Enlightening chronic obstructive pulmonary disease through patients' and caregivers' narratives

Effects of multidisciplinary rehabilitation in a patient with Ehlers-Danlos and Behçet's syndromes: a paradigmatic case report according to the narrative medicine

PURPOSE

Narrative Medicine complements the clinically centered approach, which focuses on the analytical and sanitary aspects, with the illness- and disorder- centered models, which deal respectively, with personal coping and social perception of a condition. Hypermobile Ehlers- Danlos Syndrome and Behçet's Disease are two rare multisystemic chronic disease experienced a myriad of clinical symptoms, psychological distress, and poor quality of life. The purpose of this report is to describe application of a multidisclipinary rehabilitation intervention according to the narrative medicine.

CASE DESCRIPTION AND INTERVENTION

a 35-year-old woman with a 23-year history of Hypermobile Ehlers-Danlos Syndrome and Behçet's Disease was admitted. A multimodal rehabilitation approach was implemented and described through the patient's feelings and expected short-, medium-, and long- terms goals. Moreover, she reported her feeling with periodical interview by her therapist.

HISTORY PATIENT

The patient was seen for 32 weeks. A decreased pain, as well as improved function was recorded immediately post-intervention.

CONCLUSION

Narration is not just an interpretation of the illness experience, but the result of reshaping the interpretations of the story that both patient and health professional. This discipline provides enrichment of care, especially when combined with rehabilitation in chronic disease, by paying attention to and using even in the therapeutic phase the stories of patients, family and health care personnel, giving the opportunity to define a tailored effectiveness rehabilitation approach at the light of the different points of view of the subjects.

Pulmonary rehabilitation and family/friend caregivers: the hidden reciprocal relationship improving outcomes in chronic respiratory diseases

INTRODUCTION

The experiences and needs of living with chronic respiratory diseases (CRD) can be overwhelming. Individuals often rely on informal care for daily assistance and having a family/friend caregiver has been associated with better health outcomes. Nevertheless, family/friend caregivers frequently feel alone and unsupported. Pulmonary rehabilitation (PR) leads to multidimensional benefits across CRD and individuals have suggested improvements for PR. Family/friend caregivers highly support PR in practical and psychosocial ways and have identified this intervention as an opportunity to be supported. This reciprocal relationship between PR and the family/friend caregivers has been scarcely explored and its importance for the management of CRD is poorly understood.

AREAS COVERED

This perspective synthesizes the experiences and needs of living with CRD from the perspective of people with CRD and their family/friend caregivers; and proposes a vision of a reciprocal/symbiotic relationship, through PR, for optimizing care for people with CRD and their caregivers.

EXPERT OPINION

A deeper understanding/recognition of the extensiveness and somewhat overlap of the experiences and unmet needs of individuals with CRD and their family/friend caregivers; and of the reciprocal/symbiotic relationship between PR and the family/friend caregivers might be important to optimizing management and, ultimately, individuals and caregivers' outcomes in CRD.

A novel application of lemmatize and thematic analysis to understand protective measures perspectives of patients with chronic respiratory disease during the first outbreak of COVID-19 pandemic: a qualitative study

Objective

To describe the perspectives of a group of COPD patients during the first outbreak of the COVID-19 pandemic and narrate the emotions and polarity (acceptance-rejection) regarding living with COPD during the pandemic.

Design/methods

We used a novel application of lemmatization and thematic analysis of participants' narratives. A study was carried out with eight patients with moderate-severe-very severe COPD during the first outbreak of COVID-19 using purposive sampling. In-depth interviews and field notes from the researchers were used to collect data. A statistical content analysis (lemmatization) of the patients' narratives was performed. Additionally, inductive thematic analysis was used to identify emerging themes. This study was conducted following the guidelines of Consolidated Criteria/Standards for Reporting Qualitative Research. The study was conducted in accordance with the principles articulated in the WMA Declaration of Helsinki. Participants provided verbal informed consent prior to their inclusion as previously described.

Results

The average age of our sample was 65 years, and 75% of the patients suffered from moderate COPD, 12.5% from severe COPD, and 12.5% from very severe COPD according to GOLD criteria. The lemmatized and sentiment analysis showed a predominance of positive emotions, and the polarity of the interviews indicated a very slight positive trend towards acceptance of the experience lived during the pandemic. Additionally, three main themes were identified: (1) Confinement and restriction measures, (2) COVID-19 and protective measures, and (3) Clinical care during the first outbreak of the pandemic.

