A Palliative Care Approach for breathlessness in lung cancer.ppt

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1、Author: C A Belchamber - April 2002,A Palliative Care Approach for breathlessness in lung cancer,A clinical evaluation,Author: C A Belchamber - April 2002,Background to evaluation,Anecdotal evidence in day care good results Establishment of a formal evaluation in a palliative care setting Formal stu

2、dy commenced April 1999 Aimed to recruit 30 patients Data collection completed September 2000 Report published 29th June 2001,Author: C A Belchamber - April 2002,Aims of the evaluation,The study was designed to answer the following questions; Can breathlessness or the unpleasant awareness of breathl

3、essness in lung cancer patients be significantly reduced with the use of a non-pharmacological approach? Can this intervention improve quality of life in this client group? Does this approach have any other significant effect on symptom control, apart from breathlessness? Does this approach improve

4、functional ability (and therefore independence) in this client group?,Author: C A Belchamber - April 2002,Referral criteria,Inclusion criteria Patients with small cell lung cancer, non-small cell lung cancer or mesothelioma Patients with breathlessness one month or more after completion of active tr

5、eatment Chest x-ray within one monthExclusion criteria Patients undergoing active treatment Diagnosis other than lung cancer Patients with pleural effusion,Author: C A Belchamber - April 2002,Method,Operational policy established Referrers, consultant oncologists; consultant chest physicians; clinic

6、al nurse specialists; Physiotherapists; GPs Clinicians; Physiotherapist and key worker (specialist palliative care nurse) Patient seen 3 times over a period of 4/6 weeks Assessment tools/outcome measures,Author: C A Belchamber - April 2002,Content:,Detailed patient breathing assessment Exploration o

7、f patients feelings about their illness and symptoms Training in breathing control techniques such as slow breathing, diaphragmatic breathing and relaxation training Advice on managing attacks of breathlessness Advice on coping with activities of daily living,Author: C A Belchamber - April 2002,Hurd

8、les related to illness and treatment:,Uncertainty Search for meaning Contributing to survival Maintaining self esteem Being open with others Maintaining contact with others Obtaining medical support Loss of body part or function Radiotherapy or chemotherapy (Maguire and Howell 1995),Author: C A Belc

9、hamber - April 2002,Key questions:,How do you see your illness working out? Have you been able to come up with any explanation as to why you should have become ill in this way? Have you found there is anything you can do to contribute to your survival? Has having cancer changed in any way how you fe

10、el about yourself as a person? Have you been able to be open with others abut having cancer? Have you been seeing as much of other people as you did before your illness? How do you feel about the level of support you have been receiving form the doctors and nurses who have been looking after you? (M

11、aguire and Howell 1995),Author: C A Belchamber - April 2002,Clinician Assessment tools:,Current respiratory symptoms (MRC respiratory symptom questionnaire and dyspnoea scale)Functional capacity scaleSputum production scale,Author: C A Belchamber - April 2002,Patient assessment tools:,Rotterdam symp

12、tom checklist Activity questionnaire Things which improve breathlessness Quality of life questionnaire Breathlessness visual analogue scale,Author: C A Belchamber - April 2002,Evaluation results,Patient demographics Respiratory function Functional capacity Symptom assessment Degree of breathlessness

13、 Strategies which improve breathlessness Quality of life,Author: C A Belchamber - April 2002,Patient numbers:,68 patients referred45 entered30 assessed15 died or deteriorated before completion,Author: C A Belchamber - April 2002,Patient characteristics:,Age range 35 to 81 years 24 male; 6 female 16

14、NSCLC; 3 SCLC; 10 mesothelioma 73% prior RT 27% prior surgery 10% prior chemotherapy 10% no active treatment,Author: C A Belchamber - April 2002,Medication,Author: C A Belchamber - April 2002,Current respiratory symptoms: How often are you breathless?,Most/all the time Several times a day Once or tw

15、ice a week Several times a week Once a week Less than once a week,Author: C A Belchamber - April 2002,Author: C A Belchamber - April 2002,Respiratory symptoms: results,Significant improvement (p0.001) At baseline 27% were breathless most of the time compared to 3% at completion 19 patients improved

16、9 remained stable 2 deteriorated,Author: C A Belchamber - April 2002,Functional capacity:,Climb hills or stairs without breathlessness Walks any distance on the flat without breathlessness Walks 100 yards without breathlessness Breathlessness on walking 100 yards Breathlessness on mild exertion Brea

