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CONTEXT: Little is known about the treatment and correlates of dyspnea in idiopathic pulmonary fibrosis (IPF). OBJECTIVES: The objective of this systematic review was to summarize the literature regarding the treatment and correlates of dyspnea in IPF. METHODS: MEDLINE, EMBASE, and all Evidence-Based Medicine Reviews were searched for publications that evaluated treatment or correlates of dyspnea in IPF. Reference lists and recent review articles also were searched. RESULTS: The heterogeneity of included studies did not permit meta-analysis. Dyspnea improved in studies of sildenafil, pulmonary rehabilitation, and prednisone with colchicine. Additional studies of these three treatments, however, found discordant results. One study suggested that assisted ventilation delivered by facemask improved exertional dyspnea. Oxygen and opioids improve dyspnea in other chronic lung diseases, but data in IPF are limited. Correlates of dyspnea included functional and physiological measures and comorbid diseases. CONCLUSION: Sildenafil and pulmonary rehabilitation should be considered as potential therapies for dyspnea in selected patients with IPF. Supplemental oxygen and opioids may be additional potential therapies; however, the evidence supporting their use is weak. Additional research should focus on the management of functional status and comorbidities as potential treatments for dyspnea. [ABSTRACT FROM AUTHOR]

Introduction/aim: Despite clear benefit from palliative care in end-stage chronic diseases, access is often limited, and rural access largely undescribed. This study sought to determine if a palliative approach is provided to people with chronic disease in their terminal hospital admission., Methods: Multisite, retrospective medical record audit, of decedents with a primary diagnosis of chronic lung, heart, or renal failure, or multimorbidity of these conditions over 2019., Results: Of 241 decedents, across five clinical sites, 143 (59.3%) were men, with mean age 80.47 years (SD 11.509), and diagnoses of chronic lung (n = 56, 23.2%), heart (n = 56, 23.2%), renal (n = 24, 10.0%) or multimorbidity disease (n = 105, 43.6%), and had 2.88 (3.04SD) admissions within 12 months. Outpatient chronic disease care was evident (n = 171, 73.7%), however, contact with a private physician (n = 91, 37.8%), chronic disease program (n = 61, 25.3%), or specialist nurse (n = 17, 7.1%) were less apparent. "Not-for-resuscitation" orders were common (n = 139, 57.7%), however, advance care planning (n = 71, 29.5%), preferred place of death (n = 18, 7.9%), and spiritual support (n = 18, 7.5%) were rarely documented. Referral to and input from palliative services were low (n = 74, 30.7% and n = 49, 20.3%), as was review of nonessential medications or blood tests (n = 86, 35.7%, and n = 78, 32.4%). Opioids were prescribed in 45.2% (n = 109). Hospital site and diagnosis were significantly associated with outpatient care and palliative approach (P<0.001)., Conclusions: End-of-life planning and specialist palliative care involvement occurred infrequently for people with chronic disease who died in rural hospitals. Targeted strategies are necessary to improve care for these prevalent and high needs rural populations., Competing Interests: Disclosures The authors declare that there is no conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: Half of people living with chronic obstructive pulmonary disease (COPD) do not receive high-quality, evidenced-based care as described in international guidelines. We conducted secondary data analysis of a previously published study to assess the ability of a model of lay health coaching to improve provision of guideline-based care in a primary care setting., Methods: As part of a randomized controlled trial, we recruited English- and Spanish-speaking patients with moderate to severe COPD from primary care clinics serving a low-income, predominantly African American population. Participants were randomized to receive usual care or 9 months of health coaching from primary care personnel informed by a pulmonary specialist practitioner. Outcome measures included prescription of appropriate inhaler therapy, participation in COPD-related education, engagement with specialty care, prescription of smoking cessation medications, and patient ratings of the quality of care., Results: Baseline quality measures did not differ between study arms. At 9 months, coached patients were more likely (increase of 9.3% over usual care; P=0.014) to have received guideline-based inhalers compared to those in usual care. Coached patients were more likely to engage with pulmonary specialty care (increase of 8.3% over usual care with at least 1 visit; P=0.04) and educational classes (increase of 5.3% over usual care; P=0.03). Receipt of smoking cessation medications among patients smoking at baseline in the health coaching group increased 21.1 percentage points more than in usual care, a difference near statistical significance (P=0.06)., Conclusions: Health coaching may improve the provision of quality chronic illness care for conditions such as COPD., Competing Interests: Conflicts of Interest None., (© 2023 Advocate Aurora Health, Inc.)

