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Drury A, Goss J, Afolabi J, McHugh G, O’Leary N, Brady AM. A Mixed Methods Evaluation of a Pilot Multidisciplinary Breathlessness Support Service. EVALUATION REVIEW 2023; 47:820-870. [PMID: 37014066 PMCID: PMC10492442 DOI: 10.1177/0193841x231162402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Breathlessness support services have demonstrated benefits for breathlessness mastery, quality of life and psychosocial outcomes for people living with breathlessness. However, these services have predominantly been implemented in hospital and home care contexts. This study aims to evaluate the adaptation and implementation of a hospice-based outpatient Multidisciplinary Breathlessness Support Service (MBSS) in Ireland. A sequential explanatory mixed methods design guided this study. People with chronic breathlessness participated in longitudinal questionnaires (n = 10), medical record audit (n = 14) and a post-discharge interview (n = 8). Caregivers (n = 1) and healthcare professionals involved in referral to (n = 2) and delivery of (n = 3) the MBSS participated in a cross-sectional interview. Quantitative and qualitative data were integrated deductively via the pillar integration process, guided by the RE-AIM framework. Integration of mixed methods data enhanced understanding of factors influencing the reach, adoption, implementation and maintenance of the MBSS, and the potential outcomes that were most meaningful for service users. Potential threats to the sustainability of the MBSS related to potential preconceptions of hospice care, the lack of standardized discharge pathways from the service and access to primary care services to sustain pharmacological interventions. This study suggests that an adapted multidisciplinary breathlessness support intervention is feasible and acceptable in a hospice context. However, to ensure optimal reach and maintenance of the intervention, activities are required to ensure that misconceptions about the setting do not influence willingness to accept referral to MBSS services and integration of services is needed to enable consistency in referral and discharge processes.
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Affiliation(s)
- Amanda Drury
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
- School of Nursing, Psychotherapy and Community Health, Dublin City University, Dublin, Ireland
| | - Julie Goss
- Our Lady’s Hospice and Care Services, Dublin, Ireland
| | - Jide Afolabi
- Our Lady’s Hospice and Care Services, Dublin, Ireland
| | | | - Norma O’Leary
- Our Lady’s Hospice and Care Services, Dublin, Ireland
| | - Anne-Marie Brady
- Trinity Centre Practice & Healthcare Innovation, School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland
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2
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Yi D, Reilly CC, Wei G, Higginson IJ. Optimising breathlessness triggered services for older people with advanced diseases: a multicentre economic study (OPTBreathe). Thorax 2023; 78:489-495. [PMID: 35970540 PMCID: PMC10176396 DOI: 10.1136/thoraxjnl-2021-218251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 05/11/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND In advanced disease, breathlessness becomes severe, increasing health services use. Breathlessness triggered services demonstrate effectiveness in trials and meta-analyses but lack health economic assessment. METHODS Our economic study included a discrete choice experiment (DCE), followed by a cost-effectiveness analysis modelling. The DCE comprised face-to-face interviews with older patients with chronic breathlessness and their carers across nine UK centres. Conditional logistic regression analysis of DCE data determined the preferences (or not, indicated by negative β coefficients) for service attributes. Economic modelling estimated the costs and quality-adjusted life years (QALYs) over 5 years. FINDINGS The DCE recruited 190 patients and 68 carers. Offering breathlessness services in person from general practitioner (GP) surgeries was not preferred (β=-0.30, 95% CI -0.40 to -0.21); hospital outpatient clinics (0.16, 0.06 to 0.25) or via home visits (0.15, 0.06 to 0.24) were preferred. Inperson services with comprehensive treatment review (0.15, 0.07 to 0.21) and holistic support (0.19, 0.07 to 0.31) were preferred to those without. Cost-effectiveness analysis found the most and the least preferred models of breathlessness services were cost-effective compared with usual care. The most preferred service had £5719 lower costs (95% CI -6043 to 5395), with 0.004 (95% CI -0.003 to 0.011) QALY benefits per patient. Uptake was higher when attributes were tailored to individual preferences (86% vs 40%). CONCLUSION Breathlessness services are cost-effective compared with usual care for health and social care, giving cost savings and better quality of life. Uptake of breathlessness services is higher when service attributes are individually tailored.
