The palliation of dyspnea in terminal disease

Conformity in Prescription and Administration of Respiratory Distress Protocols in a Tertiary Care Hospital in the Province of Quebec: RELIEVE Study

BACKGROUND

Respiratory distress protocols (RDPs) are protocolized prescriptions comprised of 3 medications (a benzodiazepine, an opioid, and an anticholinergic) administered simultaneously as an emergency treatment for respiratory distress in palliative care patients in the province of Quebec, Canada. However, data on appropriate use that justifies the combination of all 3 components is scarce and based on individual pharmacodynamic properties along with expert consensus.

OBJECTIVES

Our study aimed to evaluate the conformity and the effectiveness of RDPs prescribed and administered to hospitalized adult patients.

METHODS

This was a prospective and descriptive study conducted in a single center. Prescription and administration conformity were assessed based on predefined appropriateness criteria.

RESULTS

A total of 467 adult patients were prescribed a RDP, 175 administrations were documented, and 78 patients received at least 1 RDP. Prescription conformity was assessed on 1473 separate occasions over the trial period. Overall prescription conformity was found to be 37% (95% confidence interval [CI]: 33.6-40.4), and administration conformity was 37.7% (95% CI: 26.2-50.7). Low administration conformity was primarily explained by incorrect indications for RDP use. Seemingly important determinants of higher conformity were prescriber's speciality in palliative care, use of preprinted orders, pharmacist involvement, and hospitalization in the palliative care unit.

CONCLUSION

This study highlights important gaps in the use of RDPs in our institution. Health-care provider training appears necessary in order to ensure adequate conformity and allow for further evaluation of RDP effectiveness.

WITHDRAWN: Oxygen therapy for dyspnoea in adults

This review is out of date, and the original author team were not available to update this review, hence the review has been withdrawn.

The editorial group responsible for this previously published document have withdrawn it from publication.

Palliative care for the cancer patient

Palliation of symptoms to optimize QOL is the foundation of cancer care regardless of stage of disease or level of anticancer treatment. Patients commonly experience pain, constipation, nausea, vomiting, dyspnea, fatigue, and delirium. Many valid clinical tools are available to the primary care clinician to screen for symptoms, assess severity, measure treatment response, and elicit the patient's subjective symptom experience. Although there is limited evidence regarding the relative efficacy of symptom interventions from randomized controlled trials, clinical practice guidelines are available.

Oxygen therapy for dyspnoea in adults

BACKGROUND

Dyspnoea, or distressing breathing, is often a severe subjective symptom in terminal illness and may be difficult to control. Oxygen therapy is currently one of the interventions used to treat it. This review aimed to identify all randomised controlled studies (RCTs) in which oxygen therapy was used as a treatment to relieve dyspnoea in chronic terminal illness, and to synthesize the findings into a conclusion regarding the overall effectiveness of oxygen therapy for the palliation of dyspnoea in chronic terminal illness.

OBJECTIVES

The objective of this review was to determine if oxygen therapy, administered in a non-acute care setting, provided additional relief of dyspnoea in study participants with chronic end-stage disease over that provided by breathing room air or placebo air as a control.

SEARCH STRATEGY

Electronic databases were searched using predefined search terms. Searches were current to April 2006.

SELECTION CRITERIA

Only RCTs were considered for inclusion in this review. Unblinded studies were included.

DATA COLLECTION AND ANALYSIS

Data was extracted by one review author and checked by another.

MAIN RESULTS

Eight studies met the inclusion criteria for the review and included a total of 144 participants (cancer; n = 97, cardiac failure; n = 35, kyphoscoliosis; n = 12). Four cross-over studies, two studies with the participants at rest and two involving exercise testing, compared oxygen inhalation to air inhalation for dyspnoea management in adults with advanced cancer. Three cross-over studies compared the use of oxygen inhalation to air inhalation in adults with stable chronic heart failure for dyspnoea management during exercise testing and one crossover study compared ambulatory oxygen therapy with air inhalation on exercise-induced dyspnoea for study participants with kyphoscoliosis (a sideways and forwards curvature of the spine). No studies with matched or cohort controls were identified. Due to differences in study designs, few studies could be pooled for a meta-analysis. This systematic review of the literature failed to demonstrate a consistent beneficial effect of oxygen inhalation over air inhalation for study participants with dyspnoea due to end-stage cancer or cardiac failure. Some cancer study participants appeared to feel better during oxygen inhalation.

AUTHORS' CONCLUSIONS

The failure to demonstrate a beneficial effect for oxygen breathing over air breathing in cancer or cardiac failure was limited by the small volume of research studies available for inclusion, the small numbers of participants and by the methods used in the studies.

Terminal Care: The Last Weeks of Life

BACKGROUND

The care of patients in their last weeks of life is a fundamental palliative care skill, but few evidence-based reviews have focused on this critical period.

METHOD

A systematic review of published literature and expert opinion related to care in the last weeks of life.

