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Oda S, Kawakami A, Ashida K, Tanaka M. Death rattle: palliative nursing practices Delphi study. BMJ Support Palliat Care 2024:spcare-2024-004887. [PMID: 38565275 DOI: 10.1136/spcare-2024-004887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/17/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES Interventions for patients with death rattle remain under consideration, and their families strongly acknowledge the need for improved care. However, few reports exist concerning specific and comprehensive nursing practices for them. This study aimed to clarify nursing practices for patients with death rattle and their families in hospital wards and examine each practice's importance. METHODS We used a modified Delphi method with expert nurses with extensive experience in end-of-life care. Participants were recruited using convenience and snowball sampling. First, we developed a list of nursing practices through a literature review and individual interviews. Second, we conducted the Delphi survey. Two rounds of judging were performed. Items were rated on a 9-point Likert scale (1=not important at all to 9=very important). An item was considered 'important' if at least 80% of the participants rated it ≥7. RESULTS The list comprised 40 items across 8 domains: assessment of death rattle and the distress felt by the patients, oral care, repositioning, adjustment of parenteral hydration, suctioning, administration of alleviating medications, communication with and assessment of family members who witness death rattle, and nurse's attitude towards death rattle and the relevant interventions. Of the 46 recruited experts, 42 participated in both rounds. Participants regarded 37 of the 40 items as important. CONCLUSIONS This study specifically and comprehensively identified nursing practices for patients with death rattle and their families using a modified Delphi method to support clinical nursing practice and improve the quality of care.
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Affiliation(s)
- Sumika Oda
- Department of Adult Health Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Japan
| | - Aki Kawakami
- Department of Adult Health Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Japan
| | - Kaoru Ashida
- Department of Nursing, Kanto Gakuin University, Yokohama, Japan
| | - Makoto Tanaka
- Department of Adult Health Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Japan
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Hirsch C, Hall E, Shah F, Tomas J. Attitudes of ward nurses towards the administration of ‘as required’ injectable medications for symptom control at the end of life. Int J Palliat Nurs 2022; 28:522-530. [DOI: 10.12968/ijpn.2022.28.11.522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background: It is recognised good practice to prescribe ‘as required’ parenteral medication (ARPM) to provide individualised symptom control in the final days of life. The decision to administer the medication and, sometimes, to decide the dose, usually lies with the nurse. Aims: To explore attitudes towards administration of ARPM at end of life (EOL) among hospital nurses. Methods: The views of registered nurses, recruited from wards with high death rates, were explored through questionnaires and semi-structured interviews. Questionnaire responses were coded and statistically analysed. Interviews were recorded, transcribed, manually coded and thematically analysed. Results: Almost 50% of questionnaire respondents (n=62) reported feeling ‘very confident’ in recognising symptoms at the EOL. Only 39% of respondents reported undertaking specific training. Three main themes emerged through the interviews: experience; factors influencing the decision to administer ARPM; and education. Conclusion: Wider accessibility to training may support confident decision making by hospital nurses administering ARPM at the EOL.
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Affiliation(s)
- Christine Hirsch
- Associate Professor, School of Pharmacy, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Elke Hall
- Pharmacy Student, School of Pharmacy, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Fatimah Shah
- Pharmacy Student, School of Pharmacy, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Jon Tomas
- Palliative and Supportive Care Consultant, University Hospitals Birmingham NHS Foundation Trust, UK
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Hendry A, Hiscock J, Evans E, Turner B, Pottle J, Wilkinson C, Poolman M. The juxtaposition of the natural and the medical perspectives in noisy breathing at the end of life. Int J Palliat Nurs 2022; 28:72-79. [PMID: 35446669 DOI: 10.12968/ijpn.2022.28.2.72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Noisy breathing is common at the end of life. Management of noisy breathing aims to reduce the noise via repositioning the person, suctioning the person's airways and using antimuscarinic drugs. Dying people are generally thought not to be distressed by noisy breathing at the end of life, but the noise may distress others. There is doubt on whether antimuscarinic drugs are any more effective than a placebo for noisy breathing. However, antimuscarinics are still commonly administered to people at the end of life. AIM To illuminate reasons behind decision making and noisy breathing at the end of life. METHODS Semi-structured interviews and 'self-recorded brief accounts' with healthcare professionals. FINDINGS Noisy breathing at the end of life is viewed as both a natural and a medical phenomenon. However, while most participants in the interviews thought that antimuscarinics were uneffective, the prescription and administration of antimuscarinics were embedded within professional culture. CONCLUSION Managing noisy breathing is a complex issue that incorporates natural and medical viewpoints and has a long-standing culture of practice. Research should aim to determine best practice and reduce a person's distress at the end of life.
