Masanori Mori1, Takashi Kawaguchi2, Kengo Imai3, Naosuke Yokomichi4, Takashi Yamaguchi5, Kozue Suzuki6, Ryo Matsunuma7, Hiroaki Watanabe8, Isseki Maeda9, Yoshihisa Matsumoto10, Yoshinobu Matsuda11, Tatsuya Morita4. 1. Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan. Electronic address: masanori.mori@sis.seirei.or.jp. 2. Department of Practical Pharmacy, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan. 3. Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan. 4. Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan. 5. Division of Palliative Care, Department of Medicine, Konan Medical Center, Kobe, Japan. 6. Department of Palliative Care, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan. 7. Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan. 8. Department of Palliative Care, Komaki City Hospital, Komaki, Japan. 9. Department of Palliative Care, Senri-chuo Hospital, Osaka, Japan. 10. Department of Palliative Medicine, National Cancer Center Hospital East, Kashiwa, Japan. 11. Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Japan.
Abstract
CONTEXT: How physicians use opioids for dyspnea in imminently dying cancer patients (terminal dyspnea) varies markedly, which could hamper quality care. OBJECTIVES: To examine the adherence to an algorithm-based treatment for terminal dyspnea, and explore its outcomes over 24 hours. METHODS: This was a pre-planned subgroup analysis of a multicenter prospective observational study. Inclusion criteria were: advanced cancer patients admitted to palliative care units, ECOG performance status=3-4, and a dyspnea intensity≥2 on the Integrated Palliative care Outcome Scale (IPOS). We developed an algorithm to visualize how palliative care physicians would use parenteral opioids. Participating physicians (palliative care specialists) initiated parenteral opioids, choosing whether to use the algorithm based on their preference. We measured the adherence rate to the algorithm over 24 hours (predefined goal=70%), and compared dyspnea IPOS scores and adverse events between patients with and without algorithm-based treatment. RESULTS: Of 164 patients (median survival=5 days), 71 (43%) received algorithm-based treatment, and 70 (99%; 95% confidence interval=92-100%) adhered to it over 24 hours. In a complete case analysis, mean dyspnea IPOS scores significantly decreased from 2.9 (standard error=0.1) to 1.5 (0.1) in the algorithm group (n=54; p<0.001), and 2.9 (0.1) to 1.6 (0.1) in the non-algorithm group (n=72; p<0.001). There was no significant between-group difference in changes in dyspnea IPOS scores (p=0.65). Adverse events were rare (n=5). CONCLUSION: The algorithm-based treatment was feasible, and might be as effective and safe as the usual care by palliative care specialists. Its implementation may help physicians provide quality care for terminal dyspnea.
CONTEXT: How physicians use opioids for dyspnea in imminently dying cancerpatients (terminal dyspnea) varies markedly, which could hamper quality care. OBJECTIVES: To examine the adherence to an algorithm-based treatment for terminal dyspnea, and explore its outcomes over 24 hours. METHODS: This was a pre-planned subgroup analysis of a multicenter prospective observational study. Inclusion criteria were: advanced cancerpatients admitted to palliative care units, ECOG performance status=3-4, and a dyspnea intensity≥2 on the Integrated Palliative care Outcome Scale (IPOS). We developed an algorithm to visualize how palliative care physicians would use parenteral opioids. Participating physicians (palliative care specialists) initiated parenteral opioids, choosing whether to use the algorithm based on their preference. We measured the adherence rate to the algorithm over 24 hours (predefined goal=70%), and compared dyspnea IPOS scores and adverse events between patients with and without algorithm-based treatment. RESULTS: Of 164 patients (median survival=5 days), 71 (43%) received algorithm-based treatment, and 70 (99%; 95% confidence interval=92-100%) adhered to it over 24 hours. In a complete case analysis, mean dyspnea IPOS scores significantly decreased from 2.9 (standard error=0.1) to 1.5 (0.1) in the algorithm group (n=54; p<0.001), and 2.9 (0.1) to 1.6 (0.1) in the non-algorithm group (n=72; p<0.001). There was no significant between-group difference in changes in dyspnea IPOS scores (p=0.65). Adverse events were rare (n=5). CONCLUSION: The algorithm-based treatment was feasible, and might be as effective and safe as the usual care by palliative care specialists. Its implementation may help physicians provide quality care for terminal dyspnea.