Context: Despite clear benefit from palliative care in end-stage chronic, non-malignant disease, access for rural patients is often limited due to workforce gaps and geographical barriers., Objectives: This study aimed to understand existing rural service structures regarding the availability and provision of palliative care for people with chronic conditions., Methods: A cross-sectional online survey was distributed by email to rural health service leaders. Nominal and categorical data were analyzed descriptively, with free-text questions on barriers and facilitators in chronic disease analyzed using qualitative content analysis., Results: Of 42 (61.7%) health services, most were public (88.1%) and operated in acute (19, 45.2%) or community (16, 38.1%) settings. A total of 17 (41.5%) reported an on-site specialist palliative care team, primarily nurses (19, 59.5%). Nearly all services (41, 95.3%) reported off-site specialist palliative care access, including: established external relationships (38, 92.7%); visiting consultancy (26, 63.4%); and telehealth (18, 43.9%). Perceived barriers in chronic disease included: lack of specific referral pathways (18; 62.1%); negative patient expectations (18; 62.1%); and availability of trained staff (17; 58.6%). Structures identified to support palliative care in chronic disease included: increased staff/funding (20, 75.0%); formalized referral pathways (n = 18, 64.3%); professional development (16, 57.1%); and community health promotion (14, 50%)., Conclusion: Palliative care service structure and capacity varies across rural areas, and relies on a complex, at times ad hoc, network of onsite and external supports. Services for people with chronic, non-malignant disease are sparse and largely unknown, with a call for the development of specific referral pathways to improve patient care., (Copyright © 2023 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Chronic obstructive pulmonary disease (COPD) is a progressive, life-limiting condition. End-of-life (EOL) and Advance Care Planning (ACP) discussions are essential, yet access and support remain inadequate. Allied health professionals (AHPs) commonly have ongoing relationships with patients and opportunities to discuss care outside acute crises as is considered best practice. Australian and New Zealand AHPs were invited to complete an anonymous, online, cross-sectional survey that aimed to explore knowledge, attitudes and practices, and associated perceived triggers and barriers to EOL and ACP discussions with patients with COPD. Closed survey responses were summarized descriptively and free-text thematically analysed. One hundred and one AHPs (physiotherapists, social workers and occupational therapists) participated. Many held positive attitudes towards ACP but lacked procedural knowledge. Half (50%) of participants routinely discussed EOL care with patients when perceiving this to be appropriate but only 21% actually discussed ACP with the majority of their patients. Many cited lack of training to engage in sensitive EOL discussions, with barriers including: 1) clinician lack of confidence/fear of distressing patients (75%); 2) perceived patient and family reluctance (51%); 3) organizational challenges (28%); and 4) lack of role clarity (39%). AHPs commonly have ongoing relationships with patients with chronic conditions but lack the confidence and role clarity to utilise this position to engage ongoing EOL and ACP discussions. While AHPs may not traditionally consider EOL and ACP discussions as part of their role, it is crucial that they feel prepared to respond if patients broach the topic.

Context: Interprofessional education (IPE) involving palliative and end-of-life content benefits learners by addressing interprofessional and palliative care (PC) competency needs., Objectives: A synthesis of educational approaches promoting interprofessional PC in academic and clinical settings would address research gaps and promote effective teaching., Methods: A systematic review of interprofessional PC educational studies was conducted to summarize current approaches in PC IPE and to appraise teaching and research methods. Characteristics of excellence in interprofessional PC education established by Donesky et al. served as a framework for evaluating studies in this systematic review., Results: A total of 39 articles met inclusion criteria for this review. Learners from medicine and nursing were the most included professions. University programs represented most studies, and evaluation methods demonstrated achievement of mostly self-reported outcomes like learner attitude and self-efficacy. While the effect of interprofessional collaboration on patient outcomes is well-documented, the effect of IPE on PC delivery is not. Although content spanned all interprofessional and PC domains, few studies addressed cultural aspects and fewer addressed well-being for the care provider., Conclusion: In light of the current healthcare landscape, there is an imminent need to address culture and provider well-being more directly through interprofessional PC education. Education and research must also move beyond university programs into health systems to support the professional development of clinicians for systems integration, sustainability, and impact on patient outcomes. Future evaluation of interprofessional PC education would be strengthened by multisite studies, randomized controlled trials, and repeated measures looking at outcomes over time., (Copyright © 2023 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Chronic obstructive pulmonary disease (COPD) is a progressive, life-limiting illness that requires end-of-life care planning, yet remains under-served. Understanding barriers to advance care planning (ACP) from different specialties' perspectives will enable a co-ordinated, cross-disciplinary approach to improving ACP access., Methods: Australia and New Zealand palliative care nurses were invited to complete an anonymous online cross-sectional survey. Questions tested knowledge of validated ACP-related practice indicators and canvassed perspectives on barriers to ACP in COPD. Data are described and free-text thematically analyzed., Results: The 90 participants had high knowledge and positive attitudes to ACP in COPD, however, lacked consensus as to whether patients want to know their prognosis or discuss treatment options and end-of-life wishes. 59% discussed ACP in more than half their patients with COPD, and 77% and 73% routinely initiated or followed-up these discussions. Key barriers included: lack of confidence and training in COPD; reluctance to distress patients and families; referral late in the disease course; lack of consensus on referral timing; and lack of patient and clinician understanding of COPD prognoses. Many reported that lack of consensus in the treating team, paired with prognostic uncertainty, precluded timely ACP engagement., Conclusions: Palliative care nurses have substantial knowledge and positive beliefs regarding ACP, however, some beliefs and practices lack alignment with qualitative data on patients' wishes in COPD. While palliative care nurses are well placed to facilitate early implementation for patients with advanced COPD, ACP training and practice guidelines specific to COPD may increase implementation in this life-limiting disease.