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Affiliation(s)
- Annie Hendry
- Research officer, Bangor Institute for Health and Medical Research (BIHMR), Bangor University
| | - Julia Hiscock
- Research fellow, Betsi Cadwaladr University Health Board (BCUHB)
| | | | - Bethany Turner
- Palliative care doctor, Nightingale House Hospice, Specialist Palliative Care, Wrexham
| | | | | | - Marlise Poolman
- Palliative care consultant, BIHMR, Bangor University; Nightingale House Hospice, Specialist Palliative Care, Wrexham
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Matsunuma R, Suzuki K, Matsuda Y, Mori M, Watanabe H, Yamaguchi T. Palliative care physicians' perspectives of management for terminally ill cancer patients with death rattle: a nationwide survey. Jpn J Clin Oncol 2020; 50:830-833. [PMID: 32419027 DOI: 10.1093/jjco/hyaa044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/14/2020] [Accepted: 12/12/2019] [Indexed: 11/14/2022] Open
Abstract
Death rattle occurs during the last days of life, and relatives of those afflicted frequently report that it is very distressful. However, there is no effective treatment for it. The purpose of this study was to investigate the perceptions of Japanese palliative care physicians in clinical practice in Japan. We conducted a nationwide survey of 268 physicians via an anonymous, self-report questionnaire. We assessed pharmacological and non-pharmacological management and anticholinergic agent choice. One hundred eighty-nine physicians (70.5%) returned the questionnaires. Fifty-five participants (29.1%) treating patients with Type-1 (real death rattle) and 36 participants (19%) treating patients with Type-2 (pseudo-death rattle) death rattle reported that they would frequently administer an anticholinergic agent. One-fourth would administer scopolamine butylbromide or scopolamine hydrobromide. In conclusion, more Japanese palliative care physicians thought that anticholinergic agents might be effective for treating Type-1 death rattle rather than Type-2. Further clinical trials of these agents are needed.
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Affiliation(s)
- Ryo Matsunuma
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kozue Suzuki
- Department of Palliative Care, Tokyo Metropolitan Cancer, and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Hiroaki Watanabe
- Department of Palliative Care, Komaki City Hospital, Komaki, Japan
| | - Takashi Yamaguchi
- Division of Palliative Care, Department of Medicine, Konan Hospital, Kobe, Japan
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Kolb H, Snowden A, Stevens E, Atherton I. A retrospective medical records review of risk factors for the development of respiratory tract secretions (death rattle) in the dying patient. J Adv Nurs 2018; 74:1639-1648. [DOI: 10.1111/jan.13704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2018] [Indexed: 11/29/2022]
Affiliation(s)
| | - Austyn Snowden
- School of Health and Social Care; Napier University; Edinburgh UK
| | - Elaine Stevens
- School of Health Nursing and Midwifery; University of the West of Scotland; Paisley UK
| | - Iain Atherton
- School of Health and Social Care; Napier University; Edinburgh UK
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Kolb H, Snowden A, Stevens E. Systematic review and narrative summary: Treatments for and risk factors associated with respiratory tract secretions (death rattle) in the dying adult. J Adv Nurs 2018; 74:1446-1462. [DOI: 10.1111/jan.13557] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 02/15/2018] [Indexed: 11/29/2022]
Affiliation(s)
| | - Austyn Snowden
- School of Health and Social Care; Edinburgh Napier University; Edinburgh UK
| | - Elaine Stevens
- Adult Health; University of the West of Scotland; Paisley UK
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Kouladjian L, Gnjidic D, Reeve E, Chen TF, Hilmer SN. Health Care Practitioners’ Perspectives on Deprescribing Anticholinergic and Sedative Medications in Older Adults. Ann Pharmacother 2016; 50:625-36. [DOI: 10.1177/1060028016652997] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Anticholinergic and sedative (ACh-Sed) medications are commonly prescribed for older adults and are associated with adverse events. Objectives: (1) To investigate perspectives of health care practitioners (HCPs) surrounding deprescribing (withdrawal) of ACh-Sed medications in older adults; (2) to assess HCPs’ perspectives on the design and implementation of a report on a patient’s exposure to ACh-Sed medications using the Drug Burden Index (DBI) pharmacological tool. Methods: This was a qualitative study using focus groups with purposive samples of accredited pharmacists (APs), general practitioners (GPs), and specialist physicians (SPs). Participants were also asked to comment on a sample DBI report of a hypothetical patient and its potential role in practice. The discussions were audiorecorded, transcribed verbatim, and thematically analyzed to derive conceptual domains. QSR NVivo Version 10 was used for data management. Results: Several barriers and enablers to deprescribing ACh-Sed medications in older adults were identified. The most noteworthy barrier to deprescribing related to devolving responsibility. Predominantly, APs expressed frustration surrounding disregard by GPs of their recommendations to deprescribe medications. GPs expressed that deprescribing should be conducted by SPs and vice versa. The DBI report supported and addressed some of the identified barriers to deprescribing ACh-Sed medications in older adults. The HCPs also identified several opportunities and considerations for implementing the DBI report in practice, mainly highlighting that ACh-Sed medications are not the only high-risk medications for older people. Conclusions: Although HCPs recognize the harms associated with ACh-Sed medication use, they devolve prescribing and management responsibility to other groups of HCPs.