Conclusion

Patients experienced confinement with a feeling of security and protection. They strictly respect social distancing. They used masks, but these caused them to feel short of breath and fatigue, especially FFP2 masks. Half of the patients rejected the possibility of being vaccinated. Finally, they were very satisfied with the clinical care they received in the COPD unit of their hospital. Our results show that COPD patients have not experienced a negative impact of the COVID-19 pandemic.

Contributing to self-care of a person with chronic obstructive pulmonary disease: A qualitative study of the experiences of family caregivers

AIM

To explore family caregivers' experiences of contributing to self-care of patients with chronic obstructive pulmonary disease (COPD).

DESIGN

A qualitative description study.

METHODS

Individual semi-structured interviews were conducted face-to face, by telephone or video calls in a purposive sample of 17 family caregivers of patients with COPD recruited in Italy, and analysed through content analysis. The consolidated criteria for reporting qualitative studies (COREQ) checklist was used for study reporting.

RESULTS

Ten subcategories were derived from 106 codes grouped into three main categories: family caregiver contributions to maintaining disease stable and ensuring a normal life for patients; family caregiver contributions to disease monitoring; and family caregiver contributions to coping with disease exacerbations. Family caregivers provided practical and emotional support, and their contribution was essential to improve treatment adherence, to enable the patient to continue living a normal life, and to have access to the healthcare services. Family caregivers were constantly vigilant and monitored patients daily to detect worsening conditions, and they managed exacerbations especially when patients were unable to do it due to their critical conditions.

CONCLUSION

This study broadens knowledge of family caregivers' contributions to patients' self-care in COPD, describing the different ways family members provide daily care to patients and the many responsibilities they take on.

IMPACT

Family caregivers perform a variety of behaviours when supporting patients with COPD in self-care, especially when patients are more dependent and the disease more severe. Nurses should acknowledge the various contributions provided by family caregivers and develop educational interventions aiming to support them in patient care and improve patient outcomes.

PATIENT OR PUBLIC CONTRIBUTION

Researchers shared the draft study report with participants for validation and feedback. This helped to strengthen the study design and results.

Treatment Burden Discussion in Clinical Encounters: Priorities of COPD Patients, Carers and Physicians

Purpose

Many people with chronic obstructive pulmonary disease (COPD) feel overburdened with the treatment and management of their illness. Although research has begun to shed light on how COPD patients experience treatment burden, most of what we know is limited to personal experiences of patients. The aim of this study is to identify and prioritise areas of treatment burden that should be discussed during the clinical encounter from the perspectives of COPD patients, carers, and respiratory physicians.

Patients and Methods

Data were collected from participants using the nominal group technique. Five nominal group sessions were conducted in total (n = 31); three sessions with patients (n = 18), one with carers (n = 7) and another with respiratory physicians (pulmonologists or chest physicians) (n = 6). Each session was recorded and analyzed using thematic analysis.

Results

Going beyond understanding patients’ and carers’ experiences of treatment burden, this study offers a practical viewpoint of what should be discussed in a clinical encounter. Each group of participants contextualized treatment burden issues for discussion from their own perspectives. There was strong agreement, however, across the groups that difficulties accessing healthcare, lack of education and information, and worry about COPD treatment and prognosis were the most important treatment burden priorities for discussion.

Conclusion

Understanding and creating opportunities to discuss these issues in a clinical encounter is important in not only reducing treatment burden but also improving health outcomes and quality of life for COPD patients and their carers.

Sexual Health in COPD: A Systematic Review and Meta-Analysis

COPD has a profound impact on the lives of patients and their partners, but the influence on physical, psychological and social aspects of sexual health has not been reviewed systematically. Searches for studies of the impact of COPD on sexual health were conducted independently by two authors in the databases of PubMed, PsycINFO, Embases, CINAHL, Web of Science, Scopus and The Cochrane Library. English-language quantitative and qualitative studies assessing one or more aspects of sexual health in patients diagnosed with COPD were narratively reviewed and, when possible, subjected to meta-analytic evaluation. A total of 31 studies, including 4 qualitative, were included. Twelve studies assessing erectile dysfunction with the International Index of Erectile Function were subjected to meta-analysis. The pooled prevalence of erectile dysfunction was 74% (95% CI: 68-80%) in a total of 1187 patients with COPD, compared with 56% (37-73%) in 224 age-matched, non-COPD controls. The sexual health outcomes assessed in the remaining studies varied considerably, compromising the comparability of the results. None of the qualitative studies had sexual health as their primary focus. Compared with non-COPD individuals, erectile dysfunction appears to be more prevalent among patients with COPD, but more studies including non-COPD controls are needed to confirm this finding. In addition, the impact of COPD on other physical, psychological and social aspects of sexual health remains unclear due to the lack of comparable assessment methods and study designs.

