Background
Methods
Study aim
Design
Setting and participants
Research team
Recruitment
Data collection
Data analysis
Ethical considerations
Findings
Patient & carer ID number | Patient | Carer | Relationship with the patient |
---|---|---|---|
1 | Female | Male | Husband |
2 | Male | Female | Wife |
3 | Female | Male | Son |
4 | Male | Female | Wife |
5 | Male | Female | Wife |
6 | Male | Female | Wife |
7 | Male | Female | Wife |
8 | Female | Male | Husband |
9 | Male | Female | Wife |
Median age (IQR) | 77 (72–79) |
Gender | |
Female | 3 |
Ethnicity | |
Oceanian (Australia or New Zealand) | 8 |
North-West European | 1 |
Usual language spoken at home | |
English | 9 |
Residence | |
Living in a private residence | 9 |
Marital status | |
Married or de facto | 8 |
Widowed | 1 |
Highest level of education | |
Did not complete high school | 4 |
Completed high school | 1 |
Completed a trade certificate | 2 |
University Degree | 2 |
mMRC score at baseline | |
3 | 9 |
NRS Worst breathlessness (24 h) | |
4 | 1 |
6 | 2 |
7 | 3 |
8 | 2 |
9 | 1 |
AKPS | |
50 | 3 |
60 | 3 |
70 | 3 |
Median age (IQR) | 70 (69–79) |
Gender | |
Female | 6 |
Ethnicity | |
Oceanian (Australia or New Zealand) | 6 |
North-West European | 3 |
Highest level of education | |
Did not complete high school | 4 |
Completed high school | 3 |
University degree | 2 |
Marital status | |
Married or de facto | 9 |
Living with the patient | |
Yes | 8 |
No | 1 |
Median time living with the patient (years) (IQR) | 45 (21–56) |
Hands on care | |
Yes | 7 |
No | 2 |
For how long has the carer been providing hands-on-care? (median time in years) (IQR) | 4 (3–5) |
Time spent together weekly | |
> 40 h | 7 |
20–40 h | 1 |
10–20 h | 1 |
Other people involved in providing care | |
No | 9 |
Changes to employment status due to patient’s condition | |
No | 9 |
Patients & Carers | Patient | Carer |
---|---|---|
1. Shrinking world Breathlessness shrinks the physical and relational world available to patients and carers and increases the time they spend together | • Restriction of daily activities • Restriction of independence • Good days and bad days | • Restriction of their own daily activities • Describe patients have good days and bad days • Hard to disconnect from the carer’s role |
2. Mutual adaptation Patient and carers work individually and together to create optimal functioning for both | • Keep as active as possible • Try to avoid over-exertion • Some push to the limit | • Take over some tasks • Slow down • Step in to prevent perceived over-exertion |
3. Co-management Patient and carers have active and complementary roles in managing breathlessness | • Have an active role in managing breathlessness • Work with the carer to overcome breathlessness | • Have an active role in managing breathlessness • Degree of participation depends on patients’ limitations • Step in situations of acute breathlessness |
4. Emotional coping Emotional coping with breathlessness is difficult for patients, but harder for carers | • Annoyance • Frustration | • Frustration • Resentment • Feeling trapped • Giving up part of their identity |
5. Meaning in the face of death Sense of meaning created by the relationship between patients and carers | • See death as natural (no fear) • Find meaning in their relationship with the carer | • Fear patients’ death and their future • Try to bring joy and happiness to the patient |
Shrinking world
“Well it takes me a long time to get from here to the bed and back. By the time I get there, I got to get on the nebulizer you know? I can get dressed by myself but I have a girl coming to shower me.” [Patient 1]
“I have to go shopping and I bought myself a little emergency mobile phone which I haven’t told anybody anything about it. It’s just simply so I can ring home to check on her … And I bought a walker for her hoping that she would use the walker.” [Carer 1]
“We went to town about a month ago, we used to do quite a bit of that, become a tourist in your own town, sort of thing. We went there and I walked maybe 50 meters in North Terrace [a street]. I could not go any further. I just could not walk any further. So, that [mobility scooter] will fix our problem. I can even walk to the shops with J. [wife].” [Patient 9]
“I would like to go and do things with him, like go to the zoo, the art gallery, places like that but that is out of the question because I couldn’t get the car close enough for him to even get in the place. To be able to walk to get in places. We can’t get around. I don’t go to everything that I would normally go to.” [Carer 9]
“I have good days and bad days. Some days, I can’t get out of bed basically and other days is fine. ( … ) It is unexpected and you just take it day by day.” [Patient 8]
“There are good days and bad days. There are days in which she can’t do much and she just sits down or lays on the bed and does not do much. And other days she has got a lot of energy and does a lot of other stuff. There are quite a few ups and downs. ( … ) In the end you just go with the flow, treat it from day to day, whatever comes up. Yeah.” [Carer 8]
Mutual adaptation
“Occasionally, I try to do a bit of cooking. But I can’t always do it. I can’t do any cooking really when I am using this [points at the oxygen tube] because of the fire risk.” [Patient 6]
In some circumstances, carers learned how to slow down to meet the patient level of function. This strategy seemed to allowed patients to keep as much autonomy as possible.“He can’t do anything which is very annoying - not to me, but to him - because he quite often says … A couple of weeks ago he said “I’ll cook you dinner”. He was going to make a curry. He got up there and I have to switch his oxygen off - because of the gas, you see … Two minutes later he said “I am sorry, I can’t … ” and I said “It’s ok you just sit down and relax and I’ll do it”. [Carer 6]
“We have a system. T. [son] takes me shopping and I can take a trolley in. And I can do my own shopping like that.” [Patient 3]
