Meaning of living with severe chronic obstructive lung disease: a qualitative study

Experiences of patients with advanced chronic diseases and their associates with a structured palliative care nurse visit followed by an interprofessional case conference in primary care - a deductive-inductive content analysis based on qualitative interviews (KOPAL-Study)

BACKGROUND

Chronic, non-malignant diseases (CNMD) like chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and dementia in advanced stages are very burdensome for patients. Timely palliative care with strong collaboration between general practitioners (GPs) and specialist palliative home care (SPHC) teams can reduce symptom burden, hospitalization rates, hospitalization costs and overall healthcare costs. The KOPAL-study on strengthening interprofessional collaboration for patients with palliative care needs tested the effect of an intervention comprising of a SPHC nurse assessment and an interprofessional case conference. This qualitative evaluative study explores patients', proxies' and their associates' motivation to participate in the KOPAL-study and views on the (benefits of the) intervention.

METHODS

We interviewed 13 male and 10 female patients as well as 14 proxies of patients with dementia and six associates of study participants using a semi-structured interview guide. All interviews were digitally recorded, transcribed verbatim and analysed with deductive-inductive qualitative content analysis.

RESULTS

Motivation for participation was driven by curiosity, the aim to please the GP or to support research, respectively to help other patients. Few interviewees pointed out to have expected positive effects for themselves. The nurse visit was evaluated very positively. Positive changes concerning health care or quality of life were reported sparsely. Most study participants did not prepare for the SPHC nurse assessment. They had no expectations concerning potential benefits of such an assessment, the interdisciplinary case conference and an early integration of palliative care. The majority of interviewees reported that they did not talk about the nurse visit and the interprofessional case conference with their GPs.

CONCLUSION

Our results lead to the conclusion that SPHC nurses can serve as an advocate for the patient and thereby support the patients' autonomy. GPs should actively discuss the results of the interdisciplinary case conference with patients and collaboratively decide on further actions. Patient participation in the interdisciplinary case conference could be another way to increase the effects of the intervention by empowering patients to not just passively receive the intervention.

TRIAL REGISTRATION

DRKS00017795 German Clinical Trials Register, 17Nov2021, version 05.

Path analysis of the effect of positive psychological capital on health-promoting lifestyle in patients with COPD after pulmonary rehabilitation: An observational study

To investigate the effect of positive psychological capital on the health-promoting lifestyle of patients with chronic obstructive pulmonary disease (COPD) and the intermediary effects of life satisfaction and learned helplessness. A total of 482 patients who completed the pulmonary rehabilitation course at the Nantong Sixth People's Hospital of Jiangsu Province were surveyed using a self-designed questionnaire battery, encompassing the positive psychological capital, health-promoting lifestyle, life satisfaction, and learned helplessness scales. A total of 469 of the 482 questionnaires distributed were effectively returned, leading to an effective response rate of 97.3%. The mean scores on the positive psychological capital, life satisfaction, learned helplessness, and health-promoting lifestyle scales were 105.56 ± 10.44, 19.89 ± 6.33, 50.14 ± 5.47, and 104.22 ± 10.44, respectively. The structural equation model demonstrated good fit indexes. The path analysis revealed that positive psychological capital had a direct effect of 0.431 on health-promoting lifestyle, while life satisfaction and learned helplessness had a mediating effect on this relationship (both P < .05). Patients with COPD have low levels of positive psychological capital and health-promoting lifestyle. Thus, addressing psychological problems and providing continuous rehabilitation nursing to strengthen the psychological construct are essential in this patient group. Moreover, the positive psychological capital of patients with COPD can directly predict their health-promoting lifestyle and exert an influence via the chain mediating effect of life satisfaction and learned helplessness. Therefore, clinical medical staff should assess the positive psychological capital of patients with COPD and adjust the daily rehabilitation activities according to the patients' mental state. Furthermore, enhancing the patients' life satisfaction by employing diverse strategies to reduce learned helplessness can notably improve the health-promoting lifestyle of those with COPD.

Timely integration of specialist palliative home care (SPHC) for patients with congestive heart failure, chronic obstructive pulmonary disease and dementia: qualitative evaluation of the experiences of SPHC physicians in the KOPAL trial

OBJECTIVE

Chronic non-malignant diseases (CNMDs) are under-represented in specialist palliative home care (SPHC). The timely integration of SPHC for patients suffering from these diseases can reduce hospitalisation and alleviate symptom burdens. An intervention of an SPHC nurse-patient consultation followed by an interprofessional telephone case conference with the general practitioner (GP) was tested in the KOPAL trial ('Concept for strengthening interprofessional collaboration for patients with palliative care needs'). As part of the trial, the aim of this study was to gain in-depth insights into SPHC physicians' perspective on care with and without the KOPAL intervention for patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and dementia (D).

DESIGN

Qualitative evaluation of the KOPAL intervention from the perspective of SPHC physicians as part of the KOPAL trial. Thematic-focused narrative interviews analysed with grounded theory.

