Management of dyspnea in palliative care

Dyspnoea at the end of life: instrument development and validation-the CONFORTO Strategy

OBJECTIVE

To describe the construction and validation of the algorithm for Criteria for inclusion; Objective of dyspnoea; Notification of patient/family/health professionals; Facial air flow; Oxygen; Relaxion and breathing; Treating causes of dyspnoea and Opioid (CONFORTO), an instrument to guide health professionals in managing dyspnoea in patients with an advance stage of the disease at the end-of-life.

METHODS

The study was carried out in three stages: (1) literature review and construction of CONFORTO; (2) semantic validation; (3) application of the CONFORTO Strategy to health professionals as a test (before video lessons) and post-test (20 days after watching video lessons) methodology. The scores obtained in the pretest and post-test were compared using the Wilcoxon test.

RESULTS

Seventy-four professionals from different internal medicine and intensive care units participated in the study. The CONFORTO Strategy involved eight acronym-forming items: Criteria for inclusion; Objective of dyspnoea; Notification of patient/family/health professionals; Facial air flow; Oxygen; Relaxion and breathing; Treating causes of dyspnoea and Opioid. The post-test indicated a significant increase in the score for the following items: facial air flow (p=0.016); oxygen (p=0.002); relaxation and breathing (p=0.002) and treating the causes of dyspnoea (p=0.011). The increase in score occurred after the training sessions with video lessons.

CONCLUSION

The CONFORTO Strategy proved valid and reliable for managing dyspnoea in patients with an advanced stage of the disease at the end-of-life. Because the instrument is easy-to-use, it can be used by the entire health team at any assistance-providing location, and can, thus, contribute to improving dyspnoea management for these patients.

Nurses' perceptions to alleviate dyspnoea in inpatients with advanced cancer while receiving palliative care

AIM

To explore nurses' perceptions to alleviate dyspnoea in inpatients with advanced cancer while receiving palliative care.

DESIGN

A descriptive qualitative design.

METHODS

Seven focus groups were conducted with nurses (n = 27) from five specialized palliative care wards in four hospitals in south and southwest Finland. The focus groups were conducted between June and November 2019, and the transcripts were analysed using inductive analysis.

RESULTS

The findings revealed three categories: recognizing dyspnoea is a multi-faceted problem, dealing with the complexity of assessment of dyspnoea and strategies for relieving dyspnoea. Nurses perceived the complexity of dyspnoea as a symptom and emphasized the importance of utilizing patients' subjective experiences and consistent assessment scales to determine its severity. Furthermore, nonpharmacological interventions are as pertinent as pharmacological and medical interventions. The findings can assist nurses in selecting appropriate interventions for dyspnoea care, ultimately enhancing the quality of patient care and patient safety.

Which breathlessness dimensions associate most strongly with fatigue?-The population-based VASCOL study of elderly men

BACKGROUND

Breathlessness and fatigue are common symptoms in older people. We aimed to evaluate how different breathlessness dimensions (overall intensity, unpleasantness, sensory descriptors, emotional responses) were associated with fatigue in elderly men.

METHODS

This was a cross-sectional analysis of the population-based VAScular disease and Chronic Obstructive Lung Disease (VASCOL) study of 73-year old men. Breathlessness dimensions were assessed using the Dyspnoea-12 (D-12), Multidimensional Dyspnoea Profile (MDP), and the modified Medical Research Council (mMRC) scale. Fatigue was assessed using the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) questionnaire. Clinically relevant fatigue was defined as FACIT-F≤ 30 units. Scores were compared standardized as z-scores and analysed using linear regression, adjusted for body mass index, smoking, depression, cancer, sleep apnoea, prior cardiac surgery, respiratory and cardiovascular disease.

RESULTS

Of 677 participants, 11.7% had clinically relevant fatigue. Higher breathlessness scores were associated with having worse fatigue; for D-12 total, -0.35 ([95% CI] -0.41 to -0.30) and for MDP A1, -0.24 (-0.30 to -0.18). Associations were similar across all the evaluated breathlessness dimensions even when adjusting for the potential confounders.

CONCLUSION

Breathlessness assessed using D-12 and MDP was associated with worse fatigue in elderly men, similarly across different breathlessness dimensions.

Goals of care and end-of-life communication needs of persons with chronic respiratory disease

PURPOSE OF THE REVIEW

To highlight recent advances in effective communication among persons with chronic respiratory diseases. The authors focus on communication science related to goals of care (GOC) discussions, medical devices, and life-sustaining invasive treatments. The authors discuss important considerations when working with individuals with low literacy and rurality. Communication handoffs between respiratory clinicians and/or palliative care to hospice clinicians are summarized to ensure effective person-centered and caregiver-centered care.

