Narratives of breathlessness in chronic obstructive pulmonary disease

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Acceptance and adherence to non-invasive positive pressure ventilation in people with chronic obstructive pulmonary disease: a grounded theory study

Introduction

Non-Invasive Positive Pressure Ventilation (NPPV) is an established treatment for people with Chronic Obstructive Pulmonary Disease (COPD), but it is often improperly used or rejected. The patterns of acceptance and adherence to NPPV, conceiving constraints, and strengths related to its adaptation have not been explored from a qualitative perspective yet.

Objectives

This study aims to qualitatively explore patterns of adaptation to NPPV in people affected by COPD and to identify the core characteristics and the specific adaptive challenges during the adaptation process.

Methods

Forty-two people with moderate or severe COPD were recruited and 336 unstructured interviews were conducted. A Constructivist Grounded Theory was used to gather and analyze data: the transcriptions were mutually gathered in open, selective, and theoretical phases, with open, selective, and theoretical coding, respectively.

Results

The analysis resulted in a non-linear and dynamic process, characterized by three phases: deciding, trying NPPV, and using NPPV. The patterns revealed that positive and negative NPPV experiences, together with beliefs, emotions, stressful mental states, and behaviors result in different acceptance and adherence rates.

Discussions

These findings may be helpful to implement new care strategies to promote acceptance and adherence to NPPV.

A Systematic Review with Thematic Synthesis of the Experience of Hospitalization in People with Advanced Chronic Obstructive Pulmonary Disease

Hospital admissions are common for people with advanced chronic obstructive pulmonary disease (COPD). To provide effective, responsive care, it is important to understand how people experience hospitalization. The aim of this review was to explore the experience of hospitalization in people with advanced COPD, drawing from qualitative research data. Guided by a thematic synthesis approach, a systematic search of databases (n = 13) including PubMed, CINAHL, PsycINFO and ProQuest was undertaken from database inception to May 2020. Inclusion criteria included papers reporting qualitative research focused on any aspect of hospitalization for people with advanced COPD and reported in English language from peer reviewed journals. Following quality appraisal, relevant data were extracted, and a three-stage thematic synthesis method used to develop inductive themes. From 1935 papers, the 11 included studies focused on specific aspects of hospitalization (e.g., care and treatment), rather than the totality of the experience. Four analytical themes were identified: unpredictable hospitalization, benefits and burdens of treatment, overwhelming distress and the communicative attitude of staff. Hospitalization was unpredictable because of the frequent, sudden admissions required for acute breathlessness. Hospital could be perceived both as a safe place, due to immediate symptom relief, but also as a place for experiencing overwhelming distress. Breathlessness was the most difficult symptom experienced, causing physical and psychological distress. Both communication and attitudes of the staff could influence the experience. A holistic approach to the care of hospitalized individuals with advanced COPD is required to improve care.Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2021.1971186 .

Advanced nursing practice in COPD exacerbations: the solution for a gap in Switzerland?

AIM

This study aimed to address the need for adaptation of the current model of chronic obstructive pulmonary disease (COPD) care in Switzerland, particularly in regard to acute exacerbations, and how far an integrated approach involving advanced nursing practice can meet those needs.

METHODS

A state analysis guided by the PEPPA framework was initiated by the Pulmonology Clinic of University Hospital Zürich. Literature describing the current provision of COPD care regarding exacerbations in Switzerland and international qualitative studies describing the patient perspective were systematically searched and summarised. The health providers' perspective was investigated in three focus-group interviews.

RESULTS

A lack of systematic and state-of-the-art support for patient self-management in Switzerland was described in literature and confirmed by the health providers interviewed. While care was assessed as being comprehensive and of good quality in each individual sector, such as inpatient, outpatient, rehabilitation and home settings, it was identified as being highly fragmented across sectors. The interview participants described day-to-day examples in which a lack of support in COPD self-management and fragmentation of care negatively affected the patients' disease management.

