Day-to-day living with severe chronic obstructive pulmonary disease: Towards a family-based approach to the illness impacts

Burden, coping and resilience among caregivers for patients with chronic obstructive pulmonary disease: An integrative review

AIM

This study aims to synthesise quantitative and qualitative evidence to comprehensively examine the burden of family caregivers of chronic obstructive pulmonary disease patients and to understand their coping strategies and related resilience factors.

BACKGROUND

Long-term chronic obstructive pulmonary disease care causes heavy psychological and physical burden to caregivers, which is related to the coping strategies used. Resilience is a protective factor originating within the individual and has become a concept related to illness, health and care.

DESIGN

An integrative review.

METHODS

Relevant literature was comprehensively searched from China Biology Medicine, China National Knowledge Infrastructure, Wan Fang, PubMed, Embase, Web of Science and Ovid databases from the establishment of the database till January 2023, and the quality of the selected articles was evaluated. Reporting was done according to a PRISMA checklist.

FINDINGS

The burden of family caregivers with chronic obstructive pulmonary disease includes poor health, worry and fear, anticipatory loss and uncertainty, relationship tensions and disagreements, loss of identity and social isolation, lack of supportive knowledge and financial burden. Family caregivers used problem-centred coping, emotion-centred coping, avoidance coping, social support and dyadic coping with their patients to manage their burdens. The factors chronic obstructive pulmonary disease associated with a caregiver's resilience included a higher level of knowledge, social and familial support, a close relationship with patients, a caregiver's sense of responsibility, the patient's high self-efficacy, etc. CONCLUSIONS: The findings show that caregivers of chronic obstructive pulmonary disease patients face multiple burdens, adapt through different coping styles and have different psychological consequences, while coping style and mental health status also affect the magnitude of burden.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The findings informed health professionals about personalised chronic obstructive pulmonary disease home care interventions to reduce caregiver burden, effectively manage illness and maintain family intimacy.

NO PATIENT OR PUBLIC CONTRIBUTION

No patients, families, service providers or members of the public were involved in this study.

Assessing caregiving experience in COPD: content validity of the Zarit Burden Interview in Canadian and Portuguese caregivers

PURPOSE

Informal caregivers play an important role in chronic disease management but their experience is often neglected. The objective of this study was to explore the content validity of the Zarit Burden Interview (ZBI) in caregivers of individuals with COPD in Canada and Portugal.

MATERIALS AND METHODS

Cognitive debriefing interviews were conducted with informal caregivers of individuals with moderate to very severe COPD. Participants completed the ZBI and verbalised their thinking process to assess the adequacy of the questionnaire's content and instructions. Content validity was assessed using deductive content analysis of interviews and descriptive statistics of questionnaire responses.

RESULTS

Nine caregivers from Canada (age = 67 ± 8 years) and 13 from Portugal (age = 69 ± 7 years) participated. For Canadian caregivers, 3/22 items were not understood, and 8/22 items were not relevant to at least 1/3 of them. For Portuguese caregivers, 1/22 items were not understood, and 20/22 items were not relevant to at least 1/3 of them. The distribution of response choices was approximately symmetrical for 17/22 items in the Canadian sample. The response option "no/never" was selected by at least 75% of Portuguese participants for 18/22 items.

CONCLUSIONS

The instrument was well understood by caregivers of people with COPD, but its relevance is uncertain.IMPLICATIONS FOR REHABILITATIONInformal caregivers provide essential care for people living with disability and chronic disease, but their experience is often neglected.The Zarit Burden Interview assesses caregiver burden but has not been validated in caregivers of people with chronic obstructive pulmonary disease.In its current form, the Zarit Burden Interview does not adequately represent the experience of COPD caregivers.We recommend selecting tools that assess caregiver burden that have been validated in the caregiver population of interest.

COPD-Related Anxiety: A Systematic Review of Patient Perspectives

Background

Anxiety in patients with chronic obstructive pulmonary disease (COPD) is prevalent but often unidentified and therefore not adequately managed. Clinicians find it difficult to detect anxiety symptoms and to differentiate subclinical anxiety from anxiety disorders, because of the considerable overlap between symptoms of COPD and anxiety.

Purpose

We synthesized existing qualitative research on patients' experiences of COPD-related anxiety with the purpose of gaining a richer understanding and proposing a model of the construct.

Methods

Searches for qualitative studies of patients' experiences of COPD-related anxiety were conducted independently by two authors in the databases of PubMed (MEDLINE), CINAHL (EBSCO), and PsycInfo (APA). English-language studies including patients diagnosed with COPD were reviewed, and data were analyzed using thematic analysis.

Results

A total of 41 studies were included in the review. Four themes related to COPD-related anxiety were identified: initial events; internal maintaining factors; external maintaining factors; and behavioral maintaining factors. Based on the identified four themes, a conceptual model of COPD-related anxiety from the patient perspective was developed.

Conclusion

A conceptual model of COPD-related anxiety from the patient perspective is now available, with the potential to inform future attempts at improving identification and management of COPD-related anxiety. Future research should focus on the development of a COPD-specific anxiety questionnaire containing domains that are relevant from the patient perspective.

Associations of self-reported chronic obstructive pulmonary disease with indicators of economic instability and stress - 16 states, 2017

OBJECTIVES

To examine the association between chronic obstructive pulmonary disease status and indicators of economic instability and stress to better understand the magnitude of these issues in persons with chronic obstructive pulmonary disease.

METHODS

Analyzed 2017 Behavioral Risk Factor Surveillance System data from 16 states that administered the 'Social Determinants of Health' module, which included economic instability and stress measures (N = 101,461). Associations between self-reported doctor-diagnosed chronic obstructive pulmonary disease status and each measure were examined using multinomial logistic models.

