Providing home-based palliative care services for patients with advanced COPD is feasible but completing repeated questionnaires is impractical. Despite significant palliative supports, managing terminal symptoms exceeded caregivers' capacity to cope and forced hospital admission. Insights into systemic barriers and limitations of current palliative care service models can provide opportunities for local program innovation aimed at improving care for advanced COPD.
ResearchCMAJ OPEN C hronic obstructive pulmonary disease (COPD) will be the third leading cause of death globally by 2020.1 Recent Canadian data suggest that about 1 in 4 adults 35 years or older can expect to develop COPD. 2 Dyspnea is the predominant symptom, and up to 50% of patients with advanced COPD have dyspnea (persistent, episodic or both) that is refractory to conventional treatment.3 Dyspnea "crises" often trigger intense feelings of helplessness that can overwhelm patients' and caregivers' abilities to cope. 4 More than 20 years have passed since morphine was found to be associated with a reduction in dyspnea in patients with COPD.5 Despite the systematic review of a decade ago, 6 experience with using opioids in this clinical context remains limited. Subsequent evidence focuses on, or extrapolates from, short-term effects over hours 7,8 or days. 9 Longer-term clinical use over months has received relatively little attention or support until recently. 10,11 The dearth of quality evidence relating to the longer-term effects of opioids prompted our study.Building on our previous research in this area, 12,13 we designed a multicentre mixed-methods study (a) to understand further the experiences of patients living with advanced Background: Dyspnea that is refractory to conventional treatments affects up to 50% of patients with advanced chronic obstructive pulmonary disease (COPD). Although professional societies recommend opioids in this setting, evidence supporting their use over months is limited. We conducted a multicentre mixed-methods study to understand patients' experiences when opioids are added to optimized conventional treatments for advanced COPD.Methods: A total of 44 patients (median age 74, range 51-89 years) agreed to participate in this 6-month study. After baseline assessments, immediate-release morphine sulfate syrup (initially 0.5 mg twice daily) was slowly titrated upward based on weekly assessments of symptoms. We conducted semistructured interviews and collected contemporaneous measures of health-related quality of life, severity of dyspnea, anxiety, depression, global ratings of opioid "helpfulness" and adverse effects before, at 2 months and at 4-6 months after opioids were started. Results:Of the 44 patients, 32 (73%) completed the trial; 27 (90%) of 30 patients reported the opioid treatment as very (43%) or somewhat (47%) helpful. Three main themes emerged from the patients' overall positive experiences: small gains have big impact; realign hopes with reality; and "try it." Significant improvements were observed in median (interquartile range) scores between baseline and 4-6 months' assessment for health-related quality of life Interpretation: Opioids were a helpful and acceptable intervention for refractory dyspnea in patients with advanced COPD. Many of the patients experienced sustained benefits over months, which supports recent recommendations to consider opioids in this setting. Trial registration: ClinicalTrial.gov, no. NCT00982891Competing interests: Available at the en...
Chronic obstructive pulmonary disease (COPD) will be the third leading cause of death worldwide by 2020. The burdens of this increasingly prevalent illness borne by patients, their family caregivers and the healthcare system are substantial. Dyspnoea as the predominant symptom becomes increasingly difficult to palliate as COPD progresses through advanced stages and, for 50% of patients, can become refractory to conventional treatment. This narrative review focuses on the potential role for carefully initiated and titrated opioids in the management of dyspnoea for patients with advanced COPD who are not yet in a terminal stage, yet struggle with symptoms that reflect underlying mechanisms of dyspnoea that lend themselves to this approach. The many barriers that currently exist to the provision of opioids in this setting are addressed, and recommendations are provided for an approach that should engender confidence among patients, their caregivers and the physicians who treat them.Chronic obstructive pulmonary disease (COPD) will be the third leading cause of death worldwide by 2020.1 In recent years there has been a welcome increase in the focus on the care of advanced COPD in the pages of both specialist palliative care journals 2 3 and in the respiratory literature. [4][5][6] This long overdue change reflects the reality that COPD is unique among the major diseases in western society in that its prevalence, morbidity and attributable mortality continue to rise, 7 that for patients who have advanced COPD the symptom burden is substantial, 8 9 that dyspnoea as the predominant symptom is often poorly controlled and ultimately incapacitating, 10 and that palliative care services in hospital or at home and high quality symptom-focused interventional strategies in our current models of care are less accessible than they are for people with cancer.4 9 While palliative care in general is responding to calls to extend traditional boundaries to encompass patients with advanced non-malignant medical illness, we need innovative and effective approaches to symptom control in advanced stages of COPD 2 if we are to lessen the increasing burdens that advanced COPD places on the lives of patients and caregivers alike. 11The purpose of this narrative review is to (re)consider the role of opioids in the management of the patient who lives with advanced COPD and struggles with dyspnoea refractory to conventional treatment. We also set out to describe barriers to the provision of opioid therapy.The information for this narrative review was compiled from previous researches of MEDLINE, CINAHL and EMBASE since 31 December 2006 and a recent review through PUBMED to February 2009. Dyspnoea has been a research interest for the last 15 years for the senior authors, and articles from personal archives, the unpublished literature, work in progress from colleagues, text books, the searching of recent journals and references from papers have also been incorporated. Where possible, original studies are cited but, to limit references t...
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