Natalie Pattison

Intensive care in patients with lung cancer: a multinational study

BACKGROUND Detailed information about lung cancer patients requiring admission to intensive care units (ICUs) is mostly restricted to single-center studies. Our aim was to evaluate the clinical characteristics and outcomes of lung cancer patients admitted to ICUs. PATIENTS AND METHODS Prospective multicenter study in 449 patients with lung cancer (small cell, n = 55; non-small cell, n = 394) admitted to 22 ICUs in six countries in Europe and South America during 2011. Multivariate Cox proportional hazards frailty models were built to identify characteristics associated with 30-day and 6-month mortality. RESULTS Most of the patients (71%) had newly diagnosed cancer. Cancer-related complications occurred in 56% of patients; the most common was tumoral airway involvement (26%). Ventilatory support was required in 53% of patients. Overall hospital, 30-day, and 6-month mortality rates were 39%, 41%, and 55%, respectively. After adjustment for type of admission and early treatment-limitation decisions, determinants of mortality were organ dysfunction severity, poor performance status (PS), recurrent/progressive cancer, and cancer-related complications. Mortality rates were far lower in the patient subset with nonrecurrent/progressive cancer and a good PS, even those with sepsis, multiple organ dysfunctions, and need for ventilatory support. Mortality was also lower in high-volume centers. Poor PS predicted failure to receive the initially planned cancer treatment after hospital discharge. CONCLUSIONS ICU admission was associated with meaningful survival in lung cancer patients with good PS and non-recurrent/progressive disease. Conversely, mortality rates were very high in patients not fit for anticancer treatment and poor PS. In this subgroup, palliative care may be the best option.BACKGROUND Detailed information about lung cancer patients requiring admission to intensive care units (ICUs) is mostly restricted to single-center studies. Our aim was to evaluate the clinical characteristics and outcomes of lung cancer patients admitted to ICUs. PATIENTS AND METHODS Prospective multicenter study in 449 patients with lung cancer (small cell, n = 55; non-small cell, n = 394) admitted to 22 ICUs in six countries in Europe and South America during 2011. Multivariate Cox proportional hazards frailty models were built to identify characteristics associated with 30-day and 6-month mortality. RESULTS Most of the patients (71%) had newly diagnosed cancer. Cancer-related complications occurred in 56% of patients; the most common was tumoral airway involvement (26%). Ventilatory support was required in 53% of patients. Overall hospital, 30-day, and 6-month mortality rates were 39%, 41%, and 55%, respectively. After adjustment for type of admission and early treatment-limitation decisions, determinants of mortality were organ dysfunction severity, poor performance status (PS), recurrent/progressive cancer, and cancer-related complications. Mortality rates were far lower in the patient subset with nonrecurrent/progressive cancer and a good PS, even those with sepsis, multiple organ dysfunctions, and need for ventilatory support. Mortality was also lower in high-volume centers. Poor PS predicted failure to receive the initially planned cancer treatment after hospital discharge. CONCLUSIONS ICU admission was associated with meaningful survival in lung cancer patients with good PS and non-recurrent/progressive disease. Conversely, mortality rates were very high in patients not fit for anticancer treatment and poor PS. In this subgroup, palliative care may be the best option.

Development of a Novel Remote Patient Monitoring System: The Advanced Symptom Management System for Radiotherapy to Improve the Symptom Experience of Patients With Lung Cancer Receiving Radiotherapy

Background: The use of technology-enhanced patient-reported outcome measures to monitor the symptoms experienced by people with cancer is an effective way to offer timely care. Objective: This study aimed to (a) explore the feasibility and acceptability of the Advanced Symptom Management System with patients with lung cancer receiving radiotherapy and clinicians involved in their care and (b) assess changes in patient outcomes during implementation of the Advanced Symptom Management System with patients with lung cancer receiving radiotherapy in clinical practice. Methods: A repeated-measures, single-arm, mixed-methods study design was used involving poststudy interviews and completion of patient-reported outcome measures at baseline and end of treatment with 16 patients with lung cancer and 13 clinicians who used this mobile phone–based symptom monitoring system. Results: Only rarely did patients report problems in using the handset and they felt that the system covered all relevant symptoms and helped them to manage their symptoms and effectively communicate with clinicians. Clinical improvements in patient anxiety, drowsiness, and self-care self-efficacy were also observed. Clinicians perceived the use of “real-time” risk algorithms and automated self-care advice provided to patients as positively contributing to clinical care. Reducing the complexity of the system was seen as important to promote its utility. Conclusions: Although preliminary, these results suggest that monitoring patient symptoms using mobile technology in the context of radiotherapy for lung cancer is feasible and acceptable in clinical practice. Implications for practice: Future research would be most beneficial if the use of this technology was focused on the postradiotherapy phase and expanded the scope of the system to encompass a wider range of supportive care needs.