RESULTS

Adults with chronic obstructive pulmonary disease were more likely (p < 0.001) than adults without to report not having enough money at month end (21.0% vs. 7.9%) or just enough money (44.9% vs. 37.2%); being unable to pay mortgage, rent, or utility bills (19.2% vs. 8.8%); and that often or sometimes food did not last or could not afford to eat balanced meals (37.9% vs. 20.6%), as well as stress all or most of the time (27.3% vs. 11.6%). Associations were attenuated although remained significant after adjustments for sociodemographic and health characteristics.

DISCUSSION

Financial, housing, and food insecurity and frequent stress were more prevalent in adults with chronic obstructive pulmonary disease than without. Findings highlight the importance of including strategies to address challenges related to economic instability and stress in chronic obstructive pulmonary disease management programs.

Patients’ and their caregivers’ experiences with regular, low-dose, sustained-release morphine for chronic breathlessness associated with COPD: a qualitative study

Introduction

Regular, low-dose, sustained-release morphine is effective in reducing chronic breathlessness in people with advanced disease, particularly in patients with chronic obstructive pulmonary disease (COPD). Despite experiencing a reduction in breathlessness, some patients choose not to continue long-term treatment.

Aim

This study aimed to explore patients’ and caregivers’ experiences with regular, low-dose, sustained-release morphine for chronic breathlessness associated with COPD.

Methods

A qualitative study embedded in a randomised controlled trial (RCT) of regular low-dose, sustained-release morphine for chronic breathlessness for people with COPD and modified Medical Research Council breathlessness scale 3–4. After completing the RCT or withdrawing, patients and their caregivers were invited to participate in interviews in their homes focused on their experiences with the trial medication while still blinded to the arm to which they had been allocated. Data analysis used a constant comparative method informed by the principles of grounded theory.

Results

Thirteen patients and nine caregivers participated. Four themes were identified: (1) Receptivity and knowledge; (2) Function as a priority; (3) Harmful and helpful side effects; and (4) Therapy-centred aspects. The concept of ‘net effect’ emerged from the interplay between themes, subthemes and the decision to continue taking sustained-release morphine during the trial and after trial completion.

Conclusion

Clinicians’ support and preconceived ideas about morphine influence the decision to commence sustained-release morphine. The hope for functional improvement is the great driver influencing positively the decision to take sustained-release morphine in the long term. The degree of symptom reduction, improved function, side-effects’ severity and caregivers’ availability creates a net effect driving patients’ decisions to continue or discontinue the medication.

Existential suffering in the day to day lives of those living with palliative care needs arising from chronic obstructive pulmonary disease (COPD): A systematic integrative literature review

BACKGROUND

The impact of living with palliative care needs arising from COPD disrupts an individual's existential situation. However, no comprehensive synthesis of existing research has been published to determine the presentation and impact of existential suffering.

AIM

To provide a synthesis of existing evidence on existential suffering for those living with palliative care needs arising from COPD.

DESIGN

This is an integrative review paper, undertaken using the methodological approach developed by Soares and reported in accordance with PRISMA guidelines. Data analysis was undertaking using an integrated convergent synthesis approach.

DATA SOURCES

Nine electronic databases were searched from April 2019 to December 2019. A second search was undertaken in January 2021 to identify recently published papers meeting the inclusion and exclusion criteria. No date restrictions were imposed. Only papers published in the English Language were considered for inclusion. Empirical research papers employing qualitative and/or quantitative methodologies and systematic literature reviews were included. Articles were accepted for inclusion if they discussed any component of existential suffering when living with COPD and palliative care needs.

RESULTS

Thirty-five papers were included within this review comprising of seven systematic reviews, 10 quantitative studies and 18 qualitative studies. The following themes relating to existential suffering were found: Liminality, Lamented Life, Loss of Personal Liberty, Life meaning and Existential isolation. The absence of life meaning, and purpose was of most importance to participants.

CONCLUSIONS

This review suggests existential suffering is present and of significant impact within the daily lives of those living with palliative care needs arising from COPD. The absence of life meaning has the most significant impact. Further research is required to understand the essential components of an intervention to address existential suffering for this patient group, to ensure holistic palliative care delivery.

Effects of a Caregiver Educational Program on Interactions between Family Caregivers and Patients with Advanced COPD

The quality of family caregiver-patient interaction plays a crucial role in the context of chronic conditions. This study investigated the effects of a caregiver educational program on interactions between family caregivers and patients with advanced chronic obstructive pulmonary disease (COPD). In this trial, 92 pairs of family caregivers and patients in a subspecialty lung care clinic located in Birjand, Iran were allocated into intervention and control groups (n = 46 per group). The intervention consisted of eight sessions, including three educational sessions on COPD, two educational sessions on coping strategies, as well as three peer support sessions. The Dyadic Relationship Scale was completed at baseline, posttest, and follow-up (2 months after intervention). For caregivers in the intervention group, positive dyadic interaction improved significantly from baseline to follow-up and from posttest to follow-up in comparison with the control group (p < 0.05). Also, for these caregivers, negative dyadic strain enhanced significantly from baseline to posttest and from baseline to follow-up as compared with those in the control group (p < 0.05). Finally, in patients of the intervention group, negative dyadic strain from baseline to follow-up and from posttest to follow-up significantly improved when compared with that of control patients (p < 0.05).

Fear of Progression in chronic illnesses other than cancer: A systematic review and meta-analysis of a transdiagnostic construct

Fear of cancer recurrence (FCR) is the most common psychosocial issue amongst cancer survivors. However, fear of progression (FoP) has been studied outside of the cancer context. This review aimed to: (1) meta-synthesize qualitative studies of FoP in illnesses other than cancer; and (2) quantify the relationship between FoP and anxiety, depression, and quality of life (QoL) in non-cancer chronic illnesses. We identified 25 qualitative and 11 quantitative studies in a range of chronic illnesses. Participants described fears of progression and recurrence of their illness, including fears of dying, and fears of becoming a burden to family. Fears were often triggered by downward comparison (i.e. seeing people worse off than themselves). Participants coped in different ways, including by accepting the illness or seeking knowledge. Those for whom these fears caused distress reported hypervigilance to physical symptoms and avoidance. Distress, and seeking information, were associated with adherence. In quantitative analyses, FoP was moderately associated with QoL, and strongly associated with anxiety and depression. These results suggest that FoP in illnesses other than cancer is similar to FCR. FoP appears to be an important transdiagnostic construct associated with distress. Evidence-based FCR interventions could be adapted to better manage FoP in other illnesses.

