1
|
Ferreira DH, Ekström M, Bajwah S, Fazekas B, Currow DC. Regular, low-dose, sustained-release morphine for persisting breathlessness in interstitial lung disease: a randomised, double-blind, placebo-controlled, crossover trial. Eur Respir J 2023; 62:2300702. [PMID: 37678949 DOI: 10.1183/13993003.00702-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/20/2023] [Indexed: 09/09/2023]
Affiliation(s)
- Diana H Ferreira
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Magnus Ekström
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Lund, Sweden
| | - Sabrina Bajwah
- Cicely Saunders Institute, King's College London, London, UK
| | - Belinda Fazekas
- Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| |
Collapse
|
2
|
Ferreira DH, Kochovska S, Brunelli VN, Currow DC. Understanding persistent breathlessness: Impact on patients and optimal approaches to symptomatic reduction - an overview. Expert Rev Respir Med 2023:1-15. [PMID: 37102251 DOI: 10.1080/17476348.2023.2208348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
INTRODUCTION Persistent breathlessness (breathlessness persisting despite optimal treatment for the underlying condition and resulting in disability) is a prevalent syndrome associated with chronic and life-limiting conditions. Improving the clinical recognition and assessment of persistent breathlessness is essential to ensure people are provided with the best treatment for optimal symptom control. AREAS COVERED This overview focuses on the impact of persistent breathlessness on patients, carers and the health system. It highlights the importance of identifying persistent breathlessness in clinical consultations, suggests steps to recognise this syndrome and discusses the evidence for non-pharmacological and pharmacological treatments in this context. Future research directions are also suggested. EXPERT OPINION Persistent breathlessness is often invisible because 1) people may not engage with the health system and 2) both clinicians and patients are reluctant to discuss breathlessness in clinical consultations. Improving the recognition and assessment of this syndrome is critical to facilitate meaningful conversations between patients and clinicians and ensure patient-centred care. Non-pharmacological strategies are key to improving symptom management and health outcomes. Regular, low-dose, sustained-release morphine may help further reduce breathlessness in people who remain symptomatic despite disease-specific and non-pharmacological therapies.
Collapse
Affiliation(s)
- Diana H Ferreira
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales 2522, Australia
| | - Slavica Kochovska
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales 2522, Australia
| | - Vanessa N Brunelli
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales 2522, Australia
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales 2522, Australia
| |
Collapse
|
3
|
Ferreira DH, Ekström M, Verberkt C, Janssen DJA, Currow DC. Is being able to walk to the letterbox life-changing? A qualitative assessment of measures of improvement in persistent breathlessness. ERJ Open Res 2023; 9:00530-2022. [PMID: 36891068 PMCID: PMC9986768 DOI: 10.1183/23120541.00530-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/12/2022] [Indexed: 12/31/2022] Open
Abstract
Exploring clinically meaningful measures of improvement for people with persisting breathlessness https://bit.ly/3WaCzFh.
Collapse
Affiliation(s)
- Diana H Ferreira
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Magnus Ekström
- Department of Clinical Sciences, Division of Respiratory Medicine & Allergology, Lund University, Lund, Sweden
| | - Cornelia Verberkt
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Daisy J A Janssen
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Department of Research & Development, Ciro, Haelen, The Netherlands
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| |
Collapse
|
4
|
Ferreira DH, Ekström M, Fazekas B, Currow DC. Testosterone Levels in People Taking Regular Low-Dose Sustained-Release Morphine for Persisting Breathlessness: An Exploratory Study. J Palliat Med 2023; 26:402-405. [PMID: 36394475 DOI: 10.1089/jpm.2022.0381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: The intermediate- and long-term effects of regular low-dose sustained-release (SR) morphine on the testosterone levels of people with persistent breathlessness are unknown. Methods: Exploratory analysis of a randomized controlled trial of the effects of regular SR morphine (0/8/16/24 mg every 24 hours) for persistent breathlessness associated with chronic obstructive pulmonary disease. Total testosterone was measured at baseline and at cessation (greater than or equal to three months on stable medication). Results: Among 20 participants (9 males; median treatment duration between measurements 169 days [IQR 162-175]), only 3 had substantial declines in testosterone levels during the study (morphine 8, 16, 24 mg groups). All three had worsening illness at the time of the second assessment. There was no apparent relationship between change in testosterone, morphine dose, and change in breathlessness. Conclusions: Substantial declines in testosterone were uncommon and were not apparently related to changes in morphine dose or breathlessness, but they were possibly related with worsening illness.
