COPD at the end of life: Predictors of the emotional distress of patients and their family caregivers

Understanding the Unmet Needs, Experiences, and Perspectives of COPD Caregivers: A Scoping Review

Chronic Obstructive Pulmonary Disease (COPD) poses significant challenges, not only to patients but also to their caregivers, who often experience substantial unmet needs, stress, and emotional burdens. This scoping review synthesizes existing literature to understand the experiences, perspectives, and challenges faced by caregivers of COPD patients. A comprehensive search of multiple databases was conducted, focusing on studies addressing unmet needs, psychological experiences, and the day-to-day realities of caregivers. The review reveals that COPD caregivers frequently encounter inadequate support, insufficient information, and heightened emotional and physical strain. These factors contribute to negative mental health outcomes, including anxiety, depression, and caregiver burnout. Moreover, the review highlights the disparity in care and support services across different healthcare settings, with a particular emphasis on the need for targeted interventions that address the unique challenges of COPD caregiving. The findings underscore the importance of integrating caregivers' needs into COPD management plans and the development of policies that recognize and support their role. The review concludes with recommendations for future research to fill existing gaps in the literature and for healthcare providers to implement strategies that enhance caregiver well-being, thereby improving overall patient care.

Grief and Psychopathology in Bereaved Caregivers of Palliative Care Patients: The Mediating and Moderating Roles of Distress, Burden and Social Support

AIM(S)

This study examines the mediating roles of distress, burden and social support, as well as the moderating effect of social support, in the relationship between the risk of prolonged grief and psychopathology in bereaved family caregivers of palliative care patients.

DESIGN

A cross-sectional study was conducted with 125 bereaved family caregivers. Validated assessment tools and the PROCESS macro in SPSS were used for mediation and moderation analyses.

RESULTS

Emotional burden mediated the relationship between prolonged grief risk and psychopathology, while distress and physical burden did not. Instrumental social support was a key mediator, highlighting the protective role of practical assistance, whereas emotional social support did not show significant mediation. Both types of social support moderated the relationship, buffering the negative impact on mental health.

CONCLUSIONS

Findings underscore the complex interactions between bereavement risk factors and psychopathology. Addressing emotional burden and enhancing social support may help reduce mental health risks in bereaved caregivers.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Healthcare professionals in palliative care should implement targeted interventions to reduce burden and strengthen support systems for bereaved caregivers. Nursing-led initiatives focused on emotional burden reduction may mitigate psychopathology risks.

IMPACT

Findings are relevant for healthcare professionals in palliative care and those designing interventions for bereaved caregivers. Emotional burden mediated the relationship between prolonged grief and psychopathology, while instrumental and emotional social support moderated its effects.

REPORTING METHOD

This study adhered to STROBE guidelines for cross-sectional research.

PATIENT OR PUBLIC CONTRIBUTION

Beyond caregiver participation in data collection, patients and healthcare professionals contributed to study design, protocol development and dissemination.

Understanding and addressing factors affecting carers' mental health during end-of-life caregiving: synopsis of meta synthesis of literature and stakeholder collaboration

Background

Family carers provide crucial support to patients nearing end of life. This can affect carers' own mental health negatively. It is important to understand what factors may affect carers' mental health and convey this information to stakeholders who can effect change. We conducted reviews of the qualitative, observational and intervention carer literature and worked with carer advisors and other stakeholders to make findings useful and accessible.

Aim of the synopsis

To provide a synopsis of (1) project methods, (2) findings and implications from the evidence syntheses, (3) outcomes of our carer Review Advisory Panel collaboration and (4) feedback from wider stakeholder consultation.

Method

Searches of MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycInfo, Social Sciences Citation Index, EMBASE, Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effects 1 January 2009-24 November 2019. Studies included adult family carers for adult patients at the end of life cared for at home, considering any factor related to carer mental health. Collaboration with the Review Advisory Panel over nine meetings helped map review findings into a framework, shape their presentation and create Review Advisory Panel recommendations. Four workshops, two discussion groups and a survey with stakeholders (carers/patients, practitioners and policy-makers/commissioners) informed output formats and suggested actions.