A hotel-based clinic to serve Project RoomKey residents is a model for meeting the health care needs of an unhoused population. The purpose of this paper is to describe the health services provided by students and licensed clinicians at a hotel that was designed to allow unhoused community residents to shelter in place during the early stages of the Covid pandemic (May 1-June 30, 2020). Documents developed for the project may be useful to others who are setting up similar services for unhoused residents in their own communities., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Dyspnea is a subjective experience of breathing discomfort that consists of qualitatively distinct sensations, varies in intensity, and can only be known through the patient's report. Dyspnea is akin to suffocation and is one of the most distressing symptoms experienced by patients with advanced illness and at the end of life. Common approaches to dyspnea management, such as pulmonary rehabilitation, breathing strategies, or supplemental oxygen, have become accepted through pragmatic use or because studies do not include dyspnea as a measured outcome. Patients and clinicians urgently need evidence-based treatments to alleviate this frightening symptom. To fill this gap, a group of dyspnea researchers with expertise to conduct a literature review of evidence-based interventions for dyspnea in patients with serious illness produced these guidelines. We present the evidence from the strongest recommendations for practice to the weakest recommendations and include practical considerations for clinical nurses., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 by The Hospice and Palliative Nurses Association. All rights reserved.)

Chronic obstructive pulmonary disease (COPD) is a progressive, life-limiting illness. Despite significant symptom burden, access to advance care planning (ACP) and palliative care are limited. Early initiation of ACP enables patients to articulate the values that underpin the decisions they would make if, in the future, they are unable to speak for themselves. Nurses constitute the majority of health care workforce and are well placed to initiate these discussions. This study explored knowledge, attitudes, and practice regarding ACP for patients with COPD among Australian and New Zealand respiratory nurses. A cross-sectional online survey tested knowledge about ACP and canvassed attitudes about current practice. Data were analyzed using descriptive statistics and content analysis of text data. The 112 participating respiratory nurses had substantial knowledge and positive attitudes regarding ACP in COPD; however, they lacked confidence and clarity regarding their role. Despite advances in end-of-life care provision for chronic disease, well-established barriers remained (inadequate training, fear of distressing patients, and time), and discussion triggers were still linked to acute deterioration, diagnosis of severe disease, and patient initiation. Better articulating the role of the respiratory nurse in ACP and building capacity and confidence within this workforce may improve ACP access for people living with COPD., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 by The Hospice and Palliative Nurses Association. All rights reserved.)

Spirituality is a key focus and ethical obligation of nursing practice, but many nurses express uncertainty or discomfort with this aspect of their role. The purpose of this article is to explore the domains of religion, spirituality, and culture as commonly conceptualized by chaplains, as a framework for nurses to provide spiritual care interventions to patients in acute care hospitals. Using anecdotes and illustrations from palliative care practice, this article discusses the enhanced benefits to patients and families when spiritual needs are addressed, with specialty-level chaplain interventions, primary spiritual interventions provided uniquely by nurses, or interventions that require the cooperation of both professions. Lessons learned from the inpatient palliative care team experience can also apply to chaplaincy and nursing care for patients in settings beyond the acute care hospital and in disciplines beyond palliative care.

An increasing number of palliative care educational programs strive to meet the workforce need for palliative care clinicians. This growth necessitates development of robust quality standards. The purpose of this Delphi consensus process was to describe high-quality postlicensure interprofessional palliative care education programs. The steering committee, composed of 6 faculty with experience implementing interprofessional palliative care educational programs, developed initial characteristics, definitions, and subcategories, which were refined through a series of 3 iterative Delphi surveys and a public presentation at a national palliative care meeting. More than 50 palliative care clinicians and educators representing multiple professions were invited to participate in the Delphi surveys; 20 completed round 1, 23 completed round 2, and 15 participants completed round 3. The final consensus included 6 characteristics with definitions, and both required and recommended subcategories for each characteristic. Identified characteristics include competencies, content, educational strategies, interprofessional focus, evaluation, and systems integration. This initial description of quality for postlicensure interprofessional palliative care education programs may be used by learners to guide program selection, new or existing program faculty for course development or quality improvement, or professional organizations to evaluate program quality in a program certification or quality award initiative.

Background: Communication training is a hallmark of palliative care education. The purpose of this article is to report on the development, exploratory outcomes, and lessons learned from a pilot project, "TeamTalk," which adapted VitalTalk methodology for interprofessional learners. Materials and Methods: TeamTalk included a series of interactive workshops led by an interprofessional faculty team at a health sciences university. Teaching methods were small group discussion, reflection, and high-fidelity simulated patient/family encounters, using a "Skills and Capacities" handout. The course was offered between January and May of 2015 and 2016 to medical fellows, advanced practice nursing students, and chaplain interns. Pre- and post-test design and qualitative data analysis were used to assess the learners' response to the TeamTalk curriculum. Validated instruments assessed attitudes toward interprofessional collaboration and self-confidence for interprofessional communication. Results: Sixty-one learners participated in TeamTalk over two academic years. Attitudes toward interprofessional collaboration improved from pre- to post-test (126.1 ± 6.9-130.0 ± 7.1; p  < 0.01) with no difference among the professional groups. Self-confidence for interprofessional communication improved in "eliciting the contributions of colleagues, including those from other disciplines" ( p  < 0.001) for all learners during year two; chaplains improved in the greatest number of areas (15/19), followed by nurses (7/19) and physicians (4/19). Learners expressed appreciation for the opportunity to explore their professional roles together with other professions. Conclusion: Preliminary findings indicate that TeamTalk improved attitudes toward interprofessional collaboration and self-confidence for participating on an interprofessional team. The lessons derived from creating and implementing this course may be applicable to interprofessional education in serious illness management.

