Guidelines for the Use of Oxygen in Palliative Care

Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines Guidelines for the Use of Oxygen in Palli...
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Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines

Guidelines for the Use of Oxygen in Palliative Care 1

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AA Scott , CL Robinson , A Thompson , S Oakes, H Bonwick (Guideline Development Lead) 2,3 1

Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK 2Marie Curie Hospice, Liverpool, UK 3Liverpool Heart and Chest Hospital NHS Foundation Trust 4Willowbrook Hospice, Prescot, UK

Summary of Main Recommendations Introduction Oxygen is a vital resource. However there are potential problems and risks that healthcare 5-8,17 professionals should be aware of.

Patients who continue to smoke should undergo risk assessment and the appropriate authorities 29-30 informed. [Level 4]

There is no strong evidence that oxygen is beneficial for the management of breathlessness in palliative 8,11-17 care. [Level 1+]

Specialist Palliative Care In-Patient Units should have:

It may be appropriate to use other strategies, pharmacological and non-pharmacological, to 21 manage breathlessness before trialing oxygen. [Level 4] If oxygen is used, it should be reviewed after 72 hours. If it has not been beneficial, consider 17 discontinuing. [Level 1+]



Where appropriate, patients should investigated for reversible causes 21,22 breathlessness or hypoxia. [Level 4]

□ •

be of

Oxygen saturations may be used to guide the use of oxygen. The British Thoracic Society 22 recommends target saturations of:



94-98% in patients with cancers with pulmonary involvement. [Level 4] 88-92% in patients at risk of hypercapnic respiratory failure (see Table 1). [Level 3]

Where appropriate, target saturations should be 22 documented by medical staff. [Level 4]

Safe oxygen use Health professionals should be aware of potential problems associated with oxygen (see Table 3). These include dry mouth, increased risk of falls and 22 psychological dependence. Patients who continue to smoke while provided with oxygen are at risk of causing fires and burn 29-30 injuries.

Guidelines for the Use of Oxygen in Palliative Care Date of Production September 2013 Date of Review September 2017

A policy for the safe use of oxygen.



Access to a pulse oximeter.



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A range of consumables available to provide 22 oxygen. [Level 4]

Prescribing oxygen Oxygen prescriptions should state:

Clinical assessment





• •

The flow rate in litres per minute. The method of delivery e.g. nasal specs, face mask.



Frequency of use e.g. continuous or PRN.



Target saturations (if appropriate).

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[Level 4]

Patients who are discharged with home oxygen Where available, patients should be referred to the local oxygen assessment service. [Level 4]

Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines

Section 1: Introduction  Breathlessness is a common symptom in patients with advanced malignancy and other life-limiting illnesses. The aetiology may be multifactorial.1-4  Oxygen may be used in palliative care for symptom control and in situations where a patient is hypoxic.1  Traditionally, oxygen was considered a benign therapy with few risks. 5 However, there are many potential side effects associated with oxygen, not all of which are physical.6-8 Oxygen may have a symbolic association of being ‘life-saving’ which may lead to a psychological dependency.5  All specialist palliative care inpatient units should have a policy to support the safe prescribing and use of oxygen.9 [Level 4] Section 2: Scope and Purpose  This guideline is primarily aimed at professionals working in specialist palliative care inpatient units. This may include doctors, nurses, physiotherapists, occupational therapists and pharmacists. However, the principles will also be relevant to those working in primary and secondary care, including the community setting.  The aims of the guideline are to: -

ensure oxygen is being used appropriately in palliative care patients

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encourage the safe use of oxygen

 Table 1 summarises the scope and purpose of this guideline. Table 1: Scope and purpose of guideline Population

• Adults with life-limiting disease in whom oxygen has been

Populations not covered

• Patients without life-limiting disease

Healthcare setting

• • • •

considered or used

People in their usual place of residence Primary and community care Secondary care Hospice care

• Evidence-base behind use of oxygen to manage symptoms Topics

Topics not covered

• • •

in palliative care Assessment and monitoring of patients using oxygen Side effects and risks of using oxygen Prescribing of oxygen and consumables

• Use of oxygen for reasons other than symptom control

Guidelines for the Use of Oxygen in Palliative Care Date of Production September 2013 Date of Review September 2017

Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines

Section 3: Methods 3.1

Clinical Questions  The clinical questions were devised by the Guideline Development Group which has authored this guideline.

3.2

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Which patients with palliative care needs benefit from oxygen?

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What protocols should services have in place to ensure the safe use of oxygen?

