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

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*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




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Managing breathlessness must be done

systematically. There are three main aspects of

this:

1. Symptom management

1. Managing chronicity

2. Managing end of life



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The genesis of

dyspnoea and its

relationship to

respiratory control

A proposed conceptual model by

Adams & Stulbarg (1991)


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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



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Managing breathlessness

1. Non-pharmacological measures

2. Opioids

3. Oxygen

4. Manage other symptoms

5. Remember the carers!


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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.


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Non-pharmacological approaches (1)

• Using a fan


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• Exercise (a good evidence base)


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• Education and information

• Pacing


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• Supporting family relationships

• Promoting wellbeing

• Rituals for crises


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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


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Opioids

• Use them for breathlessness at rest

• Use them at the end of life

• Consider them in anyone with severe shortness of breath


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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


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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


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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)


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Positive psychology

Wellbeing or happiness is a

state in which individuals

have engagement with life, a

sense of purpose and feel

pleasure

Seligmann (2003)


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Positive psychology

‘Authentic Happiness’(Seligmann, 2003)

http://www.authentichappiness.org

http://www.authentichappiness.org/

http://www.authentichappiness.org/


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End of life planning

• When?

• With whom?

• Where?

• How?


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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


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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


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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.


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• 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.


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• 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.

facet - european journal of cancer care july 2006 slides available at: palliative care for...

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