Background: Chronic obstructive pulmonary disease (COPD) is a complex, chronic condition. Patients commonly have limited access to face-to-face support due to decreased mobility, symptom burden, and availability of services. Online health care approaches provide the potential for increased access to self-management education and support. This study sought to understand older patients with COPD's perspectives of online approaches to health care. Materials and Methods: Participants older than 65 years were recruited from a respiratory service at an academic medical center. Qualitative, focus groups were used and recorded, transcribed verbatim, and analyzed using thematic analysis to identify key and repeated emergent themes. Results: Focus groups were undertaken between January and May 2014. Thematic analysis resulted in five overall themes: (1) concern over risks in the online environment; (2) multimedia and technology use as part of everyday life; (3) online resources as an opportunity for revision of forgotten knowledge; (5) potential for facilitation of decision-making support across geographical and physical barriers; and (4) perceived benefits of online peer support for people with COPD. Conclusions: Overall, these older participants with COPD had positive views of online health information, but did raise the need for guidance to ensure valid and reliable online sources. The capacity for online sources to increase access to decision support and up-to-date information was viewed positively, as was the ability to interact with peers who had similar experiences. Telecommunication tools and approaches are already being utilized in health care interactions. Further research is required into the most appropriate, feasible, and sustainable online health approaches to support patients with chronic illnesses such as COPD.

Background: Expert communication skills are essential for the delivery of effective palliative care across the domains of care. However, few health care providers receive formal communication training. To promote communication education for interdisciplinary palliative care teams, a train-the-trainer course for interdisciplinary hospital-based palliative care teams was developed to prepare them to teach other health care professionals communication skills. Course Design: The curriculum was organized by the eight domains of the National Consensus Project Guidelines for Quality Palliative Care and provided communication skills training for California-based teams. The two-day train-the-trainer course included skill-building exercises and interactive discussions to assist participants in integrating communication skills building into their clinical settings. Using a goal-directed method of teaching, faculty assisted teams in developing three institutional goals for providing palliative care communication training to other health care professionals. Evaluation of the course included immediate postcourse evaluation and follow-up evaluation at six and nine months. Results: The first statewide interdisciplinary communication training took place in January 2018 with 26 palliative care teams consisting of primarily nurses, followed by social workers, chaplains, and physicians. The 46 course participants' postcourse evaluations demonstrated high satisfaction with the course. On a scale of 1 to 5 (1 = lowest), the course met participants' expectations and objectives (4.8). The teams' precourse goals focused on (1) staff education, training, and mentorship, and (2) institution-wide system changes. Conclusion: Palliative care interdisciplinary teams can incorporate communication skills into their practice and provide communication skills training to their institutions.

Background: Effective leadership is necessary to meet the complex care needs of patients with serious, life-limiting illness. The Cambia Health Foundation Sojourns Scholars Program is advancing leadership in palliative care through supporting emerging leaders. The 2016 Cohort has implemented a range of projects to promote their leadership development. Objective: To describe the leadership themes emerging from individual project implementation of the 2016 Sojourns Leadership. Methods: We summarize the synthesized leadership themes derived from both remote and in-person meetings and written reflections of the 2016 Cambia Sojourn Leadership Cohort. Results: The 2016 Cambia Sojourn Leadership Scholar Cohort projects are described. We identified three leadership themes related to palliative care initiatives: openness and flexibility, partnership and team building, and leveraging expertise and risk. Discussion: Unprecedented challenges in a rapidly changing health environment demand palliative care leadership to influence care quality, delivery, policy, and clinical care. Flexibility and openness; partnership and team building; and expertise to implement change emerged as critical themes to advancing the care of patients with serious, life-limiting illness. These leadership themes are consistent with both previous Cambia Sojourns Scholar cohorts and the literature, are essential for the next generation of leaders to implement new models of quality palliative care, payment for palliative care, and education for patients, caregivers, and health care providers. Conclusion: In order to design and implement quality palliative care, leadership development is essential. Use of flexibility and openness; partnership and team building; and expertise to implement change are important themes for success. Whether through the Cambia Health Foundation Sojourns Leadership Program or opportunities within professional organizations, cultivation of the next generation of leaders is critical.

Background: Recruitment and retention are two significant barriers in research, particularly for historically underrepresented groups, including racial and ethnic minorities, patients who are low-income, or people with substance use or mental health issues. Chronic obstructive pulmonary disease (COPD) is the third leading cause of death and disproportionately affects many underrepresented groups. The lack of representation of these groups in research limits the generalizability and applicability of clinical research and results. In this paper we describe our experience and rates of recruitment and retention of underrepresented groups for the Aides in Respiration (AIR) COPD Health Coaching Study., Methods: A priori design strategies included minimizing exclusion criteria, including patients in the study process, establishing partnerships with the community clinics, and ensuring that the health coaching intervention was flexible enough to accommodate patient needs., Results: Challenges to recruitment included lack of spirometric data in patient records, space constraints at the clinic sites, barriers to patient access to clinic sites, lack of current patient contact information and poor patient health. Of 282 patients identified as eligible, 192 (68%) were enrolled in the study and 158 (82%) completed the study. Race, gender, educational attainment, severity of disease, health literacy, and clinic site were not associated with recruitment or retention. However, older patients were less likely to enroll in the study and patients who used home oxygen or had more than one hospitalization during the study period were less likely to complete the study. Three key strategies to maximize recruitment and retention were identified during the study: incorporating the patient perspective, partnering with the community clinics, and building patient rapport., Conclusions: While the AIR study included design features to maximize the recruitment and retention of patients from underrepresented groups, additional challenges were encountered and responded to during the study. We also identified three key strategies recommended for future studies of COPD and similar conditions. Incorporating the approaches described into future studies may increase participation rates from underrepresented groups, providing results that can be more accurately applied to patients who carry a disparate burden of disease., Trial Registration: This trial was registered at ClinicalTrial.gov at identifier NCT02234284 on August 12, 2014. Descriptor number: 2.9 Racial, ethnic, or social disparities in lung disease and treatment.