Results

Thirty-one qualitative, 60 observational, 12 intervention and 3 mixed-methods studies were identified. Factors associated with carer mental health were: (1) patient condition, mainly psychological symptoms and quality of life; (2) impact of caring responsibilities, mainly life changes, workload and carer burden; (3) relationships, particularly carer-patient; (4) finances, whether sufficient; (5) internal processes, particularly self-efficacy; (6) support, particularly adequacy and quality; and (7) contextual factors, mainly age and gender. The Review Advisory Panel comprised five carers and a carer chair. They created recommendations for supporting carers based on syntheses findings, including: awareness raising for carers and practitioners; a road map to help carers navigate caregiving; bespoke carer support through carer assessment; assessment of patient's actual rather than 'managed' needs; co-ordinated care through a single contact point; addressing basic practical needs. Other key recommendations included holistic, co-ordinated patient care and cover of basic carer financial needs. Thirty-six stakeholders participated in workshops and discussion groups and 43 in the survey, to review synthesis findings and Review Advisory Panel recommendations. Stakeholders generally valued the qualitative evidence and recommendations over the quantitative evidence, although all outputs resonated with them. There was little consensus regarding where responsibility for carers may lie, pointing to a need for bespoke carer support roles. Some issues may require systemic-level changes.

Limitations

Findings are from Organisation for Economic Co-operation and Development country English-language publications on adult carers and patients within home care, and carer advisors and stakeholders were based in the United Kingdom, which may limit the transferability of findings.

Conclusions

Findings provide some clear indicators of factors affecting carer mental health and recommendations. Improvements may require investment in bespoke carer support roles (e.g. carer support nurses) and systemic change (e.g. improving carer identification and assessment, and financial security). Given the enormous contribution carers make to health and social care, they deserve such investment to support them in their work.

Funding

This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number 18/01/01.

Family bonds and personal factors in caregiver burden in patients at the end of life

Family caregivers are defined as those who assume substantial responsibilities for the care of an ill loved one without formal health care training. This study aims to analyze the predictors of physical and emotional burden in caregivers of palliative patients using qualitative comparative analysis methodologies (QCA) and taking into account patient and caregiver personal and relational variables. A total of 125 caregivers of patients at the end of life were assessed using an ad hoc emotional and physical burden questionnaire and patient and caregiver personal and relational variables were recorded. Results indicate moderately high levels of both emotional and physical burden. Differences in burden are found only as a function of kinship. Emotional burden is positively associated with the use of physical health medication in the caregiver and kinship; meanwhile, physical burden is positively associated with time since diagnosis, patient functional independence, and economic problems. For the QCA models, several pathways predict the observed variance in the emotional and physical burden of family caregivers of patients at the end of life, based on patient, caregiver, and relationship variables. In conclusion, it is relevant to design intervention programs focused on patient-caregiver relationship to prevent the development of emotional and physical burden.

Experiences of patients with advanced COPD affiliated to a cross-sectorial outgoing lung team: A qualitative study

AIM

To explore experiences of patients affiliated to a cross-sectorial outgoing lung team.

BACKGROUND

The outgoing lung team consisted of respiratory nurses from the hospital and community nurses. The lung team offered 24/7 help to patients with advanced chronic obstructive pulmonary disease (COPD) through visits and/or treatment in the patients' home. Affiliation to the lung team reduced both hospitalizations and length of hospital stay due to acute exacerbation of COPD. However, based on questionnaires on health-related quality of life, no significant differences were found between patients affiliated to the lung team and patients receiving usual care.

DESIGN

A qualitative interview study.

METHODS

In total, 16 patients, aged 61-88 years were interviewed between February 2019 and July 2021. They had been affiliated to the outgoing lung team for 1-3 years. Semi-structured interviews were conducted in the patients' home and audio-recorded after informed consent was obtained. The interviews were transcribed verbatim and analysed, inspired by systematic text condensation by Malterud.

FINDINGS

Four themes emerged from the analysis: (1) feeling safe, (2) improvements in living with COPD, (3) avoiding hospitalization and (4) satisfied with staying at home.

CONCLUSION

Affiliation to the cross-sectorial outgoing lung team gave the patients peace of mind and improved their ability to live with advanced COPD. The patients preferred contacting the lung team because they could stay at home and receive treatment, and thus avoid hospitalization.

IMPACT

The findings from this study support that municipalities should consider implementing an outgoing lung team, as it has the potential to bring several benefits, including improving patient self-management.

