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Lippi L, de Sire A, Aprile V, Calafiore D, Folli A, Refati F, Balduit A, Mangogna A, Ivanova M, Venetis K, Fusco N, Invernizzi M. Rehabilitation for Functioning and Quality of Life in Patients with Malignant Pleural Mesothelioma: A Scoping Review. Curr Oncol 2024; 31:4318-4337. [PMID: 39195305 DOI: 10.3390/curroncol31080322] [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] [Received: 06/10/2024] [Revised: 07/26/2024] [Accepted: 07/29/2024] [Indexed: 08/29/2024] Open
Abstract
Malignant pleural mesothelioma (MPM) represents a significant clinical challenge due to limited therapeutic options and poor prognosis. Beyond mere survivorship, setting up an effective framework to improve functioning and quality of life is an urgent need in the comprehensive management of MPM patients. Therefore, this study aims to review the current understanding of MPM sequelae and the effectiveness of rehabilitative interventions in the holistic approach to MPM. A narrative review was conducted to summarize MPM sequelae and their impact on functioning, disability, and quality of life, focusing on rehabilitation interventions in MPM management and highlighting gaps in knowledge and areas for further investigation. Our findings showed that MPM patients experience debilitating symptoms, including fatigue, dyspnea, pain, and reduced exercise tolerance, decreasing quality of life. Supportive and rehabilitative interventions, including pulmonary rehabilitation, physical exercise improvement, psychological support, pain management, and nutritional supplementation, seem promising approaches in relieving symptoms and improving quality of life but require further research. These programs emphasize the pivotal synergy among patient-tailored plans, multidisciplinary team involvement, and disease-specific focus. Despite advancements in therapeutic management, MPM remains a challenging disease with limited effective interventions that should be adapted to disease progressions. Rehabilitative strategies are essential to mitigate symptoms and improve the quality of life in MPM patients. Further research is needed to establish evidence-based guidelines for rehabilitative interventions tailored to the unique needs of MPM patients.
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Affiliation(s)
- Lorenzo Lippi
- Department of Scientific Research, Off-Campus Semmelweis University of Budapest, Campus LUdeS Lugano (CH), 1085 Budapest, Hungary
| | - Alessandro de Sire
- Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", 88100 Catanzaro, Italy
- Research Center on Musculoskeletal Health, MusculoSkeletalHealth@UMG, University of Catanzaro Magna Graecia, 88100 Catanzaro, Italy
| | - Vittorio Aprile
- Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, 56126 Pisa, Italy
| | - Dario Calafiore
- Department of Neurosciences, ASST Carlo Poma, 46100 Mantova, Italy
| | - Arianna Folli
- Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", 28100 Novara, Italy
| | - Fjorelo Refati
- Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", 28100 Novara, Italy
| | - Andrea Balduit
- Institute for Maternal and Child Health, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Burlo Garofolo, 34100 Trieste, Italy
| | - Alessandro Mangogna
- Institute of Pathological Anatomy, Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Mariia Ivanova
- Division of Pathology, European Institute of Oncology, IRCCS, 20141 Milan, Italy
| | - Konstantinos Venetis
- Division of Pathology, European Institute of Oncology, IRCCS, 20141 Milan, Italy
| | - Nicola Fusco
- Division of Pathology, European Institute of Oncology, IRCCS, 20141 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Marco Invernizzi
- Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", 28100 Novara, Italy
- Translational Medicine, Dipartimento Attività Integrate Ricerca e Innovazione (DAIRI), Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
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Rodríguez-Campos L, Andres Rodriguez-Lesmes P, Palomino Cancino A, Del Valle Díaz I, Fernando Gamboa L, Castillo Niuman A, Sebastián Salas J, Sarmiento G, Martínez-Bernal J, González-Vélez AE. Cost-utility analysis of a palliative care program in Colombia. BMC Palliat Care 2024; 23:165. [PMID: 38970056 PMCID: PMC11227163 DOI: 10.1186/s12904-024-01476-6] [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: 11/30/2022] [Accepted: 05/28/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND The economic assessment of health care models in palliative care promotes their global development. The purpose of the study is to assess the cost-effectiveness of a palliative care program (named Contigo) with that of conventional care from the perspective of a health benefit plan administrator company, Sanitas, in Colombia. METHODS The incremental cost-utility ratio (ICUR) and the incremental net monetary benefit (INMB) were estimated using micro-costing in a retrospective, analytical cross-sectional study on the care of terminally ill patients enrolled in a palliative care program. A 6-month time horizon prior to death was used. The EQ-5D-3 L questionnaire (EQ-5D-3 L) and the McGill Quality of Life Questionnaire (MQOL) were used to measure the quality of life. RESULTS The study included 43 patients managed within the program and 16 patients who received conventional medical management. The program was less expensive than the conventional practice (difference of 1,924.35 US dollars (USD), P = 0.18). When compared to the last 15 days, there is a higher perception of quality of life, which yielded 0.25 in the EQ-5D-3 L (p < 0.01) and 1.55 in the MQOL (P < 0.01). The ICUR was negative and the INMB was positive. CONCLUSION Because the Contigo program reduces costs while improving quality of life, it is considered to be net cost-saving and a model with value in health care. Greater availability of palliative care programs, such as Contigo, in Colombia can help reduce existing gaps in access to universal palliative care health coverage, resulting in more cost-effective care.
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Grants
- 143580764115 Ministerio de Ciencia, Tecnología e Innovación of Colombia
- 143580764115 Ministerio de Ciencia, Tecnología e Innovación of Colombia
- 143580764115 Ministerio de Ciencia, Tecnología e Innovación of Colombia
- 143580764115 Ministerio de Ciencia, Tecnología e Innovación of Colombia
- 143580764115 Ministerio de Ciencia, Tecnología e Innovación of Colombia
- 143580764115 Ministerio de Ciencia, Tecnología e Innovación of Colombia
- 143580764115 Ministerio de Ciencia, Tecnología e Innovación of Colombia
- 143580764115 Ministerio de Ciencia, Tecnología e Innovación of Colombia
- 143580764115 Ministerio de Ciencia, Tecnología e Innovación of Colombia
- 143580764115 Ministerio de Ciencia, Tecnología e Innovación of Colombia
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Affiliation(s)
- Luisa Rodríguez-Campos
- Pain and Palliative Medicine. Home Primary Care Unit, Centros Médicos Colsanitas, Calle 163A # 22 08, Bogotá, Colombia.
| | | | - Analhi Palomino Cancino
- National Medical Coordinator Palliative Care Program, Sanitas Health Insurance, Bogotá, Colombia
| | - Iris Del Valle Díaz
- Medical Director Primary Home Care Unit, Centros Médicos Colsanitas, Bogotá, Colombia
| | - Luis Fernando Gamboa
- Epidemiology. Division of Planning, Evaluation, and Knowledge Management, Sanitas CREA, Sanitas Health Insurance, Bogotá, Colombia
| | - Andrea Castillo Niuman
- Division of Planning, Evaluation, and Knowledge Management, Sanitas CREA, Sanitas Health Insurance, Bogotá, Colombia
| | - Juan Sebastián Salas
- Internal Medicine Postgraduate Training, Fundación Universitaria Sanitas, Bogotá, Colombia
| | - Gabriela Sarmiento
- Pain and Palliative Medicine. Home Primary Care Unit, Centros Médicos Colsanitas, Calle 163A # 22 08, Bogotá, Colombia
| | | | - Abel E González-Vélez
- Preventive Medicine and Public Health medical specialist, Teacher and Researcher Professional of Medicine Department, Universidad de Deusto, Bilbao, Spain
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Rao-Newton A, Gallagher E, Mickelsen J, Sanchez C, Forby F, Andrews K, Hosie A, Sheehan C, DeNatale M, Agar M. Timely Assessment of Breathing-Related Distress in Community Palliative Care: A Multidisciplinary Collaborative Quality Improvement Project. J Palliat Med 2024; 27:324-334. [PMID: 37962858 DOI: 10.1089/jpm.2022.0576] [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: 11/15/2023] Open
Abstract
Background: Breathlessness is a common symptom for palliative patients that can cause distress and decrease function and quality of life. Palliative care services in Australia aim to routinely assess patients for breathing-related distress, but timely reassessment is not always achieved. Objective: To improve the timeliness of breathlessness reassessment in a home-based community palliative care service in New South Wales for people with moderate-to-severe breathing-related distress. Breathing-related distress was defined as a Symptom Assessment Score for "breathing problems" of four or more. Methods: This collaborative quality improvement (QI) project between SPHERE Palliative Care CAG, Stanford University mentors, and a Sydney metropolitan specialist palliative care service included a: (1) retrospective chart audit; (2) cause and effect analyses using a fishbone diagram; (3) development and implementation of key drivers and interventions; and (4) a pre-and-post evaluation of the timeliness of reassessment of breathing-related distress and changes in Symptom Assessment Scale scores for "breathing problems." Results: Key interventions included multidisciplinary education sessions to facilitate buy-in, with nurses as case managers responsible for breathlessness reassessment and documentation of scores, access and training in electronic palliative care data entry software, fortnightly monitoring and reporting of breathing-related distress scores, and development of an educational flowchart. The proportion of patients reassessed within seven days of an initial nursing assessment of moderate-to-severe breathing-related distress increased from 34% at baseline to 92% at six months. Conclusion: A local QI project increased the proportion of patients with a timely reassessment of their breathing-related distress in a community palliative care service.
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Affiliation(s)
- Angela Rao-Newton
- School of Nursing, College of Health and Medicine, University of Tasmania, Lilyfield, New South Wales, Australia
- Improving Palliative Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Elaine Gallagher
- Calvary Health Care Kogarah, Beverley Park, New South Wales, Australia
| | - Jake Mickelsen
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Carmen Sanchez
- Calvary Health Care Kogarah, Beverley Park, New South Wales, Australia
| | - Felicity Forby
- Calvary Health Care Kogarah, Beverley Park, New South Wales, Australia
| | - Kate Andrews
- Calvary Health Care Kogarah, Beverley Park, New South Wales, Australia
| | - Annmarie Hosie
- Improving Palliative Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
- University of Notre Dame, Sydney, New South Wales, Australia
- St Vincent's Health Network Sydney, New South Wales, Australia
| | - Caitlin Sheehan
- Improving Palliative Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
- Calvary Health Care Kogarah, Beverley Park, New South Wales, Australia
| | | | - Meera Agar
- Improving Palliative Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
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Yorke J, Johnson MJ, Punnett G, Smith J, Blackhall F, Lloyd Williams M, Mackereth P, Haines J, Ryder D, Krishan A, Davies L, Khan A, Molassiotis A. Respiratory distress symptom intervention for non-pharmacological management of the lung cancer breathlessness-cough-fatigue symptom cluster: randomised controlled trial. BMJ Support Palliat Care 2024; 13:e1181-e1190. [PMID: 36283797 PMCID: PMC10850726 DOI: 10.1136/spcare-2022-003924] [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: 08/16/2022] [Accepted: 09/27/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVES In lung cancer, three prominent symptoms, such as breathlessness, cough and fatigue, are closely related with each other forming a 'respiratory distress symptom cluster'. The aim of this study was to determine the clinical and cost-effectiveness of the respiratory distress symptom intervention (RDSI) for the management of this symptom cluster in people with lung cancer. METHODS A single blind, pragmatic, randomised controlled trial conducted in eight centres in England, UK. A total of 263 patients with lung cancer were randomised, including 132 who received RDSI and 131 who received standard care. To be eligible, participants self-reported adverse impact in daily life from at least two of the three symptoms, in any combination. Outcomes were change at 12 weeks for each symptom within the cluster, including Dyspnoea-12 (D-12), Manchester Cough in Lung Cancer (MCLC) and Functional Assessment of Chronic Illness-Fatigue. RESULTS At baseline, nearly 60% of participants reported all three symptoms. At trial completion the total trial attrition was 109 (41.4%). Compared with the control group, the RDSI group demonstrated a statistically significant improvement in D-12 (p=0.007) and MCLC (p<0.001). The minimal clinically important difference MCID) was achieved for each outcome: D-12 -4.13 (MCID >3), MCLC -5.49 (MCID >3) and FACIT-F 4.91 (MCID >4). CONCLUSION RDSI is a clinically effective, low-risk intervention to support the management of the respiratory distress symptom cluster in lung cancer. However, the study did experience high attrition, which needs to be taken onto consideration when interpreting these results. TRIAL REGISTRATION NUMBER NCT03223805.
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Affiliation(s)
- Janelle Yorke
- Christie Patient Centred Research, The Christie NHS Foundation Trust, Manchester, UK
- Faculty of Health Sciences, The University of Manchester, Manchester, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, UK
| | - Grant Punnett
- Christie Patient Centred Research, The Christie NHS Foundation Trust, Manchester, UK
| | - Jaclyn Smith
- Faculty of Health Sciences, The University of Manchester, Manchester, UK
- Christie Patient Centred Research, Manchester University NHS Foundation Trust, Manchester, UK
| | - Fiona Blackhall
- Faculty of Health Sciences, The University of Manchester, Manchester, UK
| | | | - Peter Mackereth
- Christie Patient Centred Research, The Christie NHS Foundation Trust, Manchester, UK
| | - Jemma Haines
- Faculty of Health Sciences, The University of Manchester, Manchester, UK
| | - David Ryder
- Faculty of Health Sciences, The University of Manchester, Manchester, UK
| | - Ashma Krishan
- Faculty of Health Sciences, The University of Manchester, Manchester, UK
| | - Linda Davies
- Faculty of Health Sciences, The University of Manchester, Manchester, UK
| | - Aysha Khan
- Faculty of Health Sciences, The University of Manchester, Manchester, UK
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Prihartadi AS, Impelliziere Licastro G, Pearson M, Johnson MJ, Luckett T, Swan F. Non-medical devices for chronic breathlessness: use, barriers and facilitators for patients, carers and clinicians - a scoping review. BMJ Support Palliat Care 2023; 13:e244-e253. [PMID: 34215567 DOI: 10.1136/bmjspcare-2021-002962] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/10/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Non-medical devices such as the handheld fan (fan), mobility aids (wheeled walkers with seats) and inspiratory muscle training (IMT) devices offer benefits for patient management of chronic breathlessness. We examined the published evidence regarding patient, carer and clinician use of the fan, mobility aids and IMT devices for chronic breathlessness management, and the potential barriers and facilitators to day-to-day use in a range of settings. METHODS MEDLINE, Embase, Scopus, EBSCO and the Cochrane Database of Systematic Reviews were searched. Papers were imported into EndNote and Rayyan for review against a priori eligibility criteria. Outcome data relevant to use were extracted and categorised as potential barriers and facilitators, and a narrative synthesis exploring reasons for similarities and differences conducted. RESULTS Seven studies met the inclusion criteria (n=5 fan, n=2 mobility aids and n=0 IMT devices). All of the studies presented patient use of non-medical devices only. Patients found the fan easy to use at home. Mobility aids were used mainly for outdoor activities. Outdoor use for both devices were associated with embarrassment. Key barriers included: appearance; credibility; self-stigma; technical specifications. Common facilitators were ease of use, clinical benefit and feeling safe with the device. CONCLUSION The efforts of patients, carers and clinicians to adopt and use non-medical devices for the management of chronic breathlessness is impeded by lack of implementation research. Future research should improve knowledge of the barriers and facilitators to use. This would enhance understanding of how decision-making in patient-carer-clinician triads impacts on non-medical devices use for breathlessness management.