Mediating role of psychological capital in the relationship between social support and treatment burden among older patients with chronic obstructive pulmonary disease

This study was conducted to investigate the connection between social support and the treatment burden among older patients with chronic obstructive pulmonary disease (COPD), and to examine the mediating role of psychological capital within that connection. Although treatment burden is common, the current data on social support associated with it is limited, and the theoretical mechanisms underlying the relationship between the two variables have not yet been clarified. A total of 245 older outpatients with COPD were recruited. Descriptive and Structural Equation Modelling was employed to test the hypothesised model using SPSS 26 and IBM SPSS AMOS 26. The modified model yielded an adequate fit to the data. The variation in the treatment burden explained by the hypothetical model was 57.2%. The study provides a new perspective for medical professionals to manage the treatment burden by developing efficient social support and psychological capital measures.

Caring for patients at home after acute exacerbation of chronic obstructive pulmonary disease: A phenomenological study of family caregivers' experiences

AIMS AND OBJECTIVES

To understand the experiences and support needs of informal caregivers of patients with chronic obstructive pulmonary diseases chronic obstructive pulmonary disease who return home following an acute exacerbation.

BACKGROUND

The presence of an informal caregiver is important to provide practical and emotional support after an episode of acute exacerbation of chronic obstructive pulmonary disease. However, caregiving in such circumstances can be challenging and stressful.

DESIGN

Phenomenology.

METHODS

This is a phenomenological study based on semi-structured interviews with sixteen primary caregivers of chronic obstructive pulmonary disease patients. Interview data were analysed using Colaizzi's descriptive analysis framework, to identify significant themes and sub-themes. Data were collected between April-December 2017 in a Teaching Hospital in Italy. The study was designed and reported following the COREQ guidelines and checklist.

RESULTS

Analysis elicited five themes embracing various aspects of the caregivers' lived experiences: (a) a home disrupted, (b) living with constant vigilance and anxiety, (c) feeling the need to escape (d) self-justifications for caregiving role/duty, and (e) feeling abandoned by professionals.

CONCLUSIONS

Our results show that carers experience a range of difficulties when caring for their relative at home with chronic obstructive pulmonary disease. Some of these are linked to the physical disruption of their home but many are linked to feelings of inability to cope and the psycho-social impact of the caring role. The study also shows how participants felt unsupported by professionals. Focused support for carers is required to enable them to meet these challenges.

RELEVANCE TO CLINICAL PRACTICE

Healthcare professionals should be trained to provide technical and psychological support to caregivers especially during the phases of disease that may involve episodes of exacerbation. Home care and continuity of care can work if there is excellent communication and collaboration between healthcare professionals and caregivers. Developing appropriate support for family caregivers is essential to address the problems they can face.

End-stage renal disease is not yours, is not mine, is OURS: Exploring couples lived experiences through dyadic interviews

INTRODUCTION

As a psychosocial dyad, couples are greatly challenged by end-stage renal disease (ESRD). Renal replacement therapies are highly demanding and involve lifelong restrictions and readjustments that sometimes translate into profound changes in couples' routines. However, little is known about the experiences of these couples with this condition. This study examined the experiences of couples living with ESRD.

METHODS

A qualitative exploratory study was conducted with a purposive sample. Semistructured dyadic interviews were conducted with 12 patients (65.1 ± 12.8 years old; eight males) undergoing in-center hemodialysis for 18.6 (±13.3) months and their spouses (60.3 ± 11.2 years old; seven females). The interviews were digitally audio-recorded, transcribed verbatim, and submitted to thematic analysis by two independent researchers.

FINDINGS

The findings from the dyadic perspective were conceptualized into two major themes: negative impacts (emotional distress, constraints on leisure and daily activities, impacts on couples' dynamics, and difficulties in meal planning) and unmet needs (educational, relational, financial, instrumental, and supportive needs).

DISCUSSION

The findings suggested that ESRD has several negative impacts that are related to the reported unmet needs, which might difficult couples' psychosocial adjustment to the condition. Both partners may benefit from educational and supportive interventions that address their needs, targeting the couple as a unit. Recognizing ESRD as a family condition is crucial for the development of innovative family-based interventions that can promote couples' healthy adjustment to the disease.

The information needs of people with COPD-The holistic approach with special reference to gender and time since diagnosis

Aims

The aim of this study was to determine what kinds of unmet information needs people with COPD have and whether there are differences in information needs between genders or based on the time since COPD diagnosis.

Design

A descriptive cross‐sectional study.

Methods

Data on people with COPD (N = 169) were collected from a two‐part questionnaire distributed via website. On the first part, information needs concerning the medical aspects of self‐management were measured by the Lung Information Needs Questionnaire (LINQ). On the second part, which was developed specifically for this study, a more holistic view of self‐management counselling was sought. Statistical methods were used to analyse the data.

Results

The respondents had wide‐ranging information needs in many areas of COPD self‐management. The most often reported areas of unmet information needs included exacerbations, diet, fatigue, stress and anxiety, palliative care and sexual life. The information needs varied by gender and time since COPD diagnosis.

"What do we fear the most?": Exploring fears and concerns of patients, family members and dyads in end-stage renal disease

INTRODUCTION

End-stage renal disease (ESRD) and the need for haemodialysis (HD) treatment are increasing. The course of the disease and all the life readjustments needed may generate a multitude of fears in patients and families.

