Out-of-hospital opioid therapy of palliative care patients with “acute dyspnoea”: A retrospective multicenter investigation

Authors

  • Christoph H. R. Wiese, MD
  • Utz E. Bartels, MD
  • Bernhard M. Graf, MD
  • Gerd G. Hanekop, MD

DOI:

https://doi.org/10.5055/jom.2009.0013

Keywords:

palliative emergency, prehospital emergency care, dyspnoea, symptom control, respiratory depression

Abstract

Background: Prehospital emergency physicians (EP) are often confronted with the acute care of palliative care patients. Dyspnoea is a frequent acute symptom and its causes often differ from the generally known emergency medical causes. Till now, there have been no relevant concepts for emergency care of palliative care patients for their specific symptoms.
Methods: Over a 24-month period, the authors retrospectively investigated all out-of-hospital emergency medical services for palliative care patients with acute dyspnoea at four emergency physician support points. The evaluation of these services was followed retrospectively on the basis of the therapy carried out by the EP (Group 1: therapy with morphine and oxygen; Group 2: therapy with morphine, bronchodilator effective drugs and oxygen; Group 3: therapy with bronchodilator effective drugs and oxygen; Group 4: therapy with oxygen; Group 5: no medical treatment). Moreover, EPs were interviewed about their actions and their uncertainties in the treatment of palliative care patients.
Results: The diagnosis of acute dyspnoea in palliative care patients occurred 121 times (116 patients were integrated in the present investigation) within the defined period. In total, 116 patients were included (Group 1: 21, Group 2: 29, Group 3: 31, Group 4: 28, and Group 5: 7). Dyspnoea was satisfactorily treated in 41 percent of the patients (Group 1: 67 percent, Group 2: 52 percent, Group 3: 22 percent, Group 4: 18 percent, and Group 5: 71 percent). Most EPs (70 percent) revealed uncertainties in emergency medical therapy for patients at the end of life.
Conclusions: The current investigation showed a significant relief of acute dyspnoea when using opioids, in contrast with the established out-of-hospital emergency medical therapy for acute dyspnoea. Therefore, opioids should be recommended for emergency medical therapy of dyspnoea in palliative care patients. Clinical studies that recommend the use of effective opioids for the treatment of dyspnoea in palliative care patients are supported by the current retrospective study. Most EPs felt uncertain in the treatment of palliative care patients. Therefore, advanced training in palliative care medicine and endof-life care should be integrated into emergency medical training.

Author Biographies

Christoph H. R. Wiese, MD

Department of Anaesthesiology, Emergency and Intensive Care Medicine, University Medical Centre, Goettingen, Germany.

Utz E. Bartels, MD

Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre, Jena, Germany.

Bernhard M. Graf, MD

Department of Anaesthesiology, University Medical Centre, Regensburg, Germany.

Gerd G. Hanekop, MD

Department of Anaesthesiology, Emergency and Intensive Care Medicine, University Medical Centre, Goettingen, Germany.

References

Currow DC, Ward AM, Plummer JL, et al.: Comfort in the last 2 weeks of life: Relationship to accessing palliative care services. Supp Care Cancer. 2008; 16: 1255-1263.

Ensink FB, Bautz MT, Hanekop GG: Improvement of palliative outpatient treatment of terminally ill cancer patients—SUPPORT as example—The ethically preferable alternative to euthanasia. Anaesthesiol Intensivmed Notfallmed Schmerzther. 2001; 36: 530-537.

Hanekop GG, Kriegler M, Görlitz A, et al.: Ambulant Palliative Medicine. Stuttgart, New York: Schattauer, 2003: S66-S79.

Schindler T, Ewald H: Out-of-hospital and in-hospital structures in palliative medicine. Onkologe. 2005; 11: 376-383.

Nauck F: Symptom control in the final stage of disease. Schmerz. 2001; 15: 362-369.

Clemens KE, Klaschik E: Symptomatic therapy of dyspnoea with strong opioids and its effect on ventilation in palliative care patients. J Pain Symptom Manage. 2007; 33: 473-481.

Clemens KE, Quednau I, Klaschik E: Use of oxygen and opioids in the palliation of dyspnoea in hypoxic and non-hypoxic palliative care patients: A prospective study. Support Care Cancer. 2009; 17: 367-377.

Donnelly S, Walsh D: The symptoms of advanced cancer. Sem Oncol. 1995; 22(2 Suppl 3): 67-72.

Dudgeon DJ: Managing dyspnoea and cough. Hematol Oncol Clin N Am. 2002; 16: 557-577.

Elia G, Thomas J: The symptomatic relief of dyspnoea. Curr Oncol Rep. 2008; 10: 319-325.

Viola R, Kitely C, Lloyd NS, et al.: The management of dyspnoea in cancer patients: A systematic review. Support Care Cancer. 2008; 16: 329-337.

Williams CM: Dyspnoea. Cancer J. 2006; 12: 365-373.

Thomas JR, von Gunten CF: Treatment of dyspnoea in cancer patients. Oncology. (Williston Park) 2002; 16: 745-750.

Gugger M, Bachofen H: Dyspnoea: Basic principles and pathophysiology. SchweizMed Forum No. 6, 2001.

Bausewein C, Farquhar M, Booth S, et al.: Measurement of breathlessness in advanced disease: A systematic review. Respir Med. 2007; 101: 399-410.

Dorman C, Byrne A, Edwards A: Which measurement scales should we use to measure breathlessness in palliative care? A systematic review. Palliat Med. 2007; 21: 177-191.