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Affiliation(s)
| | | | - Mark Pearson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Tim Luckett
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Flavia Swan
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Kako J, Morikawa M, Kobayashi M, Kanno Y, Kajiwara K, Nakano K, Matsuda Y, Shimizu Y, Hori M, Niino M, Suzuki M, Shimazu T. Nursing support for breathlessness in patients with cancer: a scoping review. BMJ Open 2023; 13:e075024. [PMID: 37827741 PMCID: PMC10582874 DOI: 10.1136/bmjopen-2023-075024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023] Open
Abstract
OBJECTIVE To identify nursing support provided for the relief of breathlessness in patients with cancer. DESIGN A scoping review following a standard framework proposed by Arksey and O'Malley. STUDY SELECTION Electronic databases (PubMed, CINAHL, CENTRAL and Ichushi-Web of the Japan Medical Abstract Society Databases) were searched from inception to 31 January 2022. Studies reporting on patients with cancer (aged ≥18 years), intervention for relief from breathlessness, nursing support and quantitatively assessed breathlessness using a scale were included. RESULTS Overall, 2629 articles were screened, and 27 were finally included. Results of the qualitative thematic analysis were categorised into 12 nursing support components: fan therapy, nurse-led intervention, multidisciplinary intervention, psychoeducational programme, breathing technique, walking therapy, inspiratory muscle training, respiratory rehabilitation, yoga, acupuncture, guided imagery and abdominal massage. CONCLUSIONS We identified 12 components of nursing support for breathlessness in patients with cancer. The study results may be useful to understand the actual state of nursing support provided for breathlessness in patients with terminal cancer and to consider possible support that can be implemented.
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Affiliation(s)
- Jun Kako
- Graduate School of Medicine, Mie University, Tsu, Mie, Japan
| | - Miharu Morikawa
- Palliative Nursing, Course of Advanced Nursing Sciences, Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto, Japan
| | - Masamitsu Kobayashi
- Graduate of Nursing Science, St Luke's International University, Chuo-ku, Tokyo, Japan
| | - Yusuke Kanno
- Graduate School of Health Care Science, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Kohei Kajiwara
- Faculty of Nursing, Japanese Red Cross Kyushu International College of Nursing, Munakata, Fukuoka, Japan
| | - Kimiko Nakano
- Clinical Research Center for Developmental Therapeutics, Tokushima University Hospital, Kuramoto-cho, Tokushima, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Osaka, Japan
| | - Yoichi Shimizu
- School of Nursing, National College of Nursing, Kiyose, Tokyo, Japan
| | - Megumi Hori
- Faculty of Nursing, University of Shizuoka, Suruga-ku, Shizuoka, Japan
| | - Mariko Niino
- Center for Cancer Registries, Institute for Cancer Control, National Cancer Center Japan, Chuo-ku, Tokyo, Japan
| | - Miho Suzuki
- Faculty of Nursing and Medical Care, Keio University-Shonan Fujisawa Campus, Fujisawa, Kanagawa, Japan
| | - Taichi Shimazu
- Division of Behavioral Sciences, National Cancer Center Institute for Cancer Control, Research Center for Cancer Prevention and Screening, National Cancer Center, Chuo-ku, Tokyo, Japan
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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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Bayly J, Ahmedzai HH, Blandini MG, Bressi B, Caraceni AT, Carvalho Vasconcelos J, Costi S, Fugazzaro S, Guberti M, Guldin MB, Hauken M, Higginson I, Laird BJ, Ling J, Normand C, Nottelmann L, Oldervoll L, Payne C, Prevost AT, Stene GB, Vanzulli E, Veber E, Economos G, Maddocks M. Integrated Short-term Palliative Rehabilitation to improve quality of life and equitable care access in incurable cancer (INSPIRE): a multinational European research project. Palliat Care Soc Pract 2023; 17:26323524231179979. [PMID: 37377743 PMCID: PMC10291227 DOI: 10.1177/26323524231179979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/15/2023] [Indexed: 06/29/2023] Open
Abstract
Background Disability related to incurable cancer affects over a million Europeans each year and people with cancer rank loss of function among the most common unmet supportive care needs. Objectives To test the clinical and cost-effectiveness of an integrated short-term palliative rehabilitation intervention, to optimise function and quality of life in people affected by incurable cancer. Design This is a multinational, parallel group, randomised, controlled, assessor blind, superiority trial. Methods The INSPIRE consortium brings together leaders in palliative care, oncology and rehabilitation from partner organisations across Europe, with complementary expertise in health service research, trials of complex interventions, mixed-method evaluations, statistics and economics. Partnership with leading European civil society organisations ensures citizen engagement and dissemination at the highest level. We will conduct a multinational randomised controlled trial across five European countries, recruiting participants to assess the effectiveness of palliative rehabilitation for people with incurable cancer on the primary outcome - quality of life - and secondary outcomes including disability, symptom burden and goal attainment. To support trial conduct and enhance analysis of trial data, we will also conduct: comparative analysis of current integration of rehabilitation across oncology and palliative care services; mixed-method evaluations of equity and inclusivity, processes and implementation for the intervention, at patient, health service and health system levels. Finally, we will conduct an evidence synthesis, incorporating INSPIRE findings, and a Delphi consensus to develop an international framework for palliative rehabilitation practice and policy, incorporating indicators, core interventions, outcomes and integration methods. Scientific contribution If positive, the trial could produce a scalable and equitable intervention to improve function and quality of life in people with incurable cancer and reduce the burden of care for their families. It could also upskill the practitioners involved and motivate future research questions. The intervention could be adapted and integrated into different health systems using existing staff and services, with little or no additional cost.
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Affiliation(s)
- Joanne Bayly
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, 5 Bessemer Road, London SE59PJ, UK
| | | | | | - Barbara Bressi
- Physical Medicine and Rehabilitation Unit, Azienda USL – IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Joana Carvalho Vasconcelos
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
- Nightingale-Saunders Clinical Trials and Epidemiology Unit, King’s College London, London, UK
| | - Stefania Costi
- Physical Medicine and Rehabilitation Unit, Azienda USL – IRCCS di Reggio Emilia, Reggio Emilia, Italy
- Surgical, Medical and Dental Department of Morphological Sciences, University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Stefania Fugazzaro
- Physical Medicine and Rehabilitation Unit, Azienda USL – IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Monica Guberti
- Research and EBP Unit, Health Professions Department, Azienda USL – IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Mai-Britt Guldin
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - May Hauken
- Centre for Crisis Psychology, University of Bergen, Bergen, Norway
| | - Irene Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Barry J.A. Laird
- Western General Hospital and Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Julie Ling
- European Association for Palliative Care, Vilvoorde, Belgium
| | - Charles Normand
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Lise Nottelmann
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
- The Research Unit, Department of Palliative Medicine, Bispebjerg Hospital, København, Denmark
| | - Line Oldervoll
- Centre for Crisis Psychology, University of Bergen, Bergen, Norway
- Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Cathy Payne
- European Association for Palliative Care, Vilvoorde, Belgium
| | - A. Toby Prevost
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
- Nightingale-Saunders Clinical Trials and Epidemiology Unit, King’s College London, London, UK
| | - Guro B. Stene
- Centre for Crisis Psychology, University of Bergen, Bergen, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Elisa Vanzulli
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Eduardo Veber
- European Cancer Patient Coalition, Brussels, Belgium
| | - Guillaume Economos
- Centre Hospitalier Lyon-Sud, Palliative Care Centre, Pierre-Benite, France
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
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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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10
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Seidl H, Schunk M, Le L, Syunyaeva Z, Streitwieser S, Berger U, Mansmann U, Szentes BL, Bausewein C, Schwarzkopf L. Cost-Effectiveness of a Specialized Breathlessness Service Versus Usual Care for Patients With Advanced Diseases. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:81-90. [PMID: 36182632 DOI: 10.1016/j.jval.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 07/13/2022] [Accepted: 08/05/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES The Munich Breathlessness Service (MBS) significantly improved control of breathlessness measured by the Chronic Respiratory Questionnaire (CRQ) Mastery in a randomized controlled fast track trial with waitlist group design spanning 8 weeks in Germany. This study aimed to assess the within-trial cost-effectiveness of MBS from a societal perspective. METHODS Data included generic (5-level version of EQ-5D) health-related quality of life and disease-specific CRQ Mastery. Quality-adjusted life years (QALYs) were calculated based on 5-level version of EQ-5D utilities valued with German time trade-off. Direct medical costs and productivity loss were calculated based on standardized unit costs. Incremental cost-effectiveness ratios (ICER) and cost-effectiveness-acceptance curves were calculated using adjusted mean differences (AMD) in costs (gamma-distributed model) and both effect parameters (Gaussian-distributed model) and performing 1000 simultaneous bootstrap replications. Potential gender differences were investigated in stratified analyses. RESULTS Between March 2014 and April 2019, 183 eligible patients were enrolled. MBS intervention demonstrated significantly better effects regarding generic (AMD of QALY gains of 0.004, 95% confidence interval [CI] 0.0003 to 0.008) and disease-specific health-related quality of life at nonsignificantly higher costs (AMD of €605 [95% CI -1109 to 2550]). At the end of the intervention, the ICER was €152 433/QALY (95% CI -453 545 to 1 625 903) and €1548/CRQ Mastery point (95% CI -3093 to 10 168). Intervention costs were on average €357 (SD = 132). Gender-specific analyses displayed dominance for MBS in males and higher effects coupled with significantly higher costs in females. CONCLUSIONS Our results show a high ICER for MBS. Considering dominance for MBS in males, implementing MBS on approval within the German health care system should be considered.
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Affiliation(s)
- Hildegard Seidl
- Health Economics and Health Care Management (IGM) Helmholtz Zentrum München (GmbH) German Research Center for Environmental Health, Munich, Germany; Pettenkofer School of Public Health, Munich, Germany; Quality Management and Gender Medicine, München Klinik gGmbH, Munich, Germany.
| | - Michaela Schunk
- Pettenkofer School of Public Health, Munich, Germany; Department of Palliative Medicine, LMU Hospital, LMU Munich, Munich, Germany
| | - Lien Le
- Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Zulfiya Syunyaeva
- Department of Medicine V, LMU Hospital, LMU Munich, Munich, Germany; Department of Pediatric Pulmonology, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sabine Streitwieser
- Department of Palliative Medicine, LMU Hospital, LMU Munich, Munich, Germany
| | - Ursula Berger
- Pettenkofer School of Public Health, Munich, Germany; Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Ulrich Mansmann
- Pettenkofer School of Public Health, Munich, Germany; Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Boglarka Lilla Szentes
- Health Economics and Health Care Management (IGM) Helmholtz Zentrum München (GmbH) German Research Center for Environmental Health, Munich, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, LMU Hospital, LMU Munich, Munich, Germany
| | - Larissa Schwarzkopf
- Health Economics and Health Care Management (IGM) Helmholtz Zentrum München (GmbH) German Research Center for Environmental Health, Munich, Germany; Pettenkofer School of Public Health, Munich, Germany; IFT-Institut fuer Therapieforschung, Munich, Germany
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11
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Shin J, Kober K, Wong ML, Yates P, Miaskowski C. Systematic review of the literature on the occurrence and characteristics of dyspnea in oncology patients. Crit Rev Oncol Hematol 2023; 181:103870. [PMID: 36375635 DOI: 10.1016/j.critrevonc.2022.103870] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/31/2022] [Accepted: 11/10/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Dyspnea is a common and distressing symptom for oncology patients.However, dyspnea is not well-characterized and often underestimated by clinicians. This systematic review summarizes the prevalence, intensity, distress, and impact of dyspnea in oncology patients and identifies research gaps. METHODS A search of all of the relevant databases was done from 2009 to May 2022. A qualitative synthesis of the extant literature was performed using established guidelines. RESULTS One hundred-seventeen studies met inclusion criteria. Weighted grand mean prevalence of dyspnea in patients with advanced cancer was 58.0%. Intensity of dyspnea was most common dimension evaluated, followed by the impact and distress. Depression and anxiety were the most common symptoms that co-occurred with dyspnea. CONCLUSION Numerous methodologic challenges were evident across studies. Future studies need to use valid and reliable measures; evaluate the impact of dyspnea; and determine biomarkers for dyspnea.
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Affiliation(s)
- Joosun Shin
- School of Nursing, University of California, San Francisco, CA, USA.
| | - Kord Kober
- School of Nursing, University of California, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Melisa L Wong
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA; Division of Hematology/Oncology, Division of Geriatrics, University of California, San Francisco, CA, USA
| | - Patsy Yates
- Cancer & Palliative Outcomes Centre, Centre for Health Transformation, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia; School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Christine Miaskowski
- School of Nursing, University of California, San Francisco, CA, USA; School of Medicine, University of California, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
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12
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Decavèle M, Serresse L, Gay F, Nion N, Lavault S, Freund Y, Niérat MC, Steichen O, Demoule A, Morélot-Panzini C, Similowski T. ' Involve me and I learn': an experiential teaching approach to improve dyspnea awareness in medical residents. MEDICAL EDUCATION ONLINE 2022; 27:2133588. [PMID: 36218180 PMCID: PMC9559048 DOI: 10.1080/10872981.2022.2133588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/30/2022] [Accepted: 10/05/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Dyspnea is a frightening and debilitating experience. It attracts less attention than pain ('dyspnea invisibility'), possibly because of its non-universal nature. We tested the impact of self-induced experimental dyspnea on medical residents. MATERIALS AND METHODS During a teaching session following the principles of experiential learning, emergency medicine residents were taught about dyspnea theoretically, observed experimental dyspnea in their teacher, and personally experienced self-induced dyspnea. The corresponding psychophysiological reactions were described. Immediate and 1-year evaluations were conducted to assess course satisfaction (overall 0-20 grade) and the effect on the understanding of what dyspnea represents for patients. RESULTS Overall, 55 emergency medicine residents participated in the study (26 men, median age 26 years). They were moderately satisfied with previous dyspnea teaching (6 [5-7] on a 0-10 numerical rating scale [NRS]) and expressed a desire for an improvement in the teaching (8 [7-9]). Immediately after the course they reported improved understanding of patients' experience (7 [6-8]), which persisted at 1 year (8 [7-9], 28 respondents). Overall course grade was 17/20 [15-18], and there were significant correlations with experimental dyspnea ratings (intensity: r = 0.318 [0.001-0.576], p = 0.043; unpleasantness: r = 0.492 [0.208-0.699], p = 0.001). In multivariate analysis, the only factor independently associated with the overall course grade was 'experiential understanding' (the experimental dyspnea-related improvement in the understanding of dyspneic patients' experience). A separate similar experiment conducted in 50 respiratory medicine residents yielded identical results. CONCLUSIONS This study suggests that, in advanced medical residents, the personal discovery of dyspnea can have a positive impact on the understanding of what dyspnea represents for patients. This could help fight dyspnea invisibility.
