Psychoeducation/Psychoeducational Interventions

Psychoeducation/Psychoeducational Interventions

PEP Topic 
Dyspnea
Description 

Psychoeducation or psychoeducational interventions encompass a broad range of activities that combine education and other activities such as counseling and supportive interventions. Psychoeducational interventions may be delivered individually or in groups and may be tailored or standardized. This type of intervention generally includes providing patients with information about treatments, symptoms, resources and services, training to provide care and respond to disease-related problems, and problem solving strategies for coping with cancer. Interventions may include use of booklets, videos, audiotapes, and computers, and formats may be interactive between healthcare professionals and patients and caregivers, self-directed via use of CDs and other materials, online or delivered telephonically. Studies using psychoeducational interventions tend to vary substantially in specific content, format, frequency, and timing of the interventions. For this reason, ability is limited to currently examine the relative effectiveness of different formats and delivery methods. Highly specific content approaches such as mindfulness-based stress reduction and cognitive behavioral approaches are identified in these resources as separate interventions, rather than incorporated into overall psychoeducation.

Effectiveness Not Established

Research Evidence Summaries

Bredin, M., Corner, J., Krishnasamy, M., Plant, H., Bailey, C., & A’Hern, R. (1999). Multicentre randomised controlled trial of nursing intervention for breathlessness in patients with lung cancer. BMJ, 318(7188), 901–904.

doi: 10.1136/bmj.318.7188.901
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Intervention Characteristics/Basic Study Process:

Patients diagnosed with lung cancer were randomized to attend a nursing clinic offering interventions for breathlessness versus best supportive care. The intervention consisted of

  • A detailed assessment of breathlessness, what hinders it, and what aids it
  • Advice and support for patients and families on management of breathlessness
  • Exploration of the meaning of breathlessness, disease, and their future
  • Training in breathing control techniques, relaxation techniques, and distraction exercises
  • Goal setting to complement breathing and relaxation techniques, to improve function and social activities, and to help develop coping skills
  • Early identification of problems needing pharmacologic or medical intervention
  • Clinic visits once a week up to eight weeks and not less than three weeks.

Control: received standard of care for breathlessness; best supportive care involved standard management and treatment available for dyspnea. Nurse specialists used and were taught the intervention in same way, using a practice guideline to ensure correct delivery of the intervention.

Sample Characteristics:

The study reported on a sample of 119 patients with lung cancer; the goal was to recruit 150 patients for 90% power. Data from 16 patients were lost because a center was dropped from the study. Final sample included 51 in the intervention group and 52 in the control group.

Setting:

The study was conducted in nursing clinics in six hospital settings in London, United Kingdom.

Study Design:

The study design included randomization to either intervention or control group.

Measurement Instruments/Methods:

Outcome measures were conducted at baseline and at four and eight weeks.

  • VAS measuring breathlessness at worst and at best and distress caused by breathlessness
  • World Health Organization (WHO) performance status scale
  • HAD
  • Rotterdam symptom checklist

Results:

The intervention group improved significantly at eight weeks in 5 of 11 items assessed.

  • Breathlessness at best
  • WHO performance status
  • Level of depression
  • Physical symptom distress and breathlessness from Rotterdam symptom checklist

Final sample included 51 in the intervention group and 52 in the control group. Attrition: 16 patients died, and 28 withdrew. Reasons for withdrawal: 1 improved condition, 16 had deterioration, 4 were unhappy with the assigned treatment arm, and 7 were for unknown reasons. Survival of patients who withdrew was significantly worse than the intervention arm (hazard ratio = 2.5; p < 0.05). Survival of all who withdrew versus nonwithdrawals was also significantly worse (p < 0.01). Overall survival of the intervention and control groups was not different. At baseline, both groups had high level of distress caused by breathlessness and associated functional impairment.

Conclusions:

Overall conclusion is that patients attending nursing clinics for breathlessness experienced improvements in breathlessness, performance status, and physical and emotional status.

Limitations:

The analysis was based on the assumption that missing data from patients who withdrew because of poor outcomes were assigned a lower change score .The findings would have been more credible if outcomes were actually assessed. The method assumed that patients were able to show a change in either direction on rating scales, but patients who were on the extreme could only go in one direction. As stated in the Corner et al. (1996) pilot study, the contribution of each component of the intervention is unknown. Are all components needed to achieve the same outcome, or was one aspect of the intervention most significant?