Collapse
Affiliation(s)
- Diana H Ferreira
- Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Magnus Ekström
- Division of Respiratory Medicine and Allergology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Belinda Fazekas
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - David C Currow
- Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, New South Wales, Australia
| |
Collapse
|
5
|
Ferreira DH, Kochovska S, McNeill R, Currow DC. Current pharmacological strategies for symptomatic reduction of persistent breathlessness - a literature review. Expert Opin Pharmacother 2023; 24:233-244. [PMID: 36525673 DOI: 10.1080/14656566.2022.2160239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Persistent breathlessness is a debilitating symptom that is prevalent in the community, particularly in people with chronic and life-limiting illnesses. Treatment includes different steps, including pharmacological treatment aiming to improve the symptom and optimize people's wellbeing. AREAS COVERED PubMed and Google Scholar were screened using 'chronic breathlessness' OR 'persistent breathlessness,' AND 'pharmacological treatment,' OR 'opioids.' This review focuses on pharmacological treatments to reduce persistent breathlessness and discusses possible mechanisms involved in the process of breathlessness reduction through pharmacotherapy. Research gaps in the field of persistent breathlessness research are outlined, and future research directions are suggested. EXPERT OPINION Regular, low-dose (≤30 mg/day), sustained-release morphine is recommended as the first-line pharmacological treatment for persistent breathlessness. Inter-individual variation in response needs to be investigated in future studies in order to optimize clinical outcomes. This includes 1) better understanding the centrally mediated mechanisms associated with persisting breathlessness and response to pharmacological therapies, 2) understanding benefit from the perspective of people experiencing persistent breathlessness, small and meaningful gains in physical activity.
Collapse
Affiliation(s)
- Diana H Ferreira
- Faculty of Science, Medicine and Health, University of Wollongong, 2522, Wollongong, Australia
| | - Slavica Kochovska
- Faculty of Science, Medicine and Health, University of Wollongong, 2522, Wollongong, Australia.,IMPACCT, Faculty of Health, University of Technology Sydney, 2007, Ultimo, Australia
| | - Richard McNeill
- Department of palliative care, Nurse Maude Hospice, 8014, Christchurch, New Zealand.,Department of Medicine, University of Otago, 8011, Christchurch, New Zealand
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, 2522, Wollongong, Australia
| |
Collapse
|
6
|
Ferreira DH, Johnson MJ, Janssen DJA, Ekström M, Currow DC. The effect of regular, low-dose, sustained-release morphine on routine physical activity in people with persistent breathlessness: a hypothesis-generating study. Eur Respir J 2022; 60:2201484. [PMID: 36356975 DOI: 10.1183/13993003.01484-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/18/2022] [Indexed: 11/12/2022]
Affiliation(s)
- Diana H Ferreira
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Daisy J A Janssen
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Research & Development, Ciro, Haelen, The Netherlands
| | - Magnus Ekström
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Lund, Sweden
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| |
Collapse
|
7
|
Ferreira DH, Ekström M, Currow DC. Change in persisting breathlessness during treatment with regular, low‐dose, sustained‐release morphine. Intern Med J 2022; 52:1845-1846. [DOI: 10.1111/imj.15902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/08/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Diana H. Ferreira
- Faculty of Science, Medicine and Health University of Wollongong Wollongong New South Wales Australia
| | - Magnus Ekström
- Division of Respiratory Medicine, Allergology and Palliative Medicine, Department of Clinical Sciences Lund University Lund Sweden
| | - David C. Currow
- Faculty of Science, Medicine and Health University of Wollongong Wollongong New South Wales Australia
| |
Collapse
|
8
|
Ferreira DH, Ekström M, Huang C, Currow DC. Minimally Clinically Important Improvements (MCII) and Worsening (MCIW) in Symptoms. J Pain Symptom Manage 2022; 64:e107-e108. [PMID: 35429604 DOI: 10.1016/j.jpainsymman.2022.04.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Diana H Ferreira
- Faculty of Science, Medicine and Health (D.H.F., D.C.C.), University of Wollongong, Wollongong, New South Wales, Australia; Department of Clinical Sciences, Division of Respiratory Medicine & Allergology (M.E.), Lund University, Lund, Sweden; Institute for Clinical and Applied Health Research, University of Hull (C.H.), Hull, United Kingdom.