AIM

This study aimed to explore the main fears and concerns of patients with ESRD undergoing HD and their family members.

STUDY DESIGN

A qualitative study was performed.

METHODS

Individual semi-structured interviews were conducted with three groups: 20 patients, 14 family caregivers and 15 patient-family dyads. Interviews were audiotaped, transcribed verbatim and submitted to thematic analysis.

FINDINGS

Five major themes emerged: (i) fear of death (fear of earlier death, fear of a sudden death and fear of dying); (ii) fear of problems during HD (fears related to the vascular access, and fear of complications during HD); (iii) concerns related to the disease (fear of loss of autonomy, fears of getting worse, fears related to renal transplantation and concerns about dietary restrictions); (iv) fear about the future; and (v) absence of fears and concerns.

DISCUSSION

Patients with ESRD undergoing HD and their family members expressed different fears related to the disease and the treatments required. Renal care staff must acknowledge and understand such concerns and help patients and families to cope. This is important to improving people's quality of life (QoL), the dialogue between health professionals, patients, and family members, and the care offered by the dialysis care settings. Moreover, this study highlights the impact this disease has at a familial level. Future family-based interventions should acknowledge possible fears and concerns of this population and integrate them into their programs.

Does the carer support needs assessment tool cover the established support needs of carers of patients with chronic obstructive pulmonary disease? A systematic literature search and narrative review

BACKGROUND

Informal carers play a key supportive role for patients with chronic obstructive pulmonary disease. However, caring can have a considerable impact on health and wellbeing. Carers may have unidentified support needs that could be a target for intervention. Literature on the support needs of informal carers has not been fully synthesised, and our knowledge of the comprehensiveness of the Carer Support Needs Assessment Tool for these individuals is limited.

AIM

To explore whether the Carer Support Needs Assessment Tool covers the support needs of carers of patients with chronic obstructive pulmonary disease identified in published literature.

DESIGN

English language studies were identified against predetermined inclusion/exclusion criteria through database searching. Further studies were identified through searching reference lists and citations of included papers. Papers were critically appraised and data extracted and synthesised by two reviewers. Identified needs were mapped to Carer Support Needs Assessment Tool questions.

DATA SOURCES

MEDLINE, CINAHL, EMBASE, CDSR, ASSIA, PsycINFO and Scopus databases (Jan 1997-Dec 2017).

RESULTS

Twenty-four studies were included. Results suggest that carers have support needs in a range of domains including physical, social, psychological and spiritual. Many of these needs are unmet. Particular areas of concern relate to prolonged social isolation, accessing services, emotional support and information needs. Findings also suggest amendment of the Carer Support Needs Assessment Tool may be required relating to difficulties within relationship management.

CONCLUSION

Evidence suggests that carers of patients with chronic obstructive pulmonary disease would benefit from identification and response to their support needs by healthcare professionals but to enable this, the Carer Support Needs Assessment Tool requires an additional question. Future planned work will explore this with carers of patients with chronic obstructive pulmonary disease.

Family members' experiences and expectations of self-management counseling while caring for a person with chronic obstructive pulmonary disease: a systematic review of qualitative evidence

OBJECTIVE

The objective of this review was to identify and synthesize existing evidence on the experiences and expectations of self-management counseling of adult family members who are informal caregivers of a person with chronic obstructive pulmonary disease (COPD) in the context of inpatient or outpatient care.

INTRODUCTION

Chronic obstructive pulmonary disease is the fourth leading cause of mortality and morbidity worldwide. It is a progressive, lifelong and unpredictable disease. As the disease progresses, both the people with COPD and their family members require information and practical skills to manage the disease. The role of family members is particularly important at the advanced stage of COPD. This systematic review examined family members' experiences and expectations of self-management counseling.

INCLUSION CRITERIA

This review considered qualitative studies that investigated adult (older than18 years) family members' experiences or expectations of COPD self-management counseling in the context of inpatient or outpatient care. "Family member" refers to a person who is an informal caregiver because of his or her relationship to the person with COPD.

METHODS

A three-step search strategy was utilized in this review. The search strategy aimed to find published and unpublished studies in English and Finnish. The databases MEDLINE, CINAHL, PsycINFO, Scopus and the Finnish medical bibliographic database, Medic, were searched. The search was conducted in December 2015 and updated in September 2018. Titles and abstracts were screened by two independent reviewers for the review's inclusion criteria. Eligible studies were then critically appraised by two independent reviewers for methodological quality. The findings and illustrations of the findings were extracted and assigned a level of credibility. The qualitative research findings were pooled using the JBI method of meta-aggregation.

RESULTS

Ten papers were selected for inclusion in this review. These studies were published from 2002 to 2017. The quality of all included studies was at least moderate. Each study had a total score between 7 and 10 on the JBI Critical Appraisal Checklist for Qualitative Research. The following four synthesized findings were aggregated from nine categories and 39 study findings: i) Family members' experiences with unresponsive behavior from health professionals, ii) Family members' experiences of unmet needs in self-management counseling, iii) Family members' information needs concerning COPD management, and iv) Family members' information needs concerning coping strategies.

CONCLUSIONS

The synthesized findings indicate that family members are frustrated by the shortcomings of self-management counseling. They also feel unprepared for and uncertain about their caring role. They need more information about COPD and coping strategies for COPD. Counseling is essential to high-quality care and should be offered to family members caring for a loved one at any stage of COPD.

Activities Forgone because of Chronic Breathlessness: A Cross-Sectional Population Prevalence Study

Background: Chronic breathlessness is a prevalent disabling syndrome affecting many people for years. Identifying the impact of chronic breathlessness on people's activities in the general population is pivotal for designing symptom management strategies.

Objective: This study aimed to evaluate the association between chronic breathlessness and activities respondents identify can no longer be undertaken (“activities forgone”).