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Affiliation(s)
- Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Charles C Reilly
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
- Physiotherapy, King's College Hospital NHS Foundation Trust, London, UK
| | - Gao Wei
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
- Palliative care, King's College Hospital NHS Foundation Trust, London, UK
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3
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McCowan A, Gustafsson L, Bissett M, Sriram BK. Occupational therapy in adults with chronic respiratory conditions: A scoping review. Aust Occup Ther J 2023. [PMID: 36725667 DOI: 10.1111/1440-1630.12861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 12/08/2022] [Accepted: 01/17/2023] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Chronic respiratory diseases have a clear impact on occupational performance and engagement. Although occupational therapists have long provided services to this population, evidence regarding the unique role and true impact of occupational therapy is emerging. AIMS/OBJECTIVES The purpose of this scoping review was to explore the range, context, and outcomes of occupational therapy services for adults with chronic respiratory conditions. METHODS A scoping review guided by the methodological framework of Arksey and O'Malley was completed. To be included articles needed to be peer reviewed primary studies published in English between 2000 and September 2022 describing occupational therapy service delivery for people with chronic respiratory conditions. RESULTS Twenty-six articles met inclusion criteria including 12 cohort studies, seven randomised control trials, four qualitative, two case reports, and one service evaluation. Interventions were targeted at body functions and structures (n = 18), activities and participation (n = 17), and environmental factors (n = 14). Ten studies reported impacts of occupational therapy ranging from physiological responses through to quality of life. CONCLUSION Occupational therapy service delivery is common for this population, often occurring as part of multidisciplinary programs, and is inclusive of a range of assessments and interventions. Further details in future primary research are needed to describe the mode and unique occupational nature of service delivery.
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Affiliation(s)
- Amanda McCowan
- Griffith University, Queensland, Australia.,Gold Coast Hospital and Health Services, Queensland, Australia
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4
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Chen X, Moran T, Smallwood N. Real-world opioid prescription to patients with serious, non-malignant, respiratory illnesses and chronic breathlessness. Intern Med J 2022; 52:1925-1933. [PMID: 35384242 PMCID: PMC9795913 DOI: 10.1111/imj.15770] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/04/2022] [Accepted: 04/01/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Chronic breathlessness is a disabling symptom that is often under-recognised and challenging to treat despite optimal disease-directed therapy. Low-dose, oral opioids are recommended to relieve breathlessness, but little is known regarding long-term opioid prescription in this setting. AIM To investigate the long-term efficacy of, and side-effects from, opioids prescribed for chronic breathlessness to patients with advanced, non-malignant, respiratory diseases. METHODS A prospective cohort study of all patients managed by the advanced lung disease service, an integrated respiratory and palliative care service, at the Royal Melbourne Hospital from 1 April 2013 to 3 March 2020. RESULTS One hundred and nine patients were prescribed opioids for chronic breathlessness. The median length of opioid use was 9.8 (interquartile range (IQR) = 2.8-19.8) months. The most commonly prescribed initial regimen was an immediate-release preparation (i.e. Ordine) used as required (37; 33.9%). For long-term treatment, the most frequently prescribed regimen included an extended-release preparation with an as needed immediate-release (37; 33.9%). The median dose prescribed was 12 (IQR = 8-28) mg oral morphine equivalents/day. Seventy-one (65.1%) patients reported a subjective improvement in breathlessness. There was no significant change in the mean modified Medical Research Council dyspnoea score (P = 0.807) or lung function measurements (P = 0.086-0.727). There was no association between mortality and the median duration of opioid use (P = 0.201) or dose consumed (P = 0.130). No major adverse events were reported. CONCLUSION Within this integrated respiratory and palliative care service, patients with severe, non-malignant respiratory diseases safely used long-term, low-dose opioids for breathlessness with subjective benefits reported and no serious adverse events.
