The last year of life of COPD: a qualitative study of symptoms and services

The use of specialist palliative care services differs in chronic obstructive pulmonary disease and interstitial lung disease: A national cohort study

BACKGROUND

High symptom burden and psychosocial needs in chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD) warrant palliative care. We assessed the use of specialist palliative care (SPC) and its association with the use of emergency department (ED) and hospital inpatient days in COPD and ILD.

METHODS

A retrospective cohort study of all Finnish decedents who died of COPD (n = 1189) or ILD (n = 382) in 2019. Data was gathered from the registries of the Finnish Institute of Health and Welfare. Demographics, the use of SPC, the use of ED, and hospital inpatient days during the last six months of life were evaluated.

RESULTS

During the last six months of life, ILD patients used more ED (92 % vs. 84 %, p < 0.001) and spent more time at the hospital (median of 19 vs. 12 days, p < 0.001) compared to COPD. Overall, 12 % and 8 % of the ILD and COPD patients had contact with SPC, respectively (p = 0.012). During the last month of life, SPC reduced the use of ED both in COPD (57 % vs. 68 %, p = 0.036) and ILD (58 % vs. 74 %, p = 0.021), as well as the number of days spent in secondary care hospitals in ILD (median of 0 vs. 2 days, p = 0.011). Also in multivariate analysis, SPC reduced the use of ED. Most patients (72 %) died in a hospital.

CONCLUSIONS

ILD patients received more SPC than COPD patients, yet the numbers were low in both patient groups. Using acute hospital resources was common during the last months of life, but SPC reduced this.

Differences in the palliative care phase between patients with nonmalignant pulmonary disease and lung cancer: a retrospective study

BACKGROUND

Patients with chronic nonmalignant pulmonary disease and lung cancer both need palliative care, but palliative care services may be better adjusted to serve cancer patients. We compared the timing and clinical practice of palliative care and acute hospital usage during the last year of life in patients with nonmalignant pulmonary disease or lung cancer.

METHODS

This was a retrospective study of all patients in a palliative care phase (palliative goal of care) with nonmalignant pulmonary disease or lung cancer who were treated at Tampere University Hospital, Finland, during the years 2018-2020. The data were collected from the hospital's medical records. Comparisons between the groups were performed by using the Pearson chi-square test, Fisher's exact test, or Mann‒Whitney U test when appropriate. Survival was estimated by using the Kaplan‒Meier method.

RESULTS

The study population consisted of 107 patients with nonmalignant pulmonary disease and 429 patients with lung cancer. Patients with nonmalignant pulmonary disease survived longer in the palliative care phase than patients with lung cancer (115 vs. 59 days, p < 0.001). Compared to lung cancer patients, patients with nonmalignant disease received a palliative care specialist consultation more often during hospitalization (66% vs. 45%, p < 0.001) than during a preplanned outpatient visit (6% vs. 52%, p < 0.001), were less likely to be referred to palliative care pathway (79% vs. 87%, p = 0.033), and spent more days in an acute care hospital during the last year of life (median of 10 vs. 6 days, p = 0.023). Contrary to lung cancer patients, referral to the palliative care pathway was not significantly associated with decreased acute hospital resource usage during the last month of life among patients with nonmalignant pulmonary disease.

CONCLUSIONS

Compared to lung cancer patients, patients with nonmalignant pulmonary disease had longer palliative care phases but fewer visits to the palliative care outpatient clinic and fewer referrals to the palliative care pathways. Palliative care arrangements seemed to have more influence on the end-of-life care of lung cancer patients. There is a need for long-term palliative care services with better abilities to meet the special needs of patients with nonmalignant pulmonary disease.

A refined ICD-10 diagnoses-based approach for retrospective analysis of potential palliative care need and coverage in claims data of deceased

Objectives

ICD-10-based approaches often provide the basis for retrospective estimation of potential palliative care need. Applying the ICD-10-based Murtagh et al. classification from 2014 (Murtagh classification), developed using mortality data, to administrative claims data leads to inconsistencies in estimating palliative care need. The aim of the study was to refine the classification for palliative care need estimation in deceased individuals with cancer and non-cancer diagnosis.

Methods

A retrospective population-based study comparing Murtagh classification to a new ICD-10-based classification (revised by expert opinion) was conducted using outpatient and inpatient claims data, including billing codes for palliative care. Palliative care need was estimated for diagnoses groups and was contrasted with palliative care utilization rates in the last year of life. Our dataset included records of 417,405 individuals who deceased in 2016-2019.

Results

Out of individuals deceased in 2019 (n = 117,436), 81.4% had at least one diagnosis from the new classification, while 97.0% had at least one diagnosis from the Murtagh classification. Classification revision thus identified fewer individuals as potentially in need of palliative care. Among individuals with cancer, 70.7% (vs. 55.7% via Murtagh classification) received palliative care. In non-cancer subgroups, the utilization rate was considerably lower, with a maximum of 36.7% (vs. 33.7% via Murtagh classification) in 2019. Similar results were observed for the other years.

Conclusion

Compared to the ICD10-based Murtagh classification, the revised ICD-10-based classification enables more realistic estimations if the cause of death is unavailable and reveals higher rates of palliative care coverage and differences especially in cancer versus non-cancer diseases. German Clinical Trials Register (DRKS00024133).

Healthcare professionals' experiences and views of providing continence support and advice to people living at home with dementia: "That's a carer's job"

BACKGROUND

People living with dementia at home and their family carers often feel unsupported by healthcare professionals in managing continence problems. In turn, primary and community-based healthcare professionals have reported lacking specific knowledge on dementia-continence. This study aimed to understand more about healthcare professionals' experiences and views of supporting people living with dementia experiencing continence problems, as part of developing acceptable resources. Having a nuanced understanding of unmet need would facilitate the design of engaging resources that enable healthcare professionals to provide more effective continence support to people living with dementia at home.

METHODS

Semi-structured interviews were conducted with a range of healthcare professionals (n = 31) working in primary and community care in the South of England in 2023. Transcribed interviews were uploaded to NVivo 12, then analysed inductively and deductively using a thematic framework.

RESULTS

Continence-related conversations were avoided by many healthcare professionals due to lack of dementia-continence specific knowledge. Many considered that continence problems of people living with dementia were largely outside their remit once a physical cause had been ruled out. This contributed to a lack of priority and proactivity in raising the subject of continence in their consultations. Challenges to providing support included limited consultation time and lack of access to specialist services with availability to support individuals.

CONCLUSION

There is substantial scope to support primary and community-based healthcare professionals in their provision of continence-related support and advice to people living at home with dementia. This includes addressing knowledge deficits, enhancing confidence and instilling a sense of accomplishment.

Non-invasive ventilation in the care of patients with chronic obstructive pulmonary disease with palliative care needs: a scoping review

BACKGROUND

Patients with severe chronic obstructive pulmonary disease (COPD) could have palliative care (PC) needs because of unmet needs such as dyspnoea. This may lead to anxiety and may have an impact on patients' ability to perform daily activities of living. PC can be started when patients with COPD have unmet needs and can be provided alongside disease-modifying therapies. Non-invasive ventilation (NIV) could be an important measure to manage dyspnoea in patients with COPD in need of PC. A scoping review was conducted to gain an overview of the existing research and to identify knowledge gaps. The aim of this scoping review was to systematically map published studies on the use of NIV in patients with COPD with PC needs, including the perspectives and experiences of patients, families, and healthcare professionals (HCPs).

METHODS

This review was conducted following the framework of Arksey and O'Malley. The reporting of the review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. The review protocol was published. AMED, CINAHL, Embase, MEDLINE, PEDro, and PsycInfo were searched from inception to November 14, 2022. The included studies had to report the perspectives and experiences of COPD patients, relatives, and HCPs regarding NIV in the care of patients with COPD with PC needs. In pairs, the authors independently assessed studies' eligibility and extracted data. The data were organised thematically. The results were discussed in a consultation exercise.