Rationale: Socioeconomically disadvantaged patients with chronic obstructive pulmonary disease (COPD) often face barriers to evidence-based care that are difficult to address in public care settings with limited resources., Objectives: To determine the benefit of health coaching for patients with moderate to severe COPD relative to usual care., Methods: We conducted a randomized controlled trial of 9 months of health coaching versus usual care for English- or Spanish-speaking patients at least 40 years of age with moderate to severe COPD. Primary outcomes were COPD-related quality of life and the dyspnea subscale of the Chronic Respiratory Disease Questionnaire. Secondary outcomes were self-efficacy for managing COPD, exercise capacity (6-min walk test), and number of COPD exacerbations. Additional outcomes were COPD symptoms, lung function (forced expiratory volume in 1 s percent predicted), smoking status, bed days owing to COPD, quality of care (Patient Assessment of Chronic Illness Care), COPD knowledge, and symptoms of depression (Patient Health Questionnaire). Outpatient visits, emergency department visits, and hospitalizations were assessed by review of medical records. Generalized linear modeling was used to adjust for baseline values and account for clustering by clinic., Results: Of 192 patients enrolled, 158 (82%) completed 9 months of follow-up. There were no significant differences between study arms for the primary or secondary outcomes. At 9 months, patients in the coached group reported better quality of care (mean Patient Assessment of Chronic Illness Care score, 3.30 vs. 3.18; adjusted P = 0.02) and were less likely to report symptoms of moderate to severe depression (Patient Health Questionnaire score, ≥15) than those in the usual care arm (6% vs. 20%; adjusted P = 0.01). During the study, patients in the coaching arm had 48% fewer hospitalizations related to COPD (0.27/patient/yr vs. 0.52/patient/yr), but this difference was not significant in the adjusted analysis., Conclusions: These results help inform expectations regarding the limitations and benefits of health coaching for patients with COPD. They may be useful to health policy experts in assessing the potential value of reimbursement and incentives for health coaching-type activities for patients with chronic disease. Clinical trial registered with www.clinicaltrials.gov (NCT02234284).

Background: Losing a loved one in the intensive care unit can be challenging for families. Providing bereavement support may assist in the grieving process., Objective: To describe family members' experiences with bereavement after the death of a loved one in the intensive care unit., Methods: This secondary analysis used an exploratory, descriptive design to study family members' experiences with bereavement. Family members of patients from 2 intensive care units in a tertiary medical center in the western United States participated. Audiotaped telephone interviews using a semistructured questionnaire were conducted. A qualitative, descriptive technique was used for data analysis. Two independent raters coded transcripts of audiotaped interviews with family members about their bereavement experiences., Results: Seventeen family members participated in the study. Most participants were female (n = 12; 71%) and spouses of deceased patients (n = 14; 82%), and their mean (SD) age was 62.4 (10.0) years. Three themes emerged: (1) bereavement was an individual experience; (2) situations occurring during the intensive care unit encounter remained significant for family members beyond a year after the death; and (3) social, cultural, spiritual, and religious events after the death hold importance for families of patients in the intensive care unit., Conclusions: Bereavement is a challenging experience for families of deceased intensive care unit patients. The themes identified in this study add insight into the experiences of these family members. The results of this study may guide future interventions to help support bereaved families of intensive care unit patients., (©2018 American Association of Critical-Care Nurses.)

Purpose: To conduct a scoping review to explore the construct of shared mental models (SMMs) in the context of clinical teamwork among health professions learners., Method: The authors searched the PubMed, ERIC, CINAHL, Scopus, Web of Science, PsychINFO, and EMBASE databases for English-language articles published between 2000 and 2016. Eligible articles mentioned SMMs in relation to clinical teamwork and included health professions learners. Two reviewers screened studies for eligibility and extracted data to determine the depth and breadth of the literature on SMMs. The authors examined definitions of the SMM construct in the context of clinical teams, educational interventions using SMMs, and the measurement of SMMs., Results: Of the 1,273 articles retrieved, 23 met the inclusion criteria. SMMs were defined in less than two-fifths of the articles (9/23). All articles applied the construct to improvements in hospital-based patient safety, often in high-intensity settings (14/23). Most articles included graduate-level physicians (21/23) within clinical teams (18/23). Interventions designed to foster SMMs (6/23) included teamwork curricula/training and teamwork supportive tools. Measurements of SMMs (7/23) included a qualitative task analysis, quantitative analyses of speech, a concept mapping, and Likert-type surveys., Conclusions: In health professions education, the SMM construct lacks clear definition. Few studies described educational interventions aimed at SMM development, and few attempted to measure the construct. The authors propose an operational definition of SMMs in health care and illustrate how interventions intended to foster SMMs, such as team trainings or planning exercises and communication tools, could be developed, implemented, and assessed.