Literature Search  Systematic electronic database searches were done to find articles relevant to the clinical questions. AMED, EMBASE, HMIC, Ovid MEDLINE, PsychINFO, BNI, CINAHL, Health Business ELITE and Cochrane databases were searched in March 2013. A full explanation of the search strategy, results and appraisal of evidence can be found in Appendix 1. A supplementary search was undertaken in July 2013 specifically looking at home oxygen and fire risk.  Grading of level of evidence and recommendations follows the Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Guideline Development Manual and uses SIGN criteria.10

Section 4: Guideline Recommendations 4.1

Evidence base for the use of oxygen in palliative care  Long-term oxygen therapy (LTOT) has been shown to improve survival in patients with COPD.11 However published research does not support the routine use of oxygen in palliative care and at the end of life for the relief of, or palliation of, breathlessness.8,11-17 [Level 1+]  Inhalation of air has been shown to be as effective as oxygen for symptomatic relief of breathlessness.12,16-19 [Level 1+] Use of air also avoids difficulties associated with oxygen including fire risks, central hypoventilation and cost. However air is not routinely used for symptom control.17  Published research suggests that other strategies for managing breathlessness should be instituted before using oxygen.8,14,17 Once these other strategies have been optimised, a trial of oxygen for symptomatic benefit is reasonable, provided the benefits outweigh the risks and the patient has been counselled.7,14,16,17,20 [Level 1+]  It is recommended that when oxygen is trialed, patients should be reassessed after 72 hours. The oxygen should be discontinued if it has not been of benefit.17 [Level 1+]

4.2

Assessment  Breathlessness or hypoxia may be caused by an acute, reversible event. Patients should be assessed and oxygen used if clinically indicated.21,22  Patients with palliative care needs being considered for oxygen therapy for breathlessness may undergo assessment using various tools, including BORG, VAS, MRC Dyspnoea score, Dyspnoea-12 and the Multidimensional Dyspnea Profile.23-25 The measurement of oxygen saturations using a pulse

Guidelines for the Use of Oxygen in Palliative Care Date of Production September 2013 Date of Review September 2017

Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines

oximeter should be used to inform decision-making around the use of oxygen therapy.  Patients with interstitial lung disease may need oxygen because of significant desaturation on exercise. These patients should already be supported by specialist respiratory services and have regular review of their need for oxygen. Close liaison between such services and palliative care is recommended.26 [Good Practice Point}

4.3

Principles of Use of Oxygen

 Pharmacological and non-pharmacological strategies for symptom control may be utilised simultaneously.21 [Level 4]  If the patient is hypoxic, reversible causes should be identified and treated where appropriate. The use of oxygen should be considered.21,22  There is no evidence to support the use of oxygen in the absence of hypoxia.13 Where other strategies have been optimised, a trial of oxygen may be reasonable but the patient should be counselled about the risks and benefits. The effectiveness should be assessed after 72 hours.17  For patients in the last days or hours of life, the decision to continue or withdraw oxygen should be made on an individual basis and discussed with the patient and those identified as important to them. 27 4.4

Monitoring  The British Thoracic Society (BTS) recommends that in patients with cancers with pulmonary involvement, the target oxygen saturation should be 94%98%.22 [Level 4]  For patients at risk of hypercapnic respiratory failure (see Table 2), BTS Guidelines recommend target saturations of 88% to 92%. 22 [Level 3] Excess oxygen therapy may lead to respiratory depression, drowsiness or confusion. Staff should be aware of the importance of monitoring oxygen saturations.  Palliative care physicians should establish whether or not patients have a history of hypercapnic respiratory failure. This may require liaison with other services e.g. respiratory, community, specialist oxygen services. [Good Practice Point]. Table 2 Patients at risk of hypercapnic respiratory failure •

COPD



Neuromuscular disorders



Severe kyphoscoliosis



Overdose of opioids or benzodiazepines



Severe scarring from old tuberculosis

Guidelines for the Use of Oxygen in Palliative Care Date of Production September 2013 Date of Review September 2017

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Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines

 For each patient who is prescribed oxygen .medical staff should determine target saturations and clearly document in the case notes. However, checking saturations may not be appropriate in some patients, and in these cases oxygen can be titrated according to symptoms.22 [Level 4]  Specialist palliative care in-patient units should have access to a pulse oximeter in order to measure oxygen saturations. There should also be access to a range of consumables to deliver oxygen at a particular flow rate or concentration.22 [Level 4] 4.5

Side effects and risks of oxygen therapy  There are a number of side effects and risks associated with oxygen therapy and these are listed in Table 3.  Patients who smoke should be warned about the associated risks. 28 Patients who continue to smoke while provided with oxygen are at greater risk of adverse consequences, including causing fires, burn injuries and death. 29,30 It may not be appropriate to supply oxygen to patients who are still smoking. Health professionals should undertake a full risk assessment and inform the oxygen and fire services. Local policies should provide further guidance. 29,30 [Level 4] Table 3: Side effects and risks of oxygen therapy 5,7

