Browsing College of Nursing and Health Sciences by Author "Agar, Meera Ruth"
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ItemCaregivers' Perspectives on the Use of Long-Term Oxygen Therapy for the Treatment of Refractory Breathlessness: A Qualitative Study(Elsevier, 2016-11-11) Collier, Aileen; Breaden, Katrina Margaret; Phillips, Jane L; Agar, Meera Ruth; Litster, Caroline; Currow, David ChristopherContext Despite limited clinical evidence, long-term oxygen therapy (LTOT) is used for the management of refractory breathlessness in people with life-limiting illnesses who are not necessarily hypoxemic. Objectives The aim of this study was to understand caregiver factors associated with caring for someone with LTOT from the perspectives and experiences of caregivers themselves. Methods The qualitative study used semistructured interviews. The study was conducted in two states in Australia. Participants (n = 20) were self-nominated caregivers of people receiving LTOT for refractory breathlessness in the palliative setting. Results Data analyses established one overarching theme titled: “Oxygen giveth (something to help caregivers relieve breathlessness) and oxygen taketh away (from patients who lose some autonomy).” The theme captured caregivers' feelings of extreme distress in response to witnessing refractory breathlessness, and oxygen fulfilling several critical and beneficial roles in this context. In parallel, caregivers also explicitly and implicitly articulated several downsides to the use of LTOT. Conclusion Caregivers find caring for someone with refractory breathlessness extremely distressing. The benefits of LTOT are often overestimated, whereas its potential harms are underestimated. As significant stakeholders of people receiving LTOT, caregivers should be provided with opportunities to collaborate with clinicians in evidence-based decision making, efforts should be made to provide them with information and education about the most effective pharmacological and nonpharmacological strategies to manage refractory breathlessness in a palliative care setting including the appropriate use of LTOT to enable them to do so. ItemClinical practice guidelines for dementia in Australia(Australasian Medical Publishing Company, 2016-03-14) Laver, Kate; Cumming, Robert G; Agar, Meera Ruth; Anstey, Kaarin Jane; Beattie, Elizabeth; Brodaty, Henry; Broe, Tony; Clemson, Lindy; Crotty, Maria; Dietz, Margaret; Draper, Brian; Flicker, Leon; Friel, Margaret; Heuzenroeder, Louise Mary; Koch, Susan; Kurrle, Susan E; Nay, Rhonda; Pond, C Dimity; Thompson, Jane; Santalucia, Yvonne; Whitehead, Craig Hamilton; Yates, MarkAbout 9% of Australians aged 65 years and over have a diagnosis of dementia. Clinical practice guidelines aim to enhance research translation by synthesising recent evidence for health and aged care professionals. New clinical practice guidelines and principles of care for people with dementia detail the optimal diagnosis and management in community, residential and hospital settings. The guidelines have been approved by the National Health and Medical Research Council. The guidelines emphasise timely diagnosis; living well with dementia and delaying functional decline; managing symptoms through training staff in how to provide person-centred care and using non-pharmacological approaches in the first instance; and training and supporting families and carers to provide care. ItemEvidence-based occupational therapy for people with dementia and their families: What clinical practice guidelines tell us and implications for practice(Wiley, 2016-10-03) Laver, Kate; Cumming, Robert; Dyer, Suzanne M; Agar, Meera Ruth; Anstey, Kaarin; Beattie, Elizabeth; Brodaty, Henry; Broe, Tony; Clemson, Lindy; Crotty, Maria; Dietz, Margaret; Draper, Brian; Flicker, Leon; Friel, Meg; Heuzenroeder, Louise Mary; Koch, Susan; Kurrie, Susan; Nay, Rhonda; Pond, C Dimity; Thompson, Jane; Santalucia, Yvonne; Whitehead, Craig Hamilton; Yates, MarkBackground: The first evidence based Clinical Practice Guidelines and Principles of Care for People with Dementia in Australia have been released. The Guidelines detail a number of important evidence based recommendations for occupational therapists. Aim: The aim of this paper is (1) to provide an overview of Guideline development, and (2) to describe the evidence supporting a recommendation for occupational therapy. Common characteristics of effective occupational therapy programs for people with dementia are described. Methods: Guideline development involved adaptation of existing high quality guidelines developed overseas and 17 systematic reviews to ensure that the most recent high quality evidence was included. One of the systematic reviews involved examining the evidence for interventions to promote independence in people with dementia. Specifically, we looked at the evidence for occupational