17、thlessness at rest,Author: C A Belchamber - April 2002,Author: C A Belchamber - April 2002,Functional capacity: results,Improved (p0.001) At baseline only 37% could walk more than 100 yards compared to 77% at completion 21 patients improved 7 remained stable 2 deteriorated,Author: C A Belchamber - A

18、pril 2002,Author: C A Belchamber - April 2002,Changes in symptoms: Rotterdam symptom checklist,36 questions about symptoms in the last week Includes physical symptoms and psychological distress Scored as not at all (1), a little (2), moderately (3) or very much (4) Separate activity questionnaire (8

19、 items) scoring 1(able to do) to 4 (unable to do) Low scores desirable,Author: C A Belchamber - April 2002,Author: C A Belchamber - April 2002,Physical symptom distress score: results,Improved (p=0.01) 20 patients improved 2 remained the same 8 deteriorated,Author: C A Belchamber - April 2002,Psycho

20、logical symptom distress score: results,Borderline improvement (p=0.06) 18 patients improved 4 remained the same 8 deteriorated,Author: C A Belchamber - April 2002,Activity level score: results,Improved (p0.001) 24 patients improved 3 remained the same 3 deteriorated,Author: C A Belchamber - April 2

21、002,Degree of breathlessness: How breathless have you felt in the last 24 hours when your breathing has been at its best and at its worst? How much distress has your breathing caused?,Visual analogue scales 0 (none) to 10 (extremely) Low scores desirable,Author: C A Belchamber - April 2002,Author: C

22、 A Belchamber - April 2002,Breathlessness at best: results,Improved (p=0.001) 16 patients improved 12 remained the same 2 deteriorated,Author: C A Belchamber - April 2002,Breathlessness at worst: results,Improved (p0.001) 27 patients improved 3 remained the same,Author: C A Belchamber - April 2002,D

23、istress caused by breathlessness: results,Improved (p0.001) 26 patients improved 1 remained the same 3 deteriorated,Author: C A Belchamber - April 2002,Identifying strategies which might improve perception of breathlessness,Patients were asked to score 20 strategies Visual analogue scales 1 (not at

24、all helpful) to 10 (extremely helpful) Physical strategies Specific taught breathing techniques Psychological strategies Significant improvements in 17/20,Author: C A Belchamber - April 2002,Quality of life,21 questions on QOL in previous week 1 to 10 visual analogue scale Values high or low depende

25、nt on question Significant improvements in hours per day lying down, bodily strength and things which made patients happy Biggest improvements in ability to do as wanted and overall quality of life,Author: C A Belchamber - April 2002,Author: C A Belchamber - April 2002,Author: C A Belchamber - April

26、 2002,Patient satisfaction survey:,Who referred you to the clinic? How long have you been breathless? Who have you sought help from for your breathlessness? How long did you wait for your first appointment? Appointment length and frequency Were you given enough information and explanation? Were you

27、given enough time to express your needs and concerns? Has the treatment been helpful? Contact with the clinic Clinic environment,Author: C A Belchamber - April 2002,Patient satisfaction: results,57% of patients breathless 6 months 80% seen within 1-2 weeks Appointments just right for 97% 100% satisf

28、action with information, explanation and time given 93% chose hospice environment,Author: C A Belchamber - April 2002,Summary of results:,Frequency of dyspnoea:Improved Degree of breathlessness: improved Functional capacity: improved Physical symptoms and activity levels: improved Quality of life: i

29、mproved Patient satisfaction high Large drop out rate due to deterioration or death Sputum production and medication: unchanged (Hately et al 2001),Author: C A Belchamber - April 2002,Recommendations:,Working Group for Lung Cancer 1998: Breathlessness clinics should be an integral part of care for a

30、ll lung cancer patients. Referral at onset of symptom Education and training Further research (Hately et al 2001),Author: C A Belchamber - April 2002,Lewis-Manning House:,Breathlessness clinic fully established by September 2000 New referral criteria Continuing to collect data Funding remains a prob

31、lem Integration of breathlessness clinic philosophy into Day care Dissemination of information: Breathlessness study programme held biannually at Lewis-Manning House; talks at Bournemouth university and Poole Hospital Evaluation of breathlessness clinic philosophy on other cancer patients experiencing breathlessness,