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Claustrophobia

Loss of independence

Dry nose/eyes/mouth

Pressure sores to ears or nose

Drowsiness

Psychological dependence

Fire risk

Reduced mobility and risk of falls

Hypercapnic respiratory failure

Social isolation

Prescribing oxygen  Oxygen is a drug, and should be prescribed appropriately. This may be on a handwritten drug chart or via an electronic prescribing system.22 [Level 4]  Prescriptions for oxygen should specify: -

The flow rate in litres per minute

-

The method of delivery e.g. nasal specs, face mask, non-rebreather mask

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Frequency of use e.g. continuous, PRN, overnight

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Target saturations22 [Level 4]

 Prescribers should be trained on the oxygen systems available in the community and how to order these.20 [Level 4]  If a patient is discharged with oxygen therapy and a local oxygen service is available consider referring to the service for assessment. [Good Practice Point] Guidelines for the Use of Oxygen in Palliative Care Date of Production September 2013 Date of Review September 2017

Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines

Section 6: Standards 1.

Every specialist palliative care inpatient unit should have a policy for the use of oxygen. 9 [Grade D]

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All specialist palliative care in-patient units should have equipment available to measure oxygen saturations.22 [Grade D]

3.

The indication for the use of oxygen should be clearly recorded in the patient case notes.9 [Grade D]

4.

Oxygen should be prescribed, including flow rate and system of delivery. 22 [Grade D]

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If the measurement of oxygen saturation is clinically appropriate, a target range should be documented.22 [Grade D]

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The use of oxygen should be reviewed within 72 hours of starting. If it has not been beneficial, consider discontinuing.17 [Grade B]

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A patient information leaflet should be given to all patients commenced on oxygen therapy.9 [Grade D]

8.

All staff involved in administering or prescribing oxygen therapy should receive appropriate training.22 [Grade D]

9.

If oxygen is provided for a patient who continues to smoke, a risk assessment should be carried out and the patient should be counselled on the risks. This should be clearly documented.28-30 [Grade D]

10. For patients who are discharged on oxygen, primary care services should be provided with information on the equipment supplied, the flow rate and the delivery system used. 20 [Grade D]

Applications and Implications The audit of use of oxygen in the region highlighted two issues of patient safety. Firstly, the audit showed that there was scope for improvement in the prescribing of oxygen. Secondly, risk assessments for patients who smoke while supplied with oxygen are carried out infrequently at best. Individual units are encouraged to prioritise these areas. Staff education around the importance of and rationale for measuring oxygen saturations should also be addressed. Future audits of this guideline will assess whether local practice has improved. Acknowledgments and Declarations of Interest We acknowledge the work of the following in supporting these guidelines. Damian Cullen, Clinical Audit Officer, at Liverpool Heart and Chest Hospital for support and assistance in collecting and analysing audit data. Dr Martin Ledson, Consultant Respiratory Physician, at Liverpool Heart and Chest Hospital for his comments and review of the guidelines. Dr Sara Booth Associate Lecturer University of Cambridge, Honorary Consultant, Cambridge UHNHSFT, for her input as external reviewer. The guidelines were funded through the use of supporting professional activity time facilitated by the employing organisations of the authors. Guidelines for the Use of Oxygen in Palliative Care Date of Production September 2013 Date of Review September 2017

Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines

The authors contributed as follows. Literature Review: CR, AS, HB, AT. Audit Tools: AS, HB, SO, AT, CR. Writing Guidance and Grading Recommendations: AS, HB, AT, CR, SO. Standards: AS, HB, AT, CR, SO. Final writing of manuscript of guidelines: AS. Review Date The guidelines will be reviewed three years after publication as outlined in the Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Guideline Development Manual.10 References 1.

Davidson PM, Johnson MJ. Update of the role of palliative oxygen. Current Op Supp and Palliat Care 2011; 5(2): 87-91. [PubMed]

2.