RESULTS

The evidence base informing terminal care is largely descriptive, retrospective, or extrapolated. While home deaths and hospice use are increasing, medical care near death is becoming more aggressive and hospice lengths of stay remain short. Though the prediction of impending death remains imprecise, studies have identified several common terminal signs and symptoms. Decreased communication near death complicates the determination of patient wishes, and advanced directives prior to the terminal stage are recommended. Anorexia and cachexia are common in dying patients but there is no evidence that this process is painful or responsive to intervention. While there is general consensus that artificial nutrition is not beneficial in dying patients, the use of artificial hydration is controversial, especially in the setting of delirium. Breathlessness has been shown to benefit from oral and parenteral opioids but not anxiolytics. Accumulation of respiratory tract secretions (death rattle) is common and usually responds to antimuscarinics. Physical pain typically decreases toward death but its assessment in dying patients is difficult. Terminal delirium may occur in up to one-third of patients, may have a reversible cause, and may respond to antipsychotics or benzodiazepines. Palliative sedation is controversial but widely used, especially internationally. Caregiver stress and bereavement may benefit from improved communication and hospice involvement.

CONCLUSION

While the terminal care literature is characterized by varying quality, numerous knowledge gaps, and frequent inconsistencies, it supports several common clinical interventions. More research is needed to resolve controversies, define effective therapies, and improve the outcomes of dying patients.

Palliative care in cystic fibrosis

Although advances in therapy for cystic fibrosis (CF) have dramatically increased the average life span of patients, the disease is still uniformly fatal. Little attention has been paid to methods of palliative care for patients with cystic fibrosis in the medical literature. The primary palliative care issue in end-stage CF is the management of dyspnea. An observational study done at Children's Hospital in Boston suggested that doses of morphine in the range of 5 mg per hour can control the end-stage dyspnea in CF of over 50% of patients; the rest required increasing doses with the highest dose required being 30 mg/hour. The use of mechanical ventilation at the end of life is increasing in CF, particularly for those patients awaiting lung transplantation, and it appears that the consensus against the use of aggressive care at the end of life in CF may be eroding. The use of various modes of assisted ventilation in end-stage CF will add new challenges to the compassionate provision of end-of-life care. In addition to these medical issues, palliative care in CF presents some unique psychosocial issues: there may be more than one family member with the disease, and there is an involved patient community also affected by end-of-life plans. A family-centered approach to end-of-life care for patients with CF is essential.

Consensus statement: Palliative and supportive care in advanced heart failure

BACKGROUND

A consensus conference was convened to define the current state and important gaps in knowledge and needed research on "Palliative and Supportive Care in Advanced Heart Failure."

EVIDENCE

Evidence was drawn from expert opinion and from extensive review of the medical literature, evidence-based guidelines, and reviews.

CONCLUSIONS

The conference identified gaps in current knowledge, practice, and research relating to prognostication, symptom management, and supportive care for advanced heart failure (HF). Specific conclusions include: (1) although supportive care should be integrated throughout treatment of patients with advanced HF, data are needed to understand how to best decrease physical and psychosocial burdens of advanced HF and to meet patient and family needs; (2) prognostication in advanced HF is difficult and data are needed to understand which patients will benefit from which interventions and how best to counsel patients with advanced HF; (3) research is needed to identify which interventions improve quality of life and best achieve the outcomes desired by patients and family members; (4) care should be coordinated between sites of care, and barriers to evidence-based practice must be addressed programmatically; and (5) more research is needed to identify the content and technique of communicating prognosis and treatment options with patients with advanced HF; physicians caring for patients with advanced HF must develop skills to better integrate the patient's preferences into the goals of care.

Symptom management in the older adult

Palliative care begins at the time of diagnosis of a life-threatening illness and continues beyond the time of death. Defined in the broadest sense, the goal of palliative care is to provide aggressive symptom management and address the psychological and spiritual needs of the patient and the family. This article reviews the management of some symptoms commonly observed in older patients, highlighting treatment considerations specific to the older population. Ultimately the approach to symptoms must be individualized, and treatment decisions must reflect the patient's goals of care. Although symptom management in older patients may be challenging, it is possible to provide care that significantly enhances quality of life throughout the course of illness.

A double-blind, randomised, controlled Phase II trial of Heliox28 gas mixture in lung cancer patients with dyspnoea on exertion

Helium has a low density and the potential of reducing the work of breathing and improving alveolar ventilation when replacing nitrogen in air. A Phase II, double-blind, randomised, prospective, controlled trial was undertaken to assess whether Heliox28 (72% He/28% O₂) compared with oxygen-enriched air (72% N₂/28% O₂) or medical air (78.9% N₂/21.1% O₂) could reduce dyspnoea and improve the exercise capability of patients with primary lung cancer and dyspnoea on exertion (Borg >3). A total of 12 patients (seven male, five female patients, age 53–78) breathed the test gases in randomised order via a facemask and inspiratory demand valve at rest and while performing 6-min walk tests. Pulse oximetry (SaO₂) was recorded continuously. Respiratory rate and dyspnoea ratings (Borg and VAS) were taken before and immediately post-walk. Breathing Heliox28 at rest significantly increased SaO₂ compared to oxygen-enriched air (96±2 cf. 94±2, P<0.01). When compared to medical air, breathing Heliox28 but not oxygen-enriched air gave a significant improvement in the exercise capability (P<0.0001), SaO₂ (P<0.05) and dyspnoea scores (VAS, P<0.05) of lung cancer patients.