| | - Magnus Ekström
- Faculty of Science, Medicine and Health (D.H.F., D.C.C.), University of Wollongong, Wollongong, New South Wales, Australia; Department of Clinical Sciences, Division of Respiratory Medicine & Allergology (M.E.), Lund University, Lund, Sweden; Institute for Clinical and Applied Health Research, University of Hull (C.H.), Hull, United Kingdom
| | - Chao Huang
- Faculty of Science, Medicine and Health (D.H.F., D.C.C.), University of Wollongong, Wollongong, New South Wales, Australia; Department of Clinical Sciences, Division of Respiratory Medicine & Allergology (M.E.), Lund University, Lund, Sweden; Institute for Clinical and Applied Health Research, University of Hull (C.H.), Hull, United Kingdom
| | - David C Currow
- Faculty of Science, Medicine and Health (D.H.F., D.C.C.), University of Wollongong, Wollongong, New South Wales, Australia; Department of Clinical Sciences, Division of Respiratory Medicine & Allergology (M.E.), Lund University, Lund, Sweden; Institute for Clinical and Applied Health Research, University of Hull (C.H.), Hull, United Kingdom
| |
Collapse
|
9
|
Kochovska S, Ferreira DH, Garcia MV, Phillips JL, Currow DC. Perspectives on palliative oxygen for breathlessness: systematic review and meta-synthesis. Eur Respir J 2021; 58:13993003.04613-2020. [PMID: 33653807 DOI: 10.1183/13993003.04613-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/15/2021] [Indexed: 12/16/2022]
Abstract
Oxygen therapy is frequently prescribed for the palliation of breathlessness, despite lack of evidence for its effectiveness in people who are not hypoxaemic. This study aimed to compare and contrast patients', caregivers' and clinicians' experiences of palliative oxygen use for the relief of chronic breathlessness in people with advanced life-limiting illnesses, and how this shapes prescribing.A systematic review and meta-synthesis of qualitative data was conducted. MEDLINE, CINAHL and PsycINFO were searched for peer-reviewed studies in English (2000-April 2019) reporting perspectives on palliative oxygen use for reducing breathlessness in people with advanced illnesses in any healthcare setting. After data extraction, thematic synthesis used line-by-line coding of raw data (quotes) to generate descriptive and analytical themes.Of 457 articles identified, 22 met the inclusion criteria by reporting perspectives of patients (n=337), caregivers (n=91) or clinicians (n=616). Themes common to these perspectives were: 1) benefits and burdens of palliative oxygen use, 2) knowledge and perceptions of palliative oxygen use beyond the guidelines, and 3) longitudinal trajectories of palliative oxygen use.There are differing perceptions regarding the benefits and burdens of using palliative oxygen. Clinicians should be aware that oxygen use may generate differing goals of therapy for patients and caregivers. These perceptions should be taken into consideration when prescribing oxygen for the symptomatic relief of chronic breathlessness in patients who do not quality for long-term oxygen therapy.
Collapse
Affiliation(s)
- Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia.,These authors are joint first authors
| | - Diana H Ferreira
- Palliative and Supportive Services, Flinders University, Adelaide, Australia.,These authors are joint first authors
| | - Maja V Garcia
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Jane L Phillips
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - David C Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia .,Wolfson Palliative Care Research Centre, University of Hull, Hull, UK
| |
Collapse
|
10
|
Currow DC, Chang S, Grande ED, Ferreira DH, Kochovska S, Kinchin I, Johnson MJ, Ekstrom M. Quality of Life Changes With Duration of Chronic Breathlessness: A Random Sample of Community-Dwelling People. J Pain Symptom Manage 2020; 60:818-827.e4. [PMID: 32442480 DOI: 10.1016/j.jpainsymman.2020.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/05/2020] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Chronic breathlessness is associated with poorer quality of life (QoL). This population study aimed to define dimensions of QoL and duration and dominant causes of breathlessness that most diminished QoL. METHODS This cross-sectional, population-based, and randomized survey of adults (n = 2977) in South Australia collected data on demographics, modified Medical Research Council (mMRC) breathlessness, and QoL (EuroQoL five-dimension five-level [EQ-5D-5L] measure; Short Form 12 quality-of-life measure). Data weighted to the census were analyzed for relationships between EQ-5D-5L and its dimensions with mMRC. Regression models controlled for age, sex, education, rurality, and body mass index. RESULTS About 2883 responses were analyzed: 49% were males; mean age was 48 years (SD 19). As mMRC worsened, EQ-5D-5L and its dimensions worsened. More severe chronic breathlessness was iteratively associated with lower mobility, daily activities, and worse pain/discomfort. For self-care and anxiety/depression, impairment was only with the most severe breathlessness. Respondents who had chronic breathlessness for two to six years had the worst QoL scores. People who attributed their breathlessness to cardiac failure had poorer QoL. Respondents who reported a cardiac cause for their breathlessness had worse mobility, poorer usual activities, and more pain than the other causes. The regression analyses showed that worse chronic breathlessness was associated with worsening QoL in each dimension of EQ-5D-5L, with the exception of the self-care, which only worsened with the most severe breathlessness. CONCLUSIONS This is the first study to report on chronic breathlessness and impairment across dimensions of QoL and differences by its duration. Mobility, usual activity, and pain drive these reductions.