CONCLUSION

The necessity of coordinating the transition between healthcare sectors and self-management support and that these organisational boundaries should be addressed by a multi-professional team were identified. Initial evaluation indicates that advanced practice nurses potentially have the skill set to coordinate the team and address patients' self-management needs in complex patient situations. However, the legal foundation and a reimbursement system to ensure long-term implementation is not yet available.

It's hard to talk about breathlessness: a unique insight from respiratory trainees

This paper describes how difficult it can be to discuss the experience of breathlessness with patients, as identified by respiratory trainees in a psychology-led workshop. The reasons why it is considered an essential role for clinicians to facilitate conversations about patients' breathlessness are outlined within the context of the challenges of respiratory care. The benefits for both patient and clinician are described including rapport building, more focused and targeted consultations, and increasing a patient's receptivity to interventions. The value of preparing a patient to actively engage with their breathlessness management is highlighted. As a way to support clinicians to initiate talk about breathlessness, a 'five-step guide to talking' is presented.

Patients and informal caregivers' experiences of burden of treatment in lung cancer and chronic obstructive pulmonary disease (COPD): a systematic review and synthesis of qualitative research

OBJECTIVE

To identify, characterise and explain common and specific features of the experience of treatment burden in relation to patients living with lung cancer or chronic obstructive pulmonary disease (COPD) and their informal caregivers.

DESIGN

Systematic review and interpretative synthesis of primary qualitative studies. Papers were analysed using constant comparison and directed qualitative content analysis.

DATA SOURCES

CINAHL, EMBASE, MEDLINE, PsychINFO, Scopus and Web of Science searched from January 2006 to December 2015.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Primary qualitative studies in English where participants were patients with lung cancer or COPD and/or their informal caregivers, aged >18 years that contain descriptions of experiences of interacting with health or social care in Europe, North America and Australia.

RESULTS

We identified 127 articles with 1769 patients and 491 informal caregivers. Patients, informal caregivers and healthcare professionals (HCPs) acknowledged lung cancer's existential threat. Managing treatment workload was a priority in this condition, characterised by a short illness trajectory. Treatment workload was generally well supported by an immediacy of access to healthcare systems and a clear treatment pathway. Conversely, patients, informal caregivers and HCPs typically did not recognise or understand COPD. Treatment workload was balanced with the demands of everyday life throughout a characteristically long illness trajectory. Consequently, treatment workload was complicated by difficulties of access to, and navigation of, healthcare systems, and a fragmented treatment pathway. In both conditions, patients' capacity to manage workload was enhanced by the support of family and friends, peers and HCPs and diminished by illness/smoking-related stigma and social isolation.

CONCLUSION

This interpretative synthesis has affirmed significant differences in treatment workload between lung cancer and COPD. It has demonstrated the importance of the capacity patients have to manage their workload in both conditions. This suggests a workload which exceeds capacity may be a primary driver of treatment burden.

PROSPERO REGISTRATION NUMBER

CRD42016048191.

Dyspnoea and self-management strategies in patients admitted to the emergency department: A study of patients' experiences

AIMS AND OBJECTIVE

To explore patients' experiences of acute dyspnoea, physical functioning and perspectives on course of illness prior to admission to the emergency department.

BACKGROUND

Many emergency admissions are considered unnecessary and avoidable. In this perspective, it seems relevant to gain insight into the patients' perspective on acute dyspnoea and the need for emergency admission. However, only few studies have investigated reasons for emergency admission from a patient perspective.

DESIGN

A qualitative study was conducted with semi-structured interviews among six patients previously admitted to the emergency department due to dyspnoea. Data collection and analysis were carried out according to Kvale & Brinkmann using meaning condensation.

FINDINGS

Dyspnoea was experienced as an unpleasant breathlessness in the form of pain or suffocation, which limited usual physical activities, negatively impacting on quality of life. Self-management strategies such as medication, breathing exercises, distraction from breathing, and mental and physical relaxation in general were used to avoid hospital admission. The chronically ill patients saw the following ways to alternate course of disease to avoid admissions to the emergency department: easier access to specialised emergency medical care, medical supplies in the patient's home and making existing physical exercise programmes more accessible and interesting.

CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE

It would be relevant to further investigate whether prehospital interventions may remedy acute dyspnoea among chronically ill patients, and whether such interventions are cost-effective.

Narrative medicine educational project to improve the care of patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is characterised by a progressive loss of pulmonary function. Often patients do not adhere to inhaled therapies and this leads clinicians to switch treatments in order to improve control of the symptoms. Narrative medicine is a useful approach that helps healthcare professionals to think over the doctor–patient relationship and how patients live with their disease. The aim of this training project was to teach pulmonologists the basics of narrative medicine: to carefully listen to patients and to practice reflective writing in their relationship with them.

Training on narrative medicine and parallel charts was provided through a webinar and a weekly newsletter.

Across 362 narratives, written by 74 Italian pulmonologists, 92% of patients had activity limitations at their first visit. The main factor influencing the effectiveness and adherence to therapy was a positive doctor–patient relationship; indeed, if such relationship is difficult, only 21% of patients are able to resume all their activities.

After learning the narrative approach, clinicians became aware of the need to spend more time listening to patients, to reflect through writing and to understand more deeply the motivations that lead people towards adherence to new therapies.

The experience of 79 Italian pulmonologists using the narrative medicine approach in COPDhttp://ow.ly/NfnY30jdEpS

Narrative medicine to improve the management and quality of life of patients with COPD: the first experience applying parallel chart in Italy

Purpose

Poor adherence to therapy and the failure of current smoking cessation programs demonstrate that the current management of COPD can be improved, and it is necessary to educate physicians about new approaches for taking care of patients. Parallel chart is a narrative medicine tool that improves the doctor–patient relationship by asking physicians to write about their patients’ lives, thereby encouraging reflective thoughts on care.

Patients and methods

Between October 2015 and March 2016, 50 Italian pulmonologists were involved in the collection of parallel charts of anonymous patients with COPD. The narratives were analyzed according to the Grounded Theory methodology.

Results

In the 243 parallel charts collected, the patients (mean age 69 years, 68% men) are described as still active and as a resource for their families (71%). The doctor–patient relationship started as difficult in 50% of cases, and younger age and smoking were the main risk factors. The conversations turned positive in 78% of narratives, displaying deeper mutual knowledge, trust for the clinicians’ ability to establish effective therapy (92%), support efforts to quit smoking (63%), or restore patients’ activities (78%).

Conclusion

All the physicians concurred that the adoption of innovative parallel charts was useful for improving clinical care and worthy of official inclusion in protocols for the management of COPD.

The experience of being a participant in one's own care at discharge and at home, following a severe acute exacerbation in chronic obstructive pulmonary disease: a longitudinal study

PURPOSE

In healthcare related to hospital discharge and follow-up, it is acknowledged that patient participation can strengthen self-management in patients with chronic obstructive pulmonary disease. However, the meaning of participation in care following a severe acute exacerbation is less described. Therefore, the aim of this part of a larger study was to explore patients' experiences of participating in their care around discharge and in their subsequent day-to-day care at home.

METHOD

The study was designed as a qualitative, longitudinal study. Data were collected by repeated participant observations and in-depth interviews with 15 patients within a period of 18 months post-discharge. A phenomenological-hermeneutic approach was used to interpret the data.

RESULTS

Before discharge, the patients struggled to regain a sense of control in their efforts to build up strength, and acquire sufficient clarity and confidence to face self-management at home. At home, the patients strived to comply with advice and encouragement in a struggle to stay motivated and confident, and to ask for help.

CONCLUSIONS

With more knowledge about patients' participation in care, healthcare professionals can encounter patients in ways that are sensitive to their specific care and support needs and, thereby, contribute to the promotion of patients' health and well-being.

Patients' and their family members' experiences of participation in care following an acute exacerbation in chronic obstructive pulmonary disease: A phenomenological-hermeneutic study

AIM AND OBJECTIVES

To explore the experiences of patients with chronic obstructive pulmonary disease and their family members relating both to participation in care during hospitalisation for an acute exacerbation in chronic obstructive pulmonary disease, and to the subsequent day-to-day care at home.