RECENT FINDINGS

Studies suggest the following communication approaches: (1) clarify differences between palliative and end of life; (2) conduct conversations early and gradual throughout the illness trajectory; (3) distinguish types of GOC discussions as they relate to treatment preferences; (4) for patients from rural communities, include family members and spiritual leaders; (5) assess literacy and employ supportive strategies; (6) apply time-limited-trial framework for life-sustaining treatment (LST) decisions; and (7) standardize processes for communication handoffs to hospice clinicians to improve communication fidelity.

SUMMARY

Effective communication tools for clinicians to engage in GOC discussions for persons with chronic respiratory diseases are grounded in a patient-centered framework. A trained clinician should lead these conversations and include interdisciplinary team members throughout the disease trajectory including at the end of life. These approaches may enable patients to express their values and care preferences as they evolve over time.

(No) Oral Health in Palliative Care Patients: Predisposing Factors and Treatment

OBJECTIVE

To describe mouth disorders in patients undergoing palliative care (PC); to identify predisposing factors for oral disorders and pharmacological and nonpharmacological strategies.

METHODS

Observational, exploratory, correlational, and descriptive study about mouth disorders of patients admitted to a hospital specializing in PC in Portugal, between November 6, 2019, and July 31, 2020. The data collection instrument was a questionnaire and the consultation of the patient's clinical file. It was obtained the previous authorization of the ethics committee and the patient's informed consent. Data were analyzed using the SPSS® software (V.26).

RESULTS

The sample was 46, 56.52% were over 71 years old, and the male sex ratio of 63.04%. Most of the patients had an advanced oncological disease, were polymedicated, had missing teeth, and no regular hygiene habits. Xerostomia and oral candidiasis were the most identified problems. Patients with oncological diseases have more probability to suffer from mouth disorders (P = .047), compared to noncancer patients. Patients with frequent oral hygiene have fewer mouth disorders (rp = -0.304; P = .040). There is a considerable improvement in the tongue coating with an increase in oral hygiene (P = .005). Mouth care plays is important in patient comfort (n = 45; 97.83%) and nonpharmacological strategies are effective for the relief of xerostomia (n = 35; 94.59%).

CONCLUSIONS

Nonpharmacological strategies are effective in the treatment of xerostomia and tongue coating. More information to determine the effectiveness of the strategies in the treatment of mouth disorders is necessary.

A Novel Approach to Managing Thirst and Dry Mouth in Palliative Care: A Prospective Randomized Cross-Over Trial

CONTEXT

Thirst and xerostomia are significant and highly distressing symptoms experienced by patients receiving palliative and end-of-life care.

OBJECTIVES

Determine a reduction of thirst intensity and perceptions of dry mouth on a numerical scale following both the experimental intervention (mini mint ice cubes) and control (plain ice chips).

METHODS

Cross-over Randomized Controlled Trial (RCT) to assess the effectiveness of novel intervention in the treatment of dry mouth and the sensation of thirst in palliative care patients.

RESULTS

Patients rated the severity of their symptoms of dry mouth and thirst using a numeric rating scale (NRS). On commencing the study and preintervention, all patients suffered severe dry mouth and thirst (≥5/10). Mint and plain ice cubes produced improvement of symptoms immediately after interventions. Results from dry mouth ratings show, a decrease of 1.6 points for plain ice cubes (P < 0.0001), on average, ratings for mint ice cubes decreased 3.7 (P < 0.0001). For the sensation of thirst, the plain ice cube intervention group rating decreased 1.7 points (P < 0.006), ratings for mint ice cubes decreased 3.4 points (P < 0.0001). The average decrease in dry mouth and thirst intensity scores from preintervention to postintervention were significantly greater for mint ice cubes (P < 0.05) and 86.6% of patients preferred mint ice cubes.

CONCLUSION

This trial found that while usual mouth care and the intervention were both able to reduce the intensity of dry mouth and the sensation of thirst, the mint intervention had a greater response.

Polysymptomatology and Polypharmacy at End of Life in Patients with Duchenne Muscular Dystrophy

OBJECTIVE

To characterize symptom frequency and symptom-directed treatment approaches in patients who died with advanced Duchenne muscular dystrophy (DMD).

STUDY DESIGN

This was a retrospective cohort study of patients in a multidisciplinary DMD program who died between January 1, 2013, and June 30, 2021. Inclusion criteria were patients who died with advanced DMD in the time period studied; exclusion criteria were low exposure to palliative care (<2 encounters). Demographic, symptom, and end-of-life data, as well as medications used for symptom management, were abstracted from the electronic medical record.