RESULTS

This review included 33 papers from 32 studies. Four thematic groupings were identified: preferences and attitudes towards the use of NIV; patient participation in the decision-making process of NIV treatment; conflicting results on the perceived benefits and burdens of treatment; and heterogenous clinical outcomes in experimental studies. Patients perceived NIV as a 'life buoy' to keep them alive. Many patients wanted to take part in the decision-making process regarding NIV treatment but expressed varying degrees of inclusion by HCPs in such decision-making. Conflicting findings were identified regarding the perceived benefits and burdens of NIV treatment. Diversity in heterogeneous clinical outcomes were reported in experimental studies.

CONCLUSIONS

There is a need for more studies designed to investigate the effectiveness of NIV as a palliative measure for patients with COPD with PC needs using comprehensive outcomes. It is especially important to gain more knowledge on the experiences of all stakeholders in the use of home-based NIV treatment to these patients.

Exploring the perspectives of selectors and collecters of trial outcome data: an international qualitative study

INTRODUCTION

Selecting and collecting data to support appropriate primary and secondary outcomes is a critical step in designing trials that can change clinical practice. In this study, we aimed to investigate who contributes to the process of selecting and collecting trial outcomes, and how these people are involved. This work serves two main purposes: (1) it provides the trials community with evidence to demonstrate how outcomes are currently selected and collected, and (2) it allows people involved in trial design and conduct to pick apart these processes to consider how efficiencies and improvements can be made.

METHODS

One-with-one semi-structured interviews, supported by a topic guide to ensure coverage of key content. The Framework approach was used for thematic analysis of data, and themes were linked through constant comparison of data both within and across participant groups. Interviews took place between July 2020 and January 2021. Participants were twenty-nine international trialists from various contributor groups, working primarily on designing and/or delivering phase III pragmatic effectiveness trials. Their experience spanned various funders, trial settings, clinical specialties, intervention types, and participant populations.

RESULTS

We identified three descriptive themes encompassing the process of primary and secondary outcome selection, collection, and the publication of outcome data. Within these themes, participants raised issues around the following: 1) Outcome selection: clarity of the research question; confidence in selecting trial outcomes and how confidence decreases with increased experience; interplay between different interested parties; how patients and the public are involved in outcome selection; perceived impact of poor outcome selection including poor recruitment and/or retention; and use of core outcome sets. 2) Outcome collection: disconnect between decisions made by outcome selectors and the practical work done by outcome collectors; potential impact of outcome measures on trial participants; potential impact on trial staff workload; and use of routinely collected data. 3) Publication of outcome data: difficulties in finding time to write and revise manuscripts for publication due to time and funding constraints. Participants overwhelmingly focused on the process of outcome selection, a topic they talked about unprompted. When prompted, participants do discuss outcome collection, but poor communication between selectors and collectors at the trial design stage means that outcome selection is rarely linked with the data collection workload it generates.

DISCUSSION

People involved in the design and conduct of trials fail to connect decisions around outcome selection with data collection workload. Publication of outcome data and effective dissemination of trial results are hindered due to the project-based culture of some academic clinical trial research.

Stakeholders' Perspectives on the Quality of End-of-Life Health Care Services for Chronic Obstructive Airways Disease: A Focus Group Study

Introduction

Delivery of end-of-life care for severe chronic obstructive pulmonary disease (COPD) has been hampered by an unpredictable disease trajectory and poor integration of health care and social services.

Objective

To critically explore the perspectives, values, and experiences of stakeholders in COPD end-of-life healthcare services in a large district in Aotearoa New Zealand.

Design

Focus groups analysed utilising critical theory and Actor-Network Theory.

Methods

Stakeholders in end-of-life COPD healthcare services were purposively sampled from a large healthcare network in Canterbury, Aotearoa New Zealand to participate in seven focus groups (bereaved carers, community-based health professionals, non-Māori, non-Pacific patients, and support people (two groups), Māori patients, supporters and health professionals, Pacific patients, support people and health professionals, and hospital-based health professionals). Participants discussed end-of-life care services for people with COPD. Transcripts were coded utilising descriptive and structural coding to develop themes related to provision of quality care. Participants were positioned as experts. We considered how the themes arising supported and disrupted the healthcare network for end-of-life COPD.

Results

Five themes related to quality of care for end-of-life COPD were identified: compassion, competence, community, commitment, and collaboration. The absence of any of these five themes required for quality care led to power imbalances within healthcare systems. Power inequities created disconnection among stakeholders which then disrupted commitment, community, and collaboration. A dysfunctional healthcare network impeded compassion between stakeholders and did not support their competence, leading to lower quality care. All five themes were identified as essential to delivery of high-quality end-of-life care in COPD.

Conclusion

Stakeholders' perspectives of end-of-life care for COPD identified of core features of a health system network that enabled or impeded the actions of stakeholders and allocation of resources to provide quality care.

Conducting school-based health surveys with secondary schools in England: advice and recommendations from school staff, local authority professionals, and wider key stakeholders, a qualitative study

BACKGROUND

Improving the health and well-being of young people is a public health priority. Schools present an ideal setting to implement strategies to improve young people's health and well-being. A key strategy involves conducting surveys to assess student health needs, inform interventions, and monitor health over time. Conducting research in schools is, however, challenging. Schools can find it difficult to participate and adhere to research processes, even when they are keen to be involved in research, because of competing priorities (e.g., attendance and educational achievement), as well as time and resource constraints. There is a lack of literature on the perspectives of school staff and other key stakeholders working in young people's health on how best to work with schools to conduct health research, and in particular, health surveys.

METHODS

Participants (n = 26) included members of staff from 11 secondary schools (covering students aged 11-16 years), 5 local authority professionals, and 10 wider key stakeholders in young people's health and well-being (e.g., a school governor, a national government member), based in South West England. Participants took part in semi-structured interviews that were conducted either over the phone or via an online platform. Data were analysed using the Framework Method.

RESULTS

Three main themes were identified: Recruitment and Retention, Practicalities of Data Collection in Schools, and Collaboration from Design to Dissemination. It is important to acknowledge the role of local authorities and academy trusts in the English education system, and work closely with these when conducting school-based health surveys. School staff prefer to be contacted about research via email and in the summer term, following exams. Researchers should contact a member of staff involved in student health/well-being, as well as senior leadership, during recruitment. Data collection during the start and end of the school year is undesirable. Research should be collaborative with school staff and young people, consistent with school priorities and values, and flexible and tailored to school timetables and resources.

CONCLUSIONS

Overall the findings demonstrate that survey-based research methods should be school-led and tailored to each school.

The impact of COVID-19 on small- and medium-sized enterprises (SMEs): empirical evidence for green economic implications

Small- and medium-sized enterprises (SMEs) in China have been hit hard by the coronavirus (COVID-19) outbreak, which has jeopardized their going out of business altogether. As a result, this research will shed light on the long-term impacts of COVID-19 lockdown on small businesses worldwide. The information was gathered through a survey questionnaire that 313 people completed. Analyzing the model was accomplished through the use of SEM in this investigation. Management and staff at SMEs worldwide provided the study's data sources. Research shows that COVID-19 has a significantly bad influence on profitability, operational, economic, and access to finance. In the study's findings, outside funding aids have played an important role in SMEs' skill to persist and succeed through technological novelty than in their real output. SME businesses, administrations, and policymakers need to understand the implications of this study's results.

Real-world opioid prescription to patients with serious, non-malignant, respiratory illnesses and chronic breathlessness

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.