Critical care outreach referrals: a mixed-method investigative study of outcomes and experiences.

AIM To explore referrals to a critical care outreach team (CCOT), associated factors around patient management and survival to discharge, and the qualitative exploration of referral characteristics (identifying any areas for service improvement around CCOT). METHOD A single-centre mixed method study in a specialist hospital was undertaken, using an explanatory design: participant selection model. In this model, quantitative results (prospective and retrospective episode of care review, including modified early warning system (MEWS), time and delay of referral and patient outcomes for admission and survival) are further explained by qualitative (interview) data with doctors and nurses referring to outreach. Quantitative data were analysed using SPSS +17 and 19, and qualitative data were analysed using grounded theory principles. RESULTS A large proportion of referrals (124/407 = 30·5%) were made by medical staff. For 97 (97/407 = 23·8%) referrals, there was a delay between the point at which patients deteriorated (as verified by retrospective record review and MEWS score triggers) and the time at when patients were referred. The average delay was 2·96 h (95% CI 1·97-3·95; SD 9·56). Timely referrals were associated with improved outcomes; however, no causal attribution can be made from the circumstances around CCOT referral. Qualitative themes included indications for referral, facilitating factors for referral, barriers to referral and consequences of referral, with an overarching core theory of reassurance. Outreach was seen as back-up and this core theory demonstrates the important, and somewhat less tangible, role outreach has in supporting ward staff to care for at-risk patients. CONCLUSION Mapping outreach episodes of care and patient outcomes can help highlight areas for improvement. This study outlines reasons for referral and how outreach can facilitate patient pathways in critical illness.

Hope Against Hope in Cancer at the End of Life

Hope has many facets to it in the context of cancer. This article outlines an instrumental case study for a patient with aggressive lymphoma who rapidly deteriorated to the point of dying. How her and her family’s hope was managed is outlined here from various perspectives. Interviews were carried out with the patient’s family, medical consultant-in-charge (attending physician) and nurses caring for her at the end of life. The findings outline the transition from hope for cure to hope for a good death and the role that the patient and family’s Christian hope played in this. Religiosity and spirituality of hope in terms of Christian hope is explored from the theological perspective. Practical aspects of care in the face of changing hope are discussed. Conclusions are drawn about reframing hope in a changing clinical situation with reference to theories of hope. The importance of acknowledging hope, coping, spirituality and religiosity, especially at end of life, is emphasised.

Negotiating Transitions: Involvement of Critical Care Outreach Teams in End-of-Life Decision Making

BACKGROUND Little research has examined the involvement of critical care outreach teams in end-of-life decision making. OBJECTIVE To establish how much time critical care outreach teams spend with patients who are subsequently subject to limitation of medical treatment and end-of-life decisions and how much influence the teams have on those decisions. METHODS A single-center retrospective review, with qualitative analysis, in a large cancer center. Data from all patients referred emergently for critical care outreach from October 2010 to October 2011 who later had limitation of medical treatment or end-of-life care were retrieved. Findings were analyzed by using SPSS 19 and qualitative free-text analysis. RESULTS Of 890 patients referred for critical care outreach from October 2010 to October 2011, 377 were referred as an emergency; 108 of those had limitation of medical treatment and were included in the review. Thirty-five patients (32.4%) died while hospitalized. As a result of outreach intervention and a decision to limit medical treatment, 56 (51.9%) of the 108 patients received a formal end-of-life care plan (including care pathways, referral to palliative care team, hospice). About a fifth (21.5%) of clinical contact time is being spent on patients who subsequently are subject to limitation of medical treatment. Qualitative document analysis showed 5 emerging themes: difficulty of discussions about not attempting cardiopulmonary resuscitation, complexities in coordinating multiple teams, delays in referral and decision making, decision reversals and opaque decision making, and technical versus ethical imperatives. CONCLUSION A considerable amount of time is being spent on these emergency referrals, and decisions to limit medical treatment are common. The appropriateness of escalation of levels of care is often not questioned until patients become critically or acutely unwell, and outreach teams subsequently intervene.