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Affiliation(s)
- Xinye Chen
- Department of MedicineEastern HealthMelbourneVictoriaAustralia
| | - Thomas Moran
- Department of MedicineThe Royal Melbourne HospitalMelbourneVictoriaAustralia
| | - Natasha Smallwood
- Department of Respiratory MedicineThe Alfred HospitalMelbourneVictoriaAustralia,Department of Allergy, Immunology and Respiratory MedicineCentral Clinical School, The Alfred Hospital, Monash UniversityMelbourneVictoriaAustralia
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5
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Reilly CC, Bristowe K, Roach A, Chalder T, Maddocks M, Higginson IJ. "The whole of humanity has lungs, doesn't it? We are not all the same sort of people": patient preferences and choices for an online, self-guided chronic breathlessness supportive intervention: SELF-BREATHE. ERJ Open Res 2022; 8:00093-2022. [PMID: 35821758 PMCID: PMC9271754 DOI: 10.1183/23120541.00093-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/26/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction The burden of chronic breathlessness on individuals, family, society and health systems is significant and set to increase exponentially with an ageing population with complex multimorbidity, yet there is a lack of services. This has been further amplified by the coronavirus disease 2019 pandemic. Online breathlessness interventions have been proposed to fill this gap, but need development and evaluation based on patient preferences and choices. This study aimed to explore the preferences and choices of patients regarding the content of an online self-guided chronic breathlessness supportive intervention (SELF-BREATHE). Methods Semi-structured telephone interviews were conducted with adults living with advanced malignant and nonmalignant disease and chronic breathlessness (July to November 2020). Interviews were analysed using conventional and summative content analysis. Results 25 patients with advanced disease and chronic breathlessness (COPD n=13, lung cancer n=8, interstitial lung disease n=3, bronchiectasis n=1; 17 male; median (range) age 70 (47-86) years; median (range) Medical Research Council dyspnoea score 3 (2-5)) were interviewed. Individuals highlighted strong preferences for focused education, methods to increase self-motivation and engagement, interventions targeting breathing and physical function, software capability to personalise the content of SELF-BREATHE to make it more meaningful to the user, and aesthetically designed content using various communication methods including written, video and audio content. Furthermore, they identified the need to address motivation as a key potential determinant of the success of SELF-BREATHE. Conclusion Our findings provide an essential foundation for future digital intervention development (SELF-BREATHE) and scaled research.
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Affiliation(s)
- Charles C Reilly
- Dept of Physiotherapy, King's College Hospital, London, UK.,Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Katherine Bristowe
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Anna Roach
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Trudie Chalder
- King's College London, Institute of Psychiatry, Dept of Psychological Medicine, London, UK
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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6
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Long A, Cartwright M, Reilly CC. Impact of fan therapy during exercise on breathlessness and recovery time in patients with COPD: a pilot randomised controlled crossover trial. ERJ Open Res 2021; 7:00211-2021. [PMID: 34760995 PMCID: PMC8573226 DOI: 10.1183/23120541.00211-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 08/10/2021] [Indexed: 11/23/2022] Open
Abstract
Background Patients with COPD reduce physical activity to avoid the onset of breathlessness. Fan therapy can reduce breathlessness at rest, but the efficacy of fan therapy during exercise remains unknown in this population. The aim of the present study was to investigate 1) the effect of fan therapy on exercise-induced breathlessness and post-exercise recovery time in patients with COPD and 2) the acceptability of fan therapy during exercise; and 3) to assess the reproducibility of any observed improvements in outcome measures. Methods A pilot single-centre, randomised, controlled, crossover open (nonmasked) trial (clinicaltrials.gov NCT03137524) of fan therapy versus no fan therapy during 6-min walk test (6MWT) in patients with COPD and a modified Medical Research Council (mMRC) dyspnoea score ≥2. Breathlessness intensity was quantified before and on termination of the 6MWT, using the numerical rating scale (NRS) (0–10). Post-exertional recovery time was measured, defined as the time taken to return to baseline NRS breathlessness score. Oxygen saturation and heart rate