Patient, carer and health professional experiences of end-of-life care services in chronic obstructive pulmonary disease: an interpretive synthesis of qualitative studies

The objective of this systematic literature review is to identify patients’, carers’ and health professionals’ reported perspectives of end-of-life care services for severe chronic obstructive pulmonary diseases (COPD) and explore whether services are person-centred and integrated according to WHO definitions. The systematic review was qualitative with interpretive synthesis. The data sources included MEDLINE, CINAHL, Emcare, Embase, Cochrane (CENTRAL), Joanna Briggs Institute and PsycINFO databases from inception to 23 May 2022 limited to the English language. Qualitative studies were eligible if they reported open-ended patients,’ carers’ or healthcare professionals’ experiences of end-of-life care for severe COPD. Qualitative data were categorised according to healthcare stakeholder groups and conceptualised within a health services network using the Actor-Network Theory. Eighty-seven studies proved eligible. Eleven stakeholder groups constituted the healthcare services network for severe COPD (in order of frequency of interactions with other stakeholders): secondary care, primary care, community services, acute care, palliative care, carer, healthcare environment, patient, government, social supports and research. When evaluating the network for evidence of patient-centred care, patients and carers received input from all stakeholder groups. The relationship between stakeholder groups and patients was largely unidirectional (stakeholders towards patients) with low influence of patients towards all stakeholder groups. There was limited interaction between specific healthcare services, suggesting low network integration. Government services, research and social supports had few connections with other services in the healthcare network. Multiple intersecting health, community and government services acted on patients, rather than providing patient-informed care. Health services provided poorly integrated services for end-of-life care for severe COPD.

PROSPERO registration number

CRD42020168733.

Exploring Human-Data Interaction in Clinical Decision-making Using Scenarios: Co-design Study

BACKGROUND

When caring for patients with chronic conditions such as chronic obstructive pulmonary disease (COPD), health care professionals (HCPs) rely on multiple data sources to make decisions. Collating and visualizing these data, for example, on clinical dashboards, holds the potential to support timely and informed decision-making. Most studies on data-supported decision-making (DSDM) technologies for health care have focused on their technical feasibility or quantitative effectiveness. Although these studies are an important contribution to the literature, they do not further our limited understanding of how HCPs engage with these technologies and how they can be designed to support specific contexts of use. To advance our knowledge in this area, we must work with HCPs to explore this space and the real-world complexities of health care work and service structures.

OBJECTIVE

This study aimed to qualitatively explore how DSDM technologies could support HCPs in their decision-making regarding COPD care. We created a scenario-based research tool called Respire, which visualizes HCPs' data needs about their patients with COPD and services. We used Respire with HCPs to uncover rich and nuanced findings about human-data interaction in this context, focusing on the real-world challenges that HCPs face when carrying out their work and making decisions.

METHODS

We engaged 9 respiratory HCPs from 2 collaborating health care organizations to design Respire. We then used Respire as a tool to investigate human-data interaction in the context of decision-making about COPD care. The study followed a co-design approach that had 3 stages and spanned 2 years. The first stage involved 5 workshops with HCPs to identify data interaction scenarios that would support their work. The second stage involved creating Respire, an interactive scenario-based web app that visualizes HCPs' data needs, incorporating feedback from HCPs. The final stage involved 11 one-to-one sessions with HCPs to use Respire, focusing on how they envisaged that it could support their work and decisions about care.

RESULTS

We found that HCPs trust data differently depending on where it came from and who recorded it, sporadic and subjective data generated by patients have value but create challenges for decision-making, and HCPs require support in interpreting and responding to new data and its use cases.

CONCLUSIONS

Our study uncovered important lessons for the design of DSDM technologies to support health care contexts. We show that although DSDM technologies have the potential to support patient care and health care delivery, important sociotechnical and human-data interaction challenges influence the design and deployment of these technologies. Exploring these considerations during the design process can ensure that DSDM technologies are designed with a holistic view of how decision-making and engagement with data occur in health care contexts.

Trajectories of disability in activities of daily living in advanced cancer or respiratory disease: a systematic review

INTRODUCTION

Advanced cancer and/or respiratory disease threaten a person's independence in activities of daily living (ADL). Understanding how disability develops can help direct appropriate and timely interventions.

AIM

To identify different trajectories and associations of disability in ADL and appraise its measurement.

METHODS

Medline, Embase, PsychINFO, and CINAHL databases were searched for cohort studies with measures of disability in ADL in advanced cancer or respiratory disease at three or more timepoints. Data were narratively synthesized to produce a typology of disability trajectories and a model of factors and outcomes associated with increasing disability.

RESULTS

Of 5702 publications screened, 11 were included. Seventy-four disability trajectories were categorized into typologies of unchanging (n = 20), fluctuating (n = 21), and increasing disability (n = 33). Respiratory disease did not predict any particular disability trajectory. Advanced cancer frequently followed trajectories of increasing disability. Factors associated with increasing disability included: frailty, multi-morbidity, cognitive impairment, and infection. Increased disability led to recurrent hospital admissions, long-term care, and/or death. Methodological limitations included use of non-validated measures.

CONCLUSIONS

Increasing disability trajectories in advanced cancer and/or respiratory disease is related to potentially modifiable personal and environmental factors. We recommend future studies using validated disability instruments.Implications for rehabilitationDisability in activities of daily living (ADL) is a common unmet need in advanced cancer or respiratory disease and represents an important outcome for patients, caregivers and health and social care services.Trajectories of ADL disability can be categorized into increasing, fluctuating, and unchanging disability, which could help planning of rehabilitation services in advanced cancer or respiratory disease.Increasing disability in advanced cancer or respiratory disease relates to personal and environmental factors as well as bodily impairments, which can all be modifiable by intervention.This review highlights implications for the measurement of ADL disability in advanced cancer or respiratory disease and recommends use of validated measures of ADL to understand what factors can be modified through rehabilitation interventions.

Opioid Prescription Method for Breathlessness Due to Non-Cancer Chronic Respiratory Diseases: A Systematic Review

A previous pooled analysis demonstrated significant relief of breathlessness following opioid administration in patients with chronic obstructive pulmonary disease. However, in clinical practice, it is important to know the characteristics of patients responding to opioids, the best prescription methods, and the evaluation measures that can sufficiently reflect these effects. Thus, we performed a systematic review of systemic opioids for non-cancer chronic respiratory diseases. Fifteen randomized controlled studies (RCTs), four non-randomized studies, two observational studies, and five retrospective studies were included. Recent RCTs suggested that regular oral opioid use would decrease the worst breathlessness in patients with a modified Medical Research Council score ≥ 3 by a degree of 1.0 or less on a scale of 1–10. Ergometer or treadmill tests indicated mostly consistent significant acute effects of morphine or codeine. In two non-randomized studies, about 60% of patients responded to opioids and showed definite improvement in symptoms and quality of life. Furthermore, titration of opioids in these studies suggested that a major proportion of these responders had benefits after administration of approximately 10 mg/day of morphine. However, more studies are needed to clarify the prescription method to reduce withdrawal due to adverse effects, which would lead to significant improvements in overall well-being.

Palliative care integration for patients with advanced chronic obstructive pulmonary disease (COPD): Identifying essential components using participatory action research

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a life-limiting condition with palliative care needs. Despite increasing awareness about the role palliative care can play in care provision for patients with advanced COPD, integration in standard care remains underdeveloped. The unpredictability of the disease progression and misconceptions about palliative care being equivalent to end-of-life care often prevent a timely integrated approach in advanced COPD.

AIM

To identify practices designed to increase integration of palliative care in the management of patients with advanced COPD in a respiratory service in Southern Switzerland.

DESIGN

A participatory action research approach was chosen and key stakeholders were involved to develop new knowledge and practices, supported by a Theory of Change framework. Data from each cycle and retrospective analysis at the end of the whole research were analysed using thematic analysis.

SETTING/PARTICIPANTS

Five action research cycles with seven healthcare professionals working in palliative or respiratory care settings were conducted.