Design: This population-based cross-sectional online survey used a market research company's database of 30,000 registrants for each sex, generating the planned sample size—3000 adults reflecting Australia's 2016 Census by sex, age group, state of residence, and rurality.

Setting/Subjects: The population of focus (n = 583) reported a modified Medical Research Council (mMRC) breathlessness scale ≥1 and experienced this breathlessness for ≥3 months.

Measurements: Activities forgone were categorized by mMRC using coding derived from the Dyspnea Management Questionnaire domains. Activities were classified as “higher/lower intensity” using Human Energy Expenditure scale.

Results: Respondents were male 50.3%; median age 50.0 (IQR 29.0); with 66% living in metropolitan areas; reporting 1749 activities forgone. For people with mMRC 1 (n = 533), 35% had not given up any activity, decreasing to 9% for mMRC 2 (n = 38) and 3% for mMRC 3–4 (n = 12). Intense sport (e.g., jogging and bike riding) was the top activity forgone: 42% (mMRC 1), 32% (mMRC 2), and 36% (mMRC 3–4). For respondents with mMRC 3–4, the next most prevalent activities forgone were “sexual activities” (14%), “lower intensity sports” (11%), and “other activities” (11%).

Conclusions: People progressively reduce a wide range of activities because of their chronic breathlessness.

Relationship between Distress Related to Caregiver Burden and Physical Activity in Informal Caregivers of Patients with COPD

Chronic obstructive pulmonary disease (COPD) can lead to increased dependence on the informal caregiver and, consequently, to distress associated with caregiving burden. In the general population, higher levels of physical activity (PA) are related to lower distress levels; however, this relationship has been scarcely studied in COPD. This study aimed to explore the relationship between distress and PA in informal caregivers of patients with COPD, and the influence of caregivers' (age, sex) and patients' (age, sex, lung function) characteristics and caregiving duration on this relationship.A cross-sectional study was conducted with 50 caregivers (62.7 ± 9.8 years, 88% female; 78% caring for a spouse/partner; 38% caring >40 h/week; patients' FEV₁=45.2 ± 21.3% predicted). Data collection comprised questions related to the caregiving context, distress related to caregiving burden assessed with the Informal Caregiver Burden Assessment Questionnaire (QASCI; total score, 7 subscales), and self-reported PA with the Habitual Physical Activity Questionnaire (HPAQ). Spearman's correlation coefficient and linear regressions were used.Significant, negative and moderate correlations were found between the QASCI (28.5 ± 19.8) and the HPAQ (5.2 ± 1.3) (ρ=-0.46; p = 0.01); and between the HPAQ and some QASCI subscales (emotional burden ρ=-0.47; implications for personal life ρ=-0.52; financial burden ρ=-0.44; perception of efficacy and control mechanisms ρ=-0.42; p < 0.01). Two linear regression models were tested to predict QASCI total score including as predictors: 1) HPAQ alone (p = 0.001; r²=0.23); 2) HPAQ and caregiving h/week (p < 0.001; r²=0.34).Higher self-reported PA levels are related to decreased levels of distress associated with caregiver burden in COPD caregivers. Duration of caregiving may negatively influence this relationship.

Two faces of the same coin: a qualitative study of patients' and carers' coexistence with chronic breathlessness associated with chronic obstructive pulmonary disease (COPD)

BACKGROUND

Chronic breathlessness is a recognized clinical syndrome that severely impacts patients and carers, who become increasingly restricted in their daily activities. Often, patients become reliant on their carers, who are required to provide constant support. Although individual experiences of breathlessness have been previously investigated, there are few studies exploring contemporaneous experiences of breathlessness of the patient and their carer. This study aimed to understand the experience of severe chronic breathlessness in people with chronic obstructive pulmonary disease (COPD) from the perspective of the patient and carer unit.

METHODS

A qualitative study embedded in a randomised, placebo-controlled effectiveness study (RCT) of regular, low-dose (≤32 mg/day), sustained-release morphine for chronic breathlessness associated with COPD. Recruitment occurred between July 2017 and November 2018 in one respiratory and palliative care services, in South Australia. Participants were community-dwelling patients with COPD and severe breathlessness (modified Medical Research Council scale 3 or 4) and their carers. Separate semi-structured interviews were conducted with patients and carers, recorded and transcribed verbatim. Analysis was informed by grounded theory using a constant comparative approach.

RESULTS

From the 26 patients with a carer recruited for the RCT in South Australia, nine were interviewed in their homes. Six patients were men, median age 77 years. Carers were mostly women, who were their wives (n = 6), median age 70. Five themes emerged from the data: (1) shrinking world; (2) mutual adaptation; (3) co-management; (4) emotional coping; and (5) meaning in the face of death.

CONCLUSION

Chronic breathlessness is a systemic condition that permeates all aspects of the patient's and carer's lives. Working as a team, patients and carers manage chronic breathlessness to achieve maximal function and well-being. Patients and carers share many aspects of the experience of breathlessness, but the carer seems particularly susceptible to emotional distress. Future chronic breathlessness interventions should target the patient and the carer, both together and separately to address their common and individual needs.

TRIAL REGISTRATION

The main trial is registered (registration no. NCT02720822; posted March 28, 2016).

Breathlessness, Anxiety, Depression, and Function-The BAD-F Study: A Cross-Sectional and Population Prevalence Study in Adults

CONTEXT

Breathlessness is associated with depression, but its relationship to anxiety or impaired function is less clear.

OBJECTIVES

This study evaluated associations between chronic breathlessness and anxiety, depression, and functional status in the general population.

METHODS

This cross-sectional study of consenting adults (18 years and older) used an online survey. Quota sampling (n = 3000) was used reflecting the 2016 national census for sex, age, and place of residence. Other data included Four-Item Patient Health Questionnaire for depression and anxiety, the modified Medical Research Council (mMRC) Breathlessness Scale, and the Australia-modified Karnofsky Performance Scale. Multinomial logistic regression assessed predictors.