were measure pre- and post-6MWT. Results 14 patients with COPD completed the trial per protocol (four male, 10 female; median (interquartile range (IQR)) age 66.50 (60.75 to 73.50) years); mMRC dyspnoea 3 (2 to 3)). Fan therapy resulted in lower exercise-induced breathlessness (ΔNRS; Δ modified Borg scale) (within-individual differences in medians (WIDiM) −1.00, IQR −2.00 to −0.50; p<0.01; WIDiM −0.25, IQR −2.00 to 0.00; p=0.02), greater distance walked (metres) during the 6MWT (WIDiM 21.25, IQR 12.75 to 31.88; p<0.01), and improved post-exertional breathlessness (NRS) recovery time (WIDiM −10.00, IQR −78.75 to 50.00; p<0.01). Fan therapy was deemed to be acceptable by 92% of participants. Conclusion Fan therapy was acceptable and provided symptomatic relief to patients with COPD during exercise. These data will inform larger pilot studies and efficacy studies of fan therapy during exercise. Fan therapy was acceptable and provided symptomatic relief to patients with COPD during exercise; these positive preliminary findings suggest that fan therapy merits further investigation in larger and more methodologically rigorous studieshttps://bit.ly/3xR2GDW
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Affiliation(s)
- Alex Long
- Dept of Physiotherapy, King's College Hospital NHS Foundation Trust, London, UK.,School of Health Sciences, City, University of London, London, UK
| | | | - Charles C Reilly
- Dept of Physiotherapy, King's College Hospital NHS Foundation Trust, London, UK.,Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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Oluyase AO, Hocaoglu M, Cripps RL, Maddocks M, Walshe C, Fraser LK, Preston N, Dunleavy L, Bradshaw A, Murtagh FEM, Bajwah S, Sleeman KE, Higginson IJ. The Challenges of Caring for People Dying From COVID-19: A Multinational, Observational Study (CovPall). J Pain Symptom Manage 2021; 62:460-470. [PMID: 33556496 PMCID: PMC7863772 DOI: 10.1016/j.jpainsymman.2021.01.138] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/26/2021] [Accepted: 01/30/2021] [Indexed: 11/26/2022]
Abstract
CONTEXT Systematic data on the care of people dying with COVID-19 are scarce. OBJECTIVES To understand the response of and challenges faced by palliative care services during the COVID-19 pandemic, and identify associated factors. METHODS We surveyed palliative care and hospice services, contacted via relevant organizations. Multivariable logistic regression identified associations with challenges. Content analysis explored free text responses. RESULTS A total of 458 services responded; 277 UK, 85 rest of Europe, 95 rest of the world; 81% cared for patients with suspected or confirmed COVID-19, 77% had staff with suspected or confirmed COVID-19; 48% reported shortages of Personal Protective Equipment (PPE), 40% staff shortages, 24% medicines shortages, 14% shortages of other equipment. Services provided direct care and education in symptom management and communication; 91% changed how they worked. Care often shifted to increased community and hospital care, with fewer admissions to inpatient palliative care units. Factors associated with increased odds of PPE shortages were: charity rather than public management (OR 3.07, 95% CI 1.81-5.20), inpatient palliative care unit rather than other settings (OR 2.34, 95% CI 1.46-3.75). Being outside the UK was associated with lower odds of staff shortages (OR 0.44, 95% CI 0.26-0.76). Staff described increased workload, concerns for their colleagues who were ill, whilst expending time struggling to get essential equipment and medicines, perceiving they were not a front-line service. CONCLUSION Palliative care services were often overwhelmed, yet felt ignored in the COVID-19 response. Palliative care needs better integration with health care systems when planning and responding to future epidemics/pandemics.
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Affiliation(s)
- Adejoke O Oluyase
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Mevhibe Hocaoglu
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Rachel L Cripps
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Catherine Walshe
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - Lorna K Fraser
- Health Sciences, University of York, York, North Yorkshire, UK
| | - Nancy Preston
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - Lesley Dunleavy
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - Andy Bradshaw
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Fliss E M Murtagh
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK; Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK; King's College Hospital NHS Foundation Trust, Denmark Hill, UK
| | - Katherine E Sleeman
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK; King's College Hospital NHS Foundation Trust, Denmark Hill, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK; King's College Hospital NHS Foundation Trust, Denmark Hill, UK.