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Affiliation(s)
- Maxens Decavèle
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive, Réanimation, Département R3S, Paris, France
| | - Laure Serresse
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Unité Mobile de Soins Palliatifs, Paris, France
| | - Frédérick Gay
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Laboratoire de parasitologie-mycologie, Paris, France
| | - Nathalie Nion
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S, Paris, France
| | - Sophie Lavault
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S, Paris, France
| | - Yonathan Freund
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service d’accueil des urgences, Paris, France
- Sorbonne Université, INSERM, UMRS 1166, IHU ICAN, Paris, France
| | - Marie-Cécile Niérat
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Olivier Steichen
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Tenon, Service de médecine interne, Paris, France
- Sorbonne Université, INSERM, UMRS 1142 LIMICS, Paris, France
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive, Réanimation, Département R3S, Paris, France
| | - Capucine Morélot-Panzini
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Département R3S, Paris, France
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S, Paris, France
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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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14
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Gofton C, Agar M, George J. Early Implementation of Palliative and Supportive Care in Hepatocellular Carcinoma. Semin Liver Dis 2022; 42:514-530. [PMID: 36193677 DOI: 10.1055/a-1946-5592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Early palliative and supportive care referral is the standard of care for many malignancies. This paradigm results in improvements in patients' symptoms and quality of life and decreases the costs of medical care and unnecessary procedures. Leading oncology guidelines have recommended the integration of early referral to palliative and supportive services to care pathways for advanced malignancies. Currently, early referral to palliative care within the hepatocellular carcinoma (HCC) population is not utilized, with gastroenterology guidelines recommending referral of patients with Barcelona Clinic Liver Cancer stage D to these services. This review addresses this topic through analysis of the existing data within the oncology field as well as literature surrounding palliative care intervention in HCC. Early palliative and supportive care in HCC and its impact on patients, caregivers, and health services allow clinicians and researchers to identify management options that improve outcomes within existing service provisions.
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Affiliation(s)
- Cameron Gofton
- Department of Gastroenterology and Hepatology, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia.,Storr Liver Centre, Westmead Hospital, Westmead, New South Wales, Australia
| | - Meera Agar
- Department of Palliative Care, University of Technology Sydney, New South Wales, Australia
| | - Jacob George
- Storr Liver Centre, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Medicine, University of Sydney, Camperdown and Darlington Campus, Camperdown, New South Wales, Australia
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15
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Kremeike K, Bausewein C, Freytag A, Junghanss C, Marx G, Schnakenberg R, Schneider N, Schulz H, Wedding U, Voltz R. [DNVF Memorandum: Health Services Research in the Last Year of Life]. DAS GESUNDHEITSWESEN 2022. [PMID: 36220106 DOI: 10.1055/a-1889-4705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
This memorandum outlines current issues concerning health services research on seriously ill and dying people in the last year of their lives as well as support available for their relatives. Patients in the last phase of life can belong to different disease groups, they may have special characteristics (e. g., people with cognitive and complex impairments, economic disadvantage or migration background) and be in certain phases of life (e. g., parents of minor children, (old) age). The need for a designated memorandum on health services research in the last year of life results from the special situation of those affected and from the special features of health services in this phase of life. With reference to these special features, this memorandum describes methodological and ethical specifics as well as current issues in health services research and how these can be adequately addressed using quantitative, qualitative and mixed methods. It has been developed by the palliative medicine section of the German Network for Health Services Research (DNVF) according to the guidelines for DNVF memoranda.
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Affiliation(s)
- Kerstin Kremeike
- Zentrum für Palliativmedizin, Universitätsklinikum Köln, Köln, Deutschland
| | - Claudia Bausewein
- Klinik und Poliklinik für Palliativmedizin, LMU Klinikum München, München, Deutschland
| | - Antje Freytag
- Institut für Allgemeinmedizin, Universitätsklinikum Jena, Jena, Deutschland
| | - Christian Junghanss
- Hämatologie, Onkologie und Palliativmedizin, Zentrum für Innere Medizin, Universitätsmedizin Rostock, Rostock, Deutschland
| | - Gabriella Marx
- Institut und Poliklinik Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | | | - Nils Schneider
- Institut für Allgemeinmedizin und Palliativmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Holger Schulz
- Institut und Poliklinik für Medizinische Psychologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Ulrich Wedding
- Abteilung Palliativmedizin, Universitätsklinikum Jena, Jena, Deutschland
| | - Raymond Voltz
- Zentrum für Palliativmedizin, Universitätsklinikum Köln, Köln, Deutschland
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Sullivan DR, Iyer AS, Enguidanos S, Cox CE, Farquhar M, Janssen DJA, Lindell KO, Mularski RA, Smallwood N, Turnbull AE, Wilkinson AM, Courtright KR, Maddocks M, McPherson ML, Thornton JD, Campbell ML, Fasolino TK, Fogelman PM, Gershon L, Gershon T, Hartog C, Luther J, Meier DE, Nelson JE, Rabinowitz E, Rushton CH, Sloan DH, Kross EK, Reinke LF. Palliative Care Early in the Care Continuum among Patients with Serious Respiratory Illness: An Official ATS/AAHPM/HPNA/SWHPN Policy Statement. Am J Respir Crit Care Med 2022; 206:e44-e69. [PMID: 36112774 PMCID: PMC9799127 DOI: 10.1164/rccm.202207-1262st] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background: Patients with serious respiratory illness and their caregivers suffer considerable burdens, and palliative care is a fundamental right for anyone who needs it. However, the overwhelming majority of patients do not receive timely palliative care before the end of life, despite robust evidence for improved outcomes. Goals: This policy statement by the American Thoracic Society (ATS) and partnering societies advocates for improved integration of high-quality palliative care early in the care continuum for patients with serious respiratory illness and their caregivers and provides clinicians and policymakers with a framework to accomplish this. Methods: An international and interprofessional expert committee, including patients and caregivers, achieved consensus across a diverse working group representing pulmonary-critical care, palliative care, bioethics, health law and policy, geriatrics, nursing, physiotherapy, social work, pharmacy, patient advocacy, psychology, and sociology. Results: The committee developed fundamental values, principles, and policy recommendations for integrating palliative care in serious respiratory illness care across seven domains: 1) delivery models, 2) comprehensive symptom assessment and management, 3) advance care planning and goals of care discussions, 4) caregiver support, 5) health disparities, 6) mass casualty events and emergency preparedness, and 7) research priorities. The recommendations encourage timely integration of palliative care, promote innovative primary and secondary or specialist palliative care delivery models, and advocate for research and policy initiatives to improve the availability and quality of palliative care for patients and their caregivers. Conclusions: This multisociety policy statement establishes a framework for early palliative care in serious respiratory illness and provides guidance for pulmonary-critical care clinicians and policymakers for its proactive integration.
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Nkhoma KB, Cook A, Giusti A, Farrant L, Petrus R, Petersen I, Gwyther L, Venkatapuram S, Harding R. A systematic review of impact of person-centred interventions for serious physical illness in terms of outcomes and costs. BMJ Open 2022; 12:e054386. [PMID: 35831052 PMCID: PMC9280891 DOI: 10.1136/bmjopen-2021-054386] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/20/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Person-centred care (PCC) is being internationally recognised as a critical attribute of high-quality healthcare. The International Alliance of Patients Organisations defines PCC as care that is focused and organised around people, rather than disease. Focusing on delivery, we aimed to review and evaluate the evidence from interventions that aimed to deliver PCC for people with serious physical illness and identify models of PCC interventions. METHODS Systematic review of literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched AMED, CINAHL, Cochrane Library, Embase, Medline, PsycINFO, using the following key concepts: patient/person-centred care, family centred care, family based care, individualised care, holistic care, serious illness, chronic illness, long-term conditions from inception to April 2022. Due to heterogeneity of interventions and populations studied, narrative synthesis was conducted. Study quality was appraised using the Joanna Briggs checklist. RESULTS We screened n=6156 papers. Seventy-two papers (reporting n=55 different studies) were retained in the review. Most of these studies (n=47) were randomised controlled trials. Our search yielded two main types of interventions: (1) studies with self-management components and (2) technology-based interventions. We synthesised findings across these two models:Self-management component: the interventions consisted of training of patients and/or caregivers or staff. Some studies reported that interventions had effect in reduction hospital admissions, improving quality of life and reducing costs of care.Technology-based interventions: consisted of mobile phone, mobile app, tablet/computer and video. Although some interventions showed improvements for self-efficacy, hospitalisations and length of stay, quality of life did not improve across most studies. DISCUSSION PCC interventions using self-management have some effects in reducing costs of care and improving quality of life. Technology-based interventions improves self-efficacy but has no effect on quality of life. However, very few studies used self-management and technology approaches. Further work is needed to identify how self-management and technology approaches can be used to manage serious illness. PROSPERO REGISTRATION NUMBER CRD42018108302.
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Affiliation(s)
- Kennedy Bashan Nkhoma
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, King's College London, London, UK
| | - Amelia Cook
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Alessandra Giusti
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Lindsay Farrant
- School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Ruwayda Petrus
- School of Applied Human Sciences, University of KwaZulu-Natal College of Humanities, Durban, South Africa
| | - I Petersen
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Liz Gwyther
- School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | | | - Richard Harding
- Department of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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Schloesser K, Bergmann A, Eisenmann Y, Pauli B, Hellmich M, Oberste M, Hamacher S, Tuchscherer A, Frank KF, Randerath W, Herkenrath S, Simon ST. Only I Know Now, of Course, How to Deal With it, or Better to Deal With it: A Mixed Methods Phase II Study of a Cognitive and Behavioral Intervention for the Management of Episodic Breathlessness. J Pain Symptom Manage 2022; 63:758-768. [PMID: 34793948 DOI: 10.1016/j.jpainsymman.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/29/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
CONTEXT Episodic breathlessness is characterized by increased breathlessness intensity, and it is burdensome for patients. A vicious cycle of breathlessness-anxiety/panic-breathlessness leads to emergencies that can rarely be alleviated by drugs. Non-pharmacological interventions seem to be beneficial: Can a brief cognitive and behavioral intervention help patients to better manage episodic breathlessness? OBJECTIVES To evaluate the feasibility, safety, acceptability, and potential effects of a brief cognitive and behavioral intervention for the management of episodic breathlessness. METHODS Between February 2019 and February 2020, 49 patients with life-limiting diseases suffering from episodic breathlessness were enrolled in the single-arm phase II study. The baseline assessment was followed by the one- to two-hour intervention. In weeks two, four, and six after the intervention, the outcomes (main outcome of potential effects: mastery of breathlessness) were assessed, and in week six, a qualitative interview, and the final assessment took place. A mixed-methods approach was used to evaluate mainly the feasibility, including interviewing informal carers. RESULTS 46/49 patients (24 female; 36 with COPD; mean age: 66.0 years) participated in the baseline assessment, 38 attended the intervention, 32 completed the final assessment, and 22 were interviewed. Study procedures and the intervention were feasible and mainly well accepted and patients did not experience burdens caused by it (28/32). In the interviews, patients described a positive change in their competencies in managing episodic breathlessness and feelings of anxiety during the episode. Mastery of breathlessness improved after the intervention. CONCLUSION The brief cognitive and behavioral intervention and the study procedures are feasible, safe, and well accepted. We can describe a change for better management of episodic breathlessness in patients after the intervention, still, this needs to be evaluated in a Phase III trial for inclusion in the management of episodic breathlessness.
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Affiliation(s)
- Karlotta Schloesser
- Department of Palliative Medicine, Faculty of Medicine and University Hospital (K.S., Y.E., B.P., S.T.S.), University of Cologne, Cologne, Germany
| | - Anja Bergmann
- Department of Nursing Science, Faculty of Medicine and University Hospital (A.B.), University of Cologne, Cologne, Germany
| | - Yvonne Eisenmann
- Department of Palliative Medicine, Faculty of Medicine and University Hospital (K.S., Y.E., B.P., S.T.S.), University of Cologne, Cologne, Germany
| | - Berenike Pauli
- Department of Palliative Medicine, Faculty of Medicine and University Hospital (K.S., Y.E., B.P., S.T.S.), University of Cologne, Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital (M.H., M.O., S.H.), University of Cologne, Cologne, Germany
| | - Max Oberste
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital (M.H., M.O., S.H.), University of Cologne, Cologne, Germany
| | - Stefanie Hamacher
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital (M.H., M.O., S.H.), University of Cologne, Cologne, Germany
| | - Armin Tuchscherer
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital (A.T.), University of Cologne, Cologne, Germany
| | - Konrad F Frank
- Department III of Internal Medicine, Section Pneumology, Faculty of Medicine and University Hospital (K.F.F.), University of Cologne, Cologne, Germany
| | - Winfried Randerath
- Center for Sleep Medicine and Respiratory Care, Clinic for Pneumology and Allergology, Bethanien Hospital, Solingen, Germany and Institute for Pneumology at the University of Cologne (W.R., S.H.), Cologne, Germany
| | - Simon Herkenrath
- Center for Sleep Medicine and Respiratory Care, Clinic for Pneumology and Allergology, Bethanien Hospital, Solingen, Germany and Institute for Pneumology at the University of Cologne (W.R., S.H.), Cologne, Germany
| | - Steffen T Simon
- Center for Integrated Oncology, Faculty of Medicine and University Hospital, University of Cologne (S.T.S.), Cologne, Germany.
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Luckett T, Roberts M, Smith T, Garcia M, Dunn S, Swan F, Ferguson C, Kochovska S, Phillips JL, Pearson M, Currow DC, Johnson MJ. Implementing the battery-operated hand-held fan as an evidence-based, non-pharmacological intervention for chronic breathlessness in patients with chronic obstructive pulmonary disease (COPD): a qualitative study of the views of specialist respiratory clinicians. BMC Pulm Med 2022; 22:129. [PMID: 35387636 PMCID: PMC8985391 DOI: 10.1186/s12890-022-01925-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 03/25/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction The battery-operated hand-held fan (‘fan’) is an inexpensive and portable non-pharmacological intervention for chronic breathlessness. Evidence from randomised controlled trials suggests the fan reduces breathlessness intensity and improves physical activity in patients with a range of advanced chronic conditions. Qualitative data from these trials suggests the fan may also reduce anxiety and improve daily functioning for many patients. This study aimed to explore barriers and facilitators to the fan’s implementation in specialist respiratory care as a non-pharmacological intervention for chronic breathlessness in patients with chronic obstructive pulmonary disease (COPD). Methods A qualitative approach was taken, using focus groups. Participants were clinicians from any discipline working in specialist respiratory care at two hospitals. Questions asked about current fan-related practice and perceptions regarding benefits, harms and mechanisms, and factors influencing its implementation. Analysis used a mixed inductive/deductive approach. Results Forty-nine participants from nursing (n = 30), medical (n = 13) and allied health (n = 6) disciplines participated across 9 focus groups. The most influential facilitator was a belief that the fan’s benefits outweighed disadvantages. Clinicians’ beliefs about the fan’s mechanisms determined which patient sub-groups they targeted, for example anxious or palliative/end-stage patients. Barriers to implementation included a lack of clarity about whose role it was to implement the fan, what advice to provide patients, and limited access to fans in hospitals. Few clinicians implemented the fan for acute-on-chronic breathlessness or in combination with other interventions. Conclusion Implementation of the fan in specialist respiratory care may require service- and clinician-level interventions to ensure it is routinely recommended as a first-line intervention for chronic breathlessness in patients for whom this symptom is of concern, regardless of COPD stage.
