness in advanced disease and their carers. METHODS BreathEase was a single-blinded randomised controlled fast-track trial. The MBS was attended for 5-6 weeks; the control group started the MBS after 8 weeks of standard care. Randomisation was stratified by cancer and the presence of a carer. Primary outcomes were patients' mastery of breathlessness (Chronic Respiratory Disease Questionnaire (CRQ) Mastery), quality of life (CRQ QoL), symptom burden (Integrated Palliative care Outcome Scale (IPOS)) and carer burden (Zarit Burden Interview (ZBI)). Intention-to-treat (ITT) analyses were conducted with hierarchical testing. Effectiveness was investigated by linear regression on change scores, adjusting for baseline scores and stratification variables. Missing values were handled with multiple imputation. RESULTS 92 patients were randomised to the intervention group and 91 patients were randomised to the control group. Before the follow-up assessment after 8 weeks (T1), 17 and five patients dropped out from the intervention and control groups, respectively. Significant improvements in CRQ Mastery of 0.367 (95% CI 0.065-0.669) and CRQ QoL of 0.226 (95% CI 0.012-0.440) score units at T1 in favour of the intervention group were seen in the ITT analyses (n=183), but not in IPOS. Exploratory testing showed nonsignificant improvements in ZBI. CONCLUSIONS These findings demonstrate positive effects of the MBS in reducing burden caused by chronic breathlessness in advanced illness across a wide range of patients. Further evaluation in subgroups of patients and with a longitudinal perspective is needed.
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Affiliation(s)
- Michaela Schunk
- Dept of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany .,Pettenkofer School of Public Health, Munich, Germany
| | - Lien Le
- Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Zulfiya Syunyaeva
- Dept of Medicine V, University Hospital, LMU Munich, Munich, Germany.,Member of the German Center for Lung Research (DZL), Comprehensive Pneumology Center Munich, Munich, Germany
| | - Birgit Haberland
- Dept of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Susanne Tänzler
- Dept of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Ulrich Mansmann
- Pettenkofer School of Public Health, Munich, Germany.,Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Larissa Schwarzkopf
- Member of the German Center for Lung Research (DZL), Comprehensive Pneumology Center Munich, Munich, Germany.,Health Economics and Health Care Management (IGM), Helmholtz Zentrum München (GmbH), German Research Center for Environmental Health, Munich, Germany.,IFT (Institut für Therapieforschung), Munich, Germany
| | - Hildegard Seidl
- Pettenkofer School of Public Health, Munich, Germany.,Health Economics and Health Care Management (IGM), Helmholtz Zentrum München (GmbH), German Research Center for Environmental Health, Munich, Germany.,Quality Management and Gender Medicine, München Klinik gGmbH, Munich, Germany
| | - Sabine Streitwieser
- Dept of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Miriam Hofmann
- Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Thomas Müller
- Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Tobias Weiß
- Atem-und Physiotherapie Solln, Munich, Germany
| | | | - Eva Annette Rehfuess
- Pettenkofer School of Public Health, Munich, Germany.,Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Rudolf Maria Huber
- Dept of Medicine V, University Hospital, LMU Munich, Munich, Germany.,Member of the German Center for Lung Research (DZL), Comprehensive Pneumology Center Munich, Munich, Germany
| | - Ursula Berger
- Pettenkofer School of Public Health, Munich, Germany.,Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Claudia Bausewein
- Dept of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
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