RESULTS

Three elements of integrated palliative care in advanced COPD were identified: multidimensional assessment, healthcare professionals' education and interdisciplinary team meetings, which are the pillars of a new integrated palliative care model for patients with advanced COPD.

CONCLUSIONS

The new integrated palliative care model in advanced COPD includes essential elements with a focus on patients, healthcare professionals and care delivery. Further research on testing this model in clinical practice, service development, implementation processes and possible outcomes, including evaluation of the financial impact of integrated palliative care is necessary to foster this care approach across all possible settings.

A critical review of the respiratory benefits and harms of orally administered opioids for dyspnea management in COPD

INTRODUCTION

Dyspnea occurring in chronic obstructive pulmonary disease (COPD) that is refractory to traditional management strategies is a common and challenging problem. Considerable attention has been paid to the off-label use of orally administered opioids as a pharmacotherapy option for refractory dyspnea in COPD. Multiple professional respiratory society guidelines express support for the application of oral opioids for this purpose.

AREAS COVERED

This manuscript will critically review randomized controlled trials undertaken to date that evaluate the efficacy of oral opioids for dyspnea in COPD, as well as phase IV observational studies that examine for potential opioid-related respiratory harms in the COPD population (literature was searched on PubMed up to June 2021). COPD guideline recommendations relating to opioids for dyspnea will subsequently be critiqued.

EXPERT OPINION

Opioid efficacy trials demonstrate at best a small improvement in dyspnea in limited numbers of individuals with COPD, whereas safety trials consistently show an increased risk of respiratory-related exacerbation, hospitalization and death in association with opioid use. In contrast to what is expressed in guidelines, the current body of evidence does not the support the wide application of opioids to manage refractory dyspnea among individuals with COPD, but instead, a highly selective and careful approach.

Communicating uncertainty: contrasting the communication experiences of patients with advanced COPD and incurable lung cancer

BACKGROUND

Due to the uncertain disease trajectory and variable rate of progression in chronic obstructive pulmonary disease (COPD), health care professionals (HCPs) are challenged in explaining what the future may hold for patients compared to those with lung cancer (LC). Support and communication of timely information can significantly improve health outcomes.

OBJECTIVE

This study sought to identify factors that impact communication and support and recommend ways to improve patients' understanding of living with life-threatening illness.

METHODS

Semi-structured interviews with patients with LC (n = 22) and advanced COPD (n = 18), their informal carers (21 LC and 18 COPD) and HCPs (n = 51). Patients were recruited from primary and secondary care in the East of England, UK, during 2010-12.

RESULTS

Directness and clarity characterized communication in LC, whereas uncertainty and limited explanations predominated in COPD. Discussions on how the disease might impact on decisions and preferences to be made in the future were less common in COPD. Information for LC patients was mainly from hospital clinicians and any information for COPD patients mainly from primary care clinicians.

CONCLUSIONS

The experience of COPD patients could be improved by professionals soon after diagnosis explaining to them the typical pattern of decline in COPD, highlighting the inherent uncertainties about when exacerbations and death may occur. This conversation should lead to planning for the different challenges that the patient and informal carer recognize as most important to them. This contrasts with the 'breaking bad news' conversation that oncologists are highly trained to deliver.

How Well Does the Surprise Question Predict 1-year Mortality for Patients Admitted with COPD?

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) often receive burdensome care at end-of-life (EOL) and infrequently complete advance care planning (ACP). The surprise question (SQ) is a prognostic tool that may facilitate ACP.

OBJECTIVE

To assess how well the SQ predicts mortality and prompts ACP for COPD patients.

DESIGN

Retrospective cohort study.

SUBJECTS

Patients admitted to the hospital for an acute exacerbation of COPD between July 2015 and September 2018.

MAIN MEASURES

Emergency department (ED) and inpatient clinicians answered, "Would you be surprised if this patient died in the next 30 days (ED)/one year (inpatient)?" The primary outcome measure was the accuracy of the SQ in predicting 30-day and 1-year mortality. The secondary outcome was the correlation between SQ and ACP (palliative care consultation, documented goals-of-care conversation, change in code status, or completion of ACP document).

KEY RESULTS

The 30-day SQ had a high specificity but low sensitivity for predicting 30-day mortality: sensitivity 12%, specificity 95%, PPV 11%, and NPV 96%. The 1-year SQ demonstrated better accuracy for predicting 1-year mortality: sensitivity 47%, specificity 75%, PPV 35%, and NPV 83%. After multivariable adjustment for age, sex, and prior 6-month admissions, 1-year SQ+ responses were associated with greater odds of 1-year mortality (OR 2.38, 95% CI 1.39-4.08) versus SQ-. One-year SQ+ patients were more likely to have a goals-of-care conversation (25% vs. 11%, p < 0.01) and complete an advance directive or POLST (46% vs. 23%, p < 0.01). After multivariable adjustment, SQ+ responses to the 1-year SQ were associated with greater odds of ACP receipt (OR 2.67, 95% CI 1.64-4.36).

CONCLUSIONS

The 1-year surprise question may be an effective component of prognostication and advance care planning for COPD patients in the inpatient setting.

Perspectives on palliative oxygen for breathlessness: systematic review and meta-synthesis

Oxygen therapy is frequently prescribed for the palliation of breathlessness, despite lack of evidence for its effectiveness in people who are not hypoxaemic. This study aimed to compare and contrast patients', caregivers' and clinicians' experiences of palliative oxygen use for the relief of chronic breathlessness in people with advanced life-limiting illnesses, and how this shapes prescribing.A systematic review and meta-synthesis of qualitative data was conducted. MEDLINE, CINAHL and PsycINFO were searched for peer-reviewed studies in English (2000-April 2019) reporting perspectives on palliative oxygen use for reducing breathlessness in people with advanced illnesses in any healthcare setting. After data extraction, thematic synthesis used line-by-line coding of raw data (quotes) to generate descriptive and analytical themes.Of 457 articles identified, 22 met the inclusion criteria by reporting perspectives of patients (n=337), caregivers (n=91) or clinicians (n=616). Themes common to these perspectives were: 1) benefits and burdens of palliative oxygen use, 2) knowledge and perceptions of palliative oxygen use beyond the guidelines, and 3) longitudinal trajectories of palliative oxygen use.There are differing perceptions regarding the benefits and burdens of using palliative oxygen. Clinicians should be aware that oxygen use may generate differing goals of therapy for patients and caregivers. These perceptions should be taken into consideration when prescribing oxygen for the symptomatic relief of chronic breathlessness in patients who do not quality for long-term oxygen therapy.

Symptom burden in patients with chronic obstructive pulmonary disease

BACKGROUND

There is now a growing body of evidence to suggest that patients with chronic disease experience their symptoms as a burden. Although symptoms are a principal focus for diagnosis and treatment of chronic obstructive pulmonary disease (COPD), there has been little research to date on symptom burden with reference to frequency, severity, and distress of symptoms.

METHODS

A descriptive, cross-sectional survey design was used. Symptom burden was measured using the Memorial Symptom Assessment Scale (MSAS). A sample of 214 patients with COPD, recruited from one of the major teaching hospitals in Ireland.

RESULTS

Patients experienced a median of 13 symptoms. Patients with 'very severe' COPD experienced the greatest number, with a median of 15 symptoms, followed by those with 'severe' COPD, with a median of 14 symptoms. Patients with 'mild' and 'moderate' COPD reported a median of 10 symptoms each. The most burdensome symptoms were shortness of breath, lack of energy, difficulty sleeping, worrying, dry mouth, feeling nervous, and feeling irritable. Total symptom burden was found to be low. Patients with 'very severe' COPD had the greatest symptom burden, followed by those with 'severe', 'moderate', and 'mild' COPD. Symptom burden was higher for psychological symptoms, with a mean score of 1.60 compared to the physical symptoms (mean = 0.87).