Vainio A, Auvinen A, Symptom Prevalence Group: Prevalence of symptoms among patients with advanced cancer: An international collaborative study. J Pain Symptom Manage. 1996; 12: 3-10.

Wiese C, Bartels U, Ruppert D, et al.: Treatment of oncology patients in the final stadium of disease by prehospital emergency physicians. Anaesthesist. 2007; 56: 133-140.

Wright AA, Zhang B, Ray A, et al.: Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008; 300: 1665-1673.

Salomon F: Decision conflicts in emergency medicine. Anaesthesiol Intensivmed Notfallmed Schmerzther. 2000; 35: 319-325.

Salomon F: Competence in palliative medicine for the emergency physician. Notfall Rettungsmed. 2005; 8: 542-547.

Salako SE: The declaration of Helsinki 2000: Ethical principles and the dignity of difference. Med Law. 2006; 25:341-354.

Maak CA, Tabas JA, McClintock TE: Should acute treatment with Inhaled Beta agonists be withheld from patients with dyspnoea who may have heart failure? J Emerg Med. 2008. Epub ahead of print.

Pfeifer M: Dyspnoea. Pneumologe. 2005; 2: 177-187.

Wagner U, Vogelmeier C: Acute dyspnoea. Internist. 2005; 46: 965-973.

Groeben H: The acute severe asthma attack. Notfall Rettungsmed. 2005; 8: 67-77.

Miller AH, Nazeer S, Pepe P, et al.: Acutely decompensated heart failure in a county emergency department: A double-blind randomized controlled comparison of nesiritide versus placebo treatment. Ann Emerg Med. 2008; 51: 571-578.

Clemens KE, Klaschik E: Symptomatic treatment of dyspnoea in patients receiving palliative care: Nasal delivery of oxygen compared with opioid administration. Dtsch Med Wochenschr. 2007; 132: 1939-1943.

Johnson MA, Woodcock AA, Geddes DM: Dihydrocodeine for breathlessness in “pink puffers”. Br Med J. 1983; 286: 675-677.

Rice KL, Kronenberg KS, Hedemark LL, et al.: Effects of chronic administration of codeine and promethazine on breathlessness and exercise tolerance in patients with chronic airflow obstruction. Br J Dis Chest. 1987; 81: 287-292.

Escalante CP, Martin CG, Eiting LS, et al.: Dyspnoea in cancer patients. Etiology, resource utilization, and survival–implications in a managed care world. Cancer. 1996; 78: 1314-1319.

Abernethy AP, Currow DC, Frith P, et al.: Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. Br Med J. 2003; 327: 523-526.

Bruera E, MacEachern T, Ripamonti C, et al.: Subcutaneous morphine for dyspnoea in cancer patients. Ann Intern Med. 1993; 119: 906-907.

Chua TP, Harrington D, Ponikowski P, et al.: Effects of dihydrocodeine on chemosensitivity and exercise tolerance in patients with chronic heart failure. J Am Coll Cardiol. 1997; 29: 147-152.

Currow DC, Abernethy AP: Pharmacological management of dyspnoea. Curr Opin Support Palliat Care. 2007; 1: 96-101.

Mazzocato C, Buclin T, Rapin CH: The effects of morphine on dyspnoea and ventilatory function in elderly patients with advanced cancer: A randomized double-blind controlled trial. Ann Oncol. 1999; 10: 1511-1514.

Woodcock AA, Gross ER, Gellert A, et al.: Effects of dihydrocodeine, alcohol, and caffeine on breathlessness and exercise tolerance in patients with chronic obstructive lung disease and normal blood gases. N Engl J Med. 1981; 305: 1611-1616.

Cachia E, Ahmedzai SH: Breathlessness in cancer patients. Eur J Cancer. 2008; 44: 1116-1123.

Daud ML: Drug management of terminal symptoms in advanced cancer patients. Curr Opin Support Palliat Care. 2007; 1: 202-206.

Wiese CHR, Bartels U, Ruppert D, et al.: Treatment of palliative emergencies by emergency physicians in Germany. Palliat Med. 2009. Epub ahead of print.

Wiese CHR, Vossen-Wellmann A, Morgenthal HC, et al.: Emergency calls and need for emergency care in patients looked after by a palliative care team: Retrospective interview study with bereaved relatives. BMC Palliat Care. 2008; 7: 11.

Dick W: Anglo-American vs. Franco-German emergency medical services system. Prehosp Disaster Med. 2003; 18: 29-35.

Timmermann A, Russo SG, Hollmann MW: Paramedic versus emergency physician emergency medical service: Role of the anaesthesiologist and the European versus the Anglo-American concept. Curr Opin Anaesthesiol. 2008; 21: 222-227.

Wiese CHR, Bartels UE, Marezynska K, et al.: Quality of outof-hospital palliative emergency care depends on the expertise of the emergency medical team–A prospective multi-centre analysis. Support Care Cancer. 2009 Mar 25. [Epub ahead of print.]

Published

01/29/2018

How to Cite

Wiese, MD, C. H. R., U. E. Bartels, MD, B. M. Graf, MD, and G. G. Hanekop, MD. “Out-of-Hospital Opioid Therapy of Palliative Care Patients With ‘acute dyspnoea’: A Retrospective Multicenter Investigation”. Journal of Opioid Management, vol. 5, no. 2, Jan. 2018, pp. 115-22, doi:10.5055/jom.2009.0013.

Issue

Section

Articles