therapy and its effect on activities of daily living, quality of life and carer impact. Results: A total of 109 recommendations are included in the Guidelines. Occupational therapy was found to significantly increase independence in activities of daily living and improve quality of life. Effective occupational therapy programs involve: environmental assessment, problem solving strategies, carer education and interactive carer skills training. Conclusion: Occupational therapists working with people with dementia in community settings should ensure that their time is spent on those aspects of intervention that are shown to be effective. ItemPharmacovigilance in Hospice/Palliative Care: Net Effect of Haloperidol for Nausea or Vomiting(Mary Ann Liebert, Inc. publishers, 2017-08-03) Digges, Madeline; Hussein, Akram; Wilcock, Andrew; Crawford, Gregory Brian; Boland, Jason W; Agar, Meera Ruth; Sinnarajah, Aynharan; Currow, David Christopher; Johnson, Miriam JBackground: Haloperidol is widely prescribed as an antiemetic in patients receiving palliative care, but there is limited evidence to support and refine its use. Objective: To explore the immediate and short-term net clinical effects of haloperidol when treating nausea and/or vomiting in palliative care patients. Design: A prospective, multicenter, consecutive case series. Setting/Subjects: Twenty-two sites, five countries: consultative, ambulatory, and inpatient services. Measurements: When haloperidol was started in routine care as an antiemetic, data were collected at three time points: baseline; 48 hours (benefits); day seven (harms). Clinical effects were assessed using the National Cancer Institute's Common Terminology Criteria for Adverse Events (NCI CTCAE). Results: Data were collected (May 2014–March 2016) from 150 patients: 61% male; 86% with cancer; mean age 72 (standard deviation 11) years and median Australian-modified Karnofsky Performance Scale 50 (range 10–90). At baseline, nausea was moderate (88; 62%) or severe (11; 8%); 145 patients reported vomiting, with a baseline NCI CTCAE vomiting score of 1.0. The median (range) dose of haloperidol was 1.5 mg/24 hours (0.5–5 mg/24 hours) given orally or parenterally. Five patients (3%) died before further data collection. At 48 hours, 114 patients (79%) had complete resolution of their nausea and vomiting, with greater benefit seen in the resolution of nausea than vomiting. At day seven, 37 (26%) patients had a total of 62 mild/moderate harms including constipation 25 (40%); dry mouth 13 (21%); and somnolence 12 (19%). Conclusions: Haloperidol as an antiemetic provided rapid net clinical benefit with low-grade, short-term harms ItemA pragmatic, phase III, multisite, double-blind, placebo-controlled, parallel-arm, dose increment randomised trial of regular, low-dose extended-release morphine for chronic breathlessness: Breathlessness, Exertion And Morphine Sulfate (BEAMS) study protocol(BMJ Publishing Group, 2017-07-01) Currow, David Christopher; Watts, Gareth J; Johnson, Miriam J; McDonald, Christine; Miners, John Oliver; Somogyi, Andrew A; Denehy, Linda; McCaffrey, Nicola; Eckert, Danny J; McCloud, Philip; Louw, Sandra; Lam, Lawrence; Greene, Aine; Fazekas, Belinda Susan; Clark, Katherine; Fong, Kwun; Agar, Meera Ruth; Joshi, Rohit; Kilbreath, Sharon; Ferreira, Diana; Ekstrom, Magnus; Palliative Care Clinical Studies Collaborative (PaCCSC)Introduction Chronic breathlessness is highly prevalent and distressing to patients and families. No medication is registered for its symptomatic reduction. The strongest evidence is for regular, low-dose, extended- release (ER) oral morphine. A recent large phase III study suggests the subgroup most likely to benefit have chronic obstructive pulmonary disease (COPD) and modified Medical Research Council breathlessness scores of 3 or 4. This protocol is for an adequately powered, parallel-arm, placebo-controlled, multisite, factorial, block-randomised study evaluating regular ER morphine for chronic breathlessness in people with COPD. Methods and analysis The primary question is what effect regular ER morphine has on worst breathlessness, measured daily on a 0–10 numerical rating scale. Uniquely, the coprimary outcome will use a FitBit to measure habitual physical activity. Secondary questions include safety and, whether upward titration after initial benefit delivers greater net symptom reduction. Substudies include longitudinal driving simulation, sleep, caregiver, health economic and pharmacogenetic studies. Seventeen centres will recruit 171 participants from respiratory and palliative care. The study has five phases including three randomisation phases to increasing doses of ER morphine. All participants will receive placebo or active laxatives as appropriate. Appropriate statistical analysis of primary and secondary outcomes will be used. Ethics and dissemination Ethics approval has been obtained. Results of the study will be submitted for publication in peer-reviewed journals, findings presented at relevant conferences and potentially used to inform registration of ER morphine for chronic breathlessness. Trial registration number NCT02720822; Pre-results. ItemThe Prospective Evaluation of the Net Effect of Red Blood Cell Transfusions in Routine Provision of Palliative Care.