BACKGROUND

When recovering from an exacerbation, the challenges associated with an unpredictable health condition dominate everyday life for patients and can involve their family members. Proper patient and family participation in care during discharge and follow-up can help patients to improve self-management. However, knowledge of the significance of patient and family participation for recovery and subsequent everyday life is still limited.

DESIGN

This study adopted a longitudinal design informed by ethnographic fieldwork principles.

METHODS

Participant observations and interviews with 15 patients and 12 family members were conducted on a Danish hospital ward and twice at the participants' homes. A phenomenological-hermeneutic approach inspired by Ricoeur's theory of interpretation guided the data analysis.

RESULTS

Participation in care was perceived as valuable, but could be associated with tensions and increased uncertainty. While patients mostly demonstrated a reactive approach to care, family members strived to be more proactive. In hospital, preparing for discharge included an effort to find a balance between powerlessness and influence during interactions with healthcare professionals. At home, managing further recovery and self-management were characterised by navigating between mutual pressure and consideration within the family.

CONCLUSION

Family members play an important role in ensuring that patients are seen, heard and understood, but want to be acknowledged more by healthcare professionals. Appropriate interactions with healthcare professionals are crucial in order to support discharge and daily self-management.

RELEVANCE TO CLINICAL PRACTICE

Knowledge of the challenges that patients with chronic obstructive pulmonary disease and their family members face in participating in care activities could inform future development of family-centred care approaches tailored to individual needs.

Experiences of noninvasive ventilation in adults with hypercapnic respiratory failure: a review of evidence

Noninvasive ventilation (NIV) has been shown to be beneficial for patients with respiratory failure; however, many patients fail to tolerate it and require other interventions. The objective of this thematic synthesis was to describe the nature of NIV experiences in adults with hypercapnic respiratory failure. A systematic, computerised literature search of English-language databases was undertaken with no restriction on date of publication. A total of 99 papers was identified and screened for eligibility from databases including CINAHL, Medline and PsycINFO, and some were hand searched. 45 papers were critically appraised and 32 met our inclusion criteria. Thematic analysis identified six key themes: benefits of NIV; fear (of various categories, namely, fear of technology/mask, fear of death and dying, and fear of pain and suffering); adaptation to NIV machine; decision making; need for information; and relationship with healthcare professionals. For people using NIV treatment, the experience of being on the NIV machine is unexpected and can be stressful. Findings from this review offer healthcare professionals insights and understanding into the patient experience of NIV. Healthcare professionals may use these findings to implement new strategies in NIV provision and the exploration of the applicability of age-specific supportive care NIV guidelines.

Negotiating the care-giving role: family members' experience during critical exacerbation of COPD in Norway

Healthcare policies often state that complex conditions are to be treated outside hospital in various forms of public-private partnership. Chronic obstructive pulmonary disease (COPD) is a progressive illness that includes episodes of serious acute exacerbations characterised by extreme breathlessness. There is limited knowledge about COPD exacerbations from the perspective of family caregivers and implications of the changing boundary between hospital care and care at home. In this paper, we explore how caregivers negotiate their role as caregivers with patients and healthcare professionals during acute exacerbations. We conducted 10 qualitative interviews with family caregivers of COPD patients in 2011, all were spouses over the age of 60. The participants were recruited through the patient pool of ambulatory pulmonary services of two hospitals in Oslo, Norway. Data were interpreted using thematic analysis. The caregivers described a lack of understanding and support from health professionals in some situations. They shouldered considerable responsibility, but were not always acknowledged as competent carers by professionals. Caregivers had to balance their involvement. They noted that they could lose the professionals' co-operation if their involvement was perceived as interfering or preventing the professionals from exercising their expertise. However, by not sharing their personalised knowledge about the patients, they risked that the professionals would not understand the severity of the exacerbation, which could undermine their own ability to maintain a sense of safety and control. The negotiations caregivers participated in and the uncertainty they experienced shed new light on the complexity of their role, and the discrepancy between practice and ideals in healthcare policy regarding collaboration of care. It is crucial to develop further knowledge about structural, interactional and communicational facilitators and barriers for reaching shared understandings and facilitating mutual trust in these demanding situations.

