FACET - European Journal of Cancer Care July 2006 slides available at: Palliative care for...
-
Upload
julian-cole -
Category
Documents
-
view
213 -
download
0
Transcript of FACET - European Journal of Cancer Care July 2006 slides available at: Palliative care for...
FACET - European Journal of Cancer CareJuly 2006
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
Booth, S.1
Slid
e O
ne
*Click on “View”; “Notes Page” for explanatory notes
Managing breathlessness
Breathlessness is such a
common problem that it
requires all of us to be able
to begin to start treating it
FACET - European Journal of Cancer CareJuly 2006
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
Slid
e T
wo
*Click on “View”; “Notes Page” for explanatory notes
Managing breathlessness must be done
systematically. There are three main aspects of
this:
1. Symptom management
1. Managing chronicity
2. Managing end of life
FACET - European Journal of Cancer CareJuly 2006
slides available at: www.blackwellpublishing.com/journals/ecc
Slid
e T
hre
e
*Click on “View”; “Notes Page” for explanatory notes
The genesis of
dyspnoea and its
relationship to
respiratory control
A proposed conceptual model by
Adams & Stulbarg (1991)
Palliative care for intractable breathlessness in cancer
(continued)
FACET - European Journal of Cancer CareJuly 2006
slides available at: www.blackwellpublishing.com/journals/ecc
Slid
e F
ou
r
*Click on “View”; “Notes Page” for explanatory notes
Palliative care for intractable breathlessness in cancer
(continued)
Mr Orange
• Mesothelioma chest and abdomen
• Naval architect, 67 years
• Illness shadowed him for years
• Diagnosed 6 months before
• Pain was prominent symptom
• Change in 6 months ‘horrifying’
• Distraught wife and daughter
FACET - European Journal of Cancer CareJuly 2006
slides available at: www.blackwellpublishing.com/journals/ecc
Slid
e F
ive
*Click on “View”; “Notes Page” for explanatory notes
Palliative care for intractable breathlessness in cancer
(continued)
Managing breathlessness
1. Non-pharmacological measures
2. Opioids
3. Oxygen
4. Manage other symptoms
5. Remember the carers!
FACET - European Journal of Cancer CareJuly 2006
Slid
e S
ix
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
Non-pharmacological
approaches
There are a huge range of
approaches to choose from
and it must ideally be
something that the patient
can learn quite quickly and
adapt to. More than one
technique is needed.
FACET - European Journal of Cancer CareJuly 2006
Slid
e S
even
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
Non-pharmacological approaches (1)
• Using a fan
FACET - European Journal of Cancer CareJuly 2006
Slid
e E
igh
t
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
Non-pharmacological approaches (2)
• Exercise (a good evidence base)
FACET - European Journal of Cancer CareJuly 2006
Slid
e N
ine
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
Non-pharmacological approaches (3)
• Education and information
• Pacing
FACET - European Journal of Cancer CareJuly 2006
Slid
e T
en
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
Non-pharmacological approaches (4)
• Supporting family relationships
• Promoting wellbeing
• Rituals for crises
FACET - European Journal of Cancer CareJuly 2006
Slid
e E
leven
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
Impact of a breathlessness
service
• Accentuate what can be
done rather than dwell on
losses
• Expert management of a
symptom, often
unrecognised by friends
and family
• Support for carers
• Education and information
• Individual exercise
FACET - European Journal of Cancer CareJuly 2006
Slid
e T
welv
e
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
Opioids
• Use them for breathlessness at rest
• Use them at the end of life
• Consider them in anyone with severe shortness of breath
FACET - European Journal of Cancer CareJuly 2006
Slid
e T
hir
teen
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
Starting morphine for breathlessnes
For example:
Mr Orange
1. On 100mg MST bd
2. Use normal release morphine as required
3. Consider alternative route
4. Consider adding benzodiazepine
FACET - European Journal of Cancer CareJuly 2006
Slid
e F
ou
rteen
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
What about benzodiazepines?