CONCLUSION

Patients with COPD experience a remarkably high number of symptoms, and significant symptom burden of both physical and psychological symptoms. There is a need for early assessment and management of both physical and psychological symptoms in all patients with COPD.

[Palliative Sedation at the End of Life: A Comparative Study of Chronic Obstructive Pulmonary Disease and Lung Cancer Patients]

BACKGROUND

Although patients with chronic obstructive pulmonary disease (COPD) receive poor-quality palliative care, information about the use of palliative sedation (PS) in the last days of life is very scarce.

OBJECTIVES

To compare the use of PS in hospitalized patients who died from COPD or lung cancer and identify factors correlating with PS application.

METHODS

In a retrospective observational cohort study, from 1,675 patients died at a teaching hospital between 2013 and 2015, 109 patients who died from COPD and 85 from lung cancer were compared. Sociodemographic data, clinical characteristics, health care resource utilization, application of PS and prescribed drugs were recorded.

RESULTS

In the last 6 months of life, patients who died from COPD had more hospital admissions due to respiratory causes and less frequent support by a palliative home care team (PHCT). Meanwhile, during their last hospitalization, patients who died from COPD had fewer do-not-resuscitate orders and were subjected to more intensive care unit admissions and cardiopulmonary resuscitation maneuvers. PS was applied less frequently in patients who died from COPD than in those who died from lung cancer (31 vs. 53%, p = 0.002). Overall, previous use of opioid drugs, support by a PHCT, and a diagnosis of COPD (adjusted odds ratio 0.48, 95% CI: 0.26-0.89, p = 0.020) were retained as factors independently related to PS. In COPD patients, only previous use of opioid drugs was identified as a PS-related factor.

CONCLUSION

During their last days of life, hospitalized COPD patients receive PS less frequently than patients with lung cancer.

Hypnosis for the Management of Anxiety and Dyspnea in COPD: A Randomized, Sham-Controlled Crossover Trial

Background

Patients with chronic obstructive pulmonary disease (COPD) are prone to dyspnea, increased respiratory rate and other anxiety-inducing symptoms. Hypnosis constitutes a complementary procedure capable of improving subjective feelings of anxiety.

Objective

Assessing the efficacy of a 15-minute hypnosis intervention for immediate improvement of anxiety in severe COPD patients.

Methods

Twenty-one participants, COPD patients (mean FEV1 < 32.3%), were randomly assigned to two individual sessions in crossover (sham and hypnosis, 24-h washout period, arms: hypnosis-sham [n=11]/sham-hypnosis [n=10]). We tracked pre- and post-intervention anxiety (STAI-6 score) as primary endpoint.

Results

Nineteen (90.5%) participants completed the study. Anxiety diminished significantly after hypnosis (STAI-6 scores -23.8% [SD = 18.4%] hypnosis vs -3.1% [32.8%] sham; χ2=8, P<0.01, Bayes Factor 5.5). Respiratory rate also decreased after hypnosis. Improvements in SpO2 and Borg exertion scores were registered after both conditions.

Conclusion

A 15-minute hypnosis session improved participants' anxiety and lowered respiratory rate (as opposed to sham). Improvements in anxiety were correlated with an alleviation in respiratory strain. Results imply that hypnosis can contribute to the improvement of anxiety levels and breathing mechanics in severe COPD patients.

Registration Id

ISRCTN10029862.

Living with Advanced Chronic Obstructive Pulmonary Disease: A Qualitative Interview Study with Patients and Informal Carers

The disease trajectory in chronic obstructive pulmonary disease (COPD) is characterised by a progressive decline in overall function, loss of independence and reduction of health-related quality of life. Although the symptom burden is high and care is often demanding, patients' and informal carers' experiences in living with advanced COPD are seldom described. This study sought to explore patients' and informal carers' experiences in living with advanced COPD and to understand their awareness about palliative care provision in advanced COPD. About 20 patients and 20 informal carers were recruited in a respiratory care service in Southern Switzerland. Semistructured individual interviews with participants were conducted on clinic premises and audio-recorded. Interviews lasted between 35 and 45 min. Data were analysed using thematic analysis. Living day to day with COPD, psychosocial dimension of the disease and management of complex care were the main themes identified. Patients and informal carers reported a range of psychological challenges, with feelings of guilt, discrimination and blame. Most of the participants had no knowledge of palliative care and healthcare services did not provide them with any information about palliative care approaches in advanced COPD. The reported psychological challenges may influence the relationship between patients, informal carers and healthcare professionals, adding further complexity to the management of this long-term condition. Further research is needed to explore new ways of managing complex care in advanced COPD and to define how palliative care may be included in this complex care network.

Energy conservation technique improves dyspnoea when patients with severe COPD climb stairs: a randomised crossover study

In this randomised, crossover trial, 22 patients with severe chronic obstructive pulmonary disease climbed six flights of stairs (108 steps) twice, under two test conditions: (1) energy conservation technique (ECT): participants were asked to rest for at least 5 seconds every three steps and (2) control condition: participants climbed the stairs at their own pace. Significant lower dyspnoea (primary outcome), leg discomfort, minute ventilation and capillary blood lactate under the ECT condition were found, with no change in total task time. CLINICAL TRIAL REGISTRATION: NCT03564028.

Using evidence when planning for trial recruitment: An international perspective from time-poor trialists

INTRODUCTION

Recruiting participants to trials is challenging. To date, research has focussed on improving recruitment once the trial is underway, rather than planning strategies to support it, e.g. developing trial information leaflets together with people like those to be recruited. We explored whether people involved with participant recruitment have explicit planning strategies; if so, how these are developed, and if not, what prevents effective planning.

METHODS

Design: Individual qualitative semi-structured interviews. Data were analysed using a Framework approach, and themes linked through comparison of data within and across stakeholder groups. Participants: 23 international trialists (UK, Canada, South Africa, Italy, the Netherlands); 11 self-identifying as 'Designers'; those who design recruitment methods, and 12 self-identifying as 'Recruiters'; those who recruit participants. Interviewees' had recruitment experience spanning diverse interventions and clinical areas. Setting: Primary, secondary and tertiary-care sites involved in trials, academic institutions, and contract research organisations supporting pharmaceutical companies.

RESULTS

To varying degrees, respondents had prospective strategies for recruitment. These were seldom based on rigorous evidence. When describing their recruitment planning experiences, interviewees identified a range of influences that they believe impacted success: The timing of recruitment strategy development relative to the trial start date, and who is responsible for recruitment planning.The methods used to develop trialists' recruitment strategy design and implementation skills, and when these skills are gained (i.e. before the trial or throughout).The perceived barriers and facilitators to successful recruitment planning; and how trialists modify practice when recruitment is poor.

CONCLUSIONS

Respondents from all countries considered limited time and disproportionate approvals processes as major challenges to recruitment planning. Poor planning is a mistake that trialists live with throughout the trial. The experiences of our participants suggest that effective recruitment requires strategies to increase the time for trial planning, as well as access to easily implementable evidence-based strategies.

Non-pharmacological management of chronic breathlessness in stable chronic obstructive pulmonary disease

This paper will review and address the pathological processes in chronic obstructive pulmonary disease (COPD), including the prevalence of comorbidities and the implications of these factors for a common disabling COPD symptom, breathlessness. It will further consider non-pharmacological strategies that community nurses can use to support breathlessness relief in the context of holistic patient care.

Longer Duration of Palliative Care in Patients With COPD Is Associated With Death Outside the Hospital

BACKGROUND

Patients with advanced chronic obstructive pulmonary disease (COPD) have a significant symptom burden despite maximal medical therapy, yet few are referred for concomitant palliative care.

OBJECTIVE

To evaluate the utilization and impact of palliative care on the location of death and to identify clinical variables associated with palliative care contact.

DESIGN

Retrospective chart review from 2010 to 2016 at the VA Western New York Healthcare System using ICD-9/10 diagnosis of COPD. Palliative care contact was identified by Z51.5 or stop code 353.