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Atreya S, Kumar R, Salins N. Community-based palliative care during the COVID 19 pandemic. J Family Med Prim Care 2020; 9:3169-3175. [PMID: 33102264 PMCID: PMC7567295 DOI: 10.4103/jfmpc.jfmpc_1144_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 01/19/2023] Open
Abstract
Novel Coronavirus (COVID 19) has usurped human peace and mobility. Since December 2019, the virus has claimed the lives of 87,816 people across the globe as of April 9, 2020 with India reporting a high case fatality of 3.4%. Among the vulnerable population, elderly people, and patients with comorbidities such as diabetes, chronic life-threatening illnesses, such as COPD and advanced malignancies are susceptible to COVID-19 infection and may have poor clinical outcomes. Considering the imbalance in demand and supply of healthcare resources, initiating palliative care will be essential to alleviate the suffering of such patients. The current paper deliberates on the following aspects of palliative care delivery in the community; the need for palliative care in a pandemic crisis, the role of telemedicine in palliative care delivery in the community, the vital role of a family physician in providing primary palliative care in the community and a "wholistic" community palliative care package to serve the needy in the community.
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Affiliation(s)
- Shrikant Atreya
- Department of Palliative Care and Psycho-Oncology, Tata Medical Center, Kolkata, West Bengal, India
| | - Raman Kumar
- Academy of Family Physicians of India, New Delhi, India
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Bajwah S, Wilcock A, Towers R, Costantini M, Bausewein C, Simon ST, Bendstrup E, Prentice W, Johnson MJ, Currow DC, Kreuter M, Wells AU, Birring SS, Edmonds P, Higginson IJ. Managing the supportive care needs of those affected by COVID-19. Eur Respir J 2020; 55:2000815. [PMID: 32269090 PMCID: PMC7144268 DOI: 10.1183/13993003.00815-2020] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/05/2020] [Indexed: 01/08/2023]
Abstract
Globally, the number of people affected by coronavirus disease 2019 (COVID-19) is rapidly increasing. In most (>80%), the illness is relatively mild and can be self-managed out of hospital. However, in about 20% the illness causes respiratory compromise severe enough to require hospital admission [1]. Patients with severe and critical disease need full active treatment. This may include oxygen for hypoxaemia and ventilatory support, along with optimal management of complications, e.g. super-imposed bacterial infection, and any underlying co-morbidities, e.g. chronic obstructive pulmonary disease, congestive heart failure. To date, no antiviral agent has shown to be effective in treating the disease [2].
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Affiliation(s)
- Sabrina Bajwah
- Cicely Saunders Institute, Dept of Palliative Care Policy and Rehabilitation, King's College London, London, UK
| | | | - Richard Towers
- Dept of Palliative Care, King's College Hospital, London, UK
| | | | - Claudia Bausewein
- Dept of Palliative Medicine, LMU Klinikum, Ludwig-Maximilians-University, Munich, Germany
| | - Steffen T Simon
- Dept of Palliative Medicine and Center for Integrated Oncology, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Elisabeth Bendstrup
- Centre for Rare Lung Diseases, Dept of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Wendy Prentice
- Dept of Palliative Care, King's College Hospital, London, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - David C Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Thoraxklinik, University of Heidelberg, German Center for Lung Research, Heidelberg, Germany
| | | | - Surinder S Birring
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Polly Edmonds
- Dept of Palliative Care, King's College Hospital, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute, Dept of Palliative Care Policy and Rehabilitation, King's College London, London, UK
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10
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Bausewein C, Schumacher P, Bolzani A. Integrated breathlessness services for people with chronic conditions. Curr Opin Support Palliat Care 2019; 12:227-231. [PMID: 29927755 DOI: 10.1097/spc.0000000000000361] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Optimal management of breathlessness requires generally more than one component. Breathlessness services aim to provide specific interventions and support for patients suffering from breathlessness due to any advanced disease and their carers. This review aims to describe recent studies evaluating the effects of breathlessness services for patients with advanced chronic conditions. RECENT FINDINGS Various breathlessness services have been tested and vary regarding structure, duration, frequency and professionals involved. Four randomized controlled trials demonstrated a positive and significant effect on distress due to breathlessness or mastery of breathlessness or breathlessness severity. In the fifth randomized controlled trial, quantitative results were NS, but in the qualitative interviews, patients stressed the positive experience with the breathlessness service and the benefits they gained. The caring, holistic, respectful and integrated approaches were valued by patients. SUMMARY Breathlessness services combine a variety of evidence-based nonpharmacological interventions and some services also pharmacological interventions when physicians are involved. As the prevalence of breathlessness due to advanced disease is high and increasing, more such services should be provided to support patients throughout the course of their disease.