Objective: Test the feasibility and clinical outcomes of a home-based videoconferencing yoga intervention in participants diagnosed with both Chronic Obstructive Pulmonary Disease (COPD) and heart failure (HF)., Background: Yoga has potential benefit for symptom relief in participants with COPD and with HF; however, functional impairment and transportation issues can hinder access to typical yoga classes., Methods: A controlled, nonrandomized trial was conducted of an 8-week TeleYoga intervention versus an educational control (information leaflets mailed to participants with one weekly phone call). One-hour TeleYoga classes were implemented twice weekly via multipoint videoconferencing, which connected participants to live classes via an Internet connection to their televisions., Results: Fourteen participants with COPD and HF took part in the pilot study (7 in the intervention group and 8 in the control). Intervention participants were adherent to classes, able to safely participate, and found the classes enjoyable after the 8-week program. Dyspnea after exercise improved in the intervention group., Conclusions: Despite their frailty, patients diagnosed with both COPD and HF were able to perform yoga safely in the home setting. TeleYoga was acceptable and adherence was good; however, technical issues were an important hindrance to participation.

Background: Current evidence shows that an open visitation policy can benefit patients and families during intensive care unit (ICU) stays. Therefore, an unrestricted visitation policy in the ICU has been proposed as part of patient-centered care., Purpose: The purpose of this secondary analysis is to explore the likelihood of an ICU with a clinical nurse specialist (CNS) having an open visitation policy when compared with an ICU without a CNS., Design: This is a secondary analysis of a survey conducted between 2008 and 2009, describing the ICU visitation practices in more than 600 hospitals across the United States., Methods: χ Analysis was performed comparing the presence of CNS in the ICU with visitation policies, with P < 0.05 considered statistically significant., Results: There were data from 347 hospitals used in the analysis, with 47 hospitals (13.5%) having open visitation policies. There were 108 hospitals (31%) that had a CNS present in the ICU; 14 of the hospitals (13%) had open visitation policies. No significant correlation was found between a CNS being present in the ICU and open visitation policy (odds ratio, 0.93; P = .83), regardless of hospital geographic regions., Conclusions: Although CNS presence was not associated with open visitation in this study, given the strong evidence to support the benefits to patients and the CNS role as a change agent in the hospital system, liberalization of visitation in the ICU is an area that could benefit from CNS advocacy.

Purpose of Review: The purpose of this review is to synthesize the current literature on classification and management of acute breathlessness that occurs in patients who are living with chronic refractory breathlessness related to cancer, cardiopulmonary, or neuromuscular disease., Recent Findings: In the context of chronic refractory breathlessness, acute breathlessness can be classified as either episodic breathlessness or breathlessness crisis. Episodic breathlessness is characterized by the severity, duration, and predictability of the symptom, and by the presence or absence of a trigger such as exertion, emotion, or an environmental factor. Breathlessness crisis is more sustained, occurs at rest, and overwhelms the patient's and caregivers' coping abilities, similar to the nontriggered unpredictable types of episodic breathlessness. Treatment of acute breathlessness focuses on alleviating the episode as quickly as possible without escalating medical intervention that may not be consistent with the patient's treatment preferences., Summary: Attention to breathlessness in the published literature has increased exponentially in the past two decades. The challenge is now to translate the research findings into relief of symptoms, suffering, and distress in those who suffer from acute and chronic breathlessness because of chronic illness.

This study explored palliative care provider self-competence and priorities for future education in an inpatient hospice setting in Kenya. Self-competence scores for clinical skills and patient and family communication skills were hypothesized to differ according to provider type. A descriptive, cross-sectional study design was piloted at Kimbilio Hospice, a 26-bed rural, inpatient facility in Kenya. A quantitative survey instrument entitled, "Self assessment of clinical competency and concerns in end-of-life care," was administered to participants. Survey responses were collected from 5 clinical staff, 11 caregivers, and 8 support staff. Data were analyzed using Kruskal-Wallis test to compare between mean scores. Statistically significant differences were found in 5 self-competence variables: performing a basic pain assessment, use of oral opioid analgesics, assessment and management of nausea/vomiting and constipation, and discussing an end-of-life prognosis with a patient's family member ( P < .05). Sixteen participants (66%) selected pediatric palliative care as their top priority for future education. The findings support the hypothesis that palliative care providers have varying levels of self-competence. Improving education to build palliative care competencies in adult and pediatric palliative care in sub-Saharan Africa is recommended., Competing Interests: The authors have no conflicts of interest to disclose.