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Affiliation(s)
- Lisa Kouladjian
- Kolling Institute of Medical Research, St Leonards, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Danijela Gnjidic
- Kolling Institute of Medical Research, St Leonards, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Faculty of Pharmacy, University of Sydney, Sydney, NSW, Australia
| | - Emily Reeve
- Kolling Institute of Medical Research, St Leonards, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine, Dalhousie University, Nova Scotia, Canada
| | - Timothy F. Chen
- Faculty of Pharmacy, University of Sydney, Sydney, NSW, Australia
| | - Sarah N. Hilmer
- Kolling Institute of Medical Research, St Leonards, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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Abstract
There has been a paradigm shift in medicine away from tradition, anecdote and theoretical reasoning from the basic sciences towards evidence-based medicine (EBM). In palliative care however, statistically significant benefits may be marginal and may not be related to clinical meaningfulness. The typical treatment vs. placebo comparison necessitated by ‘gold standard’ randomised controlled trials (RCTs) is not necessarily applicable. The complex multimorbidity of end of life care involves considerations of the patient’s physical, psychological, social and spiritual needs. In addition, the field of palliative care covers a heterogeneous group of chronic and incurable diseases no longer limited to cancer. Adequate sample sizes can be difficult to achieve, reducing the power of studies and high attrition rates can result in inadequate follow up periods. This review uses examples of the management of cancer-related fatigue and death rattle (noisy breathing) to demonstrate the current state of EBM in palliative care. The future of EBM in palliative care needs to be as diverse as the patients who ultimately derive benefit. Non-RCT methodologies of equivalent quality, validity and size conducted by collaborative research networks using a ‘mixed methods approach’ are likely to pose the correct clinical questions and derive evidence-based yet clinically relevant outcomes.
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Affiliation(s)
- Claire Visser
- 1 Harris Manchester College, University of Oxford, Oxford OX3 9DU, UK ; 2 Sir Michael Sobell House, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK
| | - Gina Hadley
- 1 Harris Manchester College, University of Oxford, Oxford OX3 9DU, UK ; 2 Sir Michael Sobell House, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK
| | - Bee Wee
- 1 Harris Manchester College, University of Oxford, Oxford OX3 9DU, UK ; 2 Sir Michael Sobell House, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK
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Abstract
This article updates the 2002 Jamie von Roenn article about "the palliation of commonly observed symptoms in older patients, including pain, neuropsychiatric, gastrointestinal, and respiratory symptoms." When palliative care was last covered in Clinics in Geriatric Medicine, President George W. Bush had just signed the No Child Left Behind Act, Homeland Security was being established, Michael Jackson won the Artist of the Century Award at the American Music Awards, and gas cost $1.61 a gallon. What has changed in the last decade and a half?
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Affiliation(s)
- Thomas J Smith
- Palliative Medicine, Johns Hopkins Medical Institutions, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, Blalock 369, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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Affiliation(s)
- Claire Nunn
- Acute oncology clinical nurse specialist and nurse independent prescriber
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12
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Bükki J. Family needs regarding death rattle: commentary on Shimizu et al. J Pain Symptom Manage 2014; 48:1. [PMID: 25105855 DOI: 10.1016/j.jpainsymman.2014.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 05/23/2014] [Indexed: 11/23/2022]
Affiliation(s)
- Johannes Bükki
- Endowed Professorship for Interdisciplinary Research in Palliative Care, Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria; and Hospice Care DaSein, Munich, Germany.
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Mercadamte S. Death rattle: critical review and research agenda. Support Care Cancer 2013; 22:571-5. [PMID: 24253734 DOI: 10.1007/s00520-013-2047-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 10/31/2013] [Indexed: 10/26/2022]
Abstract
The aim of this critical review was to assess the literature regarding the treatment of death rattle at the end of life to provide an update information regarding this difficult issue. To provide suggestions for future research agenda, the approach was analytic and based on clinical considerations, rather than on raw evidence only. Both published and unpublished reports from an extensive search of electronic databases. Any randomized-controlled trial or clinical reports with a significant number of patients was considered. Eleven reports fulfilled the inclusion criteria in this systematic review. Four controlled studies, four comparative audits, and three clinical reports with a significant number of patients were selected. Despite anticholinergic or antimuscarinic medications are the drugs of choice in practice, there is a lack of supporting evidence for the use of anticholinergics to treat death rattle. Regardless of the methodological limitations of existing studies, an a priori observation was missed. Most studies were performed with the intent to treat rather than to prevent death rattle. However, from a pharmacological perspective, anticholinergic agents are unable to reduce the secretions once they are formed, but may just limit a further production. In conclusion, studies on the use of antisecretive agents provided only minor evidence of efficacy, ultimately raising questions about the routine inclusion of anticholinergic treatment in end of life pathways for the treatment of death rattle. However, this observation could be confuted by the use of these same drugs used earlier in a prophylactic perspective, in the context of a comprehensive management of the dying patients.
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Affiliation(s)
- Sebastiano Mercadamte
- Anesthesia & intensive Care & Pain Relief and Supportive Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy,
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Recent LiteratureFeature Editor: Paul C. Rousseau. J Palliat Med 2013. [DOI: 10.1089/jpm.2013.9466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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