Chan, C. W., Richardson, A., & Richardson, J. (2011). Managing symptoms in patients with advanced lung cancer during radiotherapy: results of a psychoeducational randomized controlled trial. Journal of Pain and Symptom Management, 41, 347–357.

doi: 10.1016/j.jpainsymman.2010.04.024
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Study Purpose:

To examine the effectiveness of a psychoeducational intervention (PEI) on the symptom cluster of anxiety, breathlessness, and fatigue compared with usual care.

Intervention Characteristics/Basic Study Process:

Education on symptom management and coaching on the use of progressive muscle relaxation was delivered to patients one week prior to the start of radiotherapy (RT) and repeated three weeks after beginning RT. Symptom data were collected at four times points:  prior to the intervention and at three, six, and 12 weeks postintervention.

Sample Characteristics:

  • In total, 140 patients (83% male, 17% female) with lung cancer receiving palliative RT were included.
  • Patients were 16 years or older.
  • Patients had stage III or IV lung cancer.

Setting:

  • Single site
  • Outpatient
  • RT unit of a publicly funded hospital in Hong Kong

Study Design:

The study was a randomized, controlled trial using a pre-/posttest design with two groups.

Measurement Instruments/Methods:

  • Breathlessness was assessed using a 100-mm visual analog scale.
  • Fatigue was measured with the intensity subscale of the revised Piper Fatigue Scale (PFS), consisting of 23 items. The instrument was translated into Chinese and found to be valid and reliable.
  • Anxiety was measured using the Chinese version of the State-Trait Anxiety Inventory (STAI), consisting of 20 items for measuring immediate feelings of apprehension, nervousness, and worry.
  • Functional ability was a secondary outcome measure, using the subscale of the Chinese version of the Short Form 36 (SF-36) Health Survey.

Results:

A significant difference (p = 0.003) was seen over time on the pattern of change of the symptom cluster between the PEI intervention and the usual care control group. Significant effects on patterns of changes in breathlessness (p = 0.002), fatigue (p = 0.011), anxiety (p = 0.001), and functional ability (p = 0.000) were found.

Conclusions:

PEI is an effective treatment for relieving the symptom cluster of anxiety, breathlessness, and fatigue and each of the individually assessed symptoms.

Limitations:

  • The study had a small sample size, with less than 100 participants.
  • A high attrition rate was due to death.

Nursing Implications:

The study provided evidence to support the symptom cluster of anxiety, breathlessness, and fatigue as interrelated, with assessment and management of those three symptoms as a cluster. Clarification of the nature of their interrelatedness is a potential area of further study. Education and counseling patients through nurses can be helpful in the management of these symptoms.

Connors, S., Graham, S., & Peel, T. (2007). An evaluation of a physiotherapy led non-pharmacological breathlessness programme for patients with intrathoracic malignancy. Palliative Medicine, 21(4), 285–287.

doi: 10.1177/0269216307079172
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Intervention Characteristics/Basic Study Process:

The intervention was a nonpharmacologic breathlessness program. Patients were seen for one hour for four consecutive weeks with a review session one month later.
  • Week 1: Breathing control and assessment
  • Week 2: Review, relaxation, and anxiety management techniques
  • Week 3: Review, energy conservation, goal setting, and lifestyle adaptation
  • Week 4: Review and assessment
  • Week 8: Review and re-assessment

This program was conducted for four years. The study was based on prior research conducted by Corner et al. (1996) and Bredin et al. (1999), also reported elsewhere in the table.

Sample Characteristics:

The study reported on a sample of 169 patients. All patients reported breathlessness as a symptom. Patients were referred from three sources to a physiotherapist-led breathlessness program for patients with intrathoracic malignancy. The three sources included an outpatient lung cancer clinic, the inpatient unit, or the community where they were referred by a specialist palliative care team. A screening questionnaire was used to identify the cause of breathlessness. If the cause was reversible, the patient received appropriate care. Only 14 of 169 completed the entire program.

Measurement Instruments/Methods:

The following tools were used at one, four, and eight weeks.

  • Chronic Respiratory Disease Questionnaire
  • Number counting
  • VAS of breathlessness at worst and at best and distress related to breathlessness

Results:

Only 14 of 169 completed the entire program. The following are characteristics of the 14 who completed the program.