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Affiliation(s)
- Claudia Bausewein
- Department of Palliative Medicine, Munich University Hospital, Ludwig-Maximilians-Universitaet Muenchen, München, Germany
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11
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Maddocks M, Brighton LJ, Farquhar M, Booth S, Miller S, Klass L, Tunnard I, Yi D, Gao W, Bajwah S, Man WDC, Higginson IJ. Holistic services for people with advanced disease and chronic or refractory breathlessness: a mixed-methods evidence synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background
Breathlessness is a common and distressing symptom of many advanced diseases, affecting around 2 million people in the UK. Breathlessness increases with disease progression and often becomes chronic or refractory. Breathlessness-triggered services that integrate holistic assessment and specialist palliative care input as part of a multiprofessional approach have been developed for this group, offering tailored interventions to support self-management and reduce distress.
Objectives
The aim was to synthesise evidence on holistic breathlessness services for people with advanced disease and chronic or refractory breathlessness. The objectives were to describe the structure, organisation and delivery of services, determine clinical effectiveness, cost-effectiveness and acceptability, identify predictors of treatment response, and elicit stakeholders’ evidence-based priorities for clinical practice, policy and research.
Design
The mixed-methods evidence synthesis comprised three components: (1) a systematic review to determine the clinical effectiveness, cost-effectiveness and acceptability of holistic breathlessness services; (2) a secondary analysis of pooled individual data from three trials to determine predictors of clinical response; and (3) a transparent expert consultation (TEC), comprising a stakeholder workshop and an online consensus survey, to identify stakeholders’ priorities.
Results
Thirty-seven papers reporting on 18 holistic breathlessness services were included in the systematic review. Most studies enrolled people with thoracic cancer, were delivered over 4–6 weeks, and included breathing training, relaxation techniques and psychological support. Meta-analysis demonstrated significant reductions in the Numeric Rating Scale (NRS) distress due to breathlessness, significant reductions in the Hospital Anxiety and Depressions Scale (HADS) depression scores, and non-significant reductions in the Chronic Respiratory Disease Questionnaire (CRQ) mastery and HADS anxiety, favouring the intervention. Recipients valued education, self-management interventions, and expertise of the staff in breathlessness and person-centred care. Evidence for cost-effectiveness was limited and inconclusive. The responder analysis (n = 259) revealed baseline CRQ mastery and NRS distress to be strong predictors of the response to breathlessness services assessed by these same measures, and no significant influence from baseline breathlessness intensity, patient diagnosis, lung function, health status, anxiety or depression. The TEC elicited 34 priorities from stakeholders. Seven priorities received high agreement and consensus, reflecting stakeholders’ (n = 74) views that services should be person-centred and multiprofessional, share their breathlessness management skills with others, and recognise the roles and support needs of informal carers.
Limitations
The evidence synthesis draws predominantly from UK services and may not be generalisable to other settings. Some meta-analyses were restricted by reporting biases and statistical heterogeneity.
Conclusions
Despite heterogeneity in composition and delivery, holistic breathlessness services are highly valued by recipients and can lead to significant improvements in the distress caused by breathlessness and depression. Outcomes of improved mastery and reduced distress caused by breathlessness are not influenced by patient diagnosis, lung function or health status. Stakeholders highlighted the need for improved access to person-centred, multiprofessional breathlessness services and support for informal carers.
Future work
Our research suggests that key therapeutic components of holistic breathlessness services be considered in clinical practice and models of delivery and educational strategies to address stakeholders’ priorities tested.
Study registration
This study is registered as PROSPERO CRD42017057508.
Funding
The National Institute for Health Research (NIHR) Health Services and Delivery programme. Matthew Maddocks, Wei Gao and Irene J Higginson are supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London; Matthew Maddocks is supported by a NIHR Career Development Fellowship (CDF-2017-009), William D-C Man is supported by the NIHR CLAHRC Northwest London and Irene J Higginson holds a NIHR Emeritus Senior Investigator Award.