RESULTS

About 2977 respondents had all relevant scores (female 51.2%; median age 45.0 [range 18-92]). Prevalence of breathlessness (mMRC ≥2) was 2.4%, anxiety 6.0%, depression 2.7%, coexisting anxiety/depression 6.1%, and poorer functional status (Australia-modified Karnofsky Performance Scale ≤60) 1.6%. In multinomial regression, depression, anxiety, and coexisting anxiety/depression were predicted by younger age, longer duration of breathlessness, and poorer functional status. The highest proportions of people with breathlessness were found in the coexisting anxiety/depression group (10.6%) and depression only group (8.8%). Poorest function was in the coexisting anxiety/depression group with 11.6%. The relationship between poorer functional status and coexisting anxiety/depression was significant (odds ratio 0.90; 95% CI 0.89, 0.92). Adjusted odds ratio for breathlessness and depression only was 3.0 (95% CI 1.2, 7.8).

CONCLUSION

Clinically important breathlessness (mMRC ≥2) was associated with depression, anxiety, and coexisting anxiety/depression. Poorer function that is associated with psychological morbidity in the general population requires further research.

Living with chronic obstructive pulmonary disease: A story conditioned by the symptoms

OBJECTIVE

To determine the meaning of the experience of people with chronic obstructive pulmonary disease.

METHOD

A qualitative approach study rooted in hermeneutic phenomenology. In-depth interviews were conducted with 10 people with critical and severe chronic obstructive pulmonary disease.

RESULTS

The findings obtained are described in three emerging topics and their consequent subtopics, which describe the process of the disease focusing on five subtopics related to awareness of the disease, the choking characteristic of the disease and tiredness as daily unpleasant symptoms, as well as choking as a death threat, rejection of oxygen dependency and coping systems to control the disease. In the second topic, family support with two subtopics are described: the loss of the patient's role, the burden of care; and the third topic concerns the support of health system on two subtopics: medical care and nursing care.

CONCLUSION

The symptoms and functional changes in general, denote a different meaning not only in everyday life, but also in times of exacerbation of the condition. Likewise, changes in lifestyle due to the loss of roles and health care processes are revealed, as experiences that do not allow effective coping and adaptation.

Effects of the health belief model following acute exacerbation of chronic obstructive pulmonary disease in a hospital in China

Background

This study aims to investigate the effects of education with health belief model (HBM) on anxiety and fatigue among patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

Methods

Patients with AECOPD admitted into Taizhou People's Hospital, Jiangsu, China between December 2012 and October 2013 were randomly selected for the present study according to random number table. A total of 99 cases with anxiety were included. These patients were divided into two groups: experimental group educated by HBM (n=47), and control group educated by conventional method (n=52). The scores for anxiety and fatigue were evaluated using the self-rating anxiety scale (SAS) and multidimensional fatigue inventory (MFI-20).

Results

After educational intervention by HBM, patients achieved a significant decrease in anxiety and fatigue scores, when compared to patients in the control group, who were educated by the conventional method at the time of admission, discharge, and 6 weeks after discharge (P<0.05).

Conclusions

HBM program effectively may alleviate anxiety and fatigue, providing necessary information for symptom management among patients with AECOPD.

Incorporating Household Spillovers in Cost Utility Analysis: A Case Study Using Behavior Change in COPD

OBJECTIVES

It is important to capture all health effects of interventions in cost-utility analyses conducted under a societal or healthcare perspective. However, this is rarely done. Household spillovers (health effects on patients' other household members) may be particularly likely in the context of technologies and interventions to change behaviors that are interdependent in the household. Our objective was to prospectively collect outcome data from household members and illustrate how these can be included in a cost-utility analysis of a behavior change intervention in chronic obstructive pulmonary disease (COPD).

METHODS

Data were collected from patients' household members (n = 153) alongside a randomized controlled trial of a COPD self-management intervention. The impact of the intervention on household members' EQ-5D-5L scores (primary outcome), was evaluated. Analyses were then carried out to estimate household members' quality-adjusted life-years (QALYs) and assess the impact of including these QALYs on cost-effectiveness.

RESULTS

The intervention had a negligible spillover on household members' EQ-5D-5L scores (-0.007; p = .75). There were also no statistically significant spillovers at the 5 percent level in household member secondary outcomes. In the base-case model, the inclusion of household member QALYs in the incremental cost-effectiveness ratio (ICER) denominator marginally increased the ICER from GBP 10,271 (EUR 13,146) to GBP 10,991 (EUR 14,068) per QALY gained.

CONCLUSIONS

This study demonstrates it is feasible to prospectively collect and include household members' outcome data in cost utility analysis, although the study highlighted several methodological issues. In this case, the intervention did not impact significantly on household members' health or health behaviors, but inclusion of household spillovers may make a difference in other contexts.

Searching for "transformative moments": A qualitative study of nurses' work during home visits to COPD patients and their caregivers in Norway

AIM

The integration of families into healthcare services is being emphasized increasingly in healthcare polices. The aim of this study was to investigate how professionals during home visits support both patients and caregivers in accepting and accommodating to illness.

DESIGN

An explorative qualitative design.

METHODS

Participant observations from home visits (N = 20) of pulmonary ambulatory nurses to COPD patients in Norway, followed by interviews with these nurses.

RESULTS

Our findings demonstrate the delicate nature of nurses' work during home visits to COPD patients and their caregivers. They support both patients and caregivers in reconciling themselves with the negative consequences of illness, as well as giving legitimation to and potential room for, sustainable arrangements within the scope of the relationship. The nurses address significant issues, having transformative potential concerning attitudes and practices related to the management of illness and adjusting to a complex illness trajectory.

Involving relatives in consultations for patients with long-term illnesses: Nurses and physicians' experiences

BACKGROUND

Due to the major changes occurring in the demographic composition of the world's population, the number of older individuals is increasing, which puts pressure on the healthcare systems in many different countries. The involvement of volunteers and family members may become necessary to fulfil a patient's needs for follow-up treatments and long-term care in their homes.