Ventilatory weaning: a case study of protracted weaning

BACKGROUND Dysfunctional ventilatory weaning response (DVWR) is characterized by interrupted and prolonged weaning. This reflective analysis presents how using nursing diagnoses in critical care can raise awareness of, and provide strategies for, managing problems related to ventilatory weaning. AIM To examine and reflect upon why one patient took so long to wean from the ventilator using the structured approach of instrumental case study and nursing diagnosis to explain aspects of the weaning process. ANALYSIS This case study examines one patients experiences around ventilatory weaning using selected nursing diagnoses, exploring the implications that physiological, social, emotional and psychological factors have on both weaning and healing processes in critical care. By using dialogue, an explicit texture is presented of how one patient felt, with particular resonance to the relationships she had and the impact they made. Various nursing diagnoses proved useful in determining why this patient had an extended weaning trajectory and included DVWR, ineffective breathing pattern, impaired spontaneous ventilation, anxiety and impaired verbal communication. There were specific points of interest, in particular her anxiety, which proved a major factor, and her significantly improved functional status after the critical care episode. A DVWR may be minimized by nursing presence, reassurance and respect for patient autonomy. Complex anatomy and physiology contributes to protracted weaning and a DVWR and is compounded by anxiety. Furthermore, there is a significant element of nursing care, timely reassurance and presence, which can have a positive impact on patient well-being. CONCLUSIONS This reflective analysis highlights the benefits and importance of the nurse-patient relationship during what was a very protracted ventilatory wean. This shared trajectory enabled significant patient empowerment, and this case study gives the patient the voice she temporarily lost.

Towards a pain free hospital: an in-depth qualitative analysis of the pain experiences of head and neck cancer patients undergoing radiotherapy

Background: Treatment for head and neck cancer can frequently be a painful experience with implications for patients in terms of quality of life, nutrition and ultimately treatment outcomes. Pain may arise for a number of reasons in this patient group including the influence of localised tissue damage from radiotherapy, the effects of chemotherapeutic agents as well as the disease process itself. Early identification of cancer pain, through screening and early analgesic and pain management are thought to be the most appropriate approaches to the problem. Aim: To explore in-depth, patients’ views of the experience of pain related to radiotherapy for head and neck cancer, within the context of a randomised controlled trial (RCT) of pain screening and intervention. Sample: A purposive sample of head and neck cancer patients undergoing radiotherapy who were participating in a separate RCT of a proactive pain screening intervention. Methods: A qualitative design using one-off, face-to-face, in-depth interviews. Data were inductively analysed for themes using thematic analysis. Data were collected from September 2012 to January 2013. Findings: Eight participants were interviewed. Several issues around pain management arose and the influence of various factors became apparent. Four dominant themes emerged: facets of radiotherapy pain in head and neck cancer, facilitators and barriers to pain management, pain services and finally interdisciplinary working. Conclusion: The specific issues faced by head and neck cancer patients undergoing radiotherapy highlight the need for pain relieving interventions delivered by pain specialists, in tandem with the development of robust self-management strategies. An integrated approach to care is optimal, comprising pain screening at each outpatient encounter, and review by specialists as necessary.