RESULTS

Only 0.5% to 2% of living patients received palliative care, increasing abruptly at death (6%). Lower diffusion capacity for carbon monoxide (DLCO) (greater emphysema) was associated with palliative care contact, independent of comorbid disease burden or age. Initial outpatient contact was associated with a longer duration of palliative care (P = .003) and death in a home-like setting. Outpatient palliative care was associated with more severe airflow obstruction (forced expiratory volume in 1 second, percent predicted [FEV1%]), whereas greater disease exacerbation frequency was associated with inpatient contact. COPD patients not referred to palliative care had a greater comorbid disease burden, similar FEV1%, fewer disease exacerbations, and a greater DLCO.

CONCLUSION

Few patients with COPD received palliative care, similar to national trends. Initial outpatient palliative contact had the longest duration of care and death in the preferred home environment. The extent of emphysema (DLCO reduction) and more frequent disease exacerbations identified in patients were more likely to receive palliative care. Our study begins to define the benefits of palliative care in advanced COPD and confirms underutilization in the years before death, where a prolonged impact on the quality of life may be realized.

Palliative Care in Chronic Obstructive Pulmonary Disease

Advanced chronic obstructive pulmonary disease (COPD), is characterized by high morbidity and mortality. Patients with COPD and their families experience a range of stresses and suffering from a variety of sources throughout the disease's progression. COPD is the fourth leading cause of death in the world. It exists as a significant contributor to global morbidity and mortality, and it results in substantial economic and social burden. This review provides some key facts regarding disease burden and encourages clinician to familiarize themselves and use both conventional and palliative approach early in the disease progression for a better quality of life.

Communication about Palliative Care for Patients with Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and disability Worldwide. For many patients, maximal therapy for COPD produces only modest relief of disabling symptoms and these symptoms result in a significantly reduced quality of life. Despite the high morbidity and mortality, patients with COPD do not receive adequate palliative care. One reason these patients may receive poor quality palliative care is that patient-physician communication about palliative and EOL care is unlikely to occur. The purpose of this review is to summarize recent research regarding patient-physician communication about palliative care for patients with COPD. Understanding the barriers to this communication may be an important step to improving communication about EOL care and improving patient-centred outcomes. Two areas that may influence the quality of care received by patients with COPD are also highlighted: 1) the role of depression, a common problem in patients with COPD, in physician-patient communication; and 2) the role of advance care planning in this communication. Further research is needed to develop and test interventions that can enhance patient-physician communication about palliative and EOL care for patients with COPD, and we describe our perspective on a research agenda in each area.

Experiences of symptoms and health service preferences among older people living with chronic diseases during the last year of life

BACKGROUND:

There is limited understanding of the symptoms that older people living with cancer, chronic obstructive pulmonary disease and chronic kidney disease experience during the last year of life in Thailand, in addition to their health service preferences.

AIMS:

To survey the symptom experiences and health service preferences at the end of life of older people with chronic illnesses from the perspective of bereaved carers.

METHODS:

The study used a retrospective post-bereavement approach to collect quantitative data. Purposive sampling was used to select 76 bereaved relatives of older people living with chronic illnesses who had died in the previous 5 to10 months. Telephone interviews and a translated version of the Views of Informal Carers-Evaluation Services (VOICES) questionnaire were conducted. Data were analysed using the statistical package SPSS version 17.

FINDINGS:

The overall quality of care received by older people living with chronic diseases during the last three months of life was described as 'good' (36%). However, in comparing the quality of care from different settings, most of the subjects (63%) thought that the quality of care at home should be rated as 'poor'. During the last twelve months, 35% of the respondents rated pain and poor appetite as the main symptoms, while 25% described experiencing 'worry' related to being at the end of life. The severity of many symptoms increased during the last three months of life; 21% of carers recommended that pain caused the most suffering to their relatives at 'all times', when compared with other symptoms of end of life. Around 21-35% reported that their relatives 'sometimes' experienced worry, low mood, breathlessness and oedema. During the last three days of life, it was reported by 97% of respondents that their relatives spent all of their time in hospital, and no respondents reported that their relatives had died at home.

CONCLUSION:

The study indicates that older people living with chronic diseases in Thailand are less likely to access specialist palliative care and are more likely to have poor symptom control at the end of life. It indicates that health services may not be meeting patients' needs and that there was clearly insufficient healthcare provision at home for older people to help them to manage their symptoms such as pain and breathlessness.

Palliative Care Provision for Patients with Advanced Chronic Obstructive Pulmonary Disease: A Systematic Integrative Literature Review

Although chronic obstructive pulmonary disease (COPD) is recognized as being a life-limiting condition with palliative care needs, palliative care provision is seldom implemented. The disease unpredictability, the misconceptions about palliative care being only for people with cancer, and only relevant in the last days of life, prevent a timely integrated care plan. This systematic review aimed to explore how palliative care is provided in advanced COPD and to identify elements defining integrated palliative care. Eight databases, including MEDLINE, EMBASE and CINAHL, were searched using a comprehensive search strategy to identify studies on palliative care provision in advanced COPD, published from January 1, 1960 to November 30, 2017. Citation tracking and evaluation of trial registers were also performed. Study quality was assessed with a critical appraisal tool for both qualitative and quantitative data. Of the 458 titles, 24 were eligible for inclusion. Experiences about advanced COPD, palliative care timing, service delivery and palliative care integration emerged as main themes, defining a developing taxonomy for palliative care provision in advanced COPD. This taxonomy involves different levels of care provision and integrated care is the last step of this dynamic process. Furthermore, palliative care involvement, holistic needs' assessment and management and advance care planning have been identified as elements of integrated care. This literature review identified elements that could be used to develop a taxonomy of palliative care delivery in advanced COPD. Further research is needed to improve our understanding on palliative care provision in advanced COPD.

Stigma and the in(visible) perspectives and expectations of home oxygen therapy among people with chronic breathlessness syndrome: A qualitative study

Background:

Chronic breathlessness syndrome in the context of advancing disease is distressing for all concerned. Oxygen is commonly prescribed in this setting; however, little is known about the perspectives of breathless people who either are on oxygen or are yet to have it prescribed.

Aim:

To understand and describe the perspectives and experiences of breathless people towards oxygen use at home.

Design:

This qualitative study utilised an interpretive description approach using semi-structured interviews and thematic analysis.

Setting/participants:

A total of 19 people with chronic breathlessness syndrome living in South Australia participated in semi-structured interviews. Participants were divided into sub-groups according to whether they were chronically breathless and (1) not using home oxygen ( n = 6), (2) using funded home oxygen for severe hypoxaemia ( n = 7) and (3) using home oxygen for palliation outside of funding guidelines ( n = 6).

Results:

Three main themes were identified: (1) managing distress and living with chronic breathlessness syndrome, with or without oxygen, requires a range of self-management strategies; (2) expectations of oxygen use: ‘Not as good as I thought it would be’; and (3) the stigma of using oxygen: the visible and invisible.

Conclusion:

People living with chronic breathlessness struggle daily with both the progression of the underlying disease and the distressing nature of the syndrome. While oxygen does provide benefit for some people, its use and the perceptions of its use are often associated with both the visible and invisible manifestations of stigma. Clinicians need to promote self-management strategies and give careful thought to the prescribing of home oxygen, especially outside the current funding guidelines.