AIM

This study aimed to explore how nurses and physicians experienced and addressed ethical challenges when they dealt with relatives in what have traditionally been one-on-one consultations at two Norwegian hospital outpatient clinics.

RESEARCH DESIGN AND METHODS

A total of eight nurses and two physicians from two different hospitals participated in individual in-depth interviews. The transcribed interviews were analysed using an eclectic approach called 'bricolage' inspired by Kvale and Brinkmann. We combined cross-case thematic and theoretical normative analyses.

ETHICAL CONSIDERATIONS

The principles of voluntariness, confidentiality, withdrawal and anonymity were respected throughout the research process. In addition, the Norwegian Social Science Data Services approved this study.

FINDINGS

The findings showed that respect for a patient's autonomy was used as an argument for delimiting the relatives' access to the patient's consultations. We found that there were insufficient routines in place for inviting and involving relatives in the patient consultations in the outpatient clinics.

DISCUSSION

The traditional Western attitudes towards the principles of patient autonomy will likely be challenged due to the growing need for family involvement in the care of a patient in the future.

CONCLUSION

This study's description of the nurses and physicians' interpretations of 'patient autonomy' as a phenomenon uncover the need for systematic ethical deliberation in the clinical setting. On an organisational level, there is a strong indication of the need to discuss the routines that are in place to invite the next of kin to participate in such patient's healthcare consultations.

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.

COPD stands for complex obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) has extensively been reported as a complex disease affecting patients' health beyond the lungs with a variety of intra- and extrapulmonary components and considerable variability between individuals. This review discusses the assessment of this complexity and underlines the importance of transdisciplinary management programmes addressing the physical, emotional and social health of the individual patient.COPD management is challenging and requires advanced, sophisticated strategies meeting the patient's individual needs. Due to the heterogeneity and complexity of the disease leading to non-linear and consequently poorly predictable treatment responses, multidimensional patient profiling is crucial to identify the right COPD patient for the right treatment. Current methods are often restricted to general, well-known and commonly used assessments neglecting potentially relevant (interactions between) individual, unique "traits" to finally ensure personalised treatment. Dynamic, personalised and holistic approaches are needed to tackle this multifaceted disease and to ensure personalised medicine and value-based healthcare.

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.

Assessing carer needs in chronic obstructive pulmonary disease

Informal carers play a key role in supporting patients with chronic obstructive pulmonary disease (COPD), particularly when disease is advanced. They also enable delivery of healthcare professional advice. There is a well-established impact of the caring role on carers in both the generic and COPD-specific literature. The needs of carers of patients with COPD are both generic to the caring role and disease specific. Healthcare professionals and health systems supporting patients with COPD need to actively identify and support carers. Carer assessment enables unmet needs to be identified and appropriately addressed. Assessments should consider carers' support needs, their caring capacity and practices, and carers own clinical needs. This narrative review outlines considerations for the assessment process including what should be assessed, who should conduct assessment and what should happen as a result of assessment.

Patients' and their family members' experiences of participation in care following an acute exacerbation in chronic obstructive pulmonary disease: A phenomenological-hermeneutic study

AIM AND OBJECTIVES

To explore the experiences of patients with chronic obstructive pulmonary disease and their family members relating both to participation in care during hospitalisation for an acute exacerbation in chronic obstructive pulmonary disease, and to the subsequent day-to-day care at home.

BACKGROUND

When recovering from an exacerbation, the challenges associated with an unpredictable health condition dominate everyday life for patients and can involve their family members. Proper patient and family participation in care during discharge and follow-up can help patients to improve self-management. However, knowledge of the significance of patient and family participation for recovery and subsequent everyday life is still limited.

DESIGN

This study adopted a longitudinal design informed by ethnographic fieldwork principles.

METHODS

Participant observations and interviews with 15 patients and 12 family members were conducted on a Danish hospital ward and twice at the participants' homes. A phenomenological-hermeneutic approach inspired by Ricoeur's theory of interpretation guided the data analysis.

RESULTS

Participation in care was perceived as valuable, but could be associated with tensions and increased uncertainty. While patients mostly demonstrated a reactive approach to care, family members strived to be more proactive. In hospital, preparing for discharge included an effort to find a balance between powerlessness and influence during interactions with healthcare professionals. At home, managing further recovery and self-management were characterised by navigating between mutual pressure and consideration within the family.

CONCLUSION

Family members play an important role in ensuring that patients are seen, heard and understood, but want to be acknowledged more by healthcare professionals. Appropriate interactions with healthcare professionals are crucial in order to support discharge and daily self-management.

RELEVANCE TO CLINICAL PRACTICE

Knowledge of the challenges that patients with chronic obstructive pulmonary disease and their family members face in participating in care activities could inform future development of family-centred care approaches tailored to individual needs.

Impacts of COPD on family carers and supportive interventions: a narrative review

Caring for a relative with chronic disease influences multiple dimensions of family carers' lives. This study aimed to provide an overview of the impacts of chronic obstructive pulmonary disease (COPD) on family carers and identify interventions aimed at supporting them. A narrative review was conducted. Searches were performed in electronic databases using a combination of keywords. Articles were screened for relevance and selected articles were analysed in two groups considering the study aims. Eighteen articles were selected. Fifteen studies evaluated the impacts of COPD on family carers and three studies presented interventions aimed at supporting them. Carers reported negative impacts of caring on physical health, emotional, social, relational and financial/employment life dimensions. Positive aspects of care-giving were reported in four studies and were related to carers' personal growth and satisfaction in being able to do something useful for their relatives. The existing interventions were directed at both patients and carers; however, studies provided limited information on how carers were involved, hindering the interpretation of findings. In conclusion, COPD poses several unique challenges to family carers related to the specificities of the disease. Further research with appropriate intervention studies is needed to promote carers' healthy adjustment to the disease.

