A Palliative Care Approach for breathlessness in lung cancer

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A Palliative Care Approach for breathlessness in
lung cancer

• A clinical evaluation

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Background to evaluation

• Anecdotal evidence in day care good results
• Establishment of a formal evaluation in a
  palliative care setting
• Formal study commenced April 1999
• Aimed to recruit 30 patients
• Data collection completed September 2000
• Report published 29th June 2001

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Aims of the evaluation

• The study was designed to answer the following
  questions
• Can breathlessness or the unpleasant awareness of
  breathlessness 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 functional ability
  (and therefore independence) in this client
  group?

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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 treatment
• Chest x-ray within one month
• Exclusion criteria
• Patients undergoing active treatment
• Diagnosis other than lung cancer
• Patients with pleural effusion

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Method

• Operational policy established
• Referrers, consultant oncologists consultant
  chest physicians clinical 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

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Content

• Detailed patient breathing assessment
• Exploration of 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

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Hurdles 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)

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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 feel
  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?
• (Maguire and Howell 1995)

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Clinician Assessment tools

• Current respiratory symptoms (MRC respiratory
  symptom questionnaire and dyspnoea scale)
• Functional capacity scale
• Sputum production scale

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Patient assessment tools

• Rotterdam symptom checklist
• Activity questionnaire
• Things which improve breathlessness
• Quality of life questionnaire
• Breathlessness visual analogue scale

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Evaluation results

• Patient demographics
• Respiratory function
• Functional capacity
• Symptom assessment
• Degree of breathlessness
• Strategies which improve breathlessness
• Quality of life

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Patient numbers

• 68 patients referred
• 45 entered
• 30 assessed
• 15 died or deteriorated before completion

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Patient characteristics

• Age range 35 to 81 years
• 24 male 6 female
• 16 NSCLC 3 SCLC 10 mesothelioma
• 73 prior RT
• 27 prior surgery
• 10 prior chemotherapy
• 10 no active treatment

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Medication
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Current respiratory symptoms How often are you
breathless?

• Most/all the time
• Several times a day
• Once or twice a week
• Several times a week
• Once a week
• Less than once a week

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Respiratory symptoms results

• Significant improvement (plt0.001)
• At baseline 27 were breathless most of the time
  compared to 3 at completion
• 19 patients improved
• 9 remained stable
• 2 deteriorated

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Functional capacity

• Climb hills or stairs without breathlessness
• Walks any distance on the flat without
  breathlessness
• Walks gt 100 yards without breathlessness
• Breathlessness on walking lt 100 yards
• Breathlessness on mild exertion
• Breathlessness at rest

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Functional capacity results

• Improved (plt0.001)
• At baseline only 37 could walk more than 100
  yards compared to 77 at completion
• 21 patients improved
• 7 remained stable
• 2 deteriorated

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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 items) scoring
  1(able to do) to 4 (unable to do)
• Low scores desirable

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Physical symptom distress score results

• Improved (p0.01)
• 20 patients improved
• 2 remained the same
• 8 deteriorated

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Psychological symptom distress score results

• Borderline improvement (p0.06)
• 18 patients improved
• 4 remained the same
• 8 deteriorated

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Activity level score results

• Improved (plt0.001)
• 24 patients improved
• 3 remained the same
• 3 deteriorated

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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

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Breathlessness at best results

• Improved (p0.001)
• 16 patients improved
• 12 remained the same
• 2 deteriorated

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Breathlessness at worst results

• Improved (plt0.001)
• 27 patients improved
• 3 remained the same

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Distress caused by breathlessness results

• Improved (plt0.001)
• 26 patients improved
• 1 remained the same
• 3 deteriorated

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Identifying strategies which might improve
perception of breathlessness

• Patients were asked to score 20 strategies
• Visual analogue scales
• 1 (not at all helpful) to 10 (extremely helpful)
• Physical strategies
• Specific taught breathing techniques
• Psychological strategies
• Significant improvements in 17/20

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Quality of life

• 21 questions on QOL in previous week
• 1 to 10 visual analogue scale
• Values high or low dependent 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

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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 given enough time to express your needs
  and concerns?
• Has the treatment been helpful?
• Contact with the clinic
• Clinic environment

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Patient satisfaction results

• 57 of patients breathless gt 6 months
• 80 seen within 1-2 weeks
• Appointments just right for 97
• 100 satisfaction with information, explanation
  and time given
• 93 chose hospice environment

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Summary of results

• Frequency of dyspnoeaImproved
• Degree of breathlessness improved
• Functional capacity improved
• Physical symptoms and activity levels improved
• Quality of life improved
• Patient satisfaction high
• Large drop out rate due to deterioration or death
• Sputum production and medication unchanged
• (Hately et al 2001)

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Recommendations

• Working Group for Lung Cancer 1998
  Breathlessness clinics should be an integral part
  of care for all lung cancer patients.
• Referral at onset of symptom
• Education and training
• Further research
• (Hately et al 2001)

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Lewis-Manning House

• Breathlessness clinic fully established by
  September 2000
• New referral criteria
• Continuing to collect data
• Funding remains a problem
• 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