SETTING

We conducted the KOPAL study and its qualitative evaluation in Lower Saxony and the greater Hamburg area, Germany.

PARTICIPANTS

11 physicians from 14 SPHC teams who participated in the trial were interviewed.

RESULTS

A grounded theory of the necessity of collaboration between GPs and SPHC teams for patients with CHF, COPD and dementia was developed. From the perspective of SPHC physicians, patients with CNMD are generally difficult to manage in GP care. The timing of SPHC initiation is patient-specific, underscoring the need for collaboration between SPHC physicians and GPs. However, the primary mandate for healthcare should remain with GPs. SPHC physicians actively seek collaboration with GPs (eg, through the KOPAL intervention), viewing themselves as advisors for GPs and aspiring to collaborate as equal partners.

CONCLUSION

Effective communication and the negotiation of future interprofessional collaboration are essential for SPHC teams.

TRIAL REGISTRATION NUMBER

DRKS00017795.

Meaning in Life: A Novel Factor for Promoting Wellbeing in COPD

Introduction

Research evidence indicates that meaning in life (MIL) is a meaningful outcome in individuals living with chronic illness, but evidence is lacking for chronic obstructive pulmonary disease (COPD).

Objectives

We hypothesized that MIL is independently associated with clinically meaningful outcomes for patients with COPD.

Methods

We performed cross-sectional analysis from a large cohort with moderate-severe COPD that participated in a home pulmonary rehabilitation study. MIL was measured using the Meaning in Life Questionnaire (MLQ), with domains of Presence and Search. The study included 340 participants: mean age 69 years old (standard deviation [SD] 9.4), 55.3% female, forced expiratory volume in 1 second (FEV1) 44.3% (SD 19.4), and a modified Medical Research Council (mMRC) dyspnea scale of 2.69 (SD 0.84).

Results

Patients with high MLQ Presence (versus low score) had meaningfully better scores (beyond the minimal clinically important difference) across all Chronic Respiratory Questionnaire (CRQ) domains: Dyspnea, Fatigue, Emotions, and Mastery (p≤0.02); self-management (p≤0.001); social support (p≤0.001); anxiety (p≤0.001); and depression (p≤0.01) scores. When adjusting for age, sex, FEV1, mMRC, social support, and anxiety, MLQ Presence was independently associated with CRQ domains Fatigue, Emotions, and self-management (p≤0.01). MLQ Search was independently associated with CRQ Dyspnea, Fatigue, and Mastery (p<0.05).

Conclusions

In patients with COPD, the perception that life has meaning or the willingness to search for MIL is associated with the outcomes that patients consider most important. Our results are novel as MIL is a potentially modifiable outcome that could complement person-centered conversations during clinical visits, pulmonary rehabilitation, and health coaching.

Integrating palliative care education in pulmonary rehabilitation: a randomized controlled study protocol

BACKGROUND

Palliative care addresses multiple unmet needs of people with chronic obstructive pulmonary disease (COPD) or interstitial lung diseases (ILD) and their family and/or friend caregivers, but it remains highly underused. Pulmonary rehabilitation (PR) may provide a key opportunity to introduce palliative care. We aim to explore the effects of palliative care education as part of PR on knowledge about this field in people with COPD or ILD and their family and/or friend caregivers.

METHODS

A randomized controlled study will compare PR with palliative care education (experimental) with traditional PR (control) in people with COPD or ILD and their family and/or friend caregivers. Family and/or friend caregivers will be invited to take part in education and psychosocial support sessions. In addition to the usual educational content, the experimental group will have a session on palliative care, a "Peer-to-peer session", two "Get-apart sessions" and online sessions. The "Peer-to-peer session" and the "Get-apart sessions" will be discussions about topics suggested by participants. The "Get-apart sessions" will be dedicated to people with COPD or ILD apart from their family and/or friend caregivers and vice versa. The online sessions will be zoom meetings to discuss any health-related issues raised by participants, at a flexible time. A mixed-methods approach will be used to evaluate the outcomes. The primary outcome will be knowledge about palliative care. Secondary outcomes will include attitude towards palliative care referral, symptoms, disease impact, health-related quality of life, needs, knowledge about the disease, burden of providing care, adherence, adverse events and referral to a specialist palliative care team. Quantitative and qualitative data will be collected at baseline and end of PR. At 6-months post-PR, only patient-reported outcomes will be collected. For the primary outcome, time*group interaction will be analyzed with mixed analysis of variance.

DISCUSSION

This study aims to demonstrate the impact of integrating palliative care into the PR education program.

TRIAL REGISTRATION

The trial was registered in the ClinicalTrials.gov U.S. National Library of Medicine, on 1st September, 2023 (NCT06046547).

Chronic breathlessness in advanced cardiorespiratory disease: patient perceptions of opioid use

OBJECTIVE

Low-dose oral opioids may improve severe chronic breathlessness in advanced cardiorespiratory diseases. Prescription of opioids for breathlessness occurs infrequently however, with little known about patients' attitudes towards their use in this setting. The aim of this qualitative study was to explore patients' perceptions regarding opioids for the management of severe chronic breathlessness in people with advanced cardiorespiratory disease.