Resilience as a concept for understanding family caregiving of adults with Chronic Obstructive Pulmonary Disease (COPD): an integrative review

Aims

This paper was a report of the synthesis of evidence on examining the origins and definitions of the concept of resilience, investigating its application in chronic illness management and exploring its utility as a means of understanding family caregiving of adults with Chronic Obstructive Pulmonary Disease.

Background

Resilience is a concept that is becoming relevant to understanding how individuals and families live with illness, especially long‐term conditions. Caregivers of adults with Chronic Obstructive Pulmonary Disease must be able to respond to exacerbations of the condition and may themselves experience cognitive imbalances. Yet, resilience as a way of understanding family caregiving of adults with COPD is little explored.

Design

Literature review – integrative review.

Data sources

CINAHL, PubMed, Google Scholar and EBSCO were searched between 1989–2015.

Review methods

The principles of rapid evidence assessment were followed.

Results

We identified 376 relevant papers: 20 papers reported the presence of the concept of resilience in family caregivers of chronic diseases patients but only 12 papers reported the presence of the concept of resilience in caregivers of Chronic Obstructive Pulmonary Disease patients and have been included in the synthesis. The term resilience in Chronic Obstructive Pulmonary Disease caregiving is most often understood using a deficit model of health.

The experience of couples being given an oxygen concentrator to use at home: A longitudinal interpretative phenomenological analysis

This longitudinal study explores the lived experience of four couples where one person from each couple is prescribed an oxygen concentrator to use at home. Transcripts were analysed using interpretative phenomenological analysis. The findings reported here focus on two super-ordinate themes: ‘the journey of acceptance’ and ‘negotiating changing relationships’. Participants described a gradual process of accepting the device into their lives, the impact on couple’s relationships and the role that expectations have in mediating that process. These themes suggest that patient education that considers the psychological and social issues may prove useful in facilitating the acceptance process.

Informal caregivers of patients with COPD: Home Sweet Home?

The burden of chronic obstructive pulmonary disease (COPD) on society is increasing. Healthcare systems should support patients with COPD in achieving an optimal quality of life, while limiting the costs of care. As a consequence, a shift from hospital care to home care seems inevitable. Therefore, patients will have to rely to a greater extent on informal caregivers. Patients with COPD as well as their informal caregivers are confronted with multiple limitations in activities of daily living. The presence of an informal caregiver is important to provide practical help and emotional support. However, caregivers can be overprotective, which can make patients more dependent. Informal caregiving may lead to symptoms of anxiety, depression, social isolation and a changed relationship with the patient. The caregivers' subjective burden is a major determinant of the impact of caregiving. Therefore, the caregiver's perception of the patient's health is an important factor. This article reviews the current knowledge about these informal caregivers of patients with COPD, the impact of COPD on their lives and their perception of the patient's health status.

Psychometric properties of an instrument to measure family disease management

An instrumental study of 392 households with sick or disabled members was conducted to analyze the psychometric properties of the Family Disease Management Scale. Three different models were analyzed using the Confirmatory Factor Analysis (CFA). One was a single-dimensional factor (family disease management) with 30 items; and two hierarchical models with three factors, which represent the dimensions, family support, family normalization and family participation, that placed the workload into another of higher order called family disease management, the first with 30 items and the second with 29. The CFA results showed that the latter 29-item model provided a better fit. The internal consistency analysis using the Cronbach alpha test showed a value of .93 for the complete scale and above .80 in the three subscales. This instrument may be useful to assess how families manage the illness or disability of its members, especially in clinical practice given the importance of the family as the primary caregiver. As well as in performing epidemiological studies, and in the field of management, planning and assistance.

Family-based psychosocial support and education as part of pulmonary rehabilitation in COPD: a randomized controlled trial

BACKGROUND

Involving family as part of the patient's rehabilitation plan of care might enhance the management of COPD. The primary aim of this study was to investigate the impact of a family-based pulmonary rehabilitation (PR) program on patients and family members' coping strategies to manage COPD.

METHODS

Family dyads (patient and family member) were randomly assigned to family-based (experimental) or conventional (control) PR. Patients from both groups underwent exercise training three times a week and psychosocial support and education once a week, during 12 weeks. Family members of the family-based PR attended the psychosocial support and education sessions together with patients. In the conventional PR, family members did not participate. Family coping and psychosocial adjustment to illness were assessed in patients and family members of both groups. Patients' exercise tolerance, functional balance, muscle strength, and health-related quality of life were also measured. All measures were collected pre/post-program.

RESULTS

Forty-two dyads participated (patients: FEV1, 70.4% ± 22.1% predicted). Patients (P = .048) and family members (P = .004) in the family-based PR had significantly greater improvements in family coping than the control group. Family members of the family-based PR had significantly greater changes in sexual relationships (P = .026) and in psychologic distress (P = .033) compared with the control group. Patients from both groups experienced significant improvements in exercise tolerance, functional balance, knee extensors strength, and health-related quality of life after intervention (P < .001).

CONCLUSIONS

This research supports family-based PR programs to enhance coping and psychosocial adjustment to illness of the family system.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT02048306; URL: www.clinicaltrials.gov.

Self-management in patients with COPD: theoretical context, content, outcomes, and integration into clinical care

In this narrative review, we put self-management in the context of a 50-year history of research about how patients with COPD respond to their illness. We review a definition of self-management, and emphasize that self-management should be combined with disease management and the chronic care model in order to be effective. Reviewing the empirical status of self-management in COPD, we conclude that self-management is part and parcel of modern, patient-oriented biopsychosocial care. In pulmonary rehabilitation programs, self-management is instrumental in improving patients' functional status and quality of life. We conclude by emphasizing how studying the way persons with COPD make sense of their illness helps in refining self-management, and thereby patient-reported outcomes in COPD.