COPD patients in need of palliative care: Identification after hospitalization through the surprise question

Currently, few patients suffering from chronic obstructive pulmonary disease (COPD) who might benefit from a palliative care approach are referred to a palliative care team. Tools to identify patients eligible for a palliative care approach have been found to be difficult to apply in daily practice. Therefore, there is need for a simple and easily applicable tool to identify those patients who would benefit from referral to a palliative care team. The aim of this study was to determine if the surprise question (SQ) "Would I be surprised if this patient dies within 12 months?" in a subset of recently hospitalized COPD patients identifies those subjects. Recently hospitalized COPD patients were included, and the answer to the SQ was provided by the treating pulmonologist. The gold standards framework (GSF) prognostic indicator guidance was regarded as the gold standard test and was assessed for each patient. Sensitivity, specificity, and negative and positive predictive values were calculated to determine the accuracy of the SQ plus recent hospitalization compared to the variables of the GSF. A total of 93 patients were analyzed. In 35 patients (38%), the answer to the SQ was "not surprised"; 78 patients (84%) met ≥1 criteria of the GSF (15 (16%) did not meet any criteria). Specificity and positive predictive value for the SQ were both 100% ((78.2-100) and (87.7-100), respectively). Sensitivity was 44.9% (33.7-56.5) and negative predictive value was 25.9% (22.2-29.9). The "not surprised" group fulfilled significantly more GSF criteria. The SQ after recent hospitalization for COPD has a very high specificity compared to a standardized tool and is therefore a useful tool for the quick identification of patients who are most likely to benefit from palliative care. However, this method doesn't identify all patients who are eligible for referral to palliative care.

Shifting Life Rhythms: Couples’ Stories about Living Together When One Spouse Has Advanced Chronic Obstructive Pulmonary Disease

Aim: This study examines couples’ experiences of living together when one partner has advanced chronic obstructive pulmonary disease (COPD). Method: Repeated qualitative interviews with four couples over an eight-month period, where one spouse in each couple suffered from advanced COPD. The final dataset comprised 19 interviews. A phenomeno-logical-hermeneutical method was used to interpret the interview text. Findings: One main theme, “living with the disease and one's spouse in a new and changeable life rhythm”, emerged from three subthemes: “living with uncertainty”, “living in a changed intimate relationship”, and “finding new ways of living together”. A mutual sense of companionship between the spouses facilitated their chances of reshaping their relationship and adapting it to the new life rhythm required by everyday life with the disease. Conclusion: The healthy spouse had major responsibility for the health of their sick spouse. Awareness of the couple's own conceptions and knowledge of health and illness is central to person-focused care, as is awareness of what values are important to them when restructuring their everyday life.

Experiences and needs of Bereaved Carers during Palliative and End-Of-Life Care for People with Chronic Obstructive Pulmonary Disease

Aim: This study explored the experiences of palliative care that bereaved carers had while providing care to a dying loved one with chronic obstructive pulmonary disease (COPD). Method: Semi-structured interviews were undertaken with nine carers who had lost a loved one in the preceding 6 to 24 months. These interviews explored levels of satisfaction with disease management, symptom management, and end-of-life care. With permission, interviews were tape recorded, transcribed, and subjected to content analysis. Findings: Three themes emerged from the data: the impact of the caring experience, the lack of support services, and end-of-life and bereavement support. Carers experienced carer burden, lack of access to support services, a need for palliative care, and bereavement support. Conclusion: The findings provide a first insight into the experiences of carers of patients with advanced COPD. Bereaved carers of patients who had suffered advanced COPD reported that they had received inadequate support and had a range of unmet palliative care needs. Special attention should be paid to educating and supporting carers during their caring and bereavement periods to ensure that their quality of life is maintained or enhanced.

Quality of Life Trends in People With and Without Cancer Referred to Volunteer-Provided Palliative Care Services (ELSA): A Longitudinal Study

CONTEXT

Trends in symptoms and functional ability are known toward the end of life, but less is understood about quality of life, particularly prospectively following service referral.

OBJECTIVES

This study compares quality of life trajectories of people with and without cancer, referred to volunteer-provided palliative care services.

METHODS

A secondary analysis of the ELSA trial (n = 85 people with cancer and n = 72 without cancer) was performed. Quality of life data (WHOQOL-BREF) were collected at baseline (referral), four weeks, eight weeks, and 12 weeks. Sociodemographic data were collected at baseline. We specified a series of joint models to estimate differences on quality of life trajectories between groups adjusting for participants who die earlier in the study.

RESULTS

People with cancer had a significantly better quality of life at referral to the volunteer-provided palliative care services than those with nonmalignant disease despite similar demographic characteristics (Cohen d's = 0.37 to 0.45). More people with cancer died during the period of the study. We observed significant differences in quality of life physical and environmental domain trajectories between groups (b = -2.35, CI -4.49, -0.21, and b = -4.11, CI -6.45, -1.76). People with cancer experienced a greater decline in quality of life than those with nonmalignant disease.

CONCLUSION

Referral triggers for those with and without cancer may be different. People with cancer can be expected to have a more rapid decline in quality of life from the point of service referral. This may indicate greater support needs, including from volunteer-provided palliative care services.

Early integrated palliative approach for idiopathic pulmonary fibrosis: A narrative study of bereaved caregivers' experiences

BACKGROUND

Idiopathic pulmonary fibrosis has an uncertain and rapid trajectory after diagnosis. Palliative care is rarely utilized, although both patients and caregivers experience a distressingly high symptom burden. Most patients die in hospital.

AIM

The purpose of this study was to explore bereaved caregivers' experiences and perceptions of an early integrated palliative approach implemented at a Multidisciplinary Interstitial Lung Disease Clinic.

DESIGN

A narrative approach was used, with thematic and content analysis of open-ended interviews.

SETTING/PARTICIPANTS

The clinic is located in a large western Canadian city. Caregivers of deceased patients were recruited through purposive sampling. The eight participants were either spouses or adult children.

RESULTS

Five major themes were identified: Having a Terminal Disease; Planning Goals and Wishes for Care; Living Life and Creating Memories; Feeling Strain and Responsibility; and Nearing the End. Caregivers had little understanding of prognosis prior to advance care planning conversations at the clinic. Advance care planning conversations enabled caregivers to know and support patients' goals and wishes. Caregivers described feeling informed, prepared, and supported when death was near. They expressed neither distress nor anxiety related to patients' symptoms or strain of relationships.

CONCLUSION

Collaboration and close communication among caregivers, respirologists, and home care enabled effective symptom management and out of hospital deaths. Patients and caregivers had opportunities to enjoy events, create memories, determine preferences, and make plans. Further research on an early integrated palliative approach in Idiopathic Pulmonary Fibrosis is warranted related to quality of life, experience with death and dying, and caregiver bereavement.

Appropriateness of End-of-Life Care in People Dying From COPD. Applying Quality Indicators on Linked Administrative Databases

CONTEXT

Large-scale evaluations of the quality of end-of-life care in people with chronic obstructive pulmonary disease (COPD) are lacking.

OBJECTIVES

By means of a validated set of quality indicators (QIs), this study aimed to 1) assess appropriateness of end-of-life care in people dying from COPD; 2) examine variation between care regions; 3) establish performance standards.

METHODS

We conducted a retrospective observational study of all deaths from COPD (ICD-10 codes J41-J44) in 2012 in Belgium, using data from administrative population-level databases. QI scores were risk-adjusted for comparison between care regions.

RESULTS

A total of 4231 people died from COPD. During the last 30 days of life, 60% was admitted to hospital and 11.8% received specialized palliative care. Large regional variation was found in specialized palliative care use (4.0%-32.0%) and diagnostic testing in the last 30 days of life (44.0%-69.7%). Based on best performing quartile scores, relative standards were set (e.g., ≤54.9% for diagnostic testing).

CONCLUSION

Our study found indications of inappropriate end-of-life care in people with COPD, such as high percentages of diagnostic testing and hospital admissions and low proportions receiving specialized palliative care. Risk-adjusted variation between regions was high for several QIs, indicating the usefulness of relative performance standards to improve quality of end-of-life COPD care.