(Mary Ann Liebert, Inc. publishers, 2017-06-09) To, Timothy H M; LeBlanc, Thomas; Eastman, Peter; Neoh, Karen; Agar, Meera Ruth; To, Luen Bik; Rowett, Debra Sharon; Vandersman, Zac; Currow, David ChristopherBackground Red Blood Cell (RBC) transfusions are commonly used in palliative care. RBCs are a finite resource, transfusions carry risks, and the net effect (benefits and harms) is poorly defined for people with life-limiting illnesses. Aim The aim of this study was to examine the indications and the effects of RBC transfusion in palliative care patients. Design This international, multisite, prospective consecutive cohort study assessed target symptoms (fatigue, breathlessness, generalised weakness, or dizziness) prior to transfusion and at day 7 by treating clinicians, using National Cancer Institute Common Terminology Criteria for Adverse Events. Assessment of harms was made at day 2. Setting/participants One-hundred and one transfusions with day 7 followup were collected. Median age was 72·0 (IQR 61·5-83·0) years, 58% male, and mean Australian-modified Karnofsky Performance Status of 48 (SD 17). Results A mean 2·1 (SD 0·6) units was transfused. The target symptom was fatigue (61%), breathlessness (16%), generalized weakness (12%), dizziness (6%) or other (5%). Forty-nine percent of transfusions improved the primary target symptom, and 78% of transfusions improved at least one of the target symptoms. Harms were infrequent and mild. An AKPS of 40-50% was associated with higher chances of symptomatic benefit in the target symptom, however no other predictors of response were identified. Conclusions In the largest prospective consecutive case series to date, clinicians generally reported benefit, with minimal harms. Ongoing work is required to define the optimal patient- and clinician-reported haematological and functional outcome measures to optimise the use of donor blood and minimise transfusion-associated risk. ItemStudy protocol: a phase III randomised, double-blind, parallel arm, stratified, block randomised, placebo-controlled trial investigating the clinical effect and cost-effectiveness of sertraline for the palliative relief of breathlessness in people with chronic breathlessness(BMJ Publishing Group, 2016-10-26) Watts, Gareth J; Clark, Katherine; Agar, Meera Ruth; Davidson, Patricia; McDonald, Christine; Lam, Lawrence; Sajkov, Dimitar; McCaffrey, Nicola; Doogue, Matthew; Abernethy, Amy Pickar; Currow, David Christopher; Palliative Care Clinical Studies Collaborative (PaCCSC)Introduction Breathlessness remains a highly prevalent and distressing symptom for many patients with progressive life-limiting illnesses. Evidence-based interventions for chronic breathlessness are limited, and there is an ongoing need for high-quality research into developing management strategies for optimal palliation of this complex symptom. Previous studies have suggested that selective serotonin reuptake inhibitors such as sertraline may have a role in reducing breathlessness. This paper presents the protocol for a large, adequately powered randomised study evaluating the use of sertraline for chronic breathlessness in people with progressive life-limiting illnesses. Methods and analysis A total of 240 participants with modified Medical Research Council Dyspnoea Scale breathlessness of level 2 or higher will be randomised to receive either sertraline or placebo for 28 days in this multisite, double-blind study. The dose will be titrated up every 3 days to a maximum of 100 mg daily. The primary outcome will be to compare the efficacy of sertraline with placebo in relieving the intensity of worst breathlessness as assessed by a 0–100 mm Visual Analogue Scale. A number of other outcome measures and descriptors of breathlessness as well as caregiver assessments will also be recorded to ensure adequate analysis of participant breathlessness and to allow an economic analysis to be performed. Participants will also be given the option of continuing blinded treatment until either study data collection is complete or net benefit ceases. Appropriate statistical analysis of primary and secondary outcomes will be used to describe the wealth of data obtained. Ethics and dissemination Ethics approval was obtained at all participating sites. Results of the study will be submitted for publication in peer-reviewed journals and the key findings presented at national and international conferences. Trial registration number ACTRN12610000464066.