REPORTING METHOD

The manuscript adhered to Consolidated criteria for reporting qualitative research (COREQ) guideline.

PATIENT OR PUBLIC CONTRIBUTION

Patients were interviewed. Additionally, no patient or public contributed to the design or conduction of the study, analysis, or interpretation of the data.

Neuroticism as a moderator of symptom-related distress and depression in 4 noncancer end-of-life populations

OBJECTIVES

Neuroticism is a significant predictor of adverse psychological outcomes in patients with cancer. Less is known about how this relationship manifests in those with noncancer illness at the end-of-life (EOL). The objective of this study was to examine the impact of neuroticism as a moderator of physical symptoms and development of depression in patients with amyotrophic lateral sclerosis (ALS), chronic obstructive pulmonary disease (COPD), end-stage renal disease (ESRD), and frailty in the last 6 months of life.

METHODS

We met this objective using secondary data collected in the Dignity and Distress across End-of-Life Populations study. The data included N = 404 patients with ALS (N = 101), COPD (N = 100), ESRD (N = 101), and frailty (N = 102) in the estimated last 6 months of life, with a range of illness-related symptoms, assessed longitudinally at 2 time points. We examined neuroticism as a moderator of illness-related symptoms at Time 1 (∼6 months before death) and depression at Time 2 (∼3 months before death) using ordinary least squares regression.

RESULTS

Results revealed that neuroticism significantly moderated the relationship between the following symptoms and depression measured 3 months later: drowsiness, fatigue, shortness of breath, wellbeing (ALS); drowsiness, trouble sleeping, will to live, activity (COPD); constipation (ESRD); and weakness and will to live (frailty).

SIGNIFICANCE OF RESULTS

These findings suggest that neuroticism represents a vulnerability factor that either attenuates or amplifies the relationship of specific illness and depressive symptoms in these noncancer illness groups at the EOL. Identifying those high in neuroticism may provide insight into patient populations that require special care at the EOL.

Factors Associated With Mode of Separation for People With Palliative Diagnoses With Preference for Home Death Receiving Care From a Nurse-Led End of Life (Palliative Extended and Care at Home) Program

Palliative Extended and Care at Home (PEACH) is a rapid response nurse-led package of care mobilized for palliative care patients who have an expressed preference to die at home. This study aimed to identify the demographic and clinical predictors of home death for patients receiving the package. Deidentified data were used from administrative and clinical information systems. Univariate and multivariate analyses were conducted to assess association of sociodemographic factors with mode of separation. Furthermore, 1754 clients received the PEACH package during the study period. Mode of separation was home death (75.7%), hospital/palliative care unit admission (13.5%), and alive/discharged from the PEACH Program (10.8%). Of participants with clear preference to die at home, 79% met their wish. Multivariate analysis demonstrated cancer diagnosis, patients who wished to be admitted when death was imminent, and patients with undecided preference for location of death were associated with an increased likelihood of being admitted to the hospital. Compared with those with spousal caregivers, those cared for by their child/grandchild and other nonspouse caregivers were significantly associated with a decreased likelihood of being admitted to the hospital/palliative care unit. Our results show that opportunities to tailor home care based on referral characteristics to meet patient preference to die at home, at individual, system, and policy levels, exist.

Depression, anxiety and insomnia in Chinese older adults and their family caregivers during the COVID-19 pandemic: an actor-partner interdependence model approach

Aims

This study aimed to explore the dyadic effects of depression and anxiety on insomnia symptoms in Chinese older adults and their caregivers living in a community setting.

Methods

Data were collected from 1,507 pairs of older adults and their caregivers who were in the Guangdong Mental Health Survey in China. The 9-item Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder module 7 (GAD-7), and Insomnia Severity Index (ISI) were used to measure depression, anxiety, and insomnia symptoms. Actor-Partner Interdependence Models (APIM) were used to determine whether anxiety or depression symptoms predicted individual or dyadic insomnia.

Results

Older adults' and caregivers' depression and anxiety had significant positive correlations with their own and their caregivers' insomnia symptoms (all P < 0.001). Actor effects were found between depression and insomnia symptoms in both older adults and caregivers (B = 0.695, P < 0.001; B = 0.547, P < 0.001, respectively), with one significant partner effects (B = 0.080, P = 0.007). Actor effects were also found between anxiety and insomnia symptoms in both older adults and caregivers (B = 0.825, P < 0.001; B = 0.751, P < 0.001, respectively), with one significant partner effects (B = 0.097, P = 0.004). However, the caregivers' depression and anxiety were not associated with older adults' insomnia symptoms in the APIM analyses.