  • Referred from the outpatient setting
  • Had radical treatment
  • Etiology of the breathlessness was either treatment-related or because of other causes but not from progression of disease.
  • Median survival was 630 days

Of the 14 who completed the program, pre- and post-assessment scores showed modest improvement, but it was not statistically significant. The majority did not complete the program. One hundred thirty-one patients (85%) were seen at least once and anecdotally had subjective benefit. Of those who did not complete the program, some had progressive disease and were too ill to participate or died before being seen. Median survival was 95 days.

Conclusions:

Patients with intra-thoracic cancer may benefit from a formal nonpharmacologic program. Patients who are frail and/or on palliative care may need a more flexible program.

Limitations:

One hundred fifty-five patients did not complete the program because of progressive disease and associated shorter survival. The small subset who did complete the program did not show significant improvement in dyspnea measures. Dropout rate was 82% versus 41% in the Corner study and 43% in the the Bredin study. Interventions in the three studies were similar. The difference in dropout rate for this study compared to Bredin and Corner’s studies is explained by the fact that the patients in this study were older and were recruited from the totality of patients with lung cancer presenting to the cancer center.

Corner, J., Plant, H., A’Hern, R., & Bailey, C. (1996). Non-pharmacological intervention for breathlessness in lung cancer. Palliative Medicine, 10(4), 299–305.

doi: 10.1177/026921639601000405
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Intervention Characteristics/Basic Study Process:

The intervention included weekly sessions with a nurse research practitioner, lasting one hour, using counseling, breathing retraining, relaxation, and the teaching of alternate coping and adaptation strategies. The interventions are the same as those commonly used to treat patients with chronic pulmonary disease. Patients were randomized either to an intervention group or control group. The intervention group met over a three- to six-week period. Additional follow-up sessions were available if necessary. The number of sessions was not stated. The control group received usual nursing care such as breathing assessment with documentation in the medical record.

Sample Characteristics:

The study reported on a sample of 20 patients with lung cancer. The patients had completed either chemotherapy or radiotherapy and were experiencing breathlessness.

Setting:

The study was conducted in a nurse-led clinic in a specialist cancer center.

Study Design:

Randomized, controlled pilot study

Measurement Instruments/Methods:

  • A 10-point VAS measuring three time frames (best, worst, and usual) to rate breathlessness over the previous week
  • Distress caused by breathlessness
  • Functional Capacity Scale
  • HADS

Results:

Median scores on all measures were improved. Distress from breathlessness improved 53%, breathlessness at worst improved 35%, and functional capacity improved by 21%. Distress in the control group worsened by a median of 10%. Significant improvements compared with the control group were observed in breathlessness at best (p < 0.02) and at worst (p < 0.5), distress caused by breathlessness (p < 0.01), and functional capacity (p < 0.02). Improvements were not observed for anxiety or depression.

Conclusions:

The study demonstrates that patients with lung cancer and breathlessness benefit from a rehabilitative approach.

Limitations:

The effect of time and attention on a weekly basis independent of intervention is unknown. The contribution of each component of the intervention is unknown. Are all components needed to achieve the same outcome, or was one aspect of the intervention most significant? The study had a small sample, and baseline data show that the intervention group rated distress caused by breathlessness higher than did the control group.

Nursing Implications:

The study is valuable as a pilot study with an aim to test feasibility.

Hately, J., Laurence, V., Scott, A., Baker, R., & Thomas, P. (2003). Breathlessness clinics within specialist palliative care settings can improve the quality of life and functional capacity of patients with lung cancer. Palliative Medicine, 17(5), 410–417.

doi: 10.1191/0269216303pm752oa
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Intervention Characteristics/Basic Study Process:

Potential patients were referred to a highly experienced palliative care physiotherapist clinic. Patients were seen by the physiotherapist at three sessions, each lasting as long as 90 minutes. Intervention consisted of breathing retraining, simple relaxation techniques, activity pacing, and psychosocial support.

Sample Characteristics:

The study reported on a sample of 30 patients with non-small cell lung cancer, small cell lung cancer, or mesothelioma (pleural effusion excluded) who experienced breathlessness not less than one month after completion of any active treatment; 68 patients were referred, 17 did not fulfill the criteria, 4 declined, and 2 were too ill to treat. Forty-five entered the study, and 15 deteriorated or died before completion. The median age was 71 years; 24 were men, and 6 were women.