METHODS

A cross-sectional, qualitative study was undertaken using outpatients with severe chronic breathlessness due to either severe chronic obstructive pulmonary disease (COPD) or chronic heart failure (CHF). Indepth, semistructured interviews were audio-recorded, transcribed verbatim and coded. Thematic analysis was undertaken to extrapolate recurring ideas from the data.

RESULTS

Twenty-four participants were purposively sampled from three different groups: opioid-naïve patients with COPD (n=7), opioid-naïve patients with CHF (n=7) and patients with COPD using opioids currently or previously for severe chronic breathlessness (n=10). Four major themes were shared by both the opioid-naïve and opioid-experienced cohorts: (1) stigmatised attitudes and beliefs regarding opioids, (2) limited knowledge and information-seeking behaviour regarding opioids, (3) the impact of the relationships with health professionals and continuity of care, and (4) the significance of past experiences with opioids. An additional theme that was unique to the opioid-experienced cohort was (5) the perception of benefit and improved quality of life.

CONCLUSION

Lack of knowledge regarding the role of opioids in managing severe chronic breathlessness, opioid misinformation and social stigmas are major barriers to opioid therapy that may be overcome by accurate information from trusted health professionals.

Analysis of in-person general practice respiratory consultations: assessing translatability to telehealth

BACKGROUND

The COVID-19 pandemic saw many GPs adopt telehealth as a consultation modality to minimise disease transmission. Patients presenting with respiratory ailments were particularly affected by this transition, given the overlap of general respiratory symptoms with those of COVID-19. It is unclear if the rapid transition to telehealth has compromised the ability to conduct certain tasks that were possible during in-person consultations.

AIM

To investigate the extent to which tasks observed during in-person GP consultations are replicable in telehealth, focusing on patients with respiratory concerns.

DESIGN & SETTING

Twenty-six respiratory consultations were extracted from a database of 281 consultations collated from various general practices in the UK.

METHOD

Interactions between GPs and respiratory patients were assessed through in-depth transcript review and de-identified video analysis. Then, tasks performed and physical artefacts used during the consultations were identified and ranked in terms of their translatability to telehealth, using a newly developed scoring system.

RESULTS

Overall, the translatability to telehealth score for these respiratory consultations was 6.7/10, suggesting that many tasks can be replicated over telehealth, but that they might require additional physical artefacts to support this. However, some tasks are not currently amenable to telehealth (for example, auscultation).

CONCLUSION

While many aspects of respiratory consultations are replicable over telehealth, some tasks cannot be replicated at this stage.

National Prevalence of Social Isolation and Loneliness in Adults with Chronic Obstructive Pulmonary Disease

Rationale: Social isolation and loneliness are gaining recognition for their role in health outcomes, yet they have not been defined in people with chronic obstructive pulmonary disease (COPD). Objective: To determine the national prevalence of and characteristics associated with social isolation and loneliness in people with COPD. Methods: This is a cross-sectional study of community-dwelling adults aged ⩾50 years in the nationally representative HRS (Health and Retirement Study) (2016-2018). Participants self-reported COPD and supplemental oxygen use and were categorized into three groups: 1) no COPD; 2) COPD; and 3) COPD on oxygen. Social isolation was defined using a nine-item scale indicating minimal household contacts, social network interaction, and community engagement. Loneliness was measured using the 3-Item UCLA Loneliness Scale. Multivariable logistic regression defined prevalence and associated characteristics for both. Results: Participants (n = 10,384) were on average 68 years old (standard deviation, ±10.5), 54% female, 10% Black, 11% self-reported COPD, and 2% self-reported supplemental oxygen. Overall, 12% were socially isolated, 12% lonely, and 3% both socially isolated and lonely. People with COPD had a higher adjusted prevalence of social isolation (no COPD: 11%; COPD: 16%; COPD on oxygen: 20%; P < 0.05) and loneliness (no COPD: 11%; COPD: 18%; COPD on oxygen: 22%; P < 0.001). In those with COPD, characteristics associated with social isolation (P < 0.05) included sex (men: 22%; women: 13%), non-Hispanic White ethnicity (White: 19%; Black: 7%), low net worth (<$6,000: 32%; $81,001-$239,000: 10%), depression (depression: 24%; no depression: 14%), having difficulty with one or more activities of daily living (one or more difficulty: 22%; no difficulty: 14%), and current cigarette use (current: 24%; never: 13%). Characteristics associated with loneliness (P < 0.05) included younger age (50-64 yr: 22%; 75-84 yr: 12%), being single (single: 32%; married: 12%), depression (depression: 36%; no depression: 13%), having difficulty with one or more activities of daily living (one or more difficulty: 29%; no difficulty: 15%), diabetes (diabetes: 26%; no diabetes: 17%), and heart disease (heart disease 23%; no heart disease: 17%). Conclusions: Nearly one in six adults with COPD experience social isolation, and one in five experience loneliness, with almost twice the prevalence among those on supplemental oxygen compared with the general population. Demographic and clinical characteristics identify those at highest risk to guide clinical and policy interventions.