Background: Self-management education for cardiopulmonary diseases is primarily provided through time-limited, face-to-face programs, with access limited to a small percentage of patients. Telecommunication tools will increasingly be an important component of future health care delivery., Objective: The purpose of this study was to describe the patterns of technology use in patients attending a cardiopulmonary clinic in an academic medical center., Methods: A prevalence survey was developed to collect data on participant demographics (age in years, sex, and socioeconomic status); access to computers, Internet, and mobile phones; and use of current online health support sites or programs. Surveys were offered by reception staff to all patients attending the outpatient clinic., Results: A total of 123 surveys were collected between March and April 2014. Technological devices were a pervasive part of everyday life with respondents engaged in regular computer (102/123, 82.9%), mobile telephone (115/117, 98.3%), and Internet (104/121, 86.0%) use. Emailing (101/121, 83.4%), researching and reading news articles (93/121, 76.9%), social media (71/121, 58.7%), and day-to-day activities (65/121, 53.7%) were the most common telecommunication activities. The majority of respondents reported that access to health support programs and assistance through the Internet (82/111, 73.9%) would be of use, with benefits reported as better understanding of health information (16/111, 22.5%), avoidance of difficult travel requirements and time-consuming face-to-face appointments (13/111, 18.3%), convenient and easily accessible help and information (12/111, 16.9%), and access to peer support and sharing (9/111, 12.7%). The majority of patients did not have concerns over participating in the online environment (87/111, 78.4%); the few concerns noted related to privacy and security (10/15), information accuracy (2/15), and computer literacy and access (2/15)., Conclusions: Chronic disease burden and long-term self-management tasks provide a compelling argument for accessible and convenient avenues to obtaining ongoing treatment and peer support. Online access to health support programs and assistance was reported as useful and perceived as providing convenient, timely, and easily accessible health support and information. Distance from the health care facility and a lack of information provision through traditional health sources were both barriers and enablers to telehealth. This is particularly important in the context of a cardiopulmonary clinic that attracts patients from a large geographical area, and in patients who are most likely to have high health care utilization needs in the future. Telecommunication interfaces will be an increasingly important adjunct to traditional forms of health care delivery.

Background: Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are highly prevalent and associated with a large symptom burden, that is compounded in a dual HF-COPD diagnosis. Yoga has potential benefit for symptom relief; however functional impairment hinders access to usual yoga classes. We developed a Tele-Yoga intervention and evaluated it in a controlled pilot trial. This paper reports on the appropriateness and acceptability of the intervention and the evaluation design., Methods: A controlled, non-randomised trial was conducted of an 8-week Tele-Yoga intervention versus an educational control (information leaflets mailed to participants with one phone call a week). Biweekly one-hour Tele-Yoga classes were implemented via multipoint videoconferencing that connected participants to live classes via an Internet connection to their televisions. Semi-structured qualitative interviews were conducted with participants post study exit to explore reasons for and experiences of participating, including views of study outcome measures and physiological tests. Transcribed interviews were analysed using thematic content analysis., Results: Fifteen people participated in the pilot study (7 in the intervention group, 8 in the control). Of these, 12 participants were interviewed, 6 in each group, mean age 71.2 years (SD 10.09); 3 were male. Themes are reported in the following categories: acceptability and appropriateness of the intervention, potential active ingredients of the intervention, acceptability and appropriateness of the control, participation in the research, and acceptability of the testing procedures. The intervention was acceptable and appropriate: the intervention group reported enjoying yoga and valuing the home-based aspect and participants described a high symptom burden and social isolation. However, technological problems resulted in poor video-streaming quality for some participants. Potential active ingredients included physical postures, breathing exercises and guidance in relaxation and meditation. The educational control intervention was acceptable and appropriate, with participants reporting little effect on their well-being and no impact on mechanisms hypothesised to explain yoga's effectiveness. The questionnaires and home physiological testing were acceptable to participants., Conclusions: Tele-Yoga is an acceptable and appropriate intervention in people with HF and COPD and further research is warranted to refine the technology used in its delivery. Findings provide guidance for researchers working in tele-interventions, yoga, and similar populations., Trial Registration: ClinicalTrials.gov Identifier: NCT02078739 (4 March 2014).

Context: The perception of dyspnea includes both sensory and affective dimensions that are shaped by emotions and psychological, social, and environmental experiences. Previous investigators have studied either measurement or strategies to decrease the affective dimension with laboratory-induced dyspnea. Few have reported the effect of a therapeutic clinical intervention on the affective dimension of dyspnea., Objectives: (1) To evaluate the effects of three different versions of a dyspnea self-management program (DM) on the affective dimension of dyspnea, measured by dyspnea-related anxiety (DA) and dyspnea-related distress (DD); and (2) to determine the stability of DA and DD over two baseline incremental treadmill tests (ITTs)., Methods: Participants with chronic obstructive pulmonary disease were randomly assigned to three 12 month DMs with varying doses of supervised exercise (DM, DM-Exposure, and DM-Training). The measurements of the affective dimension, DA and DD, were rated during ITTs on two baseline days and at two, six, and 12 months. Changes over time in DA and DD were analyzed using linear mixed-effects models., Results: Participants in the DM-Training group who received 24 nurse-coached exercise sessions had significantly greater reductions in DA and DD compared with those who had four exercise sessions (DM-Exposure) or only received a home-walking program (DM). Reductions in DA and DD in the DM-Training group were only maintained through six months. There were no significant differences in ratings of DA and DD at end between the two baseline ITTs., Conclusion: These findings provide initial support for the positive impact of a self-management program with nurse-coached exercise on the affective dimension of dyspnea. Further investigation of interventions that target the affective dimension in addition to the sensory dimension of dyspnea should be encouraged., (Copyright © 2014 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