Dyspnea and quality of life indicators in hospice patients and their caregivers

This study describe the assessment of dyspnea, symptom distress, and quality of life measures in 163 hospice patients with cancer who reported dyspnea. Mean age of the hospice patient sample was 70.22 years and 61.86 for caregivers (65% were spouses). The majority of patients and caregivers were white: 87%, 63% of the patients were male while 78% of caregivers were female. Mean dyspnea intensity as reported by patients was 4.52 (SD 2.29) and caregivers, 4.39 (SD 2.93). Patients' and caregivers' ratings of the patient's dyspnea intensity revealed no significant differences in ratings thus verifying that caregivers can assess dyspnea severity accurately. Patients' perceived quality of life ratings were not significantly correlated with ratings of their caregivers' perceived quality of life. For patients, symptom distress and education were significant predictors of variance in quality of life (R2 =.35, p =.04). However, mastery, symptom distress, age, and education were found to be significant predictors of variance in quality of life of caregivers (R2 =.40, p =.02).

The last 48 hours of life in long-term care: a focused chart audit

OBJECTIVES

As a component of palliative care educational program development, the faculty at the University of Ottawa Institute of Palliative Care wished to assess end-of-life care for patients in long-term care (LTC) settings to develop an educational strategy for physicians.

DESIGN

A chart audit, focusing on the last 48 hours of life of residents dying in LTC facilities.

SETTING

Five LTC facilities in a city in Canada.

PARTICIPANTS

Residents who died in the LTC facilities in a 12-month period. Those who died suddenly (i.e., with no palliation period) or in a hospital were excluded.

MEASUREMENTS

Symptoms highlighted in the literature as commonly found in the terminally ill and the matching treatments were recorded on an audit form created by the authors. Included were pain, dyspnea, noisy breathing, delirium, dysphagia, fever, and myoclonus.

RESULTS

One hundred eighty-five charts were reviewed. A large number of patients were cognitively impaired. Cancer was the final diagnosis in 14% of cases. Respiratory symptoms were the most prevalent symptom, with dyspnea being first and noisy breathing third. Pain was second, with a prevalence similar to that found in studies of cancer patients. Dyspnea was not treated in 23% of the patients with this symptom; opioids were used in only 27% of cases with dyspnea. Ninety-nine percent of patients who experienced pain were treated for it. Less than one-third of patients with noisy breathing were treated. Delirium was not treated in 38% of the cases, and no anti-dopaminergic medications were administered. Nurses were primarily responsible for documenting end-of-life issues, supporting the families of the dying residents, and communicating with other team members.

CONCLUSION

The focused chart audit identified the high prevalence of cognitive impairment in the patient population, which complicates symptom management. Respiratory symptoms predominated in the last 48 hours of life. This symptom profile differs from that of cancer patients, who, according to the literature, have more pain and less respiratory trouble. Management of symptoms was variable. Nurses played a crucial role in the care of dying residents through their documentation and communication of end-of-life issues. Appropriate palliative care education can provide knowledge and skills to all health-care professionals, including physicians, and assist them in the control of symptoms and improvement of quality of life for patients dying in LTC facilities.

Dyspnea assessment and management in hospice patients with pulmonary disorders

Accurate assessments and appropriate management of dyspnea are essential to provide improved quality of life for hospice patients. This study describes methods of assessing dyspnea and interventions used to manage dyspnea in 72 hospice patients with end-stage lung disease or lung cancer. The mean age of the sample was 72.46 years old and the majority was white (80 percent) and male (62 percent). Paired t-tests were used to compare mean scores on admission and near death for dyspnea severity, Karnofsky functional status, pain, and Mini-Mental Status scores. Results showed significant decline in functional and cognitive status, but no significant changes in dyspnea severity and pain. Dyspnea was often assessed subjectively with observational methods only. Use of inhalants, oxygen, positioning, steroids, and oral opioids were the most frequent therapies for dyspnea. Relaxation, guided imagery, and other complementary therapies were rarely used (five percent or less). Measurement of dyspnea needs to be done frequently by using standardized instruments to assess severity and degree of symptom distress as well as the effects of treatment. Clinical trials are needed to determine which dyspnea interventions are most effective in terminally ill patients. Guidelines such as those developed for pain management are needed for effectively managing dyspnea.