Narrative Analysis of the Impact of COVID-19 on Patients with Chronic Obstructive Pulmonary Disease, Their Caregivers, and Healthcare Professionals in Italy

Purpose

The COVID-19 pandemic has disrupted many lives, including those of people suffering from chronic obstructive pulmonary disease (COPD) and their caregivers. The main aim of this study was to use narrative medicine, a validated approach promoting quality of care to explore how the COVID-19 pandemic impacted the quality of care, quality of life, psychological factors and social factors of people affected by COPD and their caregivers and healthcare professionals (HCPs). A secondary aim was to explore the role of telemedicine in combating isolation and providing access to care.

Methods

A cross-sectional observational narrative medicine study was conducted between July and November 2020 across Italy. An online semi-structured questionnaire with a narrative plot was completed by 146 participants (79 COPD patients, 24 caregivers, and 43 HCPs). Narrations were analyzed with descriptive statistics and evaluated using NVivo 11 software to break down the text and identify recurring themes and major semantic clusters.

Results

During the first lockdown, 58.22% of responses from COPD patients indicated terror, fear and/or apprehension; at reopening, this figure was 35.44%. Among caregivers, these figures were 100% at first lockdown and 45.83% at reopening. The metaphors most commonly used by patients to describe COPD and COVID-19 were monster and murderer, respectively. Patients described their homes more often as clean and lonely than as offering no shelter. The narratives of 42 COPD patients (45.2%) described coping. Only 12.6% of COPD patients reported regular access to medical visits during lockdown, while 59.1% of general practitioners and pulmonologists reported using telemedicine, which was perceived as satisfactory by both patients and caregivers.

Conclusion

It is relevant to aim for a multidisciplinary and multilevel system of care that empowers telemedicine and integrates specific psychological support programs for COPD patients and their caregivers.

Impact of patients' attitudes and dynamics in needs and life experiences during their journey in COPD: an ethnographic study

OBJECTIVES

Despite its importance in determining coping behaviors, few studies have assessed the reality of chronic obstructive pulmonary disease (COPD) and its management perceived by patients. This study aimed at an in-depth understanding of this reality to identify COPD patients' attitudes, COPD-shaped experiences, and overlooked needs during their journey.

METHODS

Qualitative ethnographic study including 28 adult patients with moderate and severe COPD and 20 healthcare professionals. Study phases were (1) in-depth individual and (2) ethnographic interviews (qualitative), and (3) online questionnaires (quantitative), including 400 patients. Qualitative data were collected using audio, video, and observation notes. Three ethnographers analyzed data using a template covering different themes: attitudes of COPD patients, COPD-shaped experiences, and overlooked needs.

RESULTS

We identified four attitudinal profiles of COPD patients: 'active controller,' 'naïve minimizer,' 'defeated sufferer,' and 'struggling bon vivant,' which were validated in 400 COPD patients, as well as five stages in the COPD patient journey and overlookedneeds. The 'active controller' profile was associated with slower disease progression compared with the 'defeated sufferer' and 'struggling bon vivant' profiles.

CONCLUSION

Four attitudinal profiles were distinguished and validated in a large sample of COPD patients. Patients' attitudes impacted in COPD-associated experiences, limitations, and unmet needs, which differed among profiles.

Narrative Medicine to integrate patients', caregivers' and clinicians' migraine experiences: the DRONE multicentre project

Background

Although migraine is widespread and disabling, stigmatisation and poor awareness of the condition still represent barriers to effective care; furthermore, research on migraine individual and social impact must be enhanced to unveil neglected issues, such as caregiving burden. The project investigated the migraine illness experience through Narrative Medicine (NM) to understand daily life, needs and personal resources of migraneurs, their caregivers and clinicians, and to provide insights for clinical practice.

Methods

The project involved 13 Italian headache centres and targeted migraneurs, their caregivers and migraine specialists at these centres. Written narratives, composed by a sociodemographic survey and illness plot or parallel chart, were collected through the project’s webpage. Illness plots and parallel charts employed open words to encourage participants’ expression. Narratives were analysed through Nvivo software, interpretive coding and NM classifications.

Results

One hundred and seven narratives were collected from patients and 26 from caregivers, as well as 45 parallel charts from clinicians. The analysis revealed migraine perception in social, domestic and work life within the care pathway evolution and a bond between chaos narratives and day loss due to migraine; furthermore, narratives suggested the extent of the caregiving burden and a risk of underestimation of migraine burden in patients’ and caregivers’ life.

Conclusion

The project represents the first investigation on migraine illness experience through NM simultaneously considering migraneurs’, caregivers’ and clinicians’ perspectives. Comparing narratives and parallel charts allowed to obtain suggestions for clinical practice, while NM emerged as able to foster the pursuing of migraine knowledge and awareness.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10072-021-05227-w.

