Article Text
Abstract
Objective Dyspnoea is a distressing and common symptom in palliative care. There is evidence that opioids can improve the experience of dyspnoea. Limited data suggest that doctors’ attitudes may be a barrier to prescribing opioids for the relief of refractory dyspnoea. This study explored UK hospital doctors’ experience of, and attitudes towards, prescribing opioids for refractory dyspnoea in advanced disease.
Methods Anonymous semistructured questionnaires were distributed by convenience sampling. Data were collated and descriptive analysis performed. Doctors of all grades attending routine educational events within the medical directorate of a UK district general hospital were included in this study.
Results Sixty-five questionnaires were analysed. Most doctors (61/64) reported a willingness to prescribe opioids for refractory dyspnoea, although the majority felt less confident than when prescribing opioids for pain. Three-quarters of doctors (49/65) had initiated, or under supervision, prescribed opioids for refractory dyspnoea. This was most often for a patient in the last hours/days of life (44/49), followed by patients with cancer (34/49), heart failure (26/49) and chronic obstructive pulmonary disease (COPD) (21/49). Confidence in prescribing was highest in relation to the dying and lowest in COPD. A significant proportion (40/64) of respondents expressed concerns when prescribing.
Conclusions This group of doctors was aware of the use of opioids for refractory dyspnoea and reported a willingness to prescribe opioids for this symptom. However, confidence varied considerably depending on clinical context. Fears about side effects were prevalent and should be addressed. Doctors would benefit from clearer guidance on prescribing regimes, specifically in circumstances other than the dying patient.
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Introduction
Dyspnoea is a highly prevalent and distressing symptom in the palliative care population, and studies1–3 describe the significant negative impact of this symptom on patient quality of life and well-being. As one of the leading causes of emergency admissions to hospital, it also poses a significant financial burden for many healthcare systems.4 ,5 Despite this, treatment remains complex and its management poor for many sufferers.4 A growing body of clinical evidence6–8 supports the use of systemic opioids for the palliation of refractory dyspnoea in patients with advanced life-limiting illness. However, concerns relating to their use persist.9
A review by Johnson et al10 explores the current knowledge base regarding opioid use in refractory dyspnoea and identifies knowledge gaps. One such area is the lack of knowledge surrounding the barriers and facilitators to opioid prescribing for dyspnoea. To date, there is a paucity of information available regarding UK doctors’ knowledge, experience, practice and attitudes in this arena. This study explores hospital doctors’ experience of and attitudes towards prescribing opioids for refractory dyspnoea.
Methods
An anonymous semistructured questionnaire was used to gather information about knowledge, experience, attitudes and confidence in relation to opioid use for refractory dyspnoea in advanced non-curative disease. In addition to general opinion, questions explored four clinical diagnoses. These comprised the dying patient (last few hours/days), the patient with advanced heart failure (HF), the patient with advanced cancer and the patient with advanced chronic obstructive pulmonary disease (COPD).
A convenience sample was drawn from doctors working within the medical specialities of a UK district hospital who attended educational events during a period in July 2012. Sixty-five questionnaires were collected and analysed (figure 1). Simple statistical analysis was carried out based on total responses for each question, while descriptive comments allowed a qualitative approach to the interpretation of data.
Results
Fifty-five doctors (55/65) were aware of the use of opioids in the management of refractory dyspnoea. Forty-nine doctors (49/65), had previously initiated, or under supervision, prescribed opioids for refractory dyspnoea. The preferred opioid for use was morphine (63/63).
Of the 49 doctors reporting prior experience, this was most often in relation to dyspnoea in a dying patient (44/49), followed by advanced cancer (34/49), HF (26/49) and COPD (21/49).
Almost all doctors (61/64) regardless of prior experience reported they would be willing to prescribe opioids for the symptom of refractory dyspnoea in advanced non-curative disease. They were most prepared to do so in the case of a dying patient (57/61), followed by that of advanced cancer (45/61), HF (39/61) and lastly COPD (30/61).