Collapse
Affiliation(s)
- David C Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia; Wolfson Palliative Care Research Centre, University of Hull, Hull, England.
| | - Sungwon Chang
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney, Sydney, New South Wales, Australia
| | | | - Diana H Ferreira
- Discipline Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Irina Kinchin
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, England
| | - Magnus Ekstrom
- Division of Respiratory Medicine & Allergology, Department of Clinical Sciences, Lund University, Lund, Sweden
| |
Collapse
|
11
|
Kochovska S, Ferreira DH, Luckett T, Phillips JL, Currow DC. Earlier multidisciplinary palliative care intervention for people with lung cancer: a systematic review and meta-analysis. Transl Lung Cancer Res 2020; 9:1699-1709. [PMID: 32953543 PMCID: PMC7481603 DOI: 10.21037/tlcr.2019.12.18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Lung cancer is the most common cancer and leading cause of cancer mortality globally. Lung cancer is associated with significant morbidity, with symptoms often being poorly managed, causing significant symptom burden for both patients and their family caregivers. In people with life-limiting illnesses including advanced cancer, palliative care has been effective in improving symptom control, physical and mental wellbeing, quality of life, and survivorship; with benefits extending to caregivers while in the role and subsequently. Earlier integration of palliative care within oncology may be associated with improved patient outcomes, and has been supported by two Lancet commissions and national guidelines. The evidence for its effectiveness, however, has been mixed across the cancer spectrum. The aim of this review was to evaluate the current evidence for the effectiveness of early integrated palliative care in improving outcomes for people with lung cancer and their caregivers. Meta-analyses were performed where studies used the same measure. Otherwise, synthesis used a narrative approach. Similar to other types of advanced cancer, this review reveals mixed evidence for the effectiveness of early referral to palliative care and for the effectiveness of individual palliative interventions for people with lung cancer and their caregivers. Evidence that on-demand palliative care is equally, if not more effective than palliative care that is routinely provided, raises the question whether initiation and provision of palliative care as part of multidisciplinary lung cancer care ought to be guided by an early referral or need-based referral. Better understanding of what constitutes palliative care when delivered to people with lung cancer and their caregivers will help delineate the correlation with reported outcomes for these populations.
Collapse
Affiliation(s)
- Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Diana H Ferreira
- Discipline Palliative and Supportive Services, Flinders University, Adelaide, SA, Australia
| | - Tim Luckett
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Jane L Phillips
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - David C Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,Wolfson Palliative Care Research Centre, University of Hull, Hull, UK
| |
Collapse
|
12
|
Ferreira DH, Boland JW, Kochovska S, Honson A, Phillips JL, Currow DC. Patients' and caregivers' experiences of driving with chronic breathlessness before and after regular low-dose sustained-release morphine: A qualitative study. Palliat Med 2020; 34:1078-1087. [PMID: 32519599 DOI: 10.1177/0269216320929549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Chronic breathlessness is a disabling syndrome that profoundly impacts patients' and caregivers' lives. Driving is important for most people, including those with advanced disease. Regular, low-dose, sustained-release morphine safely reduces breathlessness, but little is known about its impact on driving. AIM To understand patients' and caregivers' (1) perspectives and experiences of driving with chronic breathlessness; and (2) perceived impact of regular, low-dose, sustained-release morphine on driving. DESIGN A qualitative study embedded in a pragmatic, phase III, randomised, placebo-controlled trial of low-dose, sustained-release morphine (⩽32 mg/24 h) for chronic breathlessness. Semi-structured interviews were conducted immediately after participants withdrew or completed the randomised, placebo-controlled trial. Informed by grounded theory, a constant comparative approach to analysis was adopted. SETTING/PARTICIPANTS Participants were recruited from an outpatients palliative care service in Adelaide, Australia. Participants included patients (n = 13) with severe breathlessness associated with chronic obstructive pulmonary disease and their caregivers (n = 9). RESULTS Participants were interviewed at home. Eleven received morphine 8-32 mg. Three themes emerged: (1) independence; (2) breathlessness' impact on driving; and (3) driving while taking regular, low-dose, sustained-release morphine. CONCLUSION Driving contributed to a sense of identity and independence. Being able to drive increased the physical and social space available to patients and caregivers, their social engagement and well-being. Patients reported breathlessness at rest may impair driving skills, while the introduction of sustained-release morphine seemed to have no self-reported impact on driving. Investigating this last perception objectively, especially in terms of safety, is the subject of ongoing work.