Setting:

The study was conducted in an outpatient clinic in the United Kingdom.

Study Design:

  • Uncontrolled study
  • Nonrandomized
  • Referred patients

Measurement Instruments/Methods:

Tools completed by the therapist at each visit

  • Current Respiratory Symptoms—adapted from two scales (Medical Research Council and Respiratory Symptom Questionnaire); patients were asked to score how often they were breathless, ranging from most or all the time to less than once a week
  • Functional Capacity Scale adapted from above tools; patients scored their ability to climb hills or stairs without breathlessness to experiencing breathlessness at rest
  • Sputum production scale

Self-assessment tools completed by patients at baseline and following the intervention (four to six weeks)

  • Rotterdam symptom checklist
  • VAS: breathing at worst and at best in the proceeding 24 hours as well as distress caused by breathlessness (0–10 where 10 = extreme distress)
  • Things that improve breathing (in the clinic, patients were taught techniques and coping strategies likely to improve their feeling of breathlessness); the patients were asked to score 20 helpful strategies at baseline and at the last visit on a VAS (1–10 where 10 = extremely helpful).
  • Quality-of-life questionnaire
  • Therapist recorded patients’ verbatim comments in free narrative form and added own comments.

Results:

Statistical analysis of baseline data on 12 patients who were unable to complete the study compared to 30 patients who completed the study showed significantly lower Functional Capacity Scale scores (p = 0.04) at first assessment. For patients who completed the study, a highly significant (p < 0.001) change in frequency of reported breathlessness was found. A decrease existed in reported breathlessness, from 97% reporting it at least once or twice a day, 73% several times a day, and 27% most of the time to 27% experiencing dyspnea several times a day and 3% most of the time at the final visit. A statistically significant change was seen between study entry and completion (p < 0.001) in functional capacity. Overall, 19 improved function, 9 remained stable, and 2 deteriorated.

No change in sputum production was found.

Rotterdam symptom checklist:

Significant changes were seen in the physical distress scores and activity levels (no p value given). Change in psychological distress scores were borderline.

Degree of breathlessness:

Significant improvement (p < 0.001) was found in all three parameters—breathing at best, breathing at worst, and distress caused by breathlessness.

Intervention strategies:

On study entry, patients were asked to score 20 strategies that were likely to improve feelings of breathlessness. Examples of interventions include activity pacing, abdominal breathing, slowing down, relaxation exercises, not worrying, accepting the situation, and positive thinking.

Patients reported that all of the techniques they learned were helpful and improved breathlessness. Patients reported that massage and the use of bronchodilator drugs were not helpful.

Quality of life:

Significant improvements were seen in decrease in time spent lying down (p = 0.02), improved bodily strength (p = 0.03), and increase in things that made patients happy (p = 0.04). Patients reported an increased ability to do things and improved quality of life.

Qualitative data:

The following themes were extracted from the narrative data: difficulty adjusting, issues around death, effects of treatments, and therapies’ impact on daily life.

Limitations:

The study was uncontrolled. A major limitation of the study is that it is a nonrandomized trial of referred patients. Impossible to know are the implied bias in patients who were referred or the true effect of the intervention without a control group. It was based on a prior study, with the time period shortened because of the loss of patients in the earlier study’s sample.

Yates, P., & Zhao, I. (2012). Update on complex nonpharmacological interventions for breathlessness. Current Opinion in Supportive and Palliative Care, 6(2), 144-152.

doi: 10.1097/SPC.0b013e3283536413
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Study Purpose:

The objective of the article is to report on strategies that patients with breathlessness find helpful and provide a review of current evidence about the role of nonpharmacologic interventions in managing dypsnea.

Intervention Characteristics/Basic Study Process:

This article reports a secondary analysis of data from a trial in which self-report items were used to assess the impact of dyspnea on daily activities, feelings about breathlessness, and strategies adopted by patients. Authors also review the findings of several systematic reviews of nonpharmacologic interventions for breathlessness involving patients with chronic obstructive pulmonary disease (COPD) as well as lung cancer.

Sample Characteristics:

  • The article reported on a sample of 144 patients.
  • The mean age was 67.9 years (SD = 9.6 years).
  • The sample was 60% males and 40% females.
  • Patients involved in self-report of strategies all had cancer. 
  • Most data from systematic reviews involved primarily patients with COPD.