In 2009, the American Thoracic Society (ATS) funded an assembly project, Palliative Management of Dyspnea Crisis, to focus on identification, management, and optimal resource utilization for effective palliation of acute episodes of dyspnea. We conducted a comprehensive search of the medical literature and evaluated available evidence from systematic evidence-based reviews (SEBRs) using a modified AMSTAR approach and then summarized the palliative management knowledge base for participants to use in discourse at a 2009 ATS workshop. We used an informal consensus process to develop a working definition of this novel entity and established an Ad Hoc Committee on Palliative Management of Dyspnea Crisis to further develop an official ATS document on the topic. The Ad Hoc Committee members defined dyspnea crisis as "sustained and severe resting breathing discomfort that occurs in patients with advanced, often life-limiting illness and overwhelms the patient and caregivers' ability to achieve symptom relief." Dyspnea crisis can occur suddenly and is characteristically without a reversible etiology. The workshop participants focused on dyspnea crisis management for patients in whom the goals of care are focused on palliation and for whom endotracheal intubation and mechanical ventilation are not consistent with articulated preferences. However, approaches to dyspnea crisis may also be appropriate for patients electing life-sustaining treatment. The Ad Hoc Committee developed a Workshop Report concerning assessment of dyspnea crisis; ethical and professional considerations; efficient utilization, communication, and care coordination; clinical management of dyspnea crisis; development of patient education and provider aid products; and enhancing implementation with audit and quality improvement.

Context: People with chronic obstructive pulmonary disease experience dyspnea with activities despite optimal medical management., Objectives: The purpose of this study was to test the efficacy of two 12-month dyspnea self-management programs (DSMPs), Internet-based (eDSMP) and face-to-face (fDSMP), compared with a general health education (GHE) control on the primary outcome of dyspnea with activities., Methods: Participants with chronic obstructive pulmonary disease were randomized to eDSMP (n=43), fDSMP (n=41), or GHE (n=41). The content of the DSMPs were similar and focused on education, skills training, and coaching on dyspnea self-management strategies, including exercise, and only differed in the delivery mode. Dyspnea with activities was measured with the Chronic Respiratory Questionnaire at three, six, and 12 months. Secondary outcomes included exercise behavior and performance, health-related quality of life, self-efficacy for dyspnea management, and perception of support for exercise. The study was registered at Clinicaltrials.gov (NCT00461162)., Results: There were no differences in dyspnea with activities across groups over 12 months (P=0.48). With the exception of arm endurance (P=0.04), exercise behavior, performance, and health-related quality of life did not differ across groups (P>0.05). Self-efficacy for managing dyspnea improved for the DSMPs compared with GHE (P=0.06). DSMP participants perceived high levels of support for initiating and maintaining an exercise program., Conclusion: The DSMPs did not significantly reduce dyspnea with activities compared with attention control. However, the high participant satisfaction with the DSMPs combined with positive changes in other outcomes, including self-efficacy for managing dyspnea and exercise behavior, highlight the need for additional testing of individually tailored technology-enabled interventions to optimize patient engagement and improve clinically relevant outcomes., (Copyright © 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Background: We previously reported that a twice-weekly, modified Iyengar yoga program was a safe and viable self-management strategy for patients with chronic obstructive pulmonary disease (COPD). 1, Objective: The primary purpose of this exploratory analysis was to classify yoga participants into 1 of 3 responder categories by using minimum clinically important difference (MCID) criteria for each of 3 variables: 6-minute walk distance (6MW), distress related to dyspnea (shortness of breath; DD), and functional performance (FPI). Changes in health-related quality of life (HRQL) and in psychological well-being (anxiety and depression), and participants' self-reported improvements by responder category were also examined. A secondary goal was to identify baseline participant characteristics, including initial randomization assignment that might predict response to treatment., Methods: Participants were randomly assigned to either an initial yoga (IY) or an enhanced wait-list control (WLC) group. Those in the WLC group were offered the yoga program immediately following the IY group's participation. Individuals from both groups who completed at least 18 of 24 yoga classes were categorized as responders, partial responders, or non-responders for each of the 3 outcome variables (6MW, DD, FPI) on the basis of MCID criteria. Baseline characteristics and changes in HRQL and psychological well-being were also analyzed., Results: None of the participants demonstrated MCIDs for all 3 outcomes; however, 6 were classified as responders for 2 out-come variables and 4 were classified as non-responders for all 3 outcome variables. Two-thirds of the female participant group and one-third of the male participant group completed the yoga program. DD responders showed increased anxiety levels, whereas anxiety levels of the DD non-responders remained unchanged. FPI responders reported significant improvements in physical function, whereas partial and non-FPI responders noted declined function. Participants assigned to the IY group demonstrated greater benefit from yoga than did those in the W LC group., Conclusions: Although this modified Iyengar yoga program appears to have benefited some individuals with COPD, further studies are required to assess who the intervention works for and under what conditions.

The purpose of this study was to identify determinants of frequency (days per week), duration (minutes per session), and continuity (persistence over 1 year) of home walking in 103 patients with chronic obstructive pulmonary disease (COPD) who participated in a dyspnea self-management program. Dimensions of home walking exercise were measured by logs and reports of biweekly telephone calls with the intervention nurse. The selection of personal, cognitive, and environmental determinants of home walking was guided by social cognitive theory. Participants walked more frequently if they were exercising before they entered the study, had less depressive symptoms, and were living with friends or family. Duration of walks was influenced by supervised exercise training; living with spouse, friends, or family; and physical conditioning. Participants who walked most consistently over the course of the year had more supervised exercise sessions as part of the dyspnea self-management program, exercised regularly before entering the program, and perceived a gain in social support over the year. These findings can be used to tailor exercise interventions to the specific needs of patients and improve the likelihood of consistent exercise participation., (Copyright © 2011. Published by Mosby, Inc.)