Collapse
Affiliation(s)
- Diana H Ferreira
- Palliative and Supportive Services, Flinders University, Bedford Park, SA, Australia
| | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Aaron Honson
- Palliative and Supportive Services, Flinders University, Bedford Park, SA, Australia
| | - Jane L Phillips
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - David C Currow
- Palliative and Supportive Services, Flinders University, Bedford Park, SA, Australia.,Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK.,IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| |
Collapse
|
13
|
Ferreira DH, Kochovska S, Honson A, Phillips JL, Currow DC. Two faces of the same coin: a qualitative study of patients' and carers' coexistence with chronic breathlessness associated with chronic obstructive pulmonary disease (COPD). BMC Palliat Care 2020; 19:64. [PMID: 32375747 PMCID: PMC7203967 DOI: 10.1186/s12904-020-00572-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 05/01/2020] [Indexed: 11/10/2022] Open
Abstract
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).
Collapse
Affiliation(s)
- Diana H Ferreira
- Discipline, Palliative and Supportive Services, Flinders University, GPO Box 2100, Adelaide, SA, 5001, Australia.
| | - Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, 2007, Australia
| | - Aaron Honson
- Discipline, Palliative and Supportive Services, Flinders University, GPO Box 2100, Adelaide, SA, 5001, Australia
| | - Jane L Phillips
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, 2007, Australia
| | - David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, GPO Box 2100, Adelaide, SA, 5001, Australia.,IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, 2007, Australia
| |
Collapse
|
14
|
Currow DC, Johnson MJ, Pollack A, Ferreira DH, Kochovska S, Ekström M, Harrison C. Breathlessness and opioid prescribing in COPD in general practice: a cross-sectional, observational study. ERJ Open Res 2020; 6:00299-2019. [PMID: 32775398 PMCID: PMC7402382 DOI: 10.1183/23120541.00299-2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 04/15/2020] [Indexed: 12/05/2022] Open
Abstract
Chronic breathlessness is a disabling syndrome, prevalent in people with advanced chronic obstructive pulmonary disease (COPD). Regular, low-dose, oral sustained-release morphine is approved in Australia to reduce symptomatic chronic breathlessness. We aimed to determine the current prescribing patterns of opioids for chronic breathlessness in COPD in Australian general practice and to define any associated patient and practitioner characteristics. Five years (2011 to 2016) of the Bettering the Evaluation and Care of Health database, an Australian national, continual, cross-sectional study of clinical care in general practice were used. The database included 100 consecutive clinical encounters from almost 1000 general practitioners annually (n=488 100 encounters). Descriptive analyses with subsequent regression models were generated. Breathlessness as a patient-defined reason for encounter was identified in 621 of 4522 encounters where COPD was managed. Opioids were prescribed in 309 of 4522 encounters where COPD was managed (6.8%; (95% CI) 6.1-7.6), of which only 17 were prescribed for breathlessness, and the rest for other conditions almost entirely related to pain. Patient age (45-64 years versus age 80+ years, OR 1.68; 1.19-2.36), Commonwealth Concession Card holders (OR 1.70; 1.23-2.34) and socioeconomic disadvantage (OR 1.30; 1.01-1.68) were associated with increased likelihood of opioid prescription at COPD encounters. The rate of opioid prescriptions rose over the 5 years of study. In primary care encounters for COPD, opioids were prescribed in 6.8% of cases, but almost never for breathlessness. These data create a baseline against which to compare changes in prescribing as the treatment of chronic breathlessness evolves.
