Perspectives of patients, family caregivers and physicians about the use of opioids for refractory dyspnea in advanced chronic obstructive pulmonary disease

Rocker, Graeme; Young, Joanne; Donahue, Margaret; Farquhar, Morag; Simpson, Catherine

doi:10.1503/cmaj.111758

Cited by 72 publications

(65 citation statements)

References 43 publications

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“…Nevertheless, long-held fears of further depressing respiration continue to limit more widespread acceptance by physicians [35] despite recommendations for their use in several recent professional society statements and/or clinical practice guidelines [20,36,37]. ualitative studies indicate e cacy and acceptability from patient and caregiver perspectives [35].…”

Section: Opioidsmentioning

confidence: 99%

“…ualitative studies indicate e cacy and acceptability from patient and caregiver perspectives [35]. In contrast, physicians from general practice, internal medicine, palliative care and respirology suggested that lack of education and knowledge concerning opioids were among the greatest barriers to opioid use in advanced COPD [35]. ey also worried about possible censure for prescribing opioids in this context.…”

Section: Opioidsmentioning

confidence: 99%

“…ey also worried about possible censure for prescribing opioids in this context. Distinctions were made between prescribing opioids for cancer (for which clear guidelines are available), and prescribing for dyspnea in advanced COPD (for which many considered opioids to be outside the standard of care) [35].…”

Section: Opioidsmentioning

confidence: 99%

“…O en patients are reticent to try opioids, associating them with impending death. Sensitive explanations usually di use concerns [35,38] and patents nd it convenient to move to a sustained-release preparation taken daily or twice daily (a er daily requirements of an immediate-release preparation are established), with additional immediate-release opioid for 'breakthrough' dyspnea.…”

Section: Opioidsmentioning

confidence: 99%

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'INSPIRED' Approaches to Better Care for Patients with Advanced COPD

Rocker¹,

Cook²

2013

CIM

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Chronic Obstructive Pulmonary Disease (COPD) is the most common cause of admission to acute care facilities in Canada. e burden of illness for patients, caregivers and the health care system is profound. Dyspnea in advanced COPD pervades all aspects of patients' lives. When increasing symptom burden limits patients to their homes, crucial primary care services become less accessible, and care of end-stage COPD becomes increasingly fragmented and reactive. Given the considerable physical and psychosocial consequences of advanced COPD, this phase can be devastating for patients and families. In this article we outline the need for clinical interventions and re-organized models of care designed for better continuity to achieve more favorable outcomes for these patients and their families. Outreach programs and use of personalized action plans that include advice on careful use of opioids can be remarkably e ective. e move toward an integrated approach to COPD management with more e ective advance care planning will help patients and their families make informed decisions throughout the illness trajectory. Intensive medical treatment focused on increasing survival can coexist with both holistic and palliative approaches to improve the quality of life of patients with severe end-stage COPD.

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Section: Opioidsmentioning

confidence: 99%

Section: Opioidsmentioning

confidence: 99%

Section: Opioidsmentioning

confidence: 99%

Section: Opioidsmentioning

confidence: 99%

See 2 more Smart Citations

'INSPIRED' Approaches to Better Care for Patients with Advanced COPD

Rocker¹,

Cook²

2013

CIM

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“…Although guidelines recommend opioids in palliating dyspnea, there is still a hesitance among practitioners in using these agents. Recent work by Rocker et al 35 has shown that there is lack of connection between practitioners' experience and comfort with opioids vs. patients' experiences, which are positive in those who are carefully selected and titrated. 35,36 Collaboration with palliative care should enhance treatment in this patient population.…”