Within each patient-carer unit, patients and carer had learned to adapt to breathlessness. In most cases, patients had developed an accurate sense of their exertional capacity, learning to push themselves to be as active as possible, while managing their breathlessness, including avoiding situations that created intense or unmanageable breathlessness. In these cases, carers trust the patient capacity to manage the degree of exertion they are able to tolerate.“Just be patient and let them take their time. When we go to the shops, I don’t rush mum and we just go slow. Be patient.” [Carer 3]
“And I think you adapt to the problem. You know you have a problem so you adapt to it. So you create a situation where you don’t get that short of breath, you know? Because you don’t do things.” [Patient 5]
“( … ) he sits a lot and plays games on the computer and all that, so he knows when he can’t do things. So yeah, that doesn’t concern me.” [Carer 5]
“I just don’t want it to beat me. I know my limits and I will push myself to the limits.” [Patient 7]
“The last couple of times we used the caravan, it was in the beginning of last year actually. It’s an old caravan so it takes a lot of putting the annex part of it because it doesn’t have a pull-out roof on it and it takes quite a while to put it up, but I have to say “Stop and sit down!” and he says “No, I want to get this done!” and I say “Well, you need to have a rest” so I say “I’ll make you a coffee”. So then he stops. Or we’ll go and have lunch and come back and finish it, you know?” [Carer 7]
Co-management
“My wife knows I have a problem and we just get on with it. I do most of the cooking and she does most of the cleaning.” [Patient 7]
“I do a few jobs around the house but I don’t have to do anything for him, really. He can dress himself and all things like that. I used to have to cut his toe nails … But now, because we have a care plan, we go to the podiatrist.” [Carer 7]
“Getting dressed is … hands above the head is a problem. But the rest of it is fine, it is just slow. So J. [wife] comes in and helps me and we get through it together.” [Patient 9]
“Like we had our granddaughter 21st birthday in the city and it took an hour and a half for him to get dressed. He would do one little thing and then he would get out of breath. And then I would go away and try to put something on myself and come back and do some small thing.” [Carer 9]
“When that flu hit me, I couldn’t breathe at all. It was so bad all of a sudden. M. [wife] had to call the ambulance.” [Patient 4]
“When he had that flu, I called the ambulance and they came pronto. I know what to do in those cases because I’ve done it before, but it’s a bit scary.” [Carer 4]
Emotional coping
“No, not scared [by daily breathlessness]. I tend to be a phlegmatic sort of guy; I have low anxiety levels. And I am used to it.” [Patient 2]
“Just watching him trying to get his breath … That is horrible to watch. And there is nothing you can do to help. Just keep him comfortable and be there, whatever he needs … I try not to worry too much; I try to keep calm because I don’t want him to get worse.” [Carer 2]
“But a couple of times, a couple of months ago, I had a real breathlessness attack and I could not breathe. It that was quite scary but I managed it ok, I sort of did what I had to and I was ok.” [Patient 8]
“It scares me [when she gets more intense breathlessness]. Very much! Especially when she has an infection or something a bit more serious, that is really scary.” [Carer 8]
“I get up in the morning, have breakfast, shower. I don’t shower every day because I get so breathless showering. But when I do shower, then M. [wife] helps me sometimes. And then I sit down and I have my Ipad, I look at all the papers from all over the world and I just keep my brain working thinking about things but physically, I don’t do anything at all. ( … ) sometimes I get bored. Bored you know? I think “what should I do next?””. [Patient 6]
“My life is boring! [laughs] I am a very outgoing person, I like the outdoors, and on a day like today you think “oh, let’s get in the car and go!” But I have to think of him first because he can’t walk from here to there before he gets breathlessness so I think “well … just scrap it”, and do nothing you know? So it makes it hard on me because I want to do things but I can’t you know?” [Carer 6]
Meaning in the face of death
“No, not anymore [I don’t worry about the future]. I look at it this way, if something is going to happen, it is going to happen. There is nothing you can do about it.” [Patient 4]
“I wonder just how bad he’s going to get … What is going to be like further down the track.” [Carer 4]
“Life is pretty good, yeah. B. [husband] does everything and we are together all the time. He is a good doctor! A very good doctor [laughing].” [Patient 1]
“I buy her some flowers every fortnight and I put them in there so she can sit at the table and look at them. Just to introduce a bit of color and a variety into the family. I am trying to make it fairly compatible being at home (and I think for the last year she has been home now) I think she said she was happy I think, yeah.” [Carer 1]
Discussion
Breathing
Thinking
Functioning
Limitations
Implications for future research
Implications for clinical practice
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Functional losses due to breathlessness are devastating for patients and carers and should be proactively investigated in all stages of COPD.
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Understanding the natural history of COPD and its impact on daily fluctuations in chronic breathlessness may assist in tailoring future interventions for chronic breathlessness, especially self-management strategies involving patient and carer.
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Carers are severely affected by the experience of chronic breathlessness and their specific needs need to be assessed in clinical practice. From a service point of view, the carer is both a care recipient and a co-worker with health professionals [44].
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Both patient and carer are essential in the effective management of chronic breathlessness. Both need to be targeted (together and separately) to optimise clinical outcomes in breathlessness associated with COPD.