Conclusions

Older adults and their caregivers had an interrelationship between psychological distress and insomnia. Consequently, healthcare providers might consider involving dyads when designing programs to reduce insomnia and improve psychological distress for family caregivers.

PANDORA dyadic project: hope, spiritual well-being and quality of life of dyads of patients with chronic obstructive pulmonary disease in Switzerland - a multicentre longitudinal mixed-methods protocol study

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is responsible for 2.9 million deaths annually in Europe. Symptom burden and functional decline rise as patients reach advanced stages of the disease enhancing risk of vulnerability and dependency on informal caregivers (ICs).Evidence shows that hope is an important psycho-social-spiritual construct that humans use to cope with symptom burden and adversity. Hope is associated with increased quality of life (QoL) comfort and well-being for patients and ICs. A better understanding of the meaning and experience of hope over time as patients transition through chronic illness may help healthcare professionals to plan and deliver care more appropriately.

METHODS AND ANALYSIS

This is a longitudinal multicentre mixed-methods study with a convergent design. Quantitative and qualitative data will be collected from dyads of advanced COPD patients and their ICs in two university hospitals at two points in time. The Herth Hope Index, WHO Quality of Life BREF, Functional Assessment of Chronic Illness Therapy-Spiritual Well-being and the French version of the Edmonton Symptom Assessment Scale will be used to collect data. Dyadic interviews will be conducted using a semi-structured interview guide with five questions about hope and their relationship with QoL.Statistical analysis of data will be carried out using R V.4.1.0. To test whether our theoretical model as a whole is supported by the data, structural equation modelling will be used. The comparison between T1 and T2 for level of hope, symptom burden, QoL and spiritual well-being, will be carried out using paired t-tests. The association between symptom burden, QoL, spiritual well-being and hope will be tested using Pearson correlation.

ETHICS AND DISSEMINATION

This study protocol received ethical approval on 24 May 2022 from the Commission cantonale d'éthique de la recherche sur l'être humain-Canton of Vaud. The identification number is 2021-02477.

Sociodemographic and Clinical Variables Related to the Overburden of the Informal Caregivers of Patients Hospitalized for Chronic Obstructive Pulmonary Disease Exacerbations

Objective

To increase our knowledge of the patient variables related to the overburden of the caregivers of patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPDs).

Methodology

This was a cross-sectional study of patients with severe COPD who have informal caregivers. We performed a multivariate analysis of sociodemographic (economic situation, care, dependence, social risk, and use of social services) and clinical (degree of dyspnea, previous hospitalizations, disease impact, pulmonary function, and comorbidity) factors and related these to the burden of informal caregivers, as evaluated using the Zarit scale.

Results

The study included 91 patients, age 72.6±8.7 years and 80 were male (89.7%); the mean modified Medical Research Council dyspnea scale (mMRC) score was 2.5±0.8; mean FEV₁ was 39.5 ± 13.2%; and 70 patients (76.9%) were dependent for basic activities. Of the informal caregivers, 90 (90.9%) were women, 49 (49.4%) were partners or spouses, and 29 (29.6%) were daughters. The mean Zarit questionnaire score was 51.4±14.2, with 63 of carers (69.2%) perceiving some overburden, and 34 (37.4%) describing the overburden as mild–moderate. The variables related to informal caregiver overburden in the multivariate study were the previous use of social resources [OR = 8.1 (95% CI = 1.03–69.9); p = 0.04], degree of mMRC dyspnea 3–4 [OR =4.7 (95% CI = 1.7–13.2); p = 0.003], and two or more admissions for AEPOC in the previous year [OR = 4.5 (95% CI = 1.7–13.2); p = 0.003]. Of the informal caregivers of patients who had presented two or more of these variables, 92.3% perceived an overburden.

Conclusion

The variables associated with overburden are easily accessible in patient medical records, or can be obtained by interviewing patients or their relatives. This information would allow to detect and assess the overburden of informal caregivers to provide an early warning of this problem.