Nurses' decision-making in ethically relevant clinical situations using the example of breathlessness: study protocol of a reflexive grounded theory integrating Goffman's framework analysis

INTRODUCTION

Decision-making (DM) in healthcare can be understood as an interactive process addressing decision makers' reasoning as well as their visible behaviour after the decision is made. Other key elements of DM are ethical aspects and the role as well as the treatment options of the examined professions. Nurses' DM to choose interventions in situations of severe breathlessness is such interactions. They are also ethically relevant regarding the vulnerability of affected patients and possible restrictions or treatment options. The study aims to explore which factors influence nurses' DM to use nursing interventions in situations where patients suffer from severe breathlessness.

METHODS AND ANALYSIS

Qualitative study including nurses in German hospital wards and hospices. A triangulation of different methods of data collection-participant observation and qualitative expert interviews-and analysis merge in a reflexive grounded theory approach which integrates Goffman's framework analysis. It allows an analysis of nurses' self-statements about DM, their behaviour in relevant clinical situations and its influences. Data collection and analysis will be examined simultaneously.

ETHICS AND DISSEMINATION

Informed consent will be gained from all participants and the institutional stakeholders. Ongoing consent has to be ensured since observations will take place in healthcare institutions and many patients will be highly vulnerable. The study has been evaluated and approved by the Witten/Herdecke University Ethics Committee, Witten, Germany. Results of the study will be published at congresses and in journal papers.

Manoeuvring along the edge of breathlessness: an ethnographic case study of two nurses

Background

There appears to be divergence between nurses’ and patients’ perceptions of dyspnoea onset and on how help should be given. This may affect how nurses understand and assess their patients’ anxiety and the severity of dyspnoea, potentially diminishing their chances of relieving patients’ dyspnoea. The aim of this study was to explore nurse–patient interaction in situations where patients with chronic obstructive pulmonary disease are experiencing acute or worsened dyspnoea in a hospital setting.

Methods

An ethnographic study using participant observation of two nurses’ interactions with six patients, followed by qualitative in-depth interviews with the nurses. Data were analysed in three steps. First, they were coded for identification of preliminary themes. Second, data were regrouped into preliminary themes for focused analysis which led to formulation of themes and subthemes. Third, hermeneutical principles were used as all data were interpreted from the viewpoint of each theme.

Results

Three themes were identified: Manoeuvring along the edge; Dyspnoea within the pattern; and Dyspnoea outside the pattern. They were encompassed by the main finding: Manoeuvring along the edge of breathlessness. The nurses attempted to navigate between implicit and explicit care approaches and to create a sphere for relieving or avoiding further worsening of dyspnoea. Depending on the identified pattern for a particular dyspnoeic episode, nurses attributed different significance to the dyspnoea.

Conclusions

Interacting in dyspnoeic situations places nurses in a dilemma: an implicit approach risk, deriving from exclusion of patients and performing hesitantly; or an explicit negotiation risk, where patients are exhausted and removed from focusing and breathing. The dilemma weakens nurses’ opportunities to relieve or avoid a worsening of the dyspnoea. Likewise, the divergence between nurses’ and patients’ assessment of dyspnoea as within or outside the pattern appears to jeopardize the efficiency of care. Our findings contribute to a deeper understanding of the challenges of respiratory nursing care in general, and the challenges of relieving in-patients’ dyspnoea in particular.

Maintaining a Distinction Between Possible and Impossible Topics of Conversation in the Outpatient Respiratory Medical Clinic

The aim of this study is to generate a grounded theory explaining patterns of behavior among health care professionals (HCPs) during interactions with patients in outpatient respiratory medical clinics. The findings suggest that the HCPs managed contradictory expectations to the interaction by maintaining a distinction between possible and impossible topics to counseling. Three subcategories explaining the effort that maintain the impossible and possible topics separated were identified: (a) an effort to maintain the diseased lungs as the main task in counseling, (b) navigating interactions to avoid strong emotions of suffering in patients to reveal, (c) avoiding the appearance of the non-alterable life circumstances of the patients. The HCPs' attitudes toward what patients could be offered generated a distance and a difficulty during counseling and created further suffering in the patients but likewise a discomfort and frustration among the HCPs.