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

BACKGROUND

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

AIM

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

DESIGN AND SETTING

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Exploring medicines management by COPD patients and their social networks after hospital discharge

Background Unplanned hospital admissions (UHAs) for chronic obstructive pulmonary disease (COPD) are a major burden on health services. Effective medicines management is crucial to avoid such admissions but little is known about the role of social networks in supporting medicines-taking. Objective To examine the activities and strategies recently discharged COPD patients and their social network members (SNMs) utilise to manage their medicines. Setting COPD patients recently discharged from an acute NHS Trust in Northwest England. Methods Semi-structured, face-to-face interviews; audio-recorded and transcribed with consent, NVivo v11 facilitated qualitative thematic analysis. NHS ethical approved. Main outcome measure Interview topic guide and analysis informed by Cheraghi-Sohi et al.’s conceptual framework for ‘medication work’ exploring medication–articulation, informational, emotional and surveillance work. Results Twelve interviews were conducted during March–August 2016. Participants’ social networks were small (n < 5) and restricted to family members and healthcare professionals. Participants social network members performed similar medication–articulation and surveillance work to coronary heart disease, arthritis and diabetes patients. When participants social network members resolved issues identified by surveillance work, this medication work was conceptualised as surveillance–articulation work. The social network members performed little emotional work and were infrequently involved in informational work despite some participants describing informational needs. After discharge, participants reverted to pre-admission routines/habits/strategies for obtaining medication supplies, organising medicines, keeping track of supplies, ensuring adherence within daily regimens, and monitoring symptoms, which could cause issues. Conclusion This study applied Cheraghi-Sohi’s framework for medication work to COPD patients and described the role of the social network members. Pharmacists could proactively explore medication infrastructures and work with patients and their close social network members to support medication work.

Management of COPD in End-of-Life Care by Spanish Pulmonologists

Chronic obstructive pulmonary disease is progressive and in its advanced stage is associated with major disability. Previous studies suggest that patients with this disease receive little palliative care, even in very advanced stages. Given this, our objectives were to describe the clinical practice of Spanish pulmonologists in the care of patients with end-stage chronic obstructive pulmonary disease, to identify potential barriers to implementing palliative care in these patients and to correlate these responses with doctor's years of experience. A link to an online survey was sent to pulmonologists on (a) symptom management, (b) structure of their department and collaboration with other services, (c) specialized medical training in palliative care, (d) communication with patients and their families, and (e) limiting barriers identified in the management of these patients. A total of 387 responses were received. The majority used opioids to treat dyspnea (52.9%) or pain (54.2%) and many treated anxiety/depression (41%). Around half of the respondents had no established routines in their departments to offer palliative care to patients with chronic obstructive pulmonary disease. There was little communication with end-of-life patients and their families on disease course, mainly associated with a lack of medical training (83% of cases) and changes in patient wishes regarding care through the disease course (81%). In our setting, communication with end-of-life patients with chronic obstructive pulmonary disease is poor. The key challenges identified are insufficient medical training and changing desires of patients. No substantial differences in attitude were found as a function of experience.

Living with breathlessness: a systematic literature review and qualitative synthesis

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

Prognostic variables and scores identifying the end of life in COPD: a systematic review

INTRODUCTION

COPD is a major cause of mortality, and the unpredictable trajectory of the disease can bring challenges to end-of-life care. We aimed to investigate known prognostic variables and scores that predict prognosis in COPD in a systematic literature review, specifically including variables that contribute to risk assessment of patients for death within 12 months.

METHODS

We conducted a systematic review on prognostic variables, multivariate score or models for COPD. Ovid MEDLINE, EMBASE, the Cochrane database, Cochrane CENTRAL, DARE and CINAHL were searched up to May 1, 2016.

RESULTS

A total of 5,276 abstracts were screened, leading to 516 full-text reviews, and 10 met the inclusion criteria. No multivariable indices were developed with the specific aim of predicting all-cause mortality in stable COPD within 12 months. Only nine indices were identified from four studies, which had been validated for this time period. Tools developed using expert knowledge were also identified, including the Gold Standards Framework Prognostic Indicator Guidance, the RADboud Indicators of Palliative Care Needs, the Supportive and Palliative Care Indicators Tool and the Necesidades Paliativas program tool.

CONCLUSION

A number of variables contributing to the prediction of all-cause mortality in COPD were identified. However, there are very few studies that are designed to assess, or report, the prediction of mortality at or less than 12 months. The quality of evidence remains low, such that no single variable or multivariable score can currently be recommended.

CHOICE: Choosing Health Options In Chronic Care Emergencies

Background

Over 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.

Objectives

The aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).

Design

A three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.

Setting

Primary care. Manchester and London.

Participants

People aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.

Results

Evidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.

Limitations

The findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.

Conclusions

Prior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.

Future work

The potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

The empowerment of elderly patients with chronic obstructive pulmonary disease: Managing life with the disease

Chronic obstructive pulmonary disease (COPD) is a serious health problem that has significant effects on the life status of elderly persons. Use of the empowerment approach is necessary for health promotion in older people with COPD, but little attention has so far been paid to all the dimensions of empowerment in the management of COPD, which would provide useful knowledge regarding elders with COPD. This article reports on a study exploring people's experiences of the empowerment of older people with COPD. This study adopted an exploratory qualitative design and was carried out using grounded theory methodology. Grounded theory was considered appropriate for this study because of its focus on how people respond to and act on the problems that they encounter. We collected data by conducting in-depth semi-structured interviews and taking field notes. Twenty-four participants were selected through purposive sampling. The results showed that in encountering the complexity of disease and in response to difficulties induced by COPD, three strategies were applied. Elderly persons with COPD, their family caregivers, and professional team members engaged in "managing life with COPD," "striving to keep abreast of life," "preparing for battle with disease," and "helping to stabilize the elder's life." The outcome of these strategies was "co-existence with disease." The potential of "managing life with COPD" was influenced by the following factors: "co-existence with ageing," "personal potential," "a challenged health system," and "weak social support." "Managing life with COPD" enables the elder to feel in control and live optimally. This is a fragile balance, however, and the unpredictability of COPD can tip the elder into "self-efficacy." Understanding the experiences of the empowerment process of older people with COPD can help health professionals provide more focused elderly care.

Experiences and needs of older people with end stage renal disease: bereaved carers perspective

BACKGROUND

There is a growing population of older patients with End Stage Renal Disease (ESRD) managed without dialysis in Thailand, and services have yet to be developed to specifically respond to the needs of this group. As a consequence this population are likely to have unmet needs with respect to health care and suffer from symptoms that could be better managed.

OBJECTIVE

This qualitative study explored experiences and health care needs during the last year of life among older people with ESRD, managed without dialysis, from the perspective of bereaved carers.

METHODS

A retrospective post-bereavement approach was adopted to collect qualitative interview data. Purposive sampling was used to select 12 bereaved relatives of older patients with ESRD, managed without dialysis, who had died in the previous 5-10 months. Semi-structured interviews were conducted. Data were digitally recorded, transcribed and analysed through framework analysis.

RESULTS

Four main themes were identified: symptom experiences, impacts of being managed without dialysis, symptom management, and health care needs and utilisation of services.

CONCLUSIONS

Findings confirmed patients' needs were not being met and identified the need to develop approaches to symptom management at home, health education, and psychological and spiritual support at the end of life.

End-of-life prognostic indicators in patients with COPD: Part 1

In the UK, chronic respiratory diseases cause 13% of adult disability. The major chronic respiratory disease is chronic obstructive pulmonary disease (COPD), a condition involving chronic airway inflammation that causes airflow obstruction and destruction of lung tissue. This leads to a progressive loss of respiratory membrane, which accounts for the clinical manifestation of COPD, which is difficulty maintaining sufficient gas exchange to meet metabolic demands. The primary cause is smoking, with the vast majority of COPD patients having a past or present history of smoking. However exposure to industrial pollutants is also a contributing factor, as is a rare genetic predisposition to developing COPD.