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Affiliation(s)
- Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Lisa Jane Brighton
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Morag Farquhar
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Sara Booth
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Sophie Miller
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Lara Klass
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - India Tunnard
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - William D-C Man
- National Heart and Lung Institute, Imperial College London, London, UK
- Harefield Pulmonary Rehabilitation and Muscle Research Laboratory, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
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12
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Similowski T, Serresse L. Lessons from negative dyspnoea studies: arguments for the multidimensional evaluation of multidirectional therapeutic approaches. Eur Respir J 2019; 53:53/1/1802471. [DOI: 10.1183/13993003.02471-2018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 01/02/2019] [Indexed: 12/13/2022]
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13
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Brighton LJ, Miller S, Farquhar M, Booth S, Yi D, Gao W, Bajwah S, Man WDC, Higginson IJ, Maddocks M. Holistic services for people with advanced disease and chronic breathlessness: a systematic review and meta-analysis. Thorax 2018; 74:270-281. [PMID: 30498004 PMCID: PMC6467249 DOI: 10.1136/thoraxjnl-2018-211589] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 10/09/2018] [Accepted: 10/22/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Breathlessness is a common, distressing symptom in people with advanced disease and a marker of deterioration. Holistic services that draw on integrated palliative care have been developed for this group. This systematic review aimed to examine the outcomes, experiences and therapeutic components of these services. METHODS Systematic review searching nine databases to June 2017 for experimental, qualitative and observational studies. Eligibility and quality were independently assessed by two authors. Data on service models, health and cost outcomes were synthesised, using meta-analyses as indicated. Data on recipient experiences were synthesised thematically and integrated at the level of interpretation and reporting. RESULTS From 3239 records identified, 37 articles were included representing 18 different services. Most services enrolled people with thoracic cancer, involved palliative care staff and comprised 4-6 contacts over 4-6 weeks. Commonly used interventions included breathing techniques, psychological support and relaxation techniques. Meta-analyses demonstrated reductions in Numeric Rating Scale distress due to breathlessness (n=324; mean difference (MD) -2.30, 95% CI -4.43 to -0.16, p=0.03) and Hospital Anxiety and Depression Scale (HADS) depression scores (n=408, MD -1.67, 95% CI -2.52 to -0.81, p<0.001) favouring the intervention. Statistically non-significant effects were observed for Chronic Respiratory Questionnaire (CRQ) mastery (n=259, MD 0.23, 95% CI -0.10 to 0.55, p=0.17) and HADS anxiety scores (n=552, MD -1.59, 95% CI -3.22 to 0.05, p=0.06). Patients and carers valued tailored education, self-management interventions and expert staff providing person-centred, dignified care. However, there was no observable effect on health status or quality of life, and mixed evidence around physical function. CONCLUSION Holistic services for chronic breathlessness can reduce distress in patients with advanced disease and may improve psychological outcomes of anxiety and depression. Therapeutic components of these services should be shared and integrated into clinical practice. REGISTRATION NUMBER CRD42017057508.
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Affiliation(s)
- Lisa Jane Brighton
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Sophie Miller
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Morag Farquhar
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Sara Booth
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - William D-C Man
- NIHR Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College, Harefield, UK.,Harefield Pulmonary Rehabilitation Unit, Harefield Hospital, Harefield, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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Duncan D, Ashby A. Managing chronic breathlessness in the community. Br J Community Nurs 2018; 23:318-321. [PMID: 29972663 DOI: 10.12968/bjcn.2018.23.7.318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Breathlessness or dyspnoea is a subjective experience that can be described as an unpleasant or uncomfortable awareness of breathing. It is a subjective experience for patients and often they learn to adapt to the limitations caused by their condition, which makes their breathlessness less apparent to others. Breathlessness can be subdivided in the context of chronic refractory breathlessness, such as acute breathlessness, which is either an episodic breathlessness or breathlessness crisis. Chronic refractory breathlessness is defined as breathlessness at rest or on minimal exertion that will persist chronically despite optimal treatment of the underlying causative factors. The role of the community nurse in managing the breathless patient should involve differentiating between different types of breathlessness and knowing how to effectively manage it in a holistic manner.