Collapse
Affiliation(s)
- David C. Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
- Wolfson Palliative Care Research Centre, University of Hull, Hull, England
| | - Miriam J. Johnson
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
- Wolfson Palliative Care Research Centre, University of Hull, Hull, England
| | - Allan Pollack
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Diana H. Ferreira
- Discipline Palliative and Supportive Services, Flinders University, Adelaide, Australia
| | - Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Magnus Ekström
- Dept of Clinical Sciences, Division of Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Christopher Harrison
- Menzies Centre for Health Policy, Sydney School of Public Health, University of Sydney, Sydney, Australia
| |
Collapse
|
15
|
Ferreira DH, Louw S, McCloud P, Fazekas B, McDonald CF, Agar MR, Clark K, McCaffrey N, Ekström M, Currow DC. Controlled-Release Oxycodone vs. Placebo in the Treatment of Chronic Breathlessness-A Multisite Randomized Placebo Controlled Trial. J Pain Symptom Manage 2020; 59:581-589. [PMID: 31655189 DOI: 10.1016/j.jpainsymman.2019.10.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 10/14/2019] [Accepted: 10/16/2019] [Indexed: 11/12/2022]
Abstract
CONTEXT Chronic breathlessness is a clinical syndrome that results in significant distress and disability. Morphine can reduce chronic breathlessness when the contributing etiologies are optimally treated. OBJECTIVES Does oxycodone reduce chronic breathlessness compared with placebo? METHODS A multisite, randomized, placebo-controlled, double-blind, parallel-arm, fixed-dose trial of oral controlled-release oxycodone 15 mg (5 mg, eight hourly) or placebo (ACTRN12609000806268 at www.anzctr.org.au). As-needed immediate-release morphine (2.5 mg per dose; six and less doses/day) was available for both arms as required by one ethics committee overseeing the trial. Recruitment occurred from 2010 to 2014 in 14 inpatient and outpatient respiratory, cardiology, and palliative care services across Australia. Participants were adults, with chronic breathlessness (modified Medical Research Council Scale 3 or 4), who were opioid naive. The primary end point was the proportion of people with greater than 15% reduction from baseline in the intensity of breathlessness now (0-100 mm visual analogue scale) comparing arms Days 5-7. Secondary end points were average and worst breathlessness, quality of life, function, and harms. RESULTS Of 157 participants randomized, 155 were included (74 oxycodone and 81 placebo), but the study did not reach target recruitment. There was difference in neither between groups for the primary outcome (P = 0.489) nor any of the prespecified secondary outcomes. Placebo participants used more as-needed morphine (mean 7.0 vs. 4.2 doses; P ≤ 0.001). Oxycodone participants reported more nausea (P < 0.001). CONCLUSION There was no signal of benefit from oxycodone over placebo. Future research should focus on investigating the existence of an opioid class effect on the reduction of chronic breathlessness.
Collapse
Affiliation(s)
- Diana H Ferreira
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Sandra Louw
- McCloud Consulting Group, Narabang Way, Belrose, New South Wales, Australia
| | - Philip McCloud
- McCloud Consulting Group, Narabang Way, Belrose, New South Wales, Australia
| | - Belinda Fazekas
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia; IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Christine F McDonald
- Austin Health, Heidelberg, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia
| | - Meera R Agar
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Katherine Clark
- Northern Sydney Local Health District, St Leonards, New South Wales, Australia; University of Sydney, Glebe, New South Wales, Australia
| | - Nikki McCaffrey
- Deakin Health Economics, School of Health and Social Development, Deakin University, Melbourne, Victoria, Australia
| | - Magnus Ekström
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia; Department of Clinical Sciences Lund, Lund University, Faculty of Medicine, Respiratory Medicine and Allergology, Lund, Sweden
| | - David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia; IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.
| | | |
Collapse
|
16
|
Ferreira DH, Ekström M, Sajkov D, Vandersman Z, Eckert DJ, Currow DC. Extended-Release Morphine for Chronic Breathlessness in Pulmonary Arterial Hypertension-A Randomized, Double-Blind, Placebo-Controlled, Crossover Study. J Pain Symptom Manage 2018; 56:483-492. [PMID: 30031217 DOI: 10.1016/j.jpainsymman.2018.07.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/09/2018] [Accepted: 07/11/2018] [Indexed: 12/28/2022]
Abstract
CONTEXT Pulmonary arterial hypertension (PAH) affects people of all ages and is associated with poor prognosis. Chronic breathlessness affects almost all people with PAH. OBJECTIVES This randomized, placebo-controlled, double-blind, crossover study aimed to evaluate the effects of regular, low-dose, extended-release (ER) morphine for PAH-associated chronic breathlessness. METHODS Participants with PAH-associated chronic breathlessness were randomized to 1) seven days of ER morphine 20 mg, 2) seven-day washout, and 3) seven days of identically looking placebo, or vice versa. Primary end points were breathlessness "right now"-morning and evening-measured with a Visual Analogue Scale. Secondary end points included additional breathlessness measures, quality of life, function, harms, and blinded treatment preference (ACTRN12609000209291). RESULTS Within a period of seven years, 50 patients were assessed in detail and 23 (46%) were randomized (despite broad eligibility criteria). Four participants withdrew while taking morphine. Nineteen participants completed the study. Breathlessness "right now" was higher on morphine compared with placebo both for morning [mean (M) ± SD 31.7 ± 25 mm vs. 26.9 ± 22 mm; effect size (80% CI) = -0.22 (-0.6 to 0.2)] and evening [(M ± SD 33.5 ± 28 mm vs. 25.6 ± 21 mm; effect size (80% CI) = -0.33 (-0.8 to 0.1)]. All secondary measures of breathlessness were higher with morphine as were nausea and constipation. CONCLUSION This study does not support a Phase III study of ER morphine for people with PAH-associated chronic breathlessness. Recruiting to the target sample size was difficult, the direction of effect in every measure of breathlessness favored placebo and morphine generated more harms.