Section: Referencesmentioning

confidence: 99%

Emerging concepts and therapies for chronic obstructive pulmonary disease

Raghavan¹,

McIvor²

2013

Polish Archives of Internal Medicine

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REVIEW ARTICLE Emerging concepts and therapies for chronic obstructive pulmonary disease 303 Diagnosis and symptom identification The cornerstone for the diagnosis of chronic obstructive pulmonary disease (COPD) remains evidence of airflow obstruction on spirometry with the forced expiratory volume in 1 second (FEV 1 ) to forced vital capacity ratio of less than 70%.1 Patients with compatible symptoms require spirometry to confirm airway obstruction, and FEV 1 is still used as the marker of the grade of COPD to guide treatment.The assessment, however, should not end there. A careful history of symptoms, such as dyspnea, cough, and sputum production, should also be included in the initial assessment. New tools such as the COPD assessment test (CAT) questionnaire have been shown to be useful in identifying the importance of a variety of symptoms in COPD and can be responsive to functional changes. It is a questionnaire that the patient can self-administer with 8 questions graded on a scale from 0 to 5, with a total score that can be monitored for changes over time. The CAT has been shown to deteriorate with exacerbations and is a tool that was developed to assess symptoms on a longitudinal basis. 2,3 The components of CAT may even be helpful to identify those who have COPD in the general population. 4Exacerbations are increasingly being identified as pivotal events in the disease course of a patient with COPD. The history of having an exacerbation is the single best predictor of having a subsequent exacerbation; thus, the history and frequency of exacerbations should be assessed at every visit. 5 More recent data has looked at the long-term outcome of patients after suffering their first severe exacerbation requiring hospitalization. Suissa et al. 6 investigated 73,106 patients during a 17-year follow-up. The risk of subsequent exacerbations rose 3-fold after the second serious exacerbation, and it seemed that the optimal time to intervene would be after the first exacerbation to prevent any subsequent exacerbations. REVIEW ARTICLE AbsTRACTChronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality worldwide. Although considerable advances have been made in the diagnosis and treatment of COPD, much remains to be done both to alleviate symptoms and reduce mortality associated with this condition. Previously, diagnosis, management, and research all centred on staging based on the forced expiratory flow in 1 second. It is now becoming apparent that this is inadequate to truly capture current disease burden and future deterioration. Fortunately, new approaches to care are constantly being identified. It is now known that symptoms and, in particular, exacerbations represent pivotal events in the patient's life that should trigger optimization of care. Much work is currently underway to identify various phenotypes in COPD because it has become obvious that this is a heterogeneous disease and applying the same management algorithms for all patients is insufficient. Several new me...

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Caring for the Older Person With Chronic Obstructive Pulmonary Disease

Fried¹,

Fragoso²,

Rabow³

2012

JAMA

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Chronic obstructive pulmonary disease (COPD) is a common disease in elderly patients. It is characterized by high symptom burden, healthcare utilization, mortality, and unmet needs of both patients and their caregivers. The treatment of the older patient with COPD is highly challenging. Although COPD is a major cause of respiratory failure and dyspnea in the elderly, multiple other disease entities, including heart failure, pulmonary embolism, and anxiety; medication effects; and other conditions, including deconditioning and malnutrition; may exacerbate COPD symptoms. Randomized controlled trials, which provide the strongest evidence for guideline recommendations, may underestimate the risk of adverse effects of interventions for older patients with COPD. The focus of guidelines on disease-modifying therapies may not address the full spectrum of both patient and caregiver needs engendered by the increasing burdens of advanced disease, particularly the high rates of bothersome symptoms, risk of functional and cognitive decline, and need for end-of-life care planning. Older patients tend to have a substantial disease burden coupled with functional and cognitive decline complicating the successful implementation of COPD treatments. Meeting the many needs of older COPD patients and their families requires that clinicians supplement guideline-recommended care with treatment decision making that takes into account older persons’ comorbid conditions, recognizes the trade-offs engendered by the increased risk of adverse events, focuses on symptom relief and function, and prepares patients and their loved ones for further declines in the patient’s health and their end-of-life care. A case of COPD in an 81 year old man hospitalized with severe dyspnea and respiratory failure is presented. This case highlights both the challenges in managing COPD in the elderly and the limitations in applying guidelines to geriatric patients.

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Perspectives of patients, family caregivers and physicians about the use of opioids for refractory dyspnea in advanced chronic obstructive pulmonary disease

Cited by 72 publications

References 43 publications

'INSPIRED' Approaches to Better Care for Patients with Advanced COPD

'INSPIRED' Approaches to Better Care for Patients with Advanced COPD

Emerging concepts and therapies for chronic obstructive pulmonary disease

Caring for the Older Person With Chronic Obstructive Pulmonary Disease

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