Setting:

The multi-site study was conducted in an unspecified setting in Australia.

Phase of Care and Clinical Applications:

  • Patients were undergoing end-of-life care.
  • The article has clinical applicability for palliative care.

Study Design:

Descriptive

Measurement Instruments/Methods:

  • Author-designed self-report instrument based on an assessment guide developed in the UK
  • Likert-type scoring on a 4-point scale

Results:

About half of patients reported that breathlessness had some effect on feelings of panic, fear, and anger. Activity modification was the most frequently used strategy.  Cognitive coping strategies were used by 80% of respondents. Other strategies included breathing exercises and environmental modifications. The most helpful strategies related to activity modification. Of those who used coping and breathing exercises, 60% said they were helpful. Breathing retraining was found to be effective but is mainly studied in COPD. Exercise program findings are inconclusive, and interventions to reduce anxiety have had some positive outcomes. Other interventions such as music, distraction, and complementary medicine have insufficient evidence.

Conclusions:

Patients in this study reported that activity management was helpful to manage dyspnea.

Limitations:

  • Risk of bias (no control group)
  • Risk of bias (no blinding) 
  • Risk of bias (no random assignment)
  • Risk of bias (no appropriate attentional control condition) 
  • Risk of bias (sample characteristics)
  • Measurement validity/reliability questionable
  • The likert scale used is questionable in terms of lack of differentiation in terms used for degree of effect.
  • Findings reported from systematic reviews were mainly from COPD cases, and few included patients with lung cancer. 
  • Other cancers were not included.

Nursing Implications:

Findings suggest that educating appropriate patients about activity management can be helpful for them to manage symptoms of dyspnea. Limited evidence exists about the effects of other nonpharmacologic approaches that are effective for patients with cancer.

Guideline/Expert Opinion

National Comprehensive Cancer Network. (2012). NCCN Clinical Practice Guidelines in Oncology: Palliative Care [v.2.2012]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf

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Purpose & Patient Population:

The objective of the guidelines is to provide palliative care practice guidelines for patients with cancer, facilitating the appropriate integration of palliative care into oncology practice.

Type of Resource/Evidence-Based Process:

These are consensus-based guidelines.

Phase of Care and Clinical Applications:

Included in the guidelines are multiple phases of care with palliative care applications. 

Guidelines & Recommendations:

The NCCN made recommendations on the following symptoms.

Anorexia
Nutritional support, including enteral and parenteral feeding, should be considered. Appetite stimulants such as megestrol acetate and corticosteroids can be used when appetite is an important aspect of quality of life.

Chemotherapy-Induced Nausea and Vomiting (CINV)
Recommendations include prochlorperazine, haloperidol, metoclopramide, or benzodiazepines. Adding 5-HT3 receptor agonists, anticholinergics, antihistamines, corticosteroids, antipsychotics, and cannabinoids also can be considered. Palliative sedation can be considered as a last resort.

Constipation
Increase fluid intake, dietary fiber, and physical activity. Opioid-induced constipation should be anticipated and treated prophylactically with laxatives.

Dyspnea
Pharmacologic interventions include opioids or benzodiazapines. Scopolamine, atropine hyoscyamine, and glycopyrrolate are options to reduce excessive secretions.

Pain
Do not reduce opioid dose for symptoms such as decreased blood pressure or respiratory rate. Palliative sedation can be considered for refractory pain.

Sleep/Wake Disturbances
For refractory insomnia with no underlying physiologic cause, pharmacologic management includes diazepam, zolpidem, and sedating antidepressants. Cognitive behavioral therapy may be effective. If present, restless leg syndrome can be treated with ropinirole.

Limitations:

  • Recommendations are predominantly consensus- rather than evidence-based. 
  • Recommendations are generally based on low-level evidence. 
  • Recommendations regarding CINV seem particularly out of date and are not in concert with current evidence.

Nursing Implications:

Recommendations provide expert opinion/consensus-level suggestions for management of various symptoms. Many recommendations, such as those for CINV, do not agree with current evidence in these areas.