Preliminary study of the exploration patients' experiences of chronic respiratory experiences during the COVID-19 pandemic using interpretative phenomenological analysis

During the first period of coronavirus pandemic, respiratory patients may have been more vulnerable to mental health problems in addition to their physical vulnerability. The aim was to explore and deepen our understanding of the experiences of chronic respiratory patients at risk of pandemic COVID-19 using interpretative phenomenological analysis. The study involved 8 participants with asthma, COPD or cystic fibrosis. Three main themes emerged: 1. respiratory illness as a defining experience in everyday life, 2. the impact of the COVID-19 pandemic on the self and identity organisation, and 3. adaptation to experiencing vulnerability. Breathlessness as the most frightening feature of progressive lung disease, can be linked to fear and anxiety in different ways. The experience of vulnerability is a fundamental part of their lives. The potentially contagious nature of COVID-19 draws a sharp line between the endangered Self and the dangerous Other. In terms of their adaptation, we observe essentially self-defense mechanisms and emotion-focused strategies.

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.

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.

Benefits, for patients with late stage chronic obstructive pulmonary disease, of being cared for in specialized palliative care compared to hospital. A nationwide register study

BACKGROUND

In early stage chronic obstructive pulmonary disease (COPD), dyspnea has been reported as the main symptom; but at the end of life, patients dying from COPD have a heavy symptom burden. Still, specialist palliative care is seldom offered to patients with COPD; they more often receive end of life care in hospitals. Furthermore, symptoms, symptom relief and care activities in the last week of life for COPD patients are rarely studied. The aim of this study was to compare patient and care characteristics in late stage COPD patients treated in specialized palliative care (SPC) versus hospital.

METHODS

Two nationwide registers were merged, the Swedish National Airway Register (SNAR) and the Swedish Register of Palliative Care (SRPC). Patients with COPD and < 50% of predicted forced expiratory volume in 1 s (FEV1), who had died in inpatient or outpatient SPC (n = 159) or in hospital (n = 439), were identified. Clinical COPD characteristics were extracted from the SNAR, and end of life (EOL) care characteristics from the SRPC. Descriptive statistics were used to describe the sample and the registered care and treatments. Independent samples t-test, Mantel-Haenszel chi-square test and Fisher's exact test was used to compare variables. To examine predictors of place of death, bivariate and multivariate logistic regression analyses were performed with a dependent variable with demographic and clinical variables used as independent variables.

RESULTS

The patients in hospitals were older and more likely to have heart failure or hypertension. Pain was more frequently reported and relieved in SPC than in hospitals (p = 0.001). Rattle, anxiety, delirium and nausea were reported at similar frequencies between the settings; but rattle, anxiety, delirium, and dyspnea were more frequently relieved in SPC (all p < 0.001). Compared to hospital, SPC was more often the preferred place of care (p < 0.001). In SPC, EOL discussions with patients and families were more frequently held than in hospital (p < 0.001). Heart failure increased the probability of dying in hospital while lung cancer increased the probability of dying in SPC.

CONCLUSION

This study provides evidence for referring more COPD patients to SPC, which is more focused on symptom management and psychosocial and existential support.

Chronic breathlessness and sleep problems: a population-based survey

OBJECTIVES

This study aimed to explore the relationship (presence and severity) between chronic breathlessness and sleep problems, independently of diagnoses and health service contact by surveying a large, representative sample of the general population.

SETTING

Analysis of the 2017 South Australian Health Omnibus Survey, an annual, cross-sectional, face-to-face, multistage, clustered area systematic sampling survey carried out in Spring 2017.Chronic breathlessness was self-reported using the ordinal modified Medical Research Council (mMRC; scores 0 (none) to 4 (housebound)) where breathlessness has been present for more than 3 of the previous 6 months. 'Sleep problems-ever' and 'sleep problem-current' were assessed dichotomously. Regression models were adjusted for age; sex and body mass index (BMI).

RESULTS

2900 responses were available (mean age 48.2 years (SD=18.6); 51% were female; mean BMI 27. 1 (SD=5.9)). Prevalence was: 2.7% (n=78) sleep problems-past; 6.8% (n=198) sleep problems-current and breathlessness (mMRC 1-4) was 8.8% (n=254). Respondents with sleep problemspast were more likely to be breathless, older with a higher BMI and sleep problems-present also included a higher likelihood of being female.After adjusting for age, sex and BMI, respondents with chronic breathlessness had 1.9 (95% CI=1.0 to 3.5) times the odds of sleep problems-past and sleep problems-current (adjusted OR=2.3; 95% CI=1.6 to 3.3).

CONCLUSIONS

There is a strong association between the two prevalent conditions. Future work will seek to understand if there is a causal relationship using validated sleep assessment tools and whether better managing one condition improves the other.