• Little evidence
• Rather more evidence for major tranquillisers
• Preferable to achieve anxiety-reduction by non-pharmacological means except at the end of life
• Subcutaneous opioid and benzodiazepine in severe breathlessness
FACET - European Journal of Cancer CareJuly 2006
Slid
e F
ifte
en
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
Oxygen for chronic breathlessness –
individual assessment is key
• Some evidence in non-malignant disease – related to desaturation on exercise and hypoxia at rest
• Very little evidence in cancer – use according to clinical benefit in an individual
• Use the fan first
Booth et al (2004)
FACET - European Journal of Cancer CareJuly 2006
Slid
e S
ixte
en
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
Positive psychology
Wellbeing or happiness is a
state in which individuals
have engagement with life, a
sense of purpose and feel
pleasure
Seligmann (2003)
FACET - European Journal of Cancer CareJuly 2006
Slid
e S
even
teen
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
Positive psychology
‘Authentic Happiness’(Seligmann, 2003)
http://www.authentichappiness.org
FACET - European Journal of Cancer CareJuly 2006
Slid
e E
igh
teen
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
End of life planning
• When?
• With whom?
• Where?
• How?
FACET - European Journal of Cancer CareJuly 2006
Slid
e N
inete
en
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
Consensus on research methods – more work needed!
1. Qualitative and quantitative assessment are both needed to capture the experience of breathlessness
2. 10% change in VAS score or 1 point in Borg may be called a significant clinical change in research
3. We do need to measure physiological parameters if we are to make progress
4. Many breathlessness tools but none suitable for all patient groups
FACET - European Journal of Cancer CareJuly 2006
Slid
e T
wen
ty
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
Summary
1. Provide a fan
2. Help patients to remain as active as possible
3. Get the most relevant specialist help needed if you are not able to deal with the problem yourself
4. Most importantly, give the patients and relatives the support they need
5. Say if you do not feel able to manage breathlessness yourself, that there are ways of helping the symptom beyond what you have been able to do initially
FACET - European Journal of Cancer CareJuly 2006
Slid
e T
wen
ty O
ne
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
References and further reading
• Adams L. & Stulbarg M. (1991) Manifestations of Respiratory Disease: Dyspnea In: Textbook of respiratory disease (eds Murray J. & Nadel J.) 3rd edn. WM Saunders, Philadelphia, PA, USA.
• Beach D. and Schwartzstein R.M. (2006) The genesis of breathlessness - what do we understand? In: Dyspnoea in advanced disease: a guide to clinical management (eds Booth & Dudgeon). Oxford University Press, Oxford, UK
• Booth S. (2006) Improving Research Methods in Breathlessness: A meeting convened by the MRC Clinical Trials Unit and The Cicely Saunders Foundation Palliative Medicine, 20, 219 - 220.
• Booth S., Silvester S. & Todd C. (2003) Breathlessness in cancer and chronic obstructive pulmonary disease: using a qualitative approach to describe the experience of patients and carers. Palliative and Supportive Care. 1, 337-44.
FACET - European Journal of Cancer CareJuly 2006
Slid
e T
wen
ty T
wo
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
• Booth S. & Wade R. (2003) Oxygen or air for Palliation of Breathlessness in Advanced Cancer. Journal of the Royal Society of Medicine. 96, 215-218.
• Booth S., Wade R., Johnson M., Kite S., Swannick M., Anderson H. (2004) The use of oxygen in the palliation of breathlessness. A report of the expert working group of the Scientific Committee of the Association of Palliative Medicine. Respir Med 98, 66-77.
• Carrieri-Kohlman, V. (2006) Non-pharmacological approaches In: Dyspnoea in advanced disease: a guide to clinical management (eds Booth & Dudgeon). Oxford University Press, Oxford, UK.
• Huppert F.A., Baylis N. and Keverne B. (2005) The Science of Wellbeing. Oxford University Press, New York, USA.
• Jennings A.L., Davies A.N., Higgins J.P., Gibbs J.S., Broadley K.E. (2002) A systematic review of the use of opioids in the management of dyspnoea. Thorax 57, 939-44.
FACET - European Journal of Cancer CareJuly 2006
Slid
e T
wen
ty T
hre
e
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
Palliative care for intractable breathlessness in cancer
(continued)
• Johnson M.J., McDonagh T.A., Harkness A., McKay S.E., Dargie H.J. (2002) Morphine for the relief of breathlessness in patients with chronic heart failure--a pilot study European Journal of Heart Failure 4, 753-6.
• Lynn J. (2001) Serving patients who may die soon and their families: The role of hospice and other services JAMA 285, 925-932.
• Seligmann, M.E.P. (2003) Authentic Happiness. Using the New Positive Psychology to Realize Your Potential for Lasting Fulfillment. Nicholas Brealey Publishing Ltd, London, UK.