Ten minutes to midnight: a narrative inquiry of people living with dying with advanced copd and their family members

Purpose: To explore how people with end stage chronic obstructive pulmonary disease and their family members describe living in the face of impending death.

Methods: A narrative inquiry was undertaken using a social constructionist perspective. Data were collected in 2017–18 in two in-depth interviews, lasting 90 to 120 minutes approximately 3–4 months apart, with a telephone follow-up 2–3 months later. Thematic analysis was conducted including analysis within and across participants.

Results: Sixteen people with advanced chronic obstructive pulmonary disease and seven family members participated. For both people with the disease and family members, six key themes/storylines emerged including missing life, being vigilant, hope and realism, avoiding death talk, the scary dying process, and need to prepare.

Conclusion: This study highlighted six key storylines about death and dying with advanced chronic obstructive pulmonary disease for people with the illness and their family members. The participants with the illness and their family members held similar perceptions about end of life. More supports are needed for people with advanced chronic obstructive pulmonary disease and their family members in living with their illness while ensuring that they experience a “good death.”

The emotional and social burden of heart failure: integrating physicians', patients', and caregivers' perspectives through narrative medicine

Background

The The Roadmap Using Story Telling project used a narrative medicine (NM) framework to assess the perspectives of people with heart failure (HF), their informal caregivers and HF specialists of the impact of HF on the daily life of patients and their carers.

Methods

Italian HF specialists participated on a voluntary basis, completing their own narratives, and inviting patients and their caregivers to write anonymously about their experiences, all on a dedicated online platform. The narratives were analyzed according to standard NM methodology.

Results

82 narratives were collected from patients, 61 from caregivers, and 104 from HF specialists. Analysis of the three points of view revealed the extent of the burden of illness on the entire family, particularly that of the caregiver. The impact was mainly experienced as emotional and social limitations in patients’ and their caregivers’ daily lives. The analysis of all three points of view highlighted a strong difference between how HF is perceived by patients, caregivers, and HF specialists.

Conclusions

This NM project illustrates the complex issues of living with HF and gave insights to integrate three different perspectives into the HF pathway of care.

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.

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

BACKGROUND

Few studies have focused on patients' emotional distress with end-stage chronic obstructive pulmonary disease (COPD) and their main family caregivers.

METHODS

Cross-sectional data about emotional, functional, and burden-related variables were collected from 85 patients with end-stage COPD and their 85 respective main family caregivers to determine the variables that could predict their emotional well-being. Descriptive analyses, comparison of means, hierarchical regression models, and comparative quali-quantitative analyses were carried out.

RESULTS

Data show that the great majority of patients with COPD spend years with this diagnosis, and have been admitted to the hospital several times in advance stage of illness the previous year of the moment of end-of-life stage. Furthermore, only a tiny percentage of the patients were functionally independent in the advanced stage of illness.

CONCLUSIONS

The emotional distress and the burden of the family caregiver play an essential role in the distress of the patient, in conjunction with the patient's own functional independence and the time living with the disease, and comorbidity. On the other hand, variables of the patient, such as time since diagnosis, number of hospital admissions, comorbidity, functional dependence, and emotional distress, play an important role in the family caregiver's emotional distress and burden. Understanding how these variables are related is key to designing appropriate programs to reduce the emotional distress the patients with COPD at the end of life and their family caregivers.

Use of narrative medicine to identify key factors for effective doctor-patient relationships in severe asthma

Background

In this project the authors use a narrative medicine (NM) approach to assess the promotion of trust in the relationship between physicians and their asthma patients.

Methods

Following a NM educational course for physicians, a research was carried out in which at least 5 written narratives (parallel charts) for each participating physician were collected and qualitatively analysed according to Bury’s classification and the Grounded Theory.

Results

The results of this study were of speculative and clinical interest. In particular, 66 participants wrote 314 narratives (246 on adult and 68 on paediatric patients). As a result of applying the NM approach, when the relationships remained problematic, many physicians wrote with a moral style about their adult (67%), and paediatric patients (33%) - especially in cases of asthmatic children’s or adolescents’ overprotective or absent families (40%) -. On the contrary, physicians who were able to listen to their patients with empathy (35%) made more shared decisions with patients, even with those they initially had a bad relationship. The used words of welcome, interest and acceptance were promoting patients’ trust that lead to restoring their activities in 45% of cases, according to physicians self-reporting.

Conclusions

These approaches of NM are useful in daily clinical practice, with the goal of improving the quality of life (QOL) of patients with severe asthma, even in cases in which the doctor-patient relationship isn’t initially good.