Micro-phenomenological approach to explore the patient experience during an initial spirometry examination to diagnose COPD in general practice in France

OBJECTIVES

To explore the patient experience of a spirometry test used to confirm chronic obstructive pulmonary disease (COPD) diagnosis in patients with suspected smoking-related COPD.

DESIGN

This is a qualitative study, performed with open interviews in adults following a routine spirometry test to confirm COPD diagnosis. Data were analysed with a phenomenological-inspired micro-phenomenology approach.

PARTICIPANTS

Eligible patients were recruited through their general practitioner, 10 were interviewed.

SETTING

Primary care in Centre-Val-De-Loire area, France, in 2018.

RESULTS

Participants reported the spirometry test experience as being unfamiliar but gave meaning to the symptoms they experience. Participants expressed a desire to perform the test well and a willingness to confront their state of health. After the spirometry had been completed and the results announced, participants moved through stages of grief from their pre-spirometry self and symptom perception to a state of acceptance. Overall, participants expressed a narrative of an evolving cognitive and corporeal awareness during this spirometry experience. The verbatim quotes describe a cognitive rupture with their chronic illness usually considered as a 'way of life'.

CONCLUSIONS

A spirometry test goes beyond a diagnostic value, providing patients with an opportunity to gain awareness of their own state of health, reframe their breathlessness-related limitations and thus begin to accept the disease. These awareness gains may be considered as small steps towards health behavioural change. Spirometry may have educative potential and support lifestyle changes.

Together for the Future - Development of a Digital Website to Support Chronic Obstructive Pulmonary Disease Self-Management: A Qualitative Study

Background

Symptom burden, impaired functional performance and decreased quality of life are not only consequences of the underlying physiological disorder chronic obstructive pulmonary disease (COPD) but also dependent on a patient’s ability to learn to live with and manage their illness. A digital website may be important for empowering patients with COPD to learn about and self-manage their illness. The aim of this study was to describe a developing process of a digital COPD-web as a part of a self-management education program for persons living with COPD.

Methods

A qualitative approach with a phenomenological perspective was used. The study was based on group and individual interviews with a multidisciplinary COPD-team and patients who developed the COPD-web.

Results

The developing process appears as a person-centred and holistic self-care approach both in content and development. Developing a digital COPD-web requires ongoing multidisciplinary collaboration and spawns a sense of pride that reinforces shared responsibility. The phenomenon consists of four constituents: learning by participating in development, the patient perspective as guiding approach, responsibility and motivation as driving forces and digital technology as a knowledge arena.

Conclusion

The results indicate that constructive collaboration between a multidisciplinary COPD-team and patients as co-creators in an ongoing creative and reflective process is a key concept to develop a digital COPD-web with a holistic approach. Digital resources in the future might create time and space for reflective conversations in a COPD-web with virtual chatrooms.

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

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

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

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

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

Characteristics and health related quality of life in a population with advanced chronic obstructive pulmonary disease, a cross-sectional study

BACKGROUND

It is important to understand the total burden of COPD and thereby be able to identify patients who need more intensive palliative care to avoid deteriorated quality of life. The aim of this study was to describe the psychosocial and demographic characteristics of a population with advanced COPD in a stable phase of the disease.

METHODS

This study was cross-sectional based on a prospective observational cohort. The following questionnaires were administered: Chronic Respiratory Disease Questionnaire (CRQ), The COPD Assessment Test (CAT), The Hospital and Anxiety and Depression Scale (HADS), The Medical Research Council dyspnoea scale (MRC), and self-rate general health.

RESULTS

We included 242 patients with advanced COPD from a Danish pulmonary outpatient clinic. Their mean FEV1 was 38% (±12.7) and 19% were treated with long term oxygen. The mean CRQ domain score was CRQ-dyspnea 4.21 (±1.4), CRQ-Mastery 4.88 (±1.3), CRQ-Emotional 4.81 (±1.2), CRQ-Fatigue 3.93 (±1.3). The mean CAT-score was 18.4 (± 6.7), and 44% had a CAT score > 20. The mean score on the subscale for anxiety (HADS-A) and depression (HADS-D) was 5.07 (±3.9) and 5.77 (±3.9), respectively. Thirty percent self-rated their health as bad or very bad and 19.8% were current smokers.

CONCLUSIONS

This study describes the characteristics of a population with advanced COPD in a stable phase of their disease. Our results illustrate how the population although treated in an outpatient structure already focusing on palliative needs, still live with unmet palliative needs and impaired quality of life.

How people with chronic obstructive pulmonary disease perceive their illness: a qualitative study between mind and body

Background

Although many studies on people with Chronic Obstructive Pulmonary Disease (COPD) have examined the mutual impact of physical status and emotional experience, there is limited knowledge about the way COPD people first-hand perceive their condition. This study was designed to investigate the illness perceptions of the patients and, secondarily, to explore their beliefs about the mind-body relationship.

Methods

This qualitative study has exploited an ad-hoc semi-structured interview to collect personal perspectives of participants on their illness. Twenty-seven patients (15 males and 12 females), with a mild to severe COPD, were recruited within the Respiratory Rehabilitation Unit of Don Carlo Gnocchi Foundation, in Milan. The thematic analysis of the interviews’ content was facilitated by NVivo (12th version, QSR International®).