Ahmedzai SH, Laude E, Robertson A, Troy G, Vora V. A double-blind, randomised, controlled Phase II trial of Heliox28 gas mixture in lung cancer patients with dyspnoea on exertion. Br J Cancer 2004; 90: 366371.[PubMed]

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Booth S, Wade R, Johnson M, Kite S, Swannick M. Anderson H, Swannick M. The use of oxygen in the palliation of breathlessness. A Report of the Expert Working Group of the Scientific Committee of the Association of Palliative Medicine. Respir Med 2004; 98(1): 66-77.[PubMed]

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Booth S, Wade R. Oxygen or air for palliation of breathlessness in advanced cancer. J R Soc Med 2003; 96: 215-218.[PubMed]

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Jaturapatporn D, Moran E, Obwanga C, Husain A. Patients’ experience of oxygen therapy and dyspnea: a qualitative study in home palliative care. Support Care Cancer 2010; 18(6): 765-770.[PubMed]

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Quinn-Lee L, Gianlupi A, Weggel J, Moch S, Mabin J, Davey S et al. Use of oxygen at the end of life: on what basis are decisions made? Int J Palliat Nurs 2012; 18(8): 369-370.[PubMed]

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Goody R, O’Hare J, Watson M, Warke T. Using oxygen therapy in the palliative care setting. Eur J Palliat Care 2007; 14(3): 120-123.

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Breaden K, Phillips J, Agar M, Grbich C, Abernethy AP, Currow DC. The clinical and social dimensions of prescribing palliative home oxygen for refractory dyspnoea. J Palliat Med 2013; 16(3): 268-273.[PubMed]

9.

Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Audit Group meeting, 12th September 2013.

10. Cheshire and Merseyside Palliative and End of Life Care Network Audit Group. Guideline Development Manual. 1st Edition : Cheshire and Merseyside Palliative and End of Life Network Audit Group; 2014.[Link] 11. Stringer E, McParland C, Hernandez P. Physician practices for prescribing supplemental oxygen in the palliative care setting. J Palliat Care 2004; 20(4): 303-307.[PubMed] 12. Cranston JM, Crockett AJ, Moss JR, Alpers JH. Domiciliary oxygen for chronic obstructive pulmonary disease. Cochrane Database of Systematic

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Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines

Reviews 2005. Issue 10.1002/14651858.[PubMed]

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Art

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CD001744.

DOI:

13. Cranston JM, Crockett A, Currow D, Ekström M. Oxygen therapy for dyspnoea in adults. Cochrane Database of Systematic Reviews 2008, Issue 3. Art No: CD004769. DOI: 10.1002/14651858.[PubMed] 14. Currow DC, Agar M, Smith J, Abernethy AP. Does palliative home oxygen improve dyspnoea? A consecutive cohort study. Palliat Med 2009; 23(4): 309-316.[PubMed] 15. Clemens K, Quednau I, Klaschik E. Use of oxygen and opioids in the palliation of dyspnoea in hypoxic and non-hypoxic palliative care patients: a prospective study. Support Care Cancer 2009; 17(4): 367-377.[PubMed] 16. Bruera E, Sweeney C, Willey J, Palmer JL, Strasser F, Morice RC et al. A randomised controlled trial of supplemental oxygen versus air in cancer patients with dyspnoea. Palliat Med 2003; 17(8): 659-663.[PubMed] 17. Abernethy AP, McDonald CF, Frith PA, Clark K, Herdon JE 2nd, Marcello J et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial. Lancet 2010; 376(9743): 784-793.[PubMed] 18. Philip J, Gold M, Milner A , Ilulio D, Miller B, Spruyt O. A randomised, double-blind, crossover trial of the effect of oxygen on dyspnoea in patients with advanced cancer. J Pain Symptom Manage 2006; 32(6): 541550.[PubMed] 19. Booth S, Kelly MJ, Cox NP, Adams L, Guz A. Does oxygen help dyspnea in patients with cancer? Am J Resp Crit Care Med 1996; 153(5): 15151518.[PubMed] 20. Royal College of Physicians (London). Domiciliary oxygen therapy services: Clinical guidelines and advice for prescribers. London. 1999. 21. Merseyside and Cheshire Palliative Care Network Audit Group. Guidelines for the management of intractable breathlessness in palliative care. December 2010 [Link] 22. O’Driscoll BR, Howard LS, Davison AG. BTS Guideline for emergency oxygen use in adult patients. Thorax 2008; 63 (Supplement VI).[PubMed] 23.

Bausewein C, Farquhar M, Booth S, Gysels M, Higginson IJ. Measurement of breathlessness in advanced disease: A systematic review. Respir Med 2007; 101(3): 399-410.[PubMed]

24. Yorke J, Moosavi SH, Shuldham C, Jones PW. Quantification of dyspnea using descriptors: development of initial testing of the Dyspneoa-12. Thorax 2010; 65(1): 21-26.[PubMed] 25. Meek PM, Banzett R, Parshall MB, Gracely RH, Schwartzstein RM, Lansig R. Reliability and validity of the multidimensional dyspnea profile. Chest 2012; 141(6): 1546-53.[PubMed] 26. National Institute for Clinical Excellence. CG163 Idiopathic Pulmonary Fibrosis: The diagnosis and management of suspected Idiopathic Pulmonary