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Affiliation(s)
| | - Abigail Ashby
- Senior lecturer in Nursing, Bucks New University, Buckinghamshire
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Maddocks M, Lovell N, Booth S, Man WDC, Higginson IJ. Palliative care and management of troublesome symptoms for people with chronic obstructive pulmonary disease. Lancet 2017; 390:988-1002. [PMID: 28872031 DOI: 10.1016/s0140-6736(17)32127-x] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 06/29/2017] [Accepted: 07/07/2017] [Indexed: 12/30/2022]
Abstract
People with advanced chronic obstructive pulmonary disease (COPD) have distressing physical and psychological symptoms, often have limited understanding of their disease, and infrequently discuss end-of-life issues in routine clinical care. These are strong indicators for expert multidisciplinary palliative care, which incorporates assessment and management of symptoms and concerns, patient and caregiver education, and sensitive communication to elicit preferences for care towards the end of life. The unpredictable course of COPD and the difficulty of predicting survival are barriers to timely referral and receipt of palliative care. Early integration of palliative care with respiratory, primary care, and rehabilitation services, with referral on the basis of the complexity of symptoms and concerns, rather than prognosis, can improve patient and caregiver outcomes. Models of integrated working in COPD could include: services triggered by troublesome symptoms such as refractory breathlessness; short-term palliative care; and, in settings with limited access to palliative care, consultation only in specific circumstances or for the most complex patients.
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Affiliation(s)
- Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Natasha Lovell
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Sara Booth
- Department of Palliative Medicine, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Department of Oncology, University of Cambridge, Cambridge, UK
| | - William D-C Man
- Harefield Pulmonary Rehabilitation and Muscle Research Laboratory, Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK.
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Gysels M, Reilly CC, Jolley CJ, Pannell C, Spoorendonk F, Moxham J, Bausewein C, Higginson IJ. Dignity Through Integrated Symptom Management: Lessons From the Breathlessness Support Service. J Pain Symptom Manage 2016; 52:515-524. [PMID: 27650009 DOI: 10.1016/j.jpainsymman.2016.04.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 03/02/2016] [Accepted: 04/29/2016] [Indexed: 11/19/2022]
Abstract
CONTEXT Dignity is poorly conceptualized and little empirically explored in end-of-life care. A qualitative evaluation of a service offering integrated palliative and respiratory care for patients with advanced disease and refractory breathlessness uncovered an unexpected outcome, it enhanced patients' dignity. OBJECTIVES To analyze what constitutes dignity for people suffering from refractory breathlessness with advanced disease, and its implications for the concept of dignity. METHODS Qualitative study of cross-sectional interviews with 20 patients as part of a Phase III evaluation of a randomized controlled fast-track trial. The interviews were transcribed verbatim, imported into NVivo, and analyzed through constant comparison. The findings were compared with Chochinov et al.'s dignity model. The model was adapted with the themes and subthemes specific to patients suffering from breathlessness. RESULTS The findings of this study underscore the applicability of the conceptual model of dignity for patients with breathlessness. There were many similarities in themes and subthemes. Differences specifically relevant for patients suffering from severe breathlessness were as follows: 1) physical distress and psychological mechanisms are interlinked with the disability and dependence breathlessness causes, in the illness-related concerns, 2) stigma is an important component of the social dignity inventory, 3) conditions and perspectives need to be present to practice self-care in the dignity-conserving repertoire. CONCLUSION Dignity is an integrated concept and can be affected by influences from other areas such as illness-related concerns. The intervention shows that targeting the symptom holistically and equipping patients with the means for self-care realized the outcome of dignity.
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Affiliation(s)
- Marjolein Gysels
- Department of Palliative Care, Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK; Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands.
| | - Charles C Reilly
- Department of Palliative Care, Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
| | - Caroline J Jolley
- Department of Asthma, Allergy and Respiratory Science, King's College London, London, UK; Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Caty Pannell
- Department of Palliative Care, Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
| | - Femke Spoorendonk
- Department of Palliative Care, Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
| | - John Moxham
- Department of Asthma, Allergy and Respiratory Science, King's College London, London, UK; Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Claudia Bausewein
- Department of Palliative Care, Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK; Department of Palliative Medicine, University Hospital Munich, Munich, Germany
| | - Irene J Higginson
- Department of Palliative Care, Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
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