Results

The thematic analysis of the corpus resulted in four master themes. Illness experience has been considered the primary one. Indeed, dealing with COPD every day allows these people to portray a specific representation of the mind-body relationship, to gain a certain degree of expertise and to develop a perspective on the future.

Conclusions

Individual perceptions of the illness vary among people with COPD, but some common experiences characterize them. Many patients share a profound belief that their mental state and their physical symptoms are highly interrelated.

Effects of Osteopathic Manual Therapy on Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease: A Randomized Cross-Over Study

Osteopathic manual therapy (OMT) may reduce hyperinflation in patients with chronic obstructive pulmonary disease (COPD) by improving breathing mechanics. The aim of the study was to evaluate the immediate effects of OMT on hyperinflation in stable COPD patients with forced expired volume in 1 s (FEV₁) <50% predicted. Nineteen COPD patients of the median age 68 (IQR 63-72) years and the median FEV₁ 39.8 (IQR 33.4-46.6) % predicted were enrolled into the study. For the first session, patients were randomly assigned to either OMT or sham therapy. During the second session, the two groups of patients were crossed over. Pulmonary function and dyspnea were compared before and after both procedures. Neither pulmonary function nor dyspnea differed significantly before and after OMT or sham procedures. However, 36.7% and 47.4% patients achieved the minimally important difference for residual volume (RV) reduction after both OMT and sham therapy, respectively. Responders to OMT had a greater median (IQR) baseline sense of dyspnea compared to non-responders, assessed on a visual analog scale, of 7.0 (4.5-7.0) vs. 3.0 (0.0-5.0), p = 0.040, respectively. Although OMT did not have an immediate effect on hyperinflation or dyspnea, a subgroup experienced a reduction in RV following OMT and sham therapy. Future studies are needed to identify the characteristics of responders.

Care bundles to reduce re-admissions for patients with chronic obstructive pulmonary disease: a mixed-methods study

Background

Chronic obstructive pulmonary disease (COPD) is the commonest respiratory disease in the UK, accounting for 10% of emergency hospital admissions annually. Nearly one-third of patients are re-admitted within 28 days of discharge.

Objectives

The study aimed to evaluate the effectiveness of introducing standardised packages of care (i.e. care bundles) as a means of improving hospital care and reducing re-admissions for COPD.

Design

A mixed-methods evaluation with a controlled before-and-after design.

Participants

Adults admitted to hospital with an acute exacerbation of COPD in England and Wales.

Intervention

COPD care bundles.

Main outcome measures

The primary outcome was re-admission to hospital within 28 days of discharge. The study investigated secondary outcomes including length of stay, total number of bed-days, in-hospital mortality, 90-day mortality, context, process and costs of care, and staff, patient and carer experience.

Data sources

Routine NHS data, including numbers of COPD admissions and re-admissions, in-hospital mortality and length of stay data, were provided by 31 sites for 12 months before and after the intervention roll-out. Detailed pseudo-anonymised data on care during admission were collected from a subset of 14 sites, in addition to information about delivery of individual components of care collected from random samples of medical records at each location. Six case study sites provided data from interviews, observation and documentary review to explore implementation, engagement and perceived impact on delivery of care.

Results

There is no evidence that care bundles reduced 28-day re-admission rates for COPD. All-cause re-admission rates, in-hospital mortality, length of stay, total number of bed-days, and re-admission and mortality rates in the 90 days following discharge were similar at implementation and comparator sites, as were resource utilisation, NHS secondary care costs and cost-effectiveness of care. However, the rate of emergency department (ED) attendances decreased more in implementation sites than in comparator sites {implementation: incidence rate ratio (IRR) 0.63 [95% confidence interval (CI) 0.56 to 0.70]; comparator: IRR 1.14 (95% CI 1.04 to 1.26) interactionp < 0.001}. Admission bundles appear to be more complex to implement than discharge bundles, with 3.7% of comparator patients receiving all five admission bundle elements, compared with 7.6% of patients in implementation sites, and 28.3% of patients in implementation sites receiving all five discharge bundle elements, compared with 0.8% of patients in the comparator sites. Although patients and carers were unaware that care was bundled, staff view bundles positively, as they help to standardise working practices, support a clear care pathway for patients, facilitate communication between clinicians and identify post-discharge support.

Limitations

The observational nature of the study design means that secular trends and residual confounding cannot be discounted as potential sources of any observed between-site differences. The availability of data from some sites was suboptimal.

Conclusions

Care bundles are valued by health-care professionals, but were challenging to implement and there was a blurring of the distinction between the implementation and comparator groups, which may have contributed to the lack of effect on re-admissions and mortality. Care bundles do appear to be associated with a reduced number of subsequent ED attendances, but care bundles are unlikely to be cost-effective for COPD.

Future work

A longitudinal study using implementation science methodology could provide more in-depth insights into the implementation of care bundles.