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Affiliation(s)
- Tim Luckett
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney (UTS), Building 10, Level 3, 235 Jones St, Ultimo, Sydney, NSW, 2007, Australia.
| | - Mary Roberts
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, NSW, Australia.,Ludwig Engel Centre for Respiratory Research, Westmead Institute for Medical Research, Sydney, NSW, Australia.,The University of Sydney at Westmead Hospital, Sydney, NSW, Australia
| | - Tracy Smith
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, NSW, Australia.,The University of Sydney at Westmead Hospital, Sydney, NSW, Australia
| | - Maja Garcia
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney (UTS), Building 10, Level 3, 235 Jones St, Ultimo, Sydney, NSW, 2007, Australia
| | - Sarah Dunn
- Respiratory Medicine Clinic, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Flavia Swan
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston Upon Hull, Yorkshire, UK
| | - Caleb Ferguson
- Western Sydney Nursing & Midwifery Research Centre, Blacktown Clinical & Research School, Western Sydney Local Health District, Western Sydney University, Blacktown Hospital, Sydney, NSW, Australia
| | - Slavica Kochovska
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney (UTS), Building 10, Level 3, 235 Jones St, Ultimo, Sydney, NSW, 2007, Australia
| | - Jane L Phillips
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney (UTS), Building 10, Level 3, 235 Jones St, Ultimo, Sydney, NSW, 2007, Australia.,School of Nursing, Queensland University of Technology, Brisbane, QLD, Australia
| | - Mark Pearson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston Upon Hull, Yorkshire, UK
| | - David C Currow
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney (UTS), Building 10, Level 3, 235 Jones St, Ultimo, Sydney, NSW, 2007, Australia.,Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston Upon Hull, Yorkshire, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston Upon Hull, Yorkshire, UK
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20
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Krajnik M, Hepgul N, Wilcock A, Jassem E, Bandurski T, Tanzi S, Simon ST, Higginson IJ, Jolley CJ. Do guidelines influence breathlessness management in advanced lung diseases? A multinational survey of respiratory medicine and palliative care physicians. BMC Pulm Med 2022; 22:41. [PMID: 35045847 PMCID: PMC8768441 DOI: 10.1186/s12890-022-01835-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 12/31/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Respiratory medicine (RM) and palliative care (PC) physicians' management of chronic breathlessness in advanced chronic obstructive pulmonary disease (COPD), fibrotic interstitial lung disease (fILD) and lung cancer (LC), and the influence of practice guidelines was explored via an online survey. METHODS A voluntary, online survey was distributed to RM and PC physicians via society newsletter mailing lists. RESULTS 450 evaluable questionnaires (348 (77%) RM and 102 (23%) PC) were analysed. Significantly more PC physicians indicated routine use (often/always) of opioids across conditions (COPD: 92% vs. 39%, fILD: 83% vs. 36%, LC: 95% vs. 76%; all p < 0.001) and significantly more PC physicians indicated routine use of benzodiazepines for COPD (33% vs. 10%) and fILD (25% vs. 12%) (both p < 0.001). Significantly more RM physicians reported routine use of a breathlessness score (62% vs. 13%, p < 0.001) and prioritised exercise training/rehabilitation for COPD (49% vs. 7%) and fILD (30% vs. 18%) (both p < 0.001). Overall, 40% of all respondents reported reading non-cancer palliative care guidelines (either carefully or looked at them briefly). Respondents who reported reading these guidelines were more likely to: routinely use a breathlessness score (χ2 = 13.8; p < 0.001), use opioids (χ2 = 12.58, p < 0.001) and refer to pulmonary rehabilitation (χ2 = 6.41, p = 0.011) in COPD; use antidepressants (χ2 = 6.25; p = 0.044) and refer to PC (χ2 = 5.83; p = 0.016) in fILD; and use a handheld fan in COPD (χ2 = 8.75, p = 0.003), fILD (χ2 = 4.85, p = 0.028) and LC (χ2 = 5.63; p = 0.018). CONCLUSIONS These findings suggest a need for improved dissemination and uptake of jointly developed breathlessness management guidelines in order to encourage appropriate use of existing, evidence-based therapies. The lack of opioid use by RM, and continued benzodiazepine use in PC, suggest that a wider range of acceptable therapies need to be developed and trialled.
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Affiliation(s)
- Małgorzata Krajnik
- Department of Palliative Care, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Skłodowskiej-Curie 9, 85-094, Bydgoszcz, Poland
| | - Nilay Hepgul
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Andrew Wilcock
- Palliative Medicine, Hayward House Specialist Palliative Care Unit, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - Ewa Jassem
- Department of Pneumonology, Medical University of Gdańsk, Gdańsk, Poland
| | - Tomasz Bandurski
- Department of Radiology, Informatics and Statistics, Medical University of Gdańsk, Gdańsk, Poland
| | - Silvia Tanzi
- Palliative Care Unit, Azienda USL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Steffen T Simon
- Department of Palliative Medicine and Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Caroline J Jolley
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, Shepherd's House, Rm 4.4, Guy's Campus, London, SE1 1UL, UK.
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21
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Thiessen M, Harris D, Pinches A, Vaska M, Moules N, Raffin Bouchal S, Sinclair S. Qualitative Studies Conducted Alongside Randomized Controlled Trials in Oncology: A Scoping Review of Use and Rigour of Reporting. Int J Nurs Stud 2022; 128:104174. [DOI: 10.1016/j.ijnurstu.2022.104174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 12/22/2021] [Accepted: 01/05/2022] [Indexed: 01/08/2023]
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22
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Achieving child-centred care for children and young people with life-limiting and life-threatening conditions-a qualitative interview study. Eur J Pediatr 2022; 181:3739-3752. [PMID: 35953678 PMCID: PMC9371630 DOI: 10.1007/s00431-022-04566-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/07/2022] [Accepted: 07/13/2022] [Indexed: 11/20/2022]
Abstract
UNLABELLED This study aims to identify the symptoms, concerns, and care priorities of children with life-limiting conditions and their families. A semi-structured qualitative interview study was conducted, seeking perspectives from multiple stakeholders on symptoms, other concerns, and care priorities of children and young people with life limiting and life-threatening conditions and their families. Participants were recruited from six hospitals and three children's hospices in the UK. Verbatim transcripts were analysed using framework analysis. A total of 106 participants were recruited: 26 children (5-17 years), 40 parents (of children 0-17 years), 13 siblings (5-17 years), 15 health and social care professionals, 12 commissioners. Participants described many inter-related symptoms, concerns, and care priorities impacting on all aspects of life. Burdensome symptoms included pain and seizures. Participants spoke of the emotional and social impacts of living with life-limiting conditions, such as being able to see friends, and accessing education and psychological support. Spiritual/existential concerns included the meaning of illness and planning for an uncertain future. Data revealed an overarching theme of pursuing 'normality', described as children's desire to undertake usual childhood activities. Parents need support with practical aspects of care to help realise this desire for normality. CONCLUSION Children with life-limiting conditions and their families experience a wide range of inter-related symptoms, concerns, and care priorities. A holistic, child-centred approach to care is needed, allowing focus on pursuit of normal childhood activities. Improvements in accessibility, co-ordination, and availability of health services are required to achieve this. WHAT IS KNOWN • Existing evidence regarding symptoms, concerns, and care priorities for children with life-limiting conditions is largely limited to proxy-reported data and those with a cancer diagnosis. • Child-centred care provision must be directed by children's perspectives on their priorities for care. WHAT IS NEW • Social and educational activities are more important to children with life-limiting conditions than their medical concerns. • A holistic approach to care is required that extends beyond addressing medical needs, in order to support children with life-limiting conditions to focus on pursuit of normal childhood activities.
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23
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Tsai JJ, Chen KH, Fang HF, Huang TW. Relieving from Breathlessness in the Wind: A Meta-Analysis and Subjective Report of Effectiveness of Fan Blowing in Patients with Cardiorespiratory Diseases or Cancer. Am J Hosp Palliat Care 2021; 39:977-985. [PMID: 34866434 DOI: 10.1177/10499091211056327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Breathlessness is common among terminally ill patients with cardiorespiratory disease or cancer. The experience may induce secondary physiological and behavioral responses that limit patient well-being and independence and cause emotional distress. METHODS We conducted a meta-analysis on randomized controlled trials (RCTs) that examined the effectiveness of fan blowing on breathlessness among patients with cardiorespiratory diseases or cancer. The PubMed, Cochrane Library, Embase, SCOPUS, and CINAHL databases were searched to retrieve potential articles. The primary outcome was breathlessness severity. The secondary outcomes were SpO2, anxiety, depression, and quality of life. Also, we presented the changes of vital signs and subjective feeling of a male patient who used fan blowing for relieving his breathlessness. RESULTS Eight RCTs were available for analysis. The pooled results demonstrated no significant difference in breathlessness severity between fan-to-face blowing and control methods (standard mean difference: -0.21, 95% confidence interval: -.59 to .17); however, a significant reduction in breathlessness severity was observed in the short-time intervention compared with long-time intervention. A trend occurred toward significance in the reduction of respiratory rate in fan-to-face blowing compared with control methods (MD: -.64, 95% CI: -1.37 to .09). No differences were observed between groups in oxygen saturation, anxiety, depression, or QoL. The male patient who used fan blowing showed an improved vital signs and a satisfied subjective feeling. CONCLUSIONS Consistent short-time fan-to-face blowing is effective for relieving breathlessness among conscious terminally ill patients with cardiorespiratory diseases or cancer. The use of this convenient method for relieving breathlessness symptoms in terminally ill patients is recommended.
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Affiliation(s)
- Jing-Jing Tsai
- School of Nursing, College of Nursing, 38032Taipei Medical University, Taipei, Taiwan.,Department of Nursing, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Kee-Hsin Chen
- Post-Baccalaureate Program in Nursing, College of Nursing, 38032Taipei Medical University, Taipei, Taiwan.,Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, 38032Taipei Medical University, Taipei, Taiwan.,Cochrane Taiwan, 38032Taipei Medical University, Taipei, Taiwan
| | - Hui-Fen Fang
- Deputy Director of Nursing Department, Taipei Cancer Center, 38032Taipei Medical University, Taipei, Taiwan.,Deputy Director of Cancer Center, 63474Taipei Medical University Hospital, Taipei, Taiwan.,Deputy Director of Nursing Service, 63474Taipei Medical University Hospital, Taipei, Taiwan
| | - Tsai-Wei Huang
- School of Nursing, College of Nursing, 38032Taipei Medical University, Taipei, Taiwan.,Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, 38032Taipei Medical University, Taipei, Taiwan.,Cochrane Taiwan, 38032Taipei Medical University, Taipei, Taiwan
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24
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Campbell ML, Donesky D, Sarkozy A, Reinke LF. Treatment of Dyspnea in Advanced Disease and at the End of Life. J Hosp Palliat Nurs 2021; 23:406-420. [PMID: 33883525 DOI: 10.1097/njh.0000000000000766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Dyspnea is a subjective experience of breathing discomfort that consists of qualitatively distinct sensations, varies in intensity, and can only be known through the patient's report. Dyspnea is akin to suffocation and is one of the most distressing symptoms experienced by patients with advanced illness and at the end of life. Common approaches to dyspnea management, such as pulmonary rehabilitation, breathing strategies, or supplemental oxygen, have become accepted through pragmatic use or because studies do not include dyspnea as a measured outcome. Patients and clinicians urgently need evidence-based treatments to alleviate this frightening symptom. To fill this gap, a group of dyspnea researchers with expertise to conduct a literature review of evidence-based interventions for dyspnea in patients with serious illness produced these guidelines. We present the evidence from the strongest recommendations for practice to the weakest recommendations and include practical considerations for clinical nurses.
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25
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Schunk M, Berger U, Le L, Rehfuess E, Schwarzkopf L, Streitwieser S, Müller T, Hofmann M, Holle R, Huber RM, Mansmann U, Bausewein C. BreathEase: rationale, design and recruitment of a randomised trial and embedded mixed-methods study of a multiprofessional breathlessness service in early palliative care. ERJ Open Res 2021; 7:00228-2020. [PMID: 34671668 PMCID: PMC8521025 DOI: 10.1183/23120541.00228-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/19/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The Munich Breathlessness Service has adapted novel support services to the German context, to reduce burden in patients and carers from breathlessness in advanced disease. It has been evaluated in a pragmatic fast-track randomised controlled trial (BreathEase; NCT02622412) with embedded qualitative interviews and postal survey. The aim of this article is to describe the intervention model and study design, analyse recruitment to the trial and compare sample characteristics with other studies in the field. METHODS Analysis of recruitment pathways and enrolment, sociodemographic and clinical characteristics of participants and carers. RESULTS Out of 439 people screened, 253 (58%) were offered enrolment and 183 (42%) participated. n=97 (70%) carers participated. 186 (42%) people did not qualify for inclusion, mostly because breathlessness could not be attributed to an underlying disease. All participants were self-referring; 60% through media sources. Eligibility and willingness to participate were associated to social networks and illness-related activities as recruitment routes. Mean age of participants was 71 years (51% women), with COPD (63%), chronic heart failure (8%), interstitial lung disease (9%), pulmonary hypertension (6%) and cancer (7%) as underlying conditions. Postal survey response rate was 89%. Qualitative interviews were conducted with 16 patients and nine carers. CONCLUSION The BreathEase study has a larger and more heterogeneous sample compared to other trials. The self-referral-based and prolonged recruitment drawing on media sources approximates real-world conditions of early palliative care. Integrating qualitative and quantitative components will allow a better understanding and interpretation of the results of the main effectiveness study.
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Affiliation(s)
- Michaela Schunk
- Dept of Palliative Medicine, LMU Hospital, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Ursula Berger
- Pettenkofer School of Public Health, Munich, Germany
- Faculty of Medicine, Institute for Medical Information Processing, Biometry and Epidemiology, LMU Munich, Munich, Germany
| | - Lien Le
- Faculty of Medicine, Institute for Medical Information Processing, Biometry and Epidemiology, LMU Munich, Munich, Germany
| | - Eva Rehfuess
- Pettenkofer School of Public Health, Munich, Germany
- Faculty of Medicine, Institute for Medical Information Processing, Biometry and Epidemiology, LMU Munich, Munich, Germany
| | - Larissa Schwarzkopf
- Health Economics and Health Care Management (IGM), Helmholtz Zentrum München GmbH, German Research Center for Environmental Health, Munich, Germany
- Institut für Therapieforschung, Munich, Germany
| | | | - Thomas Müller
- Faculty of Medicine, Institute for Medical Information Processing, Biometry and Epidemiology, LMU Munich, Munich, Germany
| | - Miriam Hofmann
- Faculty of Medicine, Institute for Medical Information Processing, Biometry and Epidemiology, LMU Munich, Munich, Germany
| | - Rolf Holle
- Pettenkofer School of Public Health, Munich, Germany
- Health Economics and Health Care Management (IGM), Helmholtz Zentrum München GmbH, German Research Center for Environmental Health, Munich, Germany
| | - Rudolf Maria Huber
- Dept of Medicine V, LMU Hospital, LMU Munich, Munich, Germany
- Member of the German Center of Lung Research (DZL, CPC-M), Munich, Germany
| | - Ulrich Mansmann
- Pettenkofer School of Public Health, Munich, Germany
- Faculty of Medicine, Institute for Medical Information Processing, Biometry and Epidemiology, LMU Munich, Munich, Germany
| | - Claudia Bausewein
- Dept of Palliative Medicine, LMU Hospital, LMU Munich, Munich, Germany
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26
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Zemel RA. Pharmacologic and Non-Pharmacologic Dyspnea Management in Advanced Cancer Patients. Am J Hosp Palliat Care 2021; 39:847-855. [PMID: 34510917 DOI: 10.1177/10499091211040436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
As there is a high propensity for patients with advanced malignancy to experience refractory dyspnea, it is necessary for physicians to be well-versed in the management of these patients' dyspneic symptoms. For symptomatic treatment of cancer patients with dyspnea, both pharmacologic and non-pharmacologic methods should be considered. The main source of pharmacologic symptom management for dyspnea is oral and parenteral opioids; benzodiazepines and corticosteroids may serve as helpful adjuncts alongside opioid treatments. However, oxygen administration and nebulized loop diuretics have not been shown to clinically benefit dyspneic cancer patients. Applying non-pharmacologic dyspnea management methods may be valuable palliative therapies for advanced cancer patients, as they provide benefit with negligible harm to the patient. Advantageous and minimally harmful non-pharmacologic dyspnea therapies include facial airflow, acupuncture and/or acupressure, breathing exercises, cognitive behavioral therapy, music therapy, and spiritual interventions. Thus, it is vital that physicians are prepared to provide symptomatic care for dyspnea in advanced cancer patients as to minimize suffering in this patient population during definitive cancer treatments or hospice care.