Doctors rated their self-confidence in prescribing opioids for dyspnoea in the four given clinical scenarios. A response indicative of confidence (‘confident’ or ‘very confident’) was most frequent for the dying patient (60/64) reducing with advanced malignancy (52/63), HF (37/63) and COPD (29/61).
On the whole, doctors felt more confident prescribing opioids for the symptom of pain than for dyspnoea (46/63).
Despite a general willingness towards opioid use for refractory dyspnoea, a substantial proportion of respondents (40/64) expressed concerns.
Forty-four respondents (44/65) acknowledged a need for further information or support regarding opioid prescribing for dyspnoea. This primarily related to practical aspects of prescribing such as choice of opioid, dosing regimens and the provision of guidelines.
Discussion
The majority of doctors in this study reported an awareness of the use of opioids for refractory dyspnoea with three-quarters having some type of prescribing experience in this area. Free text comments suggested acquisition of knowledge through a variety of sources with ward-based clinical experience a predominant source of learning and the support of the hospital palliative care team another important factor.
As a group, experience most commonly related to the dying patient. This was not explored further but may result in part from increased support from the palliative care team in this particular patient group, or familiarity with guidance for the management of breathlessness in the dying patient included in symptom control algorithms within the Liverpool Care Pathway for the Dying (V.11).11
Despite respondents’ general readiness to consider opioid treatment for refractory dyspnoea, both willingness to prescribe and confidence in doing so varied greatly between the four clinical settings. These were highest in the dying patient and lowest in non-malignant disease. Reluctance was particularly evident for COPD, despite some robust studies7 ,12 demonstrating the benefits of using opioids to relieve breathlessness in this condition. This observed trend may result from specific clinical experience related to the management of acutely unwell unstable hospital inpatients with non-malignant disease. However, research from Canada on doctors’ attitudes to prescribing opioids for COPD-related dyspnoea9 ,13 ,14 found an analogous reluctance to prescribe. Key factors underlying this attitude in Canadian physicians were found to be lack of confidence, lack of experience, lack of guidance and fear.14 This study therefore corroborates findings from previous studies suggesting physician barriers to prescribing opioids for dyspnoea, particularly in non-malignant disease, are prevalent and widespread.
The main concerns expressed by doctors in this UK study centred on the absence of a prescribing framework and fear of opioid side effects, particularly respiratory depression. While improved guidance might support doctors’ confidence, it has been suggested by Young et al13 that ‘innovative educational initiatives’ may be necessary to mitigate the ‘discomfort’ of prescribing opioids. It is this discomfort that may be the key factor in the knowledge–practice gap displayed by this particular group of doctors.
In the field of pain, undertreatment due to reluctance to use strong opioids is a recognised problem.15 While statistics may be lacking for the undertreatment of refractory dyspnoea in advanced disease, this study suggests that doctors are less confident in prescribing opioids for refractory dyspnoea than for pain. Consequently, patients may be even more likely to be undertreated for this equally distressing symptom.
The study's limitations include its single-centred nature, convenience sampling and use of a data collection tool that has not been validated. Results may not be generalised.
Conclusions
Doctors in this study demonstrated a high awareness of opioid use for the alleviation of breathlessness in advanced malignant and non-malignant disease. Confidence and willingness to prescribe were shown to be context specific. Concerns expressed by this group of doctors support the available literature, which suggests that physician barriers to opioid use include lack of prescribing guidance and fear of side effects. The implications of this study are that explicit guidance to support prescribing for dyspnoea, within a context-specific framework, may help facilitate use among hospital doctors. However, strategies are also required to address persistent concerns regarding side effects.
References
Footnotes
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Contributors All authors planned the study, designed the questionnaire and wrote the article. SH and S-EO undertook the data collection and data analysis. All authors are responsible for the overall content.
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Competing interests None.
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Ethics approval This study was approved by the East Kent Hospitals University Foundation Trust Research and Development department. It did not meet the criteria necessitating local Research and Ethics Committee submission and approval.
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Provenance and peer review Not commissioned; externally peer reviewed.