Qaseem, A., Snow, V., Shekelle, P., Casey, D.E., Jr., Cross, J.T., Jr, Owens, D.K., . . . Shekelle, P. (2008). Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 148, 141–146.

doi: 10.7326/0003-4819-148-2-200801150-00009
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Purpose & Patient Population:

Objectives were to

  • Present evidence that will contribute to the improvement of palliative care at the end of life.
  • Answer questions regarding critical elements.
  • Identify patients who could benefit from palliative approaches.
  • Identify treatment strategies that work for pain, dyspnea, and depression.
  • Identify elements important in advance care planning, collaboration and consultation, and assessment and support aspects helpful to caregivers.

Included were patients with any disabling or symptomatic condition at the end of life.

Type of Resource/Evidence-Based Process:

The guideline was based on a systematic evidence review, done by others, in an Agency for Healthcare Research and Quality evidence report. The guideline does not address nutritional support, complementary and alternative therapies, or spiritual support because evidence related to these areas does not often appear in the literature. Specific procedures for grading the evidence and recommendations are not described.

The guideline was developed for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Evidence and recommendations were graded using the clinical practice guidelines grading system (GRADE).

Databases searched were MEDLINE and the Database of Abstract Reviews of Effects (January 1990–November 2005); citations from the review by the National Consensus Project for Quality Palliative Care (2003) also were searched.

Search keywords were cancer, congestive heart failure, and dementia. The full description of search terms is published elsewhere.

Results Provided in the Reference:

The guideline outlines the strength of GRADE recommendations and includes a brief description of the supporting evidence for each recommendation.

Critical Elements for End-of-Life Care: Elements identified are preventing and treating pain and other symptoms; supporting families and caregivers; ensuring continuity of care; ensuring respect for patients as people and informed decision making; ensuring well-being, including consideration of existential and spiritual concerns; and supporting function and duration of survival.

Identifying Patients Who Could Benefit From Palliation: No evidence tools have been validated or effectively shown to predict optimal timing. Decisions should be based on each patient's symptoms and preferences.

Treatment Strategies:

  • Pain
    • Evidence is strong in support of the use of nonsteroidal anti-inflammatory drugs, opioids, bisphosphonates, and radiotherapy or radiopharmaceuticals for pain, with bisphosphonates used for bone pain specifically.
    • Insufficient evidence exists to evaluate the usefulness of acupuncture or exercise for pain control.
    • Palliative care teams may be moderately beneficial in providing pain management.
  • Dyspnea
    • Evidence shows a valuable effect of morphine.
    • Nebulized opioids show no additional benefit over oral opioids.
    • Evidence regarding the use of oxygen is equivocal.
    • Studies that evaluated facilitated communication or palliative care consultation showed no effect.
  • Depression
    • Evidence suggests that long-term use of tricyclic antidepressants, selective serotonin reuptake inhibitors, and psychosocial interventions are beneficial for patients with cancer who are depressed.
    • Evidence is mixed regarding the benefit of guided imagery and exercise in the defined patient population.
    • Evidence showed that care coordination had no effect.

Important Elements for Advance Care Planning: Evidence shows that extensive multicomponent interventions, goal-oriented interviews with palliative care providers, and proactive communication involving skilled discussants can reduce unnecessary services, without causing harm, and increase the use of advance directives.

Collaboration and Consultation: Use and patient-centered outcomes improve when multidisciplinary teams include nurses and social services providers, address care coordination, and use facilitated communication.

Supporting Caregivers: Evidence regarding the effects of palliative care teams for caregivers is mixed.

Guidelines & Recommendations:

The following were graded as strong recommendations with moderate quality of evidence.

  • Patients with serious illness at the end of life should be regularly assessed for pain, dyspnea, and depression.
  • For patients with cancer, clinicians should use therapies with proven effectiveness to manage pain. These therapies include nonsteroidal anti-inflammatory drugs, opioids, and bisphosphonates.
  • Clinicians should use therapies with proven effectiveness to manage dypsnea. These therapies include opioids (for unrelieved dyspnea) and oxygen (for the relief of short-term hypoxemia).
  • Clinicians should use therapies with proven effectiveness to manage depression in patients with cancer. These therapies include tricyclic antidepressants, selective serotonin reuptake inhibitors, and psychosocial interventions.
  • Clinicians should ensure that advance care planning occurs for all patients with serious illness. Such planning includes the preparation of advance directives.

Limitations:

  • Several authors had grants from the Agency for Healthcare Research and Quality or pharmaceutical companies.
  • Financial support for this guideline was entirely from the American College of Physicians.