After critical care : patient support after critical care. A mixed method longitudinal study using email interviews and questionnaires

PURPOSE To explore experiences and needs over time, of patients discharged from ICU using the Intensive Care Experience (ICE-q) questionnaire, Hospital Anxiety and Depression Scale (HADS) and EuroQoL (EQ-5D), associated clinical predictors (APACHE II, TISS, Length of stay, RIKER scores) and in-depth email interviewing. METHODS A mixed-method, longitudinal study of patients with >48hour ICU stays at 2 weeks, 6 months, 12 months using the ICE-q, HADS, EQ-5D triangulated with clinical predictors, including age, gender, length of stay (ICU and hospital), APACHE II and TISS. In-depth qualitative email interviews were completed at 1 month and 6 months. Grounded Theory analysis was applied to interview data and data were triangulated with questionnaire and clinical data. RESULTS Data was collected from January 2010 to March 2012 from 77 participants. Both mean EQ-5D visual analogue scale, utility scores and HADS scores improved from 2 weeks to 6 months, (p=<0.001; p=<0.001), but between 6 and 12 months, no change was found in data from either questionnaire, suggesting improvements level off. These variations were reflected in qualitative data themes: rehabilitation/recovery in the context of chronic illness; impact of critical care; emotional and psychological needs (including sub-themes of: information needs and relocation anxiety). The overarching, core theme related to adjustment of normality. CONCLUSIONS Patient recovery in this population appears to be shaped by ongoing illness and treatment. Email interviews offer a convenient method of gaining in-depth interview data and could be used as part of ICU follow-up.

Thirty-day mortality in critical care outreach patients with cancer: An investigative study of predictive factors related to outreach referral episodes

AIM To establish factors that predict outcome in critically ill, deteriorating cancer patients through critical care outreach referral episodes, characteristics and care reviews. METHODS A population-based prospective and retrospective study was undertaken with analysis exploring predictive factors regarding critically ill cancer patients referred to a critical care outreach team. Data collected included: diagnosis; presenting problem; early warning scores at referral and at deterioration; physiological and observation data; admission to critical care, length of stay; 30-day mortality; limitation of care including precipitating DNAR orders and documentation of not for CCU admission/intervention). RESULTS Data were collected on 407 episodes from 318 patients over a period of 8 months from 2006 to 2007. Outreach initiated decisions to limit care with medical teams in 32.2% (n=103/318) of all patients. Early warning scores were not predictive of outcome. A high heart rate at referral (HR), a high potassium, low SpO2 at time of deterioration were independently predictive of 30-day mortality. The logistic regression (LR) model, using these three variables correctly predicts the 30-day outcome of 71% of the patients, demonstrating a relatively high predictability in this patient population. The odds of mortality increase with a higher potassium, heart rate and as the oxygen saturation at deterioration (DSpO(2)) worsen. Management factors included limitation of care, which is highly associated with 30-day mortality. Cancer patients recently receiving chemotherapy may have an increased mortality once admitted to critical care. Being a haemato-oncology patient, or the timeliness of critical care outreach referral does not appear to affect 30-day mortality. CONCLUSION The LR model was able to predict 30-day outcome of 71% of the patients, demonstrating a reasonably high predictability in this cancer patient population. Critical care outreach initiated discussions on limiting treatment which had an effect on mortality.

The lived experience of men with advanced cancer in relation to their perceptions of masculinity: a qualitative phenomenological study

AIMS AND OBJECTIVES The aim of this exploratory research was to understand how men experience their advanced cancer in relation to their perceptions of masculinity. BACKGROUND There are differences in the way men and women experience illness and health care. There are inequalities in incidence and morbidities of many diseases as well as differences in rates of help-seeking behaviours. Theories on masculinity offer some explanation towards this. Mens experiences of advanced cancer in relation to masculinity are under reported, published literature suggests that there are certain issues or men dealing with advanced disease that justify investigation. DESIGN A Qualitative approach using a Husserlian Phenomenological design was conducted. SAMPLE Eight men (aged 26-68) all with advanced cancer, defined as advanced or metastatic disease for which the patient had exhausted all standard therapeutic options. METHODS In-depth interviews were conducted to capture narratives of the experiences of men. Data were analysed using Colaizzis seven stage framework. RESULTS Themes included thwarted ambition, changing expectations, protection and provision, stoicism and coping, images of illness versus images of masculinity, importance of being a fighter and loss. CONCLUSION Findings showed that the experiences of these men were complex and should be handled sensitively. Ideas for gender-specific interventions and further research were developed from the findings in relation to current literature. RELEVANCE TO CLINICAL PRACTICE A better understanding and awareness of this in this context will help nurses to consider more subtle challenges that these patients may be dealing with that in turn could affect how they cope with the burden of cancer.