Collapse
Affiliation(s)
- Diana H Ferreira
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia.
| | - Magnus Ekström
- Division of Respiratory Medicine & Allergology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Dimitar Sajkov
- Australian Respiratory and Sleep Medicine Institute and Department of Respiratory and Sleep Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Zac Vandersman
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA) and School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia; IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia; Wolfson Centre for Palliative Care Research, University of Hull, Hull, England
| |
Collapse
|
17
|
Ekström M, Johnson MJ, Taylor B, Luszcz M, Wohland P, Ferreira DH, Currow DC. Breathlessness and sexual activity in older adults: the Australian Longitudinal Study of Ageing. NPJ Prim Care Respir Med 2018; 28:20. [PMID: 29934520 PMCID: PMC6015074 DOI: 10.1038/s41533-018-0090-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 05/25/2018] [Accepted: 05/30/2018] [Indexed: 11/09/2022] Open
Abstract
Sexual activity is important to older adults (65 + ). Breathlessness affects about 25% of older adults but impact on sexual activity is unknown. We evaluated the relationships between breathlessness and sexual inactivity and self-reported health among older community-dwelling adults in the Australian Longitudinal Study of Ageing. Associations between self-reported breathlessness (hurrying on level ground or walking up a slight hill) at baseline, self-reported sexual activity, overall health and health compared to people of the same age were explored using logistic regression at baseline and 2 years, adjusted for potential confounders (age, sex, marital status, smoking status and co-morbidities). Of 798 participants (mean age 76.4 years [SD, 5.8] 65 to 103; 53% men, 73% married), 688 (86.2%) had 2-year follow-up data. People with breathlessness had higher prevalence and duration of sexual inactivity (77.7% vs. 65.6%; p < 0.001; 12 [IQR, 5-17] vs. 9.5 [IQR, 5-16] years; p = 0.043). Breathlessness was associated with more sexual inactivity, (adjusted OR 1.75; [95% CI] 1.24-2.45), worse health (adjusted OR 2.02; 1.53-2.67) and worse health compared to peers (adjusted OR 1.72; 1.25-2.38). Baseline breathlessness did not predict more sexual inactivity at 2 years. In conclusion, breathlessness contributes to sexual inactivity and worse perceived health in older adults, which calls for improved assessment and management.
Collapse
Affiliation(s)
- Magnus Ekström
- Department of Respiratory Medicine and Allergology, Institution for Clinical Sciences, Lund University, Lund, Sweden. .,IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia.
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Bridget Taylor
- Sobell House Hospice, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mary Luszcz
- School of Psychology, and Centre for Ageing Studies, Flinders University, Adelaide, SA, Australia
| | - Pia Wohland
- Institute for Clinical and Applied Health Research, Hull York Medical School, University of Hull, Hull, UK
| | - Diana H Ferreira
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, SA, Australia
| | - David C Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia.,Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| |
Collapse
|
18
|
Ferreira DH, Boland JW, Phillips JL, Lam L, Currow DC. The impact of therapeutic opioid agonists on driving-related psychomotor skills assessed by a driving simulator or an on-road driving task: A systematic review. Palliat Med 2018; 32:786-803. [PMID: 29299954 DOI: 10.1177/0269216317746583] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Driving cessation is associated with poor health-related outcomes. People with chronic diseases are often prescribed long-term opioid agonists that have the potential to impair driving. Studies evaluating the impact of opioids on driving-related psychomotor skills report contradictory results likely due to heterogeneous designs, assessment tools and study populations. A better understanding of the effects of regular therapeutic opioid agonists on driving can help to inform the balance between individual's independence and community safety. AIM To identify the literature assessing the impact of regular therapeutic opioid agonists on driving-related psychomotor skills for people with chronic pain or chronic breathlessness. DESIGN Systematic review reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis statement; PROSPERO Registration CRD42017055909. DATA SOURCES Six electronic databases and grey literature were systematically searched up to January, 2017. Inclusion criteria were as follows: (1) empirical studies reporting data on driving simulation, on-the-road driving tasks or driving outcomes; (2) people with chronic pain or chronic breathlessness; and (3) taking regular therapeutic opioid agonists. Critical appraisal used the National Institutes of Health's quality assessment tools. RESULTS From 3809 records screened, three studies matched the inclusion criteria. All reported data on people with chronic non-malignant pain. No significant impact of regular therapeutic opioid agonists on people's driving-related psychomotor skills was reported. One study reported more intense pain significantly worsened driving performance. CONCLUSION This systematic review does not identify impaired simulated driving performance when people take regular therapeutic opioid agonists for symptom control, although more prospective studies are needed.