Nursing Implications:

The guideline provides clear guidance in several areas of end-of-life care and symptom management and identifies the relevant evidence and strength of the evidence. The guideline may not apply to all patients and is not intended to override clinical judgment. In addition to recommending medication interventions for depression, the guideline recommends psychosocial interventions.

Systematic Review/Meta-Analysis

Rueda, J. R., Sola, I., Pascual, A., & Subirana Casacuberta, M. (2011). Non-invasive interventions for improving well-being and quality of life in patients with lung cancer. Cochrane Database of Systematic Reviews (Online), 9, CD004282.

doi: 10.1002/14651858.CD004282.pub3
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Purpose:

The objective of the systematic review was to assess the effectiveness of non-invasive interventions delivered by healthcare professionals in improving symptoms, psychological functioning, and quality of life.

Search Strategy:

Databases searched were Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO, AMED, British Nursing Index and Archive, and reference lists from relevant studies.

Search keywords were non-invasive interventions and lung cancer.

Randomized controlled trials and controlled clinical trials were included. The trials included involved

  • Patients of any age or gender diagnosed with lung cancer
  • Any stage of illness
  • Any non-invasive intervention treatment or action performed by healthcare professional to enhance well-being or quality of life defined to include symptoms related to cancer.

 

Literature Evaluated:

A total of 20 references were retrieved. Two authors independently assessed all the references. Three of 15 studies included in this review were evaluated together in one category labeled “Nursing Interventions to Manage Breathlessness.” Of the three studies that focused solely on breathlessness, two studies previously were evaluated in the 2009 Putting Evidence Into Practice publication.  

 

Sample Characteristics:

The final number of studies included was 15. The breathlessness category included 165 patients with lung cancer. The sample range across studies was 22-109.

Patients had lung cancer with refractory breathlessness, the majority of which were not receiving active therapy. Patients received breathlessness rehabilitation, which focused on emotional as well as physical aspects of the symptom, or breathlessness training intervention, described as training in diaphragmatic breathing, pacing, anxiety management, and relaxation.

Results:

The three studies found that the intervention was effective in improving the sensation of breathlessness at best and also had beneficial effects on performance status, functional ability, and depression. Due to the stage of disease and limited life expectancy of those diagnosed with advanced lung cancer, rapid deterioration and attrition were seen in one of the studies.

Conclusions:

The studies of breathlessness management indicate that nurse-led breathing programs may produce beneficial effects and should be encouraged.

Zhao, I., & Yates, P. (2008). Non-pharmacological interventions for breathlessness management in patients with lung cancer: A systematic review. Palliative Medicine, 22(6), 693-701.

doi: 10.1177/0269216308095024
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Purpose:

The objective of the article was to review studies that evaluated nonpharmacologic interventions for breathlessness management in patients with lung cancer.

Search Strategy:

Databases searched were Cochrane Library, EMBASE, PubMed, Ovid, EBSCO Host as a search engine for CINAHL, Pre-CINAHL (2007), Health Source: Nursing/Academic Edition, and MEDLINE (all searched 1990-July 2007).

Search keywords were breathlessness, dyspnea, management, interventions, treatment, non-pharmacological, and lung cancer.

Nonpharmacologic interventions for breathlessness in patients with lung cancer were included.

Pharmacologic interventions for breathlessness, studies that did not include patients with lung cancer, descriptive studies, and studies not published in English literature were excluded.

Literature Evaluated:

One hundred sixty-nine abstracts were retrieved, 15 articles were reviewed, and five studies ultimately were included. Studies were eliminated based on selection criteria. Standardized abstraction procedures were used to evaluate included studies.

Sample Characteristics:

A total of 370 patients were in the five studies included [Corner (20), Bredin (103), Connors (14) , Hately (30), Moore (203)].

Results:

All studies included behavioral, psychological, and educational interventions, although the method of delivery varied between studies.

Conclusions:

Evidence is moderately strong to suggest benefit of a counseling and supportive educational intervention to alleviate breathlessness in patients with lung cancer. While all studies showed benefit with a multicomponent nonpharmacologic intervention approach, whether all components are warranted or whether one component is more/less effective than another is inconclusive.

Limitations:

Studies were limited by small sample size or high attrition rates.

Nursing Implications:

Nurses should consider providing support and counseling for breathing techniques, relaxation, and breathing retraining in patients with breathlessness and lung cancer.


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