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Affiliation(s)
- Rachel A Zemel
- MedStar Georgetown University Hospital, Brookeville, MD, USA
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27
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Luckett T, Roberts M, Swami V, Smith T, Cho JG, Klimkeit E, Wheatley JR. Maintenance of non-pharmacological strategies 6 months after patients with chronic obstructive pulmonary disease (COPD) attend a breathlessness service: a qualitative study. BMJ Open 2021; 11:e050149. [PMID: 33986071 PMCID: PMC8126310 DOI: 10.1136/bmjopen-2021-050149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES This study aimed to explore the degree to which non-pharmacological strategies for chronic breathlessness are sustained 6 months after completing a breathlessness service in patients with chronic obstructive pulmonary disease (COPD), and patient perceptions regarding the need for ongoing support. DESIGN A qualitative approach was taken using semistructured telephone interviews. Thematic analysis used an integrative approach. SETTING The Westmead Breathlessness Service (WBS) trains patients with COPD to self-manage chronic breathlessness over an 8-week programme with multidisciplinary input and home visits. PARTICIPANTS Patients with moderate to very severe COPD who had completed the WBS programme 6 months earlier. RESULTS Thirty-two participants were interviewed. One or more breathlessness self-management strategies were sustained by most participants, including breathing techniques (n=22; 69%), the hand-held fan (n=17; 53%), planning/pacing and exercise (n=14 for each; 44%) and strategic use of a four-wheeled walker (n=8; 25%). However, almost a third of participants appeared to be struggling psychologically, including some who had refused psychological intervention. A 'chaos narrative' appeared to be prevalent, and many participants had poor recall of the programme. CONCLUSIONS Self-management strategies taught by breathlessness services to patients with moderate to very severe COPD have potential to be sustained 6 months later. However, psychological coping may be more challenging to maintain. Research is needed on ways to improve resilience to set-backs and uptake of psychological interventions, as well as to understand and address the implications of poor recall for self-management. TRIAL REGISTRATION NUMBER ACTRN12617000499381.
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Affiliation(s)
- Tim Luckett
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Mary Roberts
- Ludwig Engel Centre for Respiratory Research, Westmead Institute for Medical Research, Westmead, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, New South Wales, Australia
- The University of Sydney at Westmead Hospital, Westmead, NSW, Australia
| | - Vinita Swami
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - Tracy Smith
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, New South Wales, Australia
- The University of Sydney at Westmead Hospital, Westmead, NSW, Australia
| | - Jin-Gun Cho
- Ludwig Engel Centre for Respiratory Research, Westmead Institute for Medical Research, Westmead, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, New South Wales, Australia
- The University of Sydney at Westmead Hospital, Westmead, NSW, Australia
| | - Ester Klimkeit
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - John R Wheatley
- Ludwig Engel Centre for Respiratory Research, Westmead Institute for Medical Research, Westmead, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, New South Wales, Australia
- The University of Sydney at Westmead Hospital, Westmead, NSW, Australia
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Oluyase AO, Higginson IJ, Yi D, Gao W, Evans CJ, Grande G, Todd C, Costantini M, Murtagh FEM, Bajwah S. Hospital-based specialist palliative care compared with usual care for adults with advanced illness and their caregivers: a systematic review. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Most deaths still take place in hospital; cost-effective commissioning of end-of-life resources is a priority. This review provides clarity on the effectiveness of hospital-based specialist palliative care.
Objectives
The objectives were to assess the effectiveness and cost-effectiveness of hospital-based specialist palliative care.
Population
Adult patients with advanced illnesses and their unpaid caregivers.
Intervention
Hospital-based specialist palliative care.
Comparators
Inpatient or outpatient hospital care without specialist palliative care input at the point of entry to the study, or community care or hospice care provided outside the hospital setting (usual care).
Primary outcomes
Patient health-related quality of life and symptom burden.
Data sources
Six databases (The Cochrane Library, MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and CareSearch), clinical trial registers, reference lists and systematic reviews were searched to August 2019.
Review methods
Two independent reviewers screened, data extracted and assessed methodological quality. Meta-analysis was carried out using RevMan (The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark), with separate synthesis of qualitative data.
Results
Forty-two randomised controlled trials involving 7779 participants (6678 patients and 1101 unpaid caregivers) were included. Diagnoses of participants were as follows: cancer, 21 studies; non-cancer, 14 studies; and mixed cancer and non-cancer, seven studies. Hospital-based specialist palliative care was offered in the following models: ward based (one study), inpatient consult (10 studies), outpatient (six studies), hospital at home or hospital outreach (five studies) and multiple settings that included hospital (20 studies). Meta-analyses demonstrated significant improvement favouring hospital-based specialist palliative care over usual care in patient health-related quality of life (10 studies, standardised mean difference 0.26, 95% confidence interval 0.15 to 0.37; I
2 = 3%) and patient satisfaction with care (two studies, standardised mean difference 0.36, 95% confidence interval 0.14 to 0.57; I
2 = 0%), a significant reduction in patient symptom burden (six studies, standardised mean difference –0.26, 95% confidence interval –0.41 to –0.12; I
2 = 0%) and patient depression (eight studies, standardised mean difference –0.22, 95% confidence interval –0.34 to –0.10; I
2 = 0%), and a significant increase in the chances of patients dying in their preferred place (measured by number of patients with home death) (seven studies, odds ratio 1.63, 95% confidence interval 1.23 to 2.16; I
2 = 0%). There were non-significant improvements in pain (four studies, standardised mean difference –0.16, 95% confidence interval –0.33 to 0.01; I
2 = 0%) and patient anxiety (five studies, mean difference –0.63, 95% confidence interval –2.22 to 0.96; I
2 = 76%). Hospital-based specialist palliative care showed no evidence of causing serious harm. The evidence on mortality/survival and cost-effectiveness was inconclusive. Qualitative studies (10 studies, 322 participants) suggested that hospital-based specialist palliative care was beneficial as it ensured personalised and holistic care for patients and their families, while also fostering open communication, shared decision-making and respectful and compassionate care.
Limitation
In almost half of the included randomised controlled trials, there was palliative care involvement in the control group.
Conclusions
Hospital-based specialist palliative care may offer benefits for person-centred outcomes including health-related quality of life, symptom burden, patient depression and satisfaction with care, while also increasing the chances of patients dying in their preferred place (measured by home death) with little evidence of harm.
Future work
More studies are needed of populations with non-malignant diseases, different models of hospital-based specialist palliative care, and cost-effectiveness.
Study registration
This study is registered as PROSPERO CRD42017083205.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 12. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Adejoke O Oluyase
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Gunn Grande
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Chris Todd
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Massimo Costantini
- Palliative Care Unit, Azienda Unità Sanitaria Locale – Istituto di Ricovero e Cura a Carattere Scientifico (USL-IRCCS), Reggio Emilia, Italy
| | - Fliss EM Murtagh
- Cicely Saunders Institute of Palliative Care, Policy & 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 & Rehabilitation, King’s College London, London, UK
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Schloesser K, Eisenmann Y, Bergmann A, Simon ST. Development of a Brief Cognitive and Behavioral Intervention for the Management of Episodic Breathlessness-A Delphi Survey With International Experts. J Pain Symptom Manage 2021; 61:963-973.e1. [PMID: 33002596 DOI: 10.1016/j.jpainsymman.2020.09.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 12/20/2022]
Abstract
CONTEXT Episodic breathlessness is characterized by a severe worsening of breathlessness intensity that goes beyond usual fluctuations. Episodes are usually short; therefore, nonpharmacological strategies (cognitive and behavioral) seem most promising to be beneficial. Which strategies-delivered separately or in combination-might be most effective and feasible remains unclear. OBJECTIVES The Delphi survey selects and determines different nonpharmacological strategies for coping with episodic breathlessness to develop a brief cognitive and behavioral intervention for the management of episodic breathlessness. METHODS Using an online Delphi survey comprising three rounds, international, multidisciplinary experts in breathlessness summarized and determined cognitive and behavioral strategies. The a priori target agreement for close-ended questions was 70%. RESULTS Experts (n = 41/87; n = 45/85; n = 36/85) agreed on 15 of the 31 cognitive and behavioral strategies. Based on the panellists' opinion, the final version of the cognitive and behavioral intervention comprised the following characteristics: individually tailored intervention, a high proportion of communication, short duration, the involvement of carers, and use of the Breathing, Thinking, Functioning Model of Spathis et al. Consensus upon the delivery of the subsequent strategies within the intervention was reached: handheld fan, forward lean, diaphragmatic breathing, distraction, pursed lips breathing, long breaths out, and relaxation training. CONCLUSION Using the consented nonpharmacological strategies, a brief cognitive and behavioral intervention was developed that balances between individualization and standardization of the intervention.
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Affiliation(s)
- Karlotta Schloesser
- Faculty of Medicine and University Hospital, Department of Palliative Medicine, University of Cologne, Cologne, Germany.
| | - Yvonne Eisenmann
- Faculty of Medicine and University Hospital, Department of Palliative Medicine, University of Cologne, Cologne, Germany
| | - Anja Bergmann
- Faculty of Medicine and University Hospital, Department of Palliative Medicine, University of Cologne, Cologne, Germany
| | - Steffen T Simon
- Faculty of Medicine and University Hospital, Department of Palliative Medicine, University of Cologne, Cologne, Germany; Faculty of Medicine and University Hospital, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany; Faculty of Medicine and University Hospital, Clinical Trials Center (ZKS), University of Cologne, Cologne, Germany
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30
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Hui D, Bohlke K, Bao T, Campbell TC, Coyne PJ, Currow DC, Gupta A, Leiser AL, Mori M, Nava S, Reinke LF, Roeland EJ, Seigel C, Walsh D, Campbell ML. Management of Dyspnea in Advanced Cancer: ASCO Guideline. J Clin Oncol 2021; 39:1389-1411. [DOI: 10.1200/jco.20.03465] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To provide guidance on the clinical management of dyspnea in adult patients with advanced cancer. METHODS ASCO convened an Expert Panel to review the evidence and formulate recommendations. An Agency for Healthcare Research and Quality (AHRQ) systematic review provided the evidence base for nonpharmacologic and pharmacologic interventions to alleviate dyspnea. The review included randomized controlled trials (RCTs) and observational studies with a concurrent comparison group published through early May 2020. The ASCO Expert Panel also wished to address dyspnea assessment, management of underlying conditions, and palliative care referrals, and for these questions, an additional systematic review identified RCTs, systematic reviews, and guidelines published through July 2020. RESULTS The AHRQ systematic review included 48 RCTs and two retrospective cohort studies. Lung cancer and mesothelioma were the most commonly addressed types of cancer. Nonpharmacologic interventions such as fans provided some relief from breathlessness. Support for pharmacologic interventions was limited. A meta-analysis of specialty breathlessness services reported improvements in distress because of dyspnea. RECOMMENDATIONS A hierarchical approach to dyspnea management is recommended, beginning with dyspnea assessment, ascertainment and management of potentially reversible causes, and referral to an interdisciplinary palliative care team. Nonpharmacologic interventions that may be offered to relieve dyspnea include airflow interventions (eg, a fan directed at the cheek), standard supplemental oxygen for patients with hypoxemia, and other psychoeducational, self-management, or complementary approaches. For patients who derive inadequate relief from nonpharmacologic interventions, systemic opioids should be offered. Other pharmacologic interventions, such as corticosteroids and benzodiazepines, are also discussed. Additional information is available at www.asco.org/supportive-care-guidelines .
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Affiliation(s)
- David Hui
- MD Anderson Cancer Center, Houston, TX
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | - Ting Bao
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Arjun Gupta
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Aliza L. Leiser
- Rutgers RWJ Cancer Institute of New Jersey, New Brunswick, NJ
| | - Masanori Mori
- Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Stefano Nava
- IRCCS Azienda Ospedaliera University of Bologna, S. Orsola-Malpighi Hospital, Alma Mater University, Bologna, Italy
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31
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Northgraves M, Cohen J, Allgar V, Currow D, Hart S, Hird K, Hodge A, Johnson M, Mason S, Swan F, Hutchinson A. A feasibility cluster randomised controlled trial of a paramedic-administered breathlessness management intervention for acute-on-chronic breathlessness (BREATHE). ERJ Open Res 2021; 7:00955-2020. [PMID: 33816602 PMCID: PMC8005684 DOI: 10.1183/23120541.00955-2020] [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: 12/18/2020] [Accepted: 01/07/2021] [Indexed: 11/19/2022] Open
Abstract
Chronic breathlessness, persistent and disabling despite optimal treatment of underlying causes, is a prevalent and frightening symptom and is associated with many emergency presentations and admission to hospital. Breathlessness management techniques used by paramedics may reduce the need for conveyance to hospital. The Breathlessness RElief AT HomE study (BREATHE) aims to explore the feasibility of conducting a definitive cluster randomised controlled trial (cRCT) for people with acute-on-chronic breathlessness who have called an ambulance, to evaluate the effectiveness and cost-effectiveness of a paramedic-administered non-pharmacological breathlessness intervention. The trial is a mixed-methods feasibility cRCT. Eight paramedics will be randomised 1:1 to deliver either the BREATHE intervention in addition to usual care or usual care alone at call-outs for acute-on-chronic breathlessness. Sixty participants will be recruited to provide access to routine data relating to the index call-out with optional follow-up questionnaires at 14 days, 1 month and 6 months. An in-depth interview will be conducted with a subgroup. Feasibility outcomes relating to recruitment, data quality (especially candidate primary outcomes), and intervention acceptability and fidelity will be collected as well as providing data to estimate a sample size for a definitive trial. Yorkshire and The Humber–Sheffield Research Ethics Committee approved the trial protocol (19/YH/0314). The study results will inform progression to, or not, and design of a main trial according to predetermined stop-go criteria. Findings will be disseminated to relevant stakeholders and submitted for publication in a peer-reviewed journal. Acute-on-chronic breathlessness initiates many emergency presentations. The BREATHE protocol describes a feasibility, cluster randomised controlled trial of a paramedic breathlessness management intervention.https://bit.ly/2LZg72w
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Affiliation(s)
| | - Judith Cohen
- Hull Health Trials Unit, University of Hull, Hull, UK
| | - Victoria Allgar
- Hull York Medical School / Health Sciences, University of York, York, UK
| | - David Currow
- Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Simon Hart
- Respiratory Research Group, Hull York Medical School, Cottingham, UK
| | - Kelly Hird
- Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Andrew Hodge
- Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Miriam Johnson
- Wolfson Palliative Care Research Group, Hull York Medical School, Hull, UK
| | - Suzanne Mason
- CURE group, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Flavia Swan
- Wolfson Palliative Care Research Group, Hull York Medical School, Hull, UK
| | - Ann Hutchinson
- Wolfson Palliative Care Research Group, Hull York Medical School, Hull, UK
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32
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Khor YH, Saravanan K, Holland AE, Lee JYT, Ryerson CJ, McDonald CF, Goh NSL. A mixed-methods pilot study of handheld fan for breathlessness in interstitial lung disease. Sci Rep 2021; 11:6874. [PMID: 33767311 PMCID: PMC7994303 DOI: 10.1038/s41598-021-86326-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/15/2021] [Indexed: 11/26/2022] Open
Abstract
Dyspnoea is a cardinal symptom of fibrotic interstitial lung disease (ILD), with a lack of proven effective therapies. With emerging evidence of the role of facial and nasal airflow for relieving breathlessness, this pilot study was conducted to examine the feasibility of conducting a clinical trial of a handheld fan (HHF) for dyspnoea management in patients with fibrotic ILD. In this mixed-methods, randomised, assessor-blinded, controlled trial, 30 participants with fibrotic ILD who were dyspnoeic with a modified Medical Research Council Dyspnoea grade ≥ 2 were randomised to a HHF for symptom control or no intervention for 2 weeks. Primary outcomes were trial feasibility, change in Dyspnoea-12 scores at Week 2, and participants’ perspectives on using a HHF for dyspnoea management. Study recruitment was completed within nine months at a single site. Successful assessor blinding was achieved in the fan group [Bang’s Blinding Index − 0.08 (95% CI − 0.45, 0.30)] but not the control group [0.47 (0.12, 0.81)]. There were no significant between-group differences for the change in Dyspnoea-12 or secondary efficacy outcomes. During qualitative interviews, participants reported that using the HHF relieved breathlessness and provided relaxation, despite initial scepticism about its therapeutic benefit. Oxygen-experienced participants described the HHF being easier to use, but not as effective for symptomatic relief, compared to oxygen therapy. Our results confirmed the feasibility of a clinical trial of a HHF in fibrotic ILD. There was a high level of patient acceptance of a HHF for managing dyspnoea, with patients reporting both symptomatic benefits and ease of use.