RESULTS

In total, 15 patients were eligible for analysis. The median age of death was 23 years (range 15-30 years). One (6.7%) experienced a full code at death, 8 (53.3%) had do-not-resuscitate orders, and 4 (26.7%) had limited do-not-resuscitate orders. Mean palliative care exposure was 1280 days. All 15 (100%) had pain and dyspnea; 14 (93.3%) anorexia, constipation, and sleep difficulty; 13 (86.7%) wounds; and 12 (80%) anxiety and nausea/vomiting. Multiple medications and drug classes were used to target symptoms.

CONCLUSIONS

We found significant polysymptomatology and polypharmacy in patients who died with advanced DMD. Clinicians who care for patients with advanced DMD should clarify goals of care and document advance care planning. Given the complexity of multisystem disease progression, palliative care should provide subspecialty pain management and assist with psychosocial burdens.

Palliative care patient emergency department visits at tertiary university-based emergency department in Ireland

INTRODUCTION

Palliative care patients often present to the emergency department (ED) for various reasons e.g., acute illness, pain, altered mental status, and complications of therapy. Many visits involve less severe etiologies e.g., dyspnea, constipation, fear as patients approach the end of life, which may be more effectively and efficiently managed outside of the ED. The objective of this study is to identify and assess the frequency of presenting complaints, primary diagnosis, triage acuity, need for admission, in an Irish setting.

METHODS

A single-center retrospective, observational study of palliative care patients presenting to a tertiary-care university hospital emergency department in Dublin, Ireland. Study subjects were identified using the palliative care database and cross-referencing with the ED electronic patient record system database. The primary objective to identify potential areas to minimize ED visits and improve patient care and quality of life by elucidating reasons for visits. Outcome measures include presenting complaint, primary diagnosis, triage severity score, admission, discharge, death in hospital. Statistical analysis presented as descriptive statistics.

RESULTS

Four-hundred-ninety-nine ED visits, 245 (49%) were male, and 254 (51%) were female with a mean age of 69.3 years-of-age. Most patients, 285 (57.1%) self-referred to the emergency department, with general practitioners and skilled nursing facility referrals 72 (14.4%) and 39 (7.8%), respectively. Primary diagnoses were various cancers, chronic obstructive pulmonary disease, congestive heart failure, and dementia. Major reasons for visits were dyspnea, pain, falls, trauma, fever, and altered mental status. Two-hundred-eighty-nine patients (58%) had an emergency severity index (ESI) score of 1 or 2 demonstrating a higher level of acuity. Three-hundred-fifty-eight (71.7%) were admitted, 141 (28.3%) discharged to home, 64 (12.8%) admitted patients died during their hospital admission.

CONCLUSIONS

Palliative care patients utilize ED services not uncommonly. Though many of these patients presented with higher acuity triage scores, 42% had lower ESI scores and may be effectively managed outside of the ED. These data suggest developing mechanisms for these patients to be urgently evaluated in their homes or facilities obviating the need for an ED evaluation.

Managing symptoms at the end of life: a guide for non-palliative care nurses

Nurses, regardless of their area of practice, may have to care for a person in their last days and hours of life. However, many nurses outside of specialist palliative and end of life care settings do not feel adequately prepared for this. Nurses can usually obtain advice from specialists working in local hospices or palliative care centres, but they may still find it challenging to act on that advice if it is not underpinned by their own knowledge base. This article provides a guide to assist non-palliative care nurses in recognising dying and managing common symptoms at the end of life.

Pharmacologic and Non-Pharmacologic Dyspnea Management in Advanced Cancer Patients

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.

Interventions for palliative symptom control in COVID-19 patients

BACKGROUND

Individuals dying of coronavirus disease 2019 (COVID-19) may experience distressing symptoms such as breathlessness or delirium. Palliative symptom management can alleviate symptoms and improve the quality of life of patients. Various treatment options such as opioids or breathing techniques have been discussed for use in COVID-19 patients. However, guidance on symptom management of COVID-19 patients in palliative care has often been derived from clinical experiences and guidelines for the treatment of patients with other illnesses. An understanding of the effectiveness of pharmacological and non-pharmacological palliative interventions to manage specific symptoms of COVID-19 patients is required.

OBJECTIVES

To assess the efficacy and safety of pharmacological and non-pharmacological interventions for palliative symptom control in individuals with COVID-19.

SEARCH METHODS

We searched the Cochrane COVID-19 Study Register (including Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), Embase, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), medRxiv); Web of Science Core Collection (Science Citation Index Expanded, Emerging Sources); CINAHL; WHO COVID-19 Global literature on coronavirus disease; and COAP Living Evidence on COVID-19 to identify completed and ongoing studies without language restrictions until 23 March 2021. We screened the reference lists of relevant review articles and current treatment guidelines for further literature.

