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FACET - European Journal of Cancer Care July 2006

FACET - European Journal of Cancer Care July 2006. Palliative care for intractable breathlessness in cancer Booth, S. 1. Managing breathlessness Breathlessness is such a common problem that it requires all of us to be able to begin to start treating it. Slide One.

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FACET - European Journal of Cancer Care July 2006

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  1. FACET - European Journal of Cancer Care July 2006 Palliative care for intractable breathlessness in cancer Booth, S.1 Managing breathlessness Breathlessness is such a common problem that it requires all of us to be able to begin to start treating it Slide One *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  2. FACET - European Journal of Cancer Care July 2006 Palliative care for intractable breathlessness in cancer (continued) • Managing breathlessness must be done systematically. There are three main aspects of this: • Symptom management • Managing chronicity • Managing end of life Slide Two *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  3. FACET - European Journal of Cancer Care July 2006 Palliative care for intractable breathlessness in cancer (continued) The genesis of dyspnoea and its relationship to respiratory control A proposed conceptual model by Adams & Stulbarg (1991) Slide Three *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  4. FACET - European Journal of Cancer Care July 2006 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 Slide Four *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  5. FACET - European Journal of Cancer Care July 2006 Palliative care for intractable breathlessness in cancer (continued) • Managing breathlessness • Non-pharmacological measures • Opioids • Oxygen • Manage other symptoms • Remember the carers! Slide Five *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  6. FACET - European Journal of Cancer Care July 2006 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. Slide Six *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  7. FACET - European Journal of Cancer Care July 2006 Palliative care for intractable breathlessness in cancer (continued) • Non-pharmacological approaches (1) • Using a fan Slide Seven *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  8. FACET - European Journal of Cancer Care July 2006 Palliative care for intractable breathlessness in cancer (continued) • Non-pharmacological approaches (2) • Exercise (a good evidence base) Slide Eight *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  9. FACET - European Journal of Cancer Care July 2006 Palliative care for intractable breathlessness in cancer (continued) • Non-pharmacological approaches (3) • Education and information • Pacing Slide Nine *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  10. FACET - European Journal of Cancer Care July 2006 Palliative care for intractable breathlessness in cancer (continued) • Non-pharmacological approaches (4) • Supporting family relationships • Promoting wellbeing • Rituals for crises Slide Ten *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  11. FACET - European Journal of Cancer Care July 2006 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 Slide Eleven *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  12. FACET - European Journal of Cancer Care July 2006 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 Slide Twelve *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  13. FACET - European Journal of Cancer Care July 2006 Palliative care for intractable breathlessness in cancer (continued) • Starting morphine for breathlessnes • For example: • Mr Orange • On 100mg MST bd • Use normal release morphine as required • Consider alternative route • Consider adding benzodiazepine Slide Thirteen *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  14. FACET - European Journal of Cancer Care July 2006 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 Slide Fourteen *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  15. FACET - European Journal of Cancer Care July 2006 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) Slide Fifteen *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  16. FACET - European Journal of Cancer Care July 2006 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) Slide Sixteen *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  17. FACET - European Journal of Cancer Care July 2006 Palliative care for intractable breathlessness in cancer (continued) Positive psychology ‘Authentic Happiness’ (Seligmann, 2003) http://www.authentichappiness.org Slide Seventeen *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  18. FACET - European Journal of Cancer Care July 2006 Palliative care for intractable breathlessness in cancer (continued) • End of life planning • When? • With whom? • Where? • How? Slide Eighteen *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  19. FACET - European Journal of Cancer Care July 2006 Palliative care for intractable breathlessness in cancer (continued) • Consensus on research methods – more work needed! • Qualitative and quantitative assessment are both needed to capture the experience of breathlessness • 10% change in VAS score or 1 point in Borg may be called a significant clinical change in research • Wedo need to measure physiological parameters if we are to make progress • Many breathlessness tools but none suitable for all patient groups Slide Nineteen *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  20. FACET - European Journal of Cancer Care July 2006 Palliative care for intractable breathlessness in cancer (continued) • Summary • Provide a fan • Help patients to remain as active as possible • Get the most relevant specialist help needed if you are not able to deal with the problem yourself • Most importantly, give the patients and relatives the support they need • 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 Slide Twenty *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  21. FACET - European Journal of Cancer Care July 2006 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. Slide Twenty One *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  22. FACET - European Journal of Cancer Care July 2006 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 Med98,66-77. • 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. Slide Twenty Two *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

  23. FACET - European Journal of Cancer Care July 2006 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 Failure4, 753-6. • Lynn J. (2001) Serving patients who may die soon and their families: The role of hospice and other services JAMA285, 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. Slide Twenty Three *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

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