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Affiliation(s)
- Yet H Khor
- Department of Respiratory and Sleep Medicine, Austin Health, 145 Studley Road, Heidelberg, VIC, 3084, Australia. .,Institute for Breathing and Sleep, Heidelberg, VIC, Australia. .,Faculty of Medicine, University of Melbourne, Melbourne, VIC, Australia. .,Department of Respiratory Medicine, Alfred Health, Melbourne, Australia.
| | | | - Anne E Holland
- Institute for Breathing and Sleep, Heidelberg, VIC, Australia.,Department of Allergy, Immunology and Respiratory Medicine, Monash University, Melbourne, Australia.,Department of Physiotherapy, Alfred Health, Melbourne, Australia
| | - Joanna Y T Lee
- Department of Allergy, Immunology and Respiratory Medicine, Monash University, Melbourne, Australia
| | - Christopher J Ryerson
- Centre for Heart Lung Innovation, Providence Health Care, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Christine F McDonald
- Department of Respiratory and Sleep Medicine, Austin Health, 145 Studley Road, Heidelberg, VIC, 3084, Australia.,Institute for Breathing and Sleep, Heidelberg, VIC, Australia.,Faculty of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Nicole S L Goh
- Department of Respiratory and Sleep Medicine, Austin Health, 145 Studley Road, Heidelberg, VIC, 3084, Australia.,Institute for Breathing and Sleep, Heidelberg, VIC, Australia.,Faculty of Medicine, University of Melbourne, Melbourne, VIC, Australia.,Department of Respiratory Medicine, Alfred Health, Melbourne, Australia
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33
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Gupta A, Sedhom R, Sharma R, Zhang A, Waldfogel JM, Feliciano JL, Day J, Gersten RA, Davidson PM, Bass EB, Dy SM. Nonpharmacological Interventions for Managing Breathlessness in Patients With Advanced Cancer: A Systematic Review. JAMA Oncol 2021; 7:290-298. [PMID: 33211072 DOI: 10.1001/jamaoncol.2020.5184] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Breathlessness is a frequent and debilitating symptom in patients with advanced cancer. Often, in the context of breathlessness, aggressive cancer treatment is not beneficial, feasible, or aligned with goals of care. Targeted symptom-focused interventions may be helpful in this scenario. Objective To evaluate the advantages and harms of nonpharmacological interventions for managing breathlessness in adults with advanced cancer. Evidence Review PubMed, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials were searched from inception through May 2020 for published randomized clinical trials (RCTs), nonrandomized controlled trials, and observational studies of the advantages and/or harms of nonpharmacological interventions on alleviating breathlessness in adults with advanced cancer. Only English-language studies were screened for eligibility, titles, abstracts, and full text. Risk of bias and strength of evidence (SOE) were independently assessed. The key outcomes reported in studies were breathlessness, anxiety, exercise capacity, health-related quality of life, and harms. Data were analyzed from October 1, 2019, to June 30, 2020. Findings A total of 29 RCTs (2423 participants) were included. These RCTs evaluated various types of interventions, such as respiratory (9 RCTs), activity and rehabilitation (7 RCTs), behavioral and psychoeducational (3 RCTs), integrative medicine (4 RCTs), and multicomponent (6 RCTs). Several nonpharmacological interventions were associated with improved breathlessness, including fan therapy (standardized mean difference [SMD], -2.09; 95% CI, -3.81 to -0.37; I2 = 94.3%; P for heterogeneity = .02; moderate SOE) and bilevel ventilation (estimated slope difference, -0.58; 95% CI, -0.92 to -0.23; low SOE), lasting for a few minutes to hours, in the inpatient setting. In the outpatient setting, nonpharmacological interventions associated with improved breathlessness were acupressure and reflexology (integrative medicine) (low SOE) and multicomponent interventions (combined activity and rehabilitation, behavioral and psychoeducational, and integrative medicine) (low SOE) lasting for a few weeks to months. Five of the 29 RCTs (17%) reported adverse events, although adverse events and study dropouts were uncommon. Conclusions and Relevance Findings of this review include the safety and association with improved breathlessness of several nonpharmacological interventions for adults with advanced cancer. Guidelines and clinical practice should evolve to incorporate nonpharmacological interventions as first-line treatment for adults with advanced cancer and breathlessness.
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Affiliation(s)
- Arjun Gupta
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Ramy Sedhom
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Ritu Sharma
- Johns Hopkins Evidence-Based Practice Center, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Allen Zhang
- Johns Hopkins Evidence-Based Practice Center, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Julie M Waldfogel
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Josephine L Feliciano
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Jeff Day
- Department of Art as Applied to Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rebecca A Gersten
- Division of Pulmonary & Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Eric B Bass
- Johns Hopkins Evidence-Based Practice Center, Johns Hopkins School of Public Health, Baltimore, Maryland.,Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sydney M Dy
- Johns Hopkins Evidence-Based Practice Center, Johns Hopkins School of Public Health, Baltimore, Maryland.,Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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34
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Schunk M, Le L, Syunyaeva Z, Haberland B, Tänzler S, Mansmann U, Schwarzkopf L, Seidl H, Streitwieser S, Hofmann M, Müller T, Weiß T, Morawietz P, Rehfuess EA, Huber RM, Berger U, Bausewein C. Effectiveness of a specialised breathlessness service for patients with advanced disease in Germany: a pragmatic fast-track randomised controlled trial (BreathEase). Eur Respir J 2021; 58:13993003.02139-2020. [PMID: 33509957 DOI: 10.1183/13993003.02139-2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 01/12/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND The effectiveness of the Munich Breathlessness Service (MBS), integrating palliative care, respiratory medicine and physiotherapy, was tested in the BreathEase trial in patients with chronic breathlessness in advanced disease and their carers. METHODS BreathEase was a single-blinded randomised controlled fast-track trial. The MBS was attended for 5-6 weeks; the control group started the MBS after 8 weeks of standard care. Randomisation was stratified by cancer and the presence of a carer. Primary outcomes were patients' mastery of breathlessness (Chronic Respiratory Disease Questionnaire (CRQ) Mastery), quality of life (CRQ QoL), symptom burden (Integrated Palliative care Outcome Scale (IPOS)) and carer burden (Zarit Burden Interview (ZBI)). Intention-to-treat (ITT) analyses were conducted with hierarchical testing. Effectiveness was investigated by linear regression on change scores, adjusting for baseline scores and stratification variables. Missing values were handled with multiple imputation. RESULTS 92 patients were randomised to the intervention group and 91 patients were randomised to the control group. Before the follow-up assessment after 8 weeks (T1), 17 and five patients dropped out from the intervention and control groups, respectively. Significant improvements in CRQ Mastery of 0.367 (95% CI 0.065-0.669) and CRQ QoL of 0.226 (95% CI 0.012-0.440) score units at T1 in favour of the intervention group were seen in the ITT analyses (n=183), but not in IPOS. Exploratory testing showed nonsignificant improvements in ZBI. CONCLUSIONS These findings demonstrate positive effects of the MBS in reducing burden caused by chronic breathlessness in advanced illness across a wide range of patients. Further evaluation in subgroups of patients and with a longitudinal perspective is needed.
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Affiliation(s)
- Michaela Schunk
- Dept of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany .,Pettenkofer School of Public Health, Munich, Germany
| | - Lien Le
- Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Zulfiya Syunyaeva
- Dept of Medicine V, University Hospital, LMU Munich, Munich, Germany.,Member of the German Center for Lung Research (DZL), Comprehensive Pneumology Center Munich, Munich, Germany
| | - Birgit Haberland
- Dept of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Susanne Tänzler
- Dept of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Ulrich Mansmann
- Pettenkofer School of Public Health, Munich, Germany.,Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Larissa Schwarzkopf
- Member of the German Center for Lung Research (DZL), Comprehensive Pneumology Center Munich, Munich, Germany.,Health Economics and Health Care Management (IGM), Helmholtz Zentrum München (GmbH), German Research Center for Environmental Health, Munich, Germany.,IFT (Institut für Therapieforschung), Munich, Germany
| | - Hildegard Seidl
- Pettenkofer School of Public Health, Munich, Germany.,Health Economics and Health Care Management (IGM), Helmholtz Zentrum München (GmbH), German Research Center for Environmental Health, Munich, Germany.,Quality Management and Gender Medicine, München Klinik gGmbH, Munich, Germany
| | - Sabine Streitwieser
- Dept of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Miriam Hofmann
- Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Thomas Müller
- Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Tobias Weiß
- Atem-und Physiotherapie Solln, Munich, Germany
| | | | - Eva Annette Rehfuess
- Pettenkofer School of Public Health, Munich, Germany.,Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Rudolf Maria Huber
- Dept of Medicine V, University Hospital, LMU Munich, Munich, Germany.,Member of the German Center for Lung Research (DZL), Comprehensive Pneumology Center Munich, Munich, Germany
| | - Ursula Berger
- Pettenkofer School of Public Health, Munich, Germany.,Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Claudia Bausewein
- Dept of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
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35
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Higginson IJ, Reilly CC, Maddocks M. Breathlessness. Respir Med 2021. [DOI: 10.1007/978-3-030-81788-6_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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36
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Smith TA, Roberts MM, Cho JG, Klimkeit E, Luckett T, McCaffrey N, Kirby A, Wheatley JR. Protocol for a Single-Blind, Randomized, Parallel-Group Study of a Nonpharmacological Integrated Care Intervention to Reduce the Impact of Breathlessness in Patients with Chronic Obstructive Pulmonary Disease. Palliat Med Rep 2020; 1:296-306. [PMID: 34223489 PMCID: PMC8241373 DOI: 10.1089/pmr.2020.0081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Patients with chronic obstructive pulmonary disease (COPD) frequently experience breathlessness despite maximal medical therapy. Nonpharmacological management is effective in studies enrolling patients with a variety of respiratory diseases; however, the impact on patients with COPD is unclear. Methods: A protocol for a mixed-methods, single-center, observer-blinded, fast-track randomized-controlled, parallel-group trial comparing an immediate eight-week nonpharmacological Westmead Breathlessness Service (WBS) to a standard care control group is described. Population: At least moderate COPD (FEV1:FVC ≤0.7; FEV1%predicted ≤60%) and persistent disabling breathlessness (modified Medical Research Council ≥2). Intervention: Individualized prescription of nonpharmacological breathlessness interventions, including a handheld fan, breathing techniques, postures to relieve breathlessness, relaxation, nutritional advice, energy conservation, and exercise advice delivered by a team including doctors, nurses, a physiotherapist, an occupational therapist, a dietitian, and speech pathologist. Control: Participants who receive the WBS intervention after an eight-week period while receiving usual care (standard care group). Outcome: Primary outcome—Chronic Respiratory Questionnaire (CRQ) Mastery subscale. Secondary outcomes include numerical rating scale of breathlessness intensity, unpleasantness, and confidence managing breathlessness; quality of life as measured by other CRQ subscales; Hospital Anxiety and Depression Scale score; daily step count; health resource utilization 12 months pre- and postintervention; and cost-effectiveness. Qualitative analysis of participant interviews will provide additional context for interpreting the quantitative results. Discussion: This study aims to establish the efficacy and cost-effectiveness of an eight-week nonpharmacological breathlessness intervention in patients with COPD. Trial Registration: The Australian New Zealand Clinical Trial Registry ACTRN12617000499381 (06/04/17).
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Affiliation(s)
- Tracy A Smith
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Wentworthville, New South Wales, Australia.,Westmead Clinical School, Sydney Medical School, University of Sydney at Westmead Hospital, Wentworthville, New South Wales, Australia
| | - Mary M Roberts
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Wentworthville, New South Wales, Australia.,Westmead Clinical School, Sydney Medical School, University of Sydney at Westmead Hospital, Wentworthville, New South Wales, Australia.,Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Wentworthville, New South Wales, Australia
| | - Jin-Gun Cho
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Wentworthville, New South Wales, Australia.,Westmead Clinical School, Sydney Medical School, University of Sydney at Westmead Hospital, Wentworthville, New South Wales, Australia.,Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Wentworthville, New South Wales, Australia
| | - Ester Klimkeit
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Wentworthville, New South Wales, Australia
| | - Tim Luckett
- Improving Palliative, Aged, and Chronic Care through Clinical Research and Translation (IMPACCT) Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Nikki McCaffrey
- Deakin University, School of Health and Social Development, Deakin Health Economics, Institute for Health Transformation, Burwood, Victoria, Australia
| | - Adrienne Kirby
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - John R Wheatley
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Wentworthville, New South Wales, Australia.,Westmead Clinical School, Sydney Medical School, University of Sydney at Westmead Hospital, Wentworthville, New South Wales, Australia.,Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Wentworthville, New South Wales, Australia
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Tometich DB, Hyland KA, Soliman H, Jim HSL, Oswald L. Living with Metastatic Cancer: A Roadmap for Future Research. Cancers (Basel) 2020; 12:E3684. [PMID: 33302472 PMCID: PMC7763639 DOI: 10.3390/cancers12123684] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/03/2020] [Accepted: 12/05/2020] [Indexed: 02/06/2023] Open
Abstract
Living with metastatic cancer, or metavivorship, differs from cancer survivorship and has changed as novel treatments have increased survival time. The purpose of this narrative review is to describe factors that impact challenges in metavivorship within a conceptual framework to guide future research. This review focuses on the specific metavivorship outcomes of progressive disease, survival time, symptoms, distress, financial toxicity, and quality of life. We describe the predisposing, precipitating, and perpetuating (3P) model of metavivorship. Understanding the biological, psychological, and social 3P factors that contribute to the development and maintenance of challenges in metavivorship provides a roadmap for future research. Implications of this model include prevention by targeting predisposing factors, management of precipitating factors after onset of metastatic disease, and treatment of perpetuating factors to reduce symptoms and improve quality of life during the chronic phase of metavivorship. This can be accomplished through biopsychosocial screening efforts, monitoring of patient-reported outcomes, education and communication interventions, interdisciplinary symptom management, advance care planning, and behavioral interventions to cultivate psychological resilience.