Collapse
Affiliation(s)
- Diana H Ferreira
- 1 Discipline, Palliative and Supportive Services, Flinders University, Adelaide, SA, Australia
| | - Jason W Boland
- 2 Hull York Medical School, University of Hull, Hull, UK
| | - Jane L Phillips
- 3 IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Lawrence Lam
- 3 IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - David C Currow
- 1 Discipline, Palliative and Supportive Services, Flinders University, Adelaide, SA, Australia.,2 Hull York Medical School, University of Hull, Hull, UK.,3 IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,4 Wolfson Centre for Palliative Care Research, Hull York Medical School, University of Hull, Hull, UK
| |
Collapse
|
19
|
Ferreira DH, Silva JP, Quinn S, Abernethy AP, Johnson MJ, Oxberry SG, Currow DC. Blinded Patient Preference for Morphine Compared to Placebo in the Setting of Chronic Refractory Breathlessness--An Exploratory Study. J Pain Symptom Manage 2016; 51:247-54. [PMID: 26598037 DOI: 10.1016/j.jpainsymman.2015.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 09/28/2015] [Accepted: 10/06/2015] [Indexed: 12/14/2022]
Abstract
CONTEXT Patients' preference for morphine therapy has received little attention in the setting of chronic refractory breathlessness. However, this is one important factor in considering longer term therapy. OBJECTIVES The aim of this secondary analysis was to explore blinded patient preference of morphine compared to placebo for this indication and to define any predictors of preference. METHODS Data were pooled from three randomized, double-blind, crossover, placebo-controlled studies of morphine (four days each) in chronic refractory breathlessness. Blinded patient preferences were chosen at the end of each study. A multivariable regression model was used to establish patient predictors of preference. RESULTS Sixty-five participants provided sufficient data (60 men; median age 74 years; heart failure 55%, chronic obstructive pulmonary disease 45%; median Eastern Cooperative Oncology Group performance status 2). Forty-three percent of participants preferred morphine (32% placebo and 25% no preference). Morphine preference and younger age were strongly associated: odds ratio = 0.85, 95% confidence interval 0.78-0.93; P < 0.001). There was also an inverse association between morphine preference and sedation (odds ratio = 0.77, 95% confidence interval 0.60-0.99; P < 0.05). An inverse association was also seen between nausea and morphine preference in the univariate model only (P < 0.05). No association was seen between morphine preference and breathlessness intensity, either at baseline or change from baseline. CONCLUSION Participants preferred morphine over placebo for the relief of chronic refractory breathlessness. Morphine offers clinically important improvement, but net benefit can be easily outweighed by side effects, reducing net benefits. Side effects require aggressive management to allow more patients to realize benefits.
Collapse
Affiliation(s)
- Diana H Ferreira
- Department of Internal Medicine, Hospital de Egas Moniz-CHLO, Lisbon, Portugal; Department of Medical Oncology, Portuguese Institute of Oncology (IPO) of Lisbon Francisco Gentil EPE, Lisbon, Portugal
| | - José P Silva
- Department of Internal Medicine, Hospital de Egas Moniz-CHLO, Lisbon, Portugal; Department of Medical Oncology, Portuguese Institute of Oncology (IPO) of Lisbon Francisco Gentil EPE, Lisbon, Portugal.
| | - Stephen Quinn
- School of Medicine, Flinders University, Bedford Park, South Australia, Australia
| | - Amy P Abernethy
- Discipline, Palliative and Supportive Services, Flinders University, Bedford Park, South Australia, Australia; Department of Medicine, Duke University Medical Centre, Durham, North Carolina, USA
| | - Miriam J Johnson
- Palliative Medicine, Hull York Medical School, University of Hull, Hull, United Kingdom
| | | | - David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Bedford Park, South Australia, Australia
| |
Collapse
|