Trial registration

Current Controlled Trials ISRCTN13022442.

Funding

This project was funded by the National Institute for Health Research Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 7, No. 21. See the NIHR Journals Library website for further project information.

Assessing spirituality: is there a beneficial role in the management of COPD?

Here,we report on the role of spirituality assessment in the management of chronic obstructive pulmonary disease (COPD). Although a positive effect of addressing spirituality in health care has been proved in a number of chronic diseases, its potential in COPD has received less attention. Although limited, available evidence suggests that spirituality may play an important role in improving quality of life of patients with COPD. The fruitful results in other long-term conditions may lay the foundation for further research on addressing spirituality in COPD. This should focus where the burden of COPD is greatest, including low-resource settings globally. Implementation research should include exploration of an acceptable consultation process to identify patients who would welcome spiritual discussions; how to integrate spiritual approaches into health care professional curricula so that they are aware of its importance and have the confidence to raise it with patients and how to integrate spiritual approaches into holistic COPD care.

Lung cancer symptom appraisal among people with chronic obstructive pulmonary disease: A qualitative interview study

OBJECTIVE

The incidence of lung cancer is four times higher in people with chronic obstructive pulmonary disease (COPD) compared with the general population. Promotion of a shorter time from symptom onset to presentation is one potential strategy for earlier lung cancer diagnosis, but distinguishing respiratory symptoms can be difficult. We investigated how the experience of COPD influences symptom appraisal and help seeking for potential lung cancer symptoms.

METHODS

We conducted qualitative interviews with men (n = 17) and women (n = 23) aged 40 to 83 years with COPD. Topic guides drew on the integrated symptom-response framework and covered symptom experience, interpretation, action, recognition, help seeking, evaluation, and reevaluation. We used the framework method to analyse the data.

RESULTS

Participants said that they attributed chest symptoms to their COPD; no other cause was considered. Participants said that family/friends noticed changes in their symptoms and encouraged help seeking. Others felt isolated by their COPD because they could not get out, were fatigued, or were embarrassed. Participants visited health professionals frequently, but increased risk of lung cancer was not discussed.

CONCLUSIONS

Our study provides insight into different levels of influence on symptom appraisal and targets for intervention. Greater awareness of increased lung cancer risk and support to act on symptom changes is essential and could be achieved through a concerted information campaign. Health professionals working with people with COPD could also optimise appointments to support symptom appraisal of potential lung cancer symptoms.

Wishes to die at the end of life and subjective experience of four different typical dying trajectories. A qualitative interview study

RESEARCH AIMS

The motivations that lead to wishes to die (WTD) in palliative care patients with cancer are relatively well studied. But little is known about WTD in other pathologies and the relation between subjective understandings of dying trajectories and a WTD. We investigated the WTD of palliative patients in four different dying trajectories: neurological diseases, organ failure, frailty due to age, and cancer.

STUDY POPULATION

62 palliative cancer (n = 30) and non-cancer (n = 32) patients (10 neurological disease; 11 organ failure; 11 frailty), their families and health professionals in different palliative care settings (248 interviews).

STUDY DESIGN AND METHODS

Qualitative semi-structured interviews. Data analysis through Interpretive Phenomenological Analysis and Grounded Theory.

RESULTS

In addition to personal motivations, we found that people dealing with similar trajectories were often confronted with similar questions and concerns due to similar challenges. For four trajectories we show typical patterns, similarities and differences that should be considered when talking with patients about their WTD. These illness-related considerations do not explain the WTD completely, but give important information on the challenges for particular patient groups that might experience a WTD. In all patient groups, there were clear moments that triggered a WTD: for neurological patients it was experiencing breathlessness, high-dependency care, or when considering tube feeding or respiratory support; for persons with organ failure it was an acute burdensome crisis; for patients with cancer after the initial diagnosis, it was the first relapse or the move into advanced palliative care; for elderly frail persons it was the move into care facilities, or the loss of important relationships or capabilities. The feeling of being a burden to others was reported in all patient groups.

INTERPRETATION

WTD can be triggered within disease trajectories by specific conditions and transitional points that affect agency and self-understanding. A better understanding of the concerns and challenges of a particular dying trajectory as well as its characteristic trigger points can facilitate early and comprehensive communication about patients' WTD, and the underlying motivations and protective factors.

Recollection of participating in a trial: A qualitative study of patients with severe and very severe chronic obstructive pulmonary disease

BACKGROUND

Despite having similar palliative needs to patients with lung cancer, advanced chronic obstructive pulmonary disease (COPD) patients are less likely to receive palliative care. To evaluate the effect of introducing specialized palliative care with severe to very severe COPD patients, a randomized controlled trial (RCT) was conducted in Switzerland.

AIM

To explore COPD patients' recollection of the trial, their needs and the usefulness of the palliative care interventions.

DESIGN AND SETTING

Qualitative study with advanced COPD patients who participated in a specialized palliative care intervention, conducted in a general hospital.

METHOD

Eighteen patients with severe to very severe COPD were interviewed about their experiences. Interviews were transcribed and thematic content analysis was performed.