Exploring the Unmet Needs of the Patients in the Outpatient Respiratory Medical Clinic: Patients versus Clinicians Perspectives

Aim. Developing a theoretical framework explaining patients' behaviour and actions related to unmet needs during interactions with health care professionals in hospital-based outpatient respiratory medical clinics. Background. The outpatient respiratory medical clinic plays a prominent role in many patients' lives regarding treatment and counselling increasing the need for a better understanding of patients' perspective to the counselling of the health care professionals. Design. The study is exploratory and based on Charmaz's interpretation of grounded theory. Methods. The study included 65 field observations with a sample of 43 patients, 11 doctors, and 11 nurses, as well as 30 interviews with patients, conducted through theoretical sampling from three outpatient respiratory medical clinics in Denmark. Findings. The patients' efforts to share their significant stories triggered predominantly an adaptation or resistance behaviour, conceptualized as "fitting in" and "fighting back" behaviour, explaining the patients' counterreactions to unrecognized needs during the medical encounter. Conclusion. Firstly this study allows for a better understanding of patients' counterreactions in the time-pressured and, simultaneously, tight structured guidance program in the outpatient clinic. Secondly the study offers practical and ethical implications as to how health care professionals' attitudes towards patients can increase their ability to support emotional suffering and increase patient participation and responsiveness to guidance in the lifestyle changes.

Pulmonary rehabilitation and severe exacerbations of COPD: solution or white elephant?

Hospitalisations for severe exacerbations of chronic obstructive pulmonary disease are associated with significant physical and psychological consequences including an increase in symptom severity, severe reductions in physical activity, a deleterious effect on skeletal muscle, impaired exercise tolerance/ability to self-care, decline in quality of life, and increased anxiety and depression. As these consequences are potentially amenable to exercise training, there is a clear rationale for pulmonary rehabilitation in the peri/post-exacerbation setting. Although a 2011 Cochrane review was overwhelmingly positive, subsequent trials have shown less benefit and real-life observational studies have revealed poor acceptability. Qualitative studies have demonstrated that the patient experience is a determining factor while the presence of comorbidities may influence referral, adherence and response to pulmonary rehabilitation. Systematic reviews of less supervised interventions, such as self-management, have shown limited benefits in the post-exacerbation setting. The recent update of the Cochrane review of peri-exacerbation pulmonary rehabilitation showed that benefits were associated with the "comprehensive" nature of the intervention (the number of sessions received, the intensity of exercise training and education delivered, and the degree of supervision) but implementation is demanding. The challenge is to develop interventions that are deliverable and acceptable around the time of an acute exacerbation but also deliver the desired clinical impact.

Using a Narrative Approach to Enhance Clinical Care for Patients With Asthma

There are currently > 230 million people in the world with asthma, and asthma attacks result in the hospitalization of someone every 7 min. The National Heart, Lung, and Blood Institute outlines four components of clinical practice guidelines for the diagnosis and management of asthma, which tend to take a biomedical focus: (1) measures of assessment and monitoring, obtained by objective tests, physical examination, patient history, and patient report, to diagnose and assess the characteristics and severity of asthma and to monitor whether asthma control is achieved and maintained; (2) education for a partnership in asthma care; (3) control of environmental factors and comorbid conditions that affect asthma; and (4) pharmacologic therapy. Many national guidelines include providing patients with asthma with (1) written action plans, (2) inhaler technique training, and (3) structured annual reviews. Although current guidelines help improve clinical processes of care for asthma, there is also a need to improve self-care of asthma by empowering individuals to take more control of their condition. There is a growing appreciation that a narrative approach with patients with asthma, which focuses on the illness experience and aims to enhance patient-clinician understanding, might improve self-care. We explore how a framework for clinicians to listen to patients' stories, developed from research on individuals with asthma, might enhance communication, improve patient-clinician relationship, and foster better patient self-care. The article closes with the implications of this approach for clinical practice and future research.