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Affiliation(s)
- Danielle B. Tometich
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL 33612, USA; (D.B.T.); (H.S.L.J.)
| | - Kelly A. Hyland
- Department of Psychology, University of South Florida, Tampa, FL 33612, USA;
| | - Hatem Soliman
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA;
| | - Heather S. L. Jim
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL 33612, USA; (D.B.T.); (H.S.L.J.)
| | - Laura Oswald
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL 33612, USA; (D.B.T.); (H.S.L.J.)
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Chorattas A, Papastavrou E, Charalambous A, Kouta C. Home-Based Educational Programs for Management of Dyspnea: A Systematic Literature Review. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2020. [DOI: 10.1177/1084822320907908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Dyspnea or breathlessness is a symptom of a plethora of diseases; despite that its management poses a challenge, it leads to frequent hospitalizations and a poor quality of life. In lung cancer, dyspnea may appear at any time of the disease but mainly during the end-of-life period. This article aims to explore the effectiveness of home-based educational programs for the management of dyspnea. This is a systematic review. The inclusion criteria were studies published between 2000 and 2018, and structured nurse-led home educational programs for the management of dyspnea due to cancer. The search via PUBMED, COCHRANE, EBSCO, and Google Scholar was worldwide for English- and Greek-language articles. The keywords included “education, program, intervention, patient, dyspnea, breathlessness, cancer, home, nurse.” The review was expanded to dyspnea being due to any chronic disease as it gave only one research article for lung cancer. The review identified seven research articles evaluating the effectiveness of various home-based educational programs for dyspnea management due to chronic obstructive pulmonary disease, heart failure, and lung cancer. They showed that a structured home-based educational program is of benefit for the patients by improving their dyspnea levels and their quality of life. There is the need to evaluate the benefits of home-based educational programs for cancer patients with dyspnea at home either as part of a symptom alone support program or as part of the general support given to cancer patients at home.
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Affiliation(s)
- Aristides Chorattas
- Nicosia General Hospital, Strovolos, Cyprus
- Cyprus University of Technology, Limassol, Cyprus
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Bajwah S, Oluyase AO, Yi D, Gao W, Evans CJ, Grande G, Todd C, Costantini M, Murtagh FE, Higginson IJ. The effectiveness and cost-effectiveness of hospital-based specialist palliative care for adults with advanced illness and their caregivers. Cochrane Database Syst Rev 2020; 9:CD012780. [PMID: 32996586 PMCID: PMC8428758 DOI: 10.1002/14651858.cd012780.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Serious illness is often characterised by physical/psychological problems, family support needs, and high healthcare resource use. Hospital-based specialist palliative care (HSPC) has developed to assist in better meeting the needs of patients and their families and potentially reducing hospital care expenditure. There is a need for clarity on the effectiveness and optimal models of HSPC, given that most people still die in hospital and also to allocate scarce resources judiciously. OBJECTIVES To assess the effectiveness and cost-effectiveness of HSPC compared to usual care for adults with advanced illness (hereafter patients) and their unpaid caregivers/families. SEARCH METHODS We searched CENTRAL, CDSR, DARE and HTA database via the Cochrane Library; MEDLINE; Embase; CINAHL; PsycINFO; CareSearch; National Health Service Economic Evaluation Database (NHS EED) and two trial registers to August 2019, together with checking of reference lists and relevant systematic reviews, citation searching and contact with experts to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) evaluating the impact of HSPC on outcomes for patients or their unpaid caregivers/families, or both. HSPC was defined as specialist palliative care delivered by a palliative care team that is based in a hospital providing holistic care, co-ordination by a multidisciplinary team, and collaboration between HSPC providers and generalists. HSPC was provided to patients while they were admitted as inpatients to acute care hospitals, outpatients or patients receiving care from hospital outreach teams at home. The comparator was usual care, defined as inpatient or outpatient hospital care without specialist palliative care input at the point of entry into the study, community care or hospice care provided outside of the hospital setting. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We assessed risk of bias and extracted data. To account for use of different scales across studies, we calculated standardised mean differences (SMDs) with 95% confidence intervals (CIs) for continuous data. We used an inverse variance random-effects model. For binary data, we calculated odds ratio (ORs) with 95% CIs. We assessed the evidence using GRADE and created a 'Summary of findings' table. Our primary outcomes were patient health-related quality of life (HRQoL) and symptom burden (a collection of two or more symptoms). Key secondary outcomes were pain, depression, satisfaction with care, achieving preferred place of death, mortality/survival, unpaid caregiver burden, and cost-effectiveness. Qualitative data was analysed where available. MAIN RESULTS We identified 42 RCTs involving 7779 participants (6678 patients and 1101 caregivers/family members). Twenty-one studies were with cancer populations, 14 were with non-cancer populations (of which six were with heart failure patients), and seven with mixed cancer and non-cancer populations (mixed diagnoses). HSPC was offered in different ways and included the following models: ward-based, inpatient consult, outpatient, hospital-at-home or hospital outreach, and service provision across multiple settings which included hospital. For our main analyses, we pooled data from studies reporting adjusted endpoint values. Forty studies had a high risk of bias in at least one domain. Compared with usual care, HSPC improved patient HRQoL with a small effect size of 0.26 SMD over usual care (95% CI 0.15 to 0.37; I2 = 3%, 10 studies, 1344 participants, low-quality evidence, higher scores indicate better patient HRQoL). HSPC also improved other person-centred outcomes. It reduced patient symptom burden with a small effect size of -0.26 SMD over usual care (95% CI -0.41 to -0.12; I2 = 0%, 6 studies, 761 participants, very low-quality evidence, lower scores indicate lower symptom burden). HSPC improved patient satisfaction with care with a small effect size of 0.36 SMD over usual care (95% CI 0.41 to 0.57; I2 = 0%, 2 studies, 337 participants, low-quality evidence, higher scores indicate better patient satisfaction with care). Using home death as a proxy measure for achieving patient's preferred place of death, patients were more likely to die at home with HSPC compared to usual care (OR 1.63, 95% CI 1.23 to 2.16; I2 = 0%, 7 studies, 861 participants, low-quality evidence). Data on pain (4 studies, 525 participants) showed no evidence of a difference between HSPC and usual care (SMD -0.16, 95% CI -0.33 to 0.01; I2 = 0%, very low-quality evidence). Eight studies (N = 1252 participants) reported on adverse events and very low-quality evidence did not demonstrate an effect of HSPC on serious harms. Two studies (170 participants) presented data on caregiver burden and both found no evidence of effect of HSPC (very low-quality evidence). We included 13 economic studies (2103 participants). Overall, the evidence on cost-effectiveness of HSPC compared to usual care was inconsistent among the four full economic studies. Other studies that used only partial economic analysis and those that presented more limited resource use and cost information also had inconsistent results (very low-quality evidence). Quality of the evidence The quality of the evidence assessed using GRADE was very low to low, downgraded due to a high risk of bias, inconsistency and imprecision. AUTHORS' CONCLUSIONS Very low- to low-quality evidence suggests that when compared to usual care, HSPC may offer small benefits for several person-centred outcomes including patient HRQoL, symptom burden and patient satisfaction with care, while also increasing the chances of patients dying in their preferred place (measured by home death). While we found no evidence that HSPC causes serious harms, the evidence was insufficient to draw strong conclusions. Although these are only small effect sizes, they may be clinically relevant at an advanced stage of disease with limited prognosis, and are person-centred outcomes important to many patients and families. More well conducted studies are needed to study populations with non-malignant diseases and mixed diagnoses, ward-based models of HSPC, 24 hours access (out-of-hours care) as part of HSPC, pain, achieving patient preferred place of care, patient satisfaction with care, caregiver outcomes (satisfaction with care, burden, depression, anxiety, grief, quality of life), and cost-effectiveness of HSPC. In addition, research is needed to provide validated person-centred outcomes to be used across studies and populations.
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Affiliation(s)
- Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Adejoke O Oluyase
- 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
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Gunn Grande
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Chris Todd
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Fliss E 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
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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Choratas A, Papastavrou E, Charalambous A, Kouta C. Developing and Assessing the Effectiveness of a Nurse-Led Home-Based Educational Programme for Managing Breathlessness in Lung Cancer Patients. A Feasibility Study. Front Oncol 2020; 10:1366. [PMID: 32983967 PMCID: PMC7492635 DOI: 10.3389/fonc.2020.01366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 06/29/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Breathlessness is the most common and refractory symptom in lung cancer patients. Even though various educational programmes have been developed, only a few were intended for implementation in the home setting for its management. Aim: Feasibility of a study for implementing a nurse-led educational programme for breathlessness management of lung cancer patients at home. Method: A randomized feasibility study was undertaken between February 2017 and October 2018. Patients were recruited through referral from oncologists from two oncology centers in Cyprus under certain inclusion and exclusion criteria. Patients were randomized in the intervention or control group via a computer programme, and their named family caregivers (f.c.) were allocated in the same group. Participants were not blinded to group assignment. The intervention consisted of a PowerPoint presentation and implementation of three non-pharmacological interventions. The control group received usual care. Patients were assessed for breathlessness, anxiety, and depression levels, whereas f.c. were assessed for anxiety, depression, and burden levels. F.c. also assessed patients' dyspnea level. The duration of the study process for both the intervention and control group was over a period of 4 weeks. Results: Twenty-four patients and their f.c. (n = 24) were allocated equally in the intervention and control group. Five patients withdrew, and the final sample entered analysis was 19 patients and 19 family caregivers. In the intervention group n = 11 + 11, and in the control group n = 8 + 8. In the intervention group patients' breathlessness and anxiety levels showed improvement and their f.c.s in the anxiety and burden levels. Major consideration was the sample size and the recruitment of the patients by the referring oncologists. Attrition was minor during the study process. No harm was recorded by the participants of the study. Conclusions: The study provided evidence of the feasibility of the implementation of the educational programme. For the future definitive study major consideration should be patients' recruitment method in order to achieve adequate sample size. Moreover, qualitative data should be collected in relation to the intervention and the involvement of f.c. The feasibility study was registered to the Cyprus Bioethics Committee with the registration number 2016/16. There was no funding of the study.
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Affiliation(s)
- Aristides Choratas
- Nursing Department, Cyprus University of Technology, Limassol, Cyprus
- *Correspondence: Aristides Choratas
| | | | - Andreas Charalambous
- Nursing Department, Cyprus University of Technology, Limassol, Cyprus
- Nursing Department, University of Turku, Turku, Finland
| | - Christiana Kouta
- Nursing Department, Cyprus University of Technology, Limassol, Cyprus
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Abstract
PURPOSE OF REVIEW Breathlessness is a common yet complex symptom of advanced disease. Effective management will most likely draw upon the skills of multiple disciplines and professions. This review considers recent advances in the management of chronic breathlessness with regards to interdisciplinary working. RECENT FINDINGS There are growing data on interventions for chronic breathlessness that incorporate psychosocial mechanisms of action, for example, active mind-body treatments; and holistic breathlessness services that exemplify interprofessional working with professionals sharing skills and practice for user benefit. Patients value the personalized, empathetic and understanding tenor of care provided by breathlessness services, above the profession that delivers any intervention. Workforce training, decision support tools and self-management interventions may provide methods to scale-up these services and improve reach, though testing around the clinical effects of these approaches is required. SUMMARY Chronic breathlessness provides an ideal context within which to realize the benefits of interdisciplinary working. Holistic breathlessness services can commit to a comprehensive approach to initial assessment, as they can subsequently deliver a wide range of interventions suited to needs as they are identified.
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Patient perspectives on how to optimise benefits from a breathlessness service for people with COPD. NPJ Prim Care Respir Med 2020; 30:16. [PMID: 32269222 PMCID: PMC7142111 DOI: 10.1038/s41533-020-0172-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 03/12/2020] [Indexed: 12/03/2022] Open
Abstract
This study aimed to inform understanding of how to optimise patient-perceived benefits from a breathlessness service designed for patients with moderate to very severe chronic obstructive pulmonary disease (COPD). The Westmead Breathlessness Service (WBS) trains patients to self-manage over an 8-week programme, with multidisciplinary input and home visits. A qualitative approach was taken, using semi-structured telephone interviews. Each transcript was globally rated as suggesting ‘significant’, ‘some’ or ‘no’ impact from WBS, and thematic analysis used an integrative approach. Forty-one consecutive participants were interviewed to reach ‘information power’. Eighteen (44%) participants reported ‘significant’ impact, 17 (41%) ‘some’ impact, and two (5%) ‘no’ impact. Improvements to breathlessness were usually in the affective and impact dimensions but, more uncommonly, also sensory-perceptual. Participants who benefited in self-esteem, confidence and motivation attributed this to one-to-one multidisciplinary coaching and home visits. Further research should test whether including/excluding more intensive programme elements based on individual need might improve cost-effectiveness.
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Johnston KN, Young M, Kay D, Booth S, Spathis A, Williams MT. Attitude change and increased confidence with management of chronic breathlessness following a health professional training workshop: a survey evaluation. BMC MEDICAL EDUCATION 2020; 20:90. [PMID: 32228544 PMCID: PMC7106669 DOI: 10.1186/s12909-020-02006-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 03/17/2020] [Indexed: 05/12/2023]
Abstract
BACKGROUND Clinicians and people living with chronic breathlessness have expressed a need to better understand and manage this symptom. The aim of this study was to evaluate a 3-day health professional training workshop on the practical management of chronic breathlessness. METHODS Workshop design and delivery were based on current understandings and clinical models of chronic breathlessness management, principles of transformative learning, and included sessions co-designed with people living with breathlessness. Registrants were invited to complete pre and post-workshop surveys. Pre and 1-week post-workshop online questionnaires assessed familiarity and confidence about workshop objectives (0[lowest]-10[highest] visual analogue scale), attitudes and practices regarding chronic breathlessness (agreement with statements on 5-point Likert scales). Post-workshop, participants were asked to describe implementation plans and anticipated barriers. Baseline familiarity and confidence were reported as mean (SD) and change examined with paired t-tests. Pre-post attitudes and practices were summarised by frequency/percentages and change examined non-parametrically (5-point Likert scale responses) or using a McNemar test of change (binary responses). RESULTS Forty-seven of 55 registrants joined the study; 39 completed both pre and post-workshop questionnaires (35 female; 87% clinicians; median 8 years working with people with chronic breathlessness). Post-workshop, greatest gains in confidence were demonstrated for describing biopsychosocial concepts unpinning chronic breathlessness (mean change confidence = 3.2 points; 95% CI 2.7 to 4.0, p < 0.001). Respondents significantly changed their belief toward agreement that people are able to rate their breathlessness intensity on a scale (60 to 81% agreement) although only a minority strongly agreed with this statement at both time points (pre 11%, post 22%). The largest shift in attitude was toward agreement (z statistic 3.74, p < 0.001, effect size r = 0.6) that a person's experience of breathlessness should be used to guide treatment decisions (from 43 to 73% strong agreement). Participants' belief that cognitive behavioural strategies are effective for relief of breathlessness changed further toward agreement after the workshop (81 to 100%, McNemar test chi- square = 5.14, p = 0.02). CONCLUSION The focus of this training on biopsychosocial understandings of chronic breathlessness and involvement of people living with this symptom were valued. These features were identified as facilitators of change in fundamental attitudes and preparedness for practice.
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Affiliation(s)
- Kylie N Johnston
- School of Health Sciences, Innovation, Implementation and Clinical Translation in Health (IIMPACT), University of South Australia, Adelaide, South Australia, Australia.
| | - Mary Young
- Department of Thoracic Medicine, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Debra Kay
- , Adelaide, South Australia, Australia
| | - Sara Booth
- Cambridge Breathlessness Intervention Service, Cambridge University Hospitals NHS Foundation Trust, University of Cambridge, Cambridge, UK
| | - Anna Spathis
- Cambridge Breathlessness Intervention Service, Cambridge University Hospitals NHS Foundation Trust, University of Cambridge, Cambridge, UK
| | - Marie T Williams
- School of Health Sciences, Innovation, Implementation and Clinical Translation in Health (IIMPACT), University of South Australia, Adelaide, South Australia, Australia
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Jadalla A, Ginex P, Coleman M, Vrabel M, Bevans M. Family Caregiver Strain and Burden: A Systematic Review of Evidence-Based Interventions When Caring for Patients With Cancer. Clin J Oncol Nurs 2020; 24:31-50. [DOI: 10.1188/20.cjon.31-50] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Are the MORECare guidelines on reporting of attrition in palliative care research populations appropriate? A systematic review and meta-analysis of randomised controlled trials. BMC Palliat Care 2020; 19:6. [PMID: 31918702 PMCID: PMC6953282 DOI: 10.1186/s12904-019-0506-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 12/12/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Palliative care trials have higher rates of attrition. The MORECare guidance recommends applying classifications of attrition to report attrition to help interpret trial results. The guidance separates attrition into three categories: attrition due to death, illness or at random. The aim of our study is to apply the MORECare classifications on reported attrition rates in trials. METHODS A systematic review was conducted and attrition classifications retrospectively applied. Four databases, EMBASE; Medline, CINHAL and PsychINFO, were searched for randomised controlled trials of palliative care populations from 01.01.2010 to 08.10.2016. This systematic review is part of a larger review looking at recruitment to randomised controlled trials in palliative care, from January 1990 to early October 2016. We ran random-effect models with and without moderators and descriptive statistics to calculate rates of missing data. RESULTS One hundred nineteen trials showed a total attrition of 29% (95% CI 28 to 30%). We applied the MORECare classifications of attrition to the 91 papers that contained sufficient information. The main reason for attrition was attrition due to death with a weighted mean of 31.6% (SD 27.4) of attrition cases. Attrition due to illness was cited as the reason for 17.6% (SD 24.5) of participants. In 50.8% (SD 26.5) of cases, the attrition was at random. We did not observe significant differences in missing data between total attrition in non-cancer patients (26%; 95% CI 18-34%) and cancer patients (24%; 95% CI 20-29%). There was significantly more missing data in outpatients (29%; 95% CI 22-36%) than inpatients (16%; 95% CI 10-23%). We noted increased attrition in trials with longer durations. CONCLUSION Reporting the cause of attrition is useful in helping to understand trial results. Prospective reporting using the MORECare classifications should improve our understanding of future trials.
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Abstract
Breathlessness is a common symptom for patients with terminal illness and can be challenging to manage. Breathlessness is acknowledged to be an interaction between body and mind. There are a variety of pharmacological and non-pharmacological therapies that can be beneficial. The holistic assessment of the breathlessness patient should enable delivery of a tailored package of care focused on relief of symptoms.
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Affiliation(s)
- Suzie Gillon
- Consultant in Palliative Medicine, Department of Palliative Care, St James's University Hospital, Leeds LS9 7TF
| | - Ian J Clifton
- Consultant in Respiratory Medicine, Department of Respiratory Medicine, St James's University Hospital, Leeds
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Johnson MJ, Cockayne S, Currow DC, Bell K, Hicks K, Fairhurst C, Gabe R, Torgerson D, Jefferson L, Oxberry S, Ghosh J, Hogg KJ, Murphy J, Allgar V, Cleland JG, Clark AL. Oral modified release morphine for breathlessness in chronic heart failure: a randomized placebo-controlled trial. ESC Heart Fail 2019; 6:1149-1160. [PMID: 31389157 PMCID: PMC6989293 DOI: 10.1002/ehf2.12498] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/19/2019] [Accepted: 06/18/2019] [Indexed: 02/03/2023] Open
Abstract
AIMS Morphine is shown to relieve chronic breathlessness in chronic obstructive pulmonary disease. There are no definitive data in people with heart failure. We aimed to determine the effectiveness and cost-effectiveness of 12 weeks morphine therapy for the relief of chronic breathlessness in people with chronic heart failure compared with placebo. METHODS AND RESULTS Parallel group, double-blind, randomized, placebo-controlled, phase III trial of 20 mg daily oral modified release morphine was conducted in 13 sites in England and Scotland: hospital/community cardiology or palliative care outpatients. The primary analysis compared between-group numerical rating scale average breathlessness/24 hours at week 4 using a covariance pattern linear mixed model. Secondary outcomes included treatment-emergent harms (worse or new). The trial closed early due to slow recruitment, randomizing 45 participants [average age 72 (range 39-89) years; 84% men; 98% New York Heart Association class III]. For the primary analysis, the adjusted mean difference was 0.26 (95% confidence interval, -0.86 to 1.37) in favour of placebo. All other breathlessness measures improved in both groups (week 4 change-from-baseline) but by more in those assigned to morphine. Neither group was excessively drowsy at baseline or week 4. There were no between-group differences in quality of life (Kansas) or cognition (Montreal) at any time point. There was no exercise-related desaturation and no change between baseline and week 4 in either group. There was no change in vital signs at week 4. The natriuretic peptide measures fell in both groups but by more in the morphine group [morphine 2169 (1092, 3851) pg/mL vs. placebo 2851 (1694, 5437)] pg/mL. There was no excess serious adverse events in the morphine group. Treatment-emergent harms during the first week were more common in the morphine group; all apart from 1 were ≤ grade 2. CONCLUSIONS We could not answer our primary objectives due to inadequate power. However, we provide novel placebo-controlled medium-term benefit and safety data useful for clinical practice and future trial design. Morphine should only be prescribed in this population when other measures are unhelpful and with early management of side effects.
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Affiliation(s)
- Miriam J. Johnson
- Wolfson Palliative Care Research CentreUniversity of HullHullHU6 7RXUK
| | | | - David C. Currow
- Wolfson Palliative Care Research CentreUniversity of HullHullHU6 7RXUK
- IMPACCT, Faculty of HealthUniversity of Technology SydneyUltimoNSWAustralia
| | - Kerry Bell
- York Trials UnitUniversity of YorkYorkUK
| | - Kate Hicks
- York Trials UnitUniversity of YorkYorkUK
| | | | - Rhian Gabe
- Hull York Medical School and York Trials UnitUniversity of YorkYorkUK
| | | | | | - Stephen Oxberry
- Calderdale & Huddersfield Foundation TrustHuddersfield Royal InfirmaryHuddersfieldUK
| | - Justin Ghosh
- Department of CardiologyScarborough HospitalScarboroughUK
| | - Karen J. Hogg
- Department of CardiologyGlasgow Royal Infirmary, University of GlasgowGlasgowUK
| | - Jeremy Murphy
- Department of CardiologyDarlington Memorial HospitalDarlingtonUK
| | - Victoria Allgar
- Hull York Medical School and Department of Health SciencesUniversity of YorkYorkUK
| | - John G.F. Cleland
- Robertson Centre for Biostatistics & Clinical Trials, Institute of Health & Well‐beingUniversity of GlasgowGlasgowUK
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48
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Ernecoff NC, Check D, Bannon M, Hanson LC, Dionne-Odom JN, Corbelli J, Klein-Fedyshin M, Schenker Y, Zimmermann C, Arnold RM, Kavalieratos D. Comparing Specialty and Primary Palliative Care Interventions: Analysis of a Systematic Review. J Palliat Med 2019; 23:389-396. [PMID: 31644399 DOI: 10.1089/jpm.2019.0349] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Investigators have tested interventions delivered by specialty palliative care (SPC) clinicians, or by clinicians without palliative care specialization (primary palliative care, PPC). Objective: To compare the characteristics and outcomes of randomized clinical trials (RCTs) of SPC and PPC interventions. Design: Systematic review secondary analysis. Setting/Subjects: RCTs of palliative care interventions. Measurements: Interventions were classified SPC if delivered by palliative care board-certified or subspecialty trained clinicians, or those with extensive clinical experience; all others were PPC. We abstracted data for each intervention: delivery setting, delivery clinicians, outcomes measured, trial results, and Cochrane's Risk of Bias. We conducted narrative synthesis for quality of life, symptom burden, and survival. Results: Of 43 RCTs, 27 tested SPC and 16 tested PPC interventions. SPC interventions were more comprehensive (4.2 elements of palliative care vs. 3.1 in PPC, p = 0.02). SPC interventions were delivered in inpatient (44%) or outpatient settings (52%) by specialty physicians (44%) and nurses (44%); PPC interventions were delivered in inpatient (38%) and home settings (38%) by nurses (75%). PPC trials were more often of high risk of bias than SPC trials. Improvements were demonstrated on quality of life by SPC and PPC trials and on physical symptoms by SPC trials. Conclusions: Compared to PPC, SPC interventions were more comprehensive, were more often delivered in clinical settings, and demonstrated stronger evidence for improving physical symptoms. In the face of SPC workforce limitations, PPC interventions should be tested in more trials with low risk of bias, and may effectively meet some palliative care needs.
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Affiliation(s)
- Natalie C Ernecoff
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Devon Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.,Duke Cancer Institute, Durham, North Carolina
| | - Megan Bannon
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Laura C Hanson
- Cecil G. Sheps Center for Health Services Research, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina.,Division of Geriatric Medicine & Palliative Care Program, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina
| | | | - Jennifer Corbelli
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Camilla Zimmermann
- Division of Palliative Care, University Health Network, Toronto, Ontario, Canada.,School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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49
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Wright C, Hart SP, Allgar V, English A, Swan F, Dyson J, Richardson G, Twiddy M, Cohen J, Hussain J, Johnson M, Hargreaves I, Crooks MG. A feasibility, randomised controlled trial of a complex breathlessness intervention in idiopathic pulmonary fibrosis (BREEZE-IPF): study protocol. ERJ Open Res 2019; 5:00186-2019. [PMID: 31649946 PMCID: PMC6801212 DOI: 10.1183/23120541.00186-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 07/27/2019] [Indexed: 12/15/2022] Open
Abstract
Introduction Idiopathic pulmonary fibrosis (IPF) is a chronic and progressive lung disease that causes breathlessness and cough that worsen over time, limiting daily activities and negatively impacting quality of life. Although treatments are now available that slow the rate of lung function decline, trials of these treatments have failed to show improvement in symptoms or quality of life. There is an immediate unmet need for evidenced-based interventions that improve patients' symptom burden and make a difference to everyday living. This study aims to assess the feasibility of conducting a definitive randomised controlled trial of a holistic, complex breathlessness intervention in people with IPF. Methods and analysis The trial is a two-centre, randomised controlled feasibility trial of a complex breathlessness intervention compared with usual care in patients with IPF. 50 participants will be recruited from secondary care IPF clinics and randomised 1:1 to either start the intervention within 1 week of randomisation (fast-track group) or to receive usual care for 8 weeks before receiving the intervention (wait-list group). Participants will remain in the study for a total of 16 weeks. Outcome measures will be feasibility outcomes, including recruitment, retention, acceptability and fidelity of the intervention. Clinical outcomes will be measured to inform outcome selection and sample size calculation for a definitive trial. Ethics and dissemination Yorkshire and The Humber – Bradford Leeds Research Ethics Committee approved the study protocol (REC 18/YH/0147). Results of the main trial and all secondary end-points will be submitted for publication in a peer-reviewed journal. Idiopathic pulmonary fibrosis (IPF) is a chronic and progressive lung disease. This study protocol describes the BREEZE-IPF study: a feasibility, randomised controlled trial of a holistic, complex breathlessness intervention in IPF.http://bit.ly/33eF9im
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Affiliation(s)
- Caroline Wright
- Respiratory Research Group, Hull York Medical School, Cottingham, UK
| | - Simon P Hart
- Respiratory Research Group, Hull York Medical School, Cottingham, UK
| | | | - Anne English
- Dove House Hospice Palliative Care Physiotherapy Team, NHS Humber Foundation Trust, Willerby, UK
| | - Flavia Swan
- Wolfson Palliative Care Research Group, Hull York Medical School, Cottingham, UK
| | - Judith Dyson
- Institute of Clinical and Applied Health Research, University of Hull, Kingston upon Hull, UK
| | | | - Maureen Twiddy
- Institute of Clinical and Applied Health Research, University of Hull, Kingston upon Hull, UK
| | - Judith Cohen
- Hull Health Trials Unit, University of Hull, Kingston upon Hull, UK
| | - Jamilla Hussain
- Wolfson Palliative Care Research Group, Hull York Medical School, Cottingham, UK
| | - Miriam Johnson
- Wolfson Palliative Care Research Group, Hull York Medical School, Cottingham, UK
| | - Ian Hargreaves
- Respiratory Research Group, Hull York Medical School, Cottingham, UK
| | - Michael G Crooks
- Respiratory Research Group, Hull York Medical School, Cottingham, UK
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50
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Yu S, Sun K, Xing X, Zhong Y, Yan X, Qiu W, Yan M. Fan Therapy for the Relief of Dyspnea in Adults with Advanced Disease and Terminal Illness: A Meta-Analysis of Randomized Controlled Trials. J Palliat Med 2019; 22:1603-1609. [PMID: 31573417 DOI: 10.1089/jpm.2019.0140] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background: Dyspnea is one of the most common symptoms in patients with advanced disease and terminal illness, associated with poorer quality of life. The efficacy of fan therapy to palliate dyspnea is inconsistent and unclear. Objective: The aim of this meta-analysis was to evaluate the efficacy of fan therapy for the relief of dyspnea in adults with advanced disease and terminal illness. Design: The CENTRAL, MEDLINE, EMBASE, CINAHL, and PsycINFO were searched to retrieve all randomized controlled trials examining the benefits of fan therapy for the relief of dyspnea in patients at the advanced stages of illness. Risk of bias was assessed according to the Cochrane Collaboration standard scheme. Results: Five studies involving 198 adults were identified. Fan therapy was associated with a significant relief of breathlessness intensity immediately after intervention (mean differences [MDs], -1.01; 95% confidence interval [CI], -1.57 to -0.45; p < 0.001) and 10 minutes after intervention (MDs, -0.90; 95% CI, -1.53 to -0.27; p = 0.005). Long-term application of fan therapy for at least one month was not related to changes of dyspnea severity (MDs, 0.10; 95% CI, -1.14 to 1.35; p = 0.870). However, significant heterogeneity and low quality of the included trials limit applicability of the results in general practice. No difference was found in activity performance, respiratory rate and SpO2, changes in other symptom intensities, and adverse events. Conclusion: Current trials provided low-quality evidence for a significant short-term effect after fan therapy in the relief of dyspnea and no beneficial effect in the long-term application in adults with advanced disease and terminal illness.
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Affiliation(s)
- Shui Yu
- Department of Anesthesiology and Pain Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Kai Sun
- Department of Anesthesiology and Pain Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiufang Xing
- Department of Anesthesiology and Pain Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yinbo Zhong
- Department of Anesthesiology and Pain Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xuemei Yan
- Department of Anesthesiology, Weifang Medical University, Weifang, China
| | - Weidong Qiu
- Department of Anesthesiology and Pain Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Min Yan
- Department of Anesthesiology and Pain Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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