SELECTION CRITERIA

We followed standard Cochrane methodology as outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We included studies evaluating palliative symptom management for individuals with a confirmed diagnosis of COVID-19 receiving interventions for palliative symptom control, with no restrictions regarding comorbidities, age, gender, or ethnicity. Interventions comprised pharmacological as well as non-pharmacological treatment (e.g. acupressure, physical therapy, relaxation, or breathing techniques). We searched for the following types of studies: randomized controlled trials (RCT), quasi-RCTs, controlled clinical trials, controlled before-after studies, interrupted time series (with comparison group), prospective cohort studies, retrospective cohort studies, (nested) case-control studies, and cross-sectional studies. We searched for studies comparing pharmacological and non-pharmacological interventions for palliative symptom control with standard care. We excluded studies evaluating palliative interventions for symptoms caused by other terminal illnesses. If studies enrolled populations with or exposed to multiple diseases, we would only include these if the authors provided subgroup data for individuals with COVID-19. We excluded studies investigating interventions for symptom control in a curative setting, for example patients receiving life-prolonging therapies such as invasive ventilation.  DATA COLLECTION AND ANALYSIS: We used a modified version of the Newcastle Ottawa Scale for non-randomized studies of interventions (NRSIs) to assess bias in the included studies. We included the following outcomes: symptom relief (primary outcome); quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; serious adverse events; and grade 3 to 4 adverse events. We rated the certainty of evidence using the GRADE approach.  As meta-analysis was not possible, we used tabulation to synthesize the studies and histograms to display the outcomes.  MAIN RESULTS: Overall, we identified four uncontrolled retrospective cohort studies investigating pharmacological interventions for palliative symptom control in hospitalized patients and patients in nursing homes. None of the studies included a comparator. We rated the risk of bias high across all studies. We rated the certainty of the evidence as very low for the primary outcome symptom relief, downgrading mainly for high risk of bias due to confounding and unblinded outcome assessors. Pharmacological interventions for palliative symptom control We identified four uncontrolled retrospective cohort studies (five references) investigating pharmacological interventions for palliative symptom control. Two references used the same register to form their cohorts, and study investigators confirmed a partial overlap of participants. We therefore do not know the exact number of participants, but individual reports included 61 to 2105 participants. Participants received multimodal pharmacological interventions: opioids, neuroleptics, anticholinergics, and benzodiazepines for relieving dyspnea (breathlessness), delirium, anxiety, pain, audible upper airway secretions, respiratory secretions, nausea, cough, and unspecified symptoms.  Primary outcome: symptom relief All identified studies reported this outcome. For all symptoms (dyspnea, delirium, anxiety, pain, audible upper airway secretions, respiratory secretions, nausea, cough, and unspecified symptoms), a majority of interventions were rated as completely or partially effective by outcome assessors (treating clinicians or nursing staff). Interventions used in the studies were opioids, neuroleptics, anticholinergics, and benzodiazepines.  We are very uncertain about the effect of pharmacological interventions on symptom relief (very low-certainty evidence). The initial rating of the certainty of evidence was low since we only identified uncontrolled NRSIs. Our main reason for downgrading the certainty of evidence was high risk of bias due to confounding and unblinded outcome assessors. We therefore did not find evidence to confidently support or refute whether pharmacological interventions may be effective for palliative symptom relief in COVID-19 patients. Secondary outcomes We planned to include the following outcomes: quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; serious adverse events; and grade 3 to 4 adverse events. We did not find any data for these outcomes, or any other information on the efficacy and safety of used interventions. Non-pharmacological interventions for palliative symptom control None of the identified studies used non-pharmacological interventions for palliative symptom control.

AUTHORS' CONCLUSIONS

We found very low certainty evidence for the efficacy of pharmacological interventions for palliative symptom relief in COVID-19 patients. We found no evidence on the safety of pharmacological interventions or efficacy and safety of non-pharmacological interventions for palliative symptom control in COVID-19 patients. The evidence presented here has no specific implications for palliative symptom control in COVID-19 patients because we cannot draw any conclusions about the effectiveness or safety based on the identified evidence. More evidence is needed to guide clinicians, nursing staff, and caregivers when treating symptoms of COVID-19 patients at the end of life. Specifically, future studies ought to investigate palliative symptom control in prospectively registered studies, using an active-controlled setting, assess patient-reported outcomes, and clearly define interventions. The publication of the results of ongoing studies will necessitate an update of this review. The conclusions of an updated review could differ from those of the present review and may allow for a better judgement regarding pharmacological and non-pharmacological interventions for palliative symptom control in COVID-19 patients.