RESULTS

Patients had poor recollection of the trial and difficulties understanding the palliative care intervention. No major differences were observed between patients who received the specialized intervention and those who did not. Content analysis emphasized that although they experienced disabling symptoms, participants tended to attribute their limitations to problems other than COPD and some declared that they were not sick. Patients reported restrictions due to oxygen therapy, and the burden of becoming dependent on it. This dependence resulted in intense anxiety, leading participants to focus on the present only. A strong feeling of perceived helplessness emerged from the patients' interviews.

CONCLUSIONS

Our findings suggest that poor recollection and understanding of the palliative care intervention act as barriers to the conduct of clinical trials with severe and very severe COPD patients. Their cognitive difficulties, perception of COPD, functional limitations, overwhelming anxiety, focus on the present and perceived helplessness also seem to hinder the implementation of such care.

Palliative and end-of-life care for adults with advanced chronic obstructive pulmonary disease: a rapid review focusing on patient and family caregiver perspectives

PURPOSE OF REVIEW

The aim of the review was to explore patient and family caregiver perspectives on key issues for ensuring quality of end-of-life care for people with chronic obstructive pulmonary disease (COPD). The growing evidence on the value of specialist palliative care services demonstrates significant improvements in treatments and provisions; however, much of the literature is generic in nature or centred on people with a cancer diagnosis. In this review, we examine the literature to ascertain the views and needs of patients and carers affected by advanced COPD, a highly debilitating condition that can have a profoundly negative impact on the quality of end-of-life experience.

RECENT FINDINGS

A total of 19 papers were included in the review. The main themes in the literature were Holistic Care, Illness Trajectory and Technology.

SUMMARY

Areas of unmet need emphasized across physical, psychosocial and spiritual domains were identified, particularly in relation to appropriate and timely conversations. Positive developments in the care and treatment of advanced COPD include the use of the STIOLTO Respimat inhaler, a brief educative and psychosocial intervention based on cognitive-behavioural therapy, and high-intensity exercise training. There is some evidence regarding the use of technology in end-stage COPD.

Living with breathlessness: a systematic literature review and qualitative synthesis

What is the experience of people living with breathlessness due to medical conditions, those caring for them and those treating them, with regard to quality of life and the nature of clinical interactions?Electronic databases (Ovid MEDLINE, Embase, CINAHL Plus and PsycINFO) were searched (January 1987 to October 2017; English language), for qualitative studies exploring the experience of chronic breathlessness (patients, carers and clinicians). Two independent reviewers screened titles, abstracts and papers retrieved against inclusion criteria. Disagreements were resolved with a third reviewer. Primary qualitative data were extracted and synthesised using thematic synthesis.Inclusion and synthesis of 101 out of 2303 international papers produced four descriptive themes: 1) widespread effects of breathlessness; 2) coping; 3) help-seeking behaviour; and 4) clinicians' responsiveness to the symptom of breathlessness. The themes were combined to form the concept of "breathing space", to show how engaged coping and appropriate help-seeking (patient) and attention to symptom (clinician) helps maximise the patient's quality of living with breathlessness.Breathlessness has widespread impact on both patient and carer and affects breathing space. The degree of breathing space is influenced by interaction between the patient's coping style, their help-seeking behaviour and their clinician's responsiveness to breathlessness itself, in addition to managing the underlying disease.

Salford Lung Study in chronic obstructive pulmonary disease (SLS COPD): follow-up interviews on patient-centred outcomes

This study investigated patient perceptions, experiences and management of COPD throughout the SLS COPD study. Follow-up interviews were conducted with 400 patients who completed SLS COPD; a mixed-methods approach was used to collect quantitative and qualitative information. Structured interviews using closed-ended questions were conducted with 360 patients, detailing aspects of background/lifestyle information and COPD. Extended interviews containing open-ended questions on perceptions of COPD and quality of life (QoL) in addition to the closed-ended questions were completed by 40 further patients. Participants also completed the Adherence Starts with Knowledge-12 (ASK-12) and the COPD and Asthma Sleep Impact Scale (CASIS) questionnaire. Quantitative data were analysed descriptively; qualitative data were analysed using qualitative description. The participants (n = 400) were reasonably representative of the SLS COPD population; mean age was 66.2 years. Breathlessness was the most commonly recalled symptom of/associated with COPD (88.5% of patients) and was the symptom that changed the most (improved, 26.8%/worsened, 20.9%) throughout the study. Participants' daily functioning and activities were most affected by symptoms of/associated with COPD, followed by relationships and psychological issues. 66.5% of participants experienced exacerbations, 60.5% of whom reported self-management as their first treatment strategy (taking antibiotics, resting and/or corticosteroids). Qualitative analysis revealed COPD symptoms, breathlessness in particular, to have a significant impact on mobility and in turn QoL. In conclusion, breathlessness was cited in these interviews as the COPD symptom with the greatest impact on participants' daily functioning, activities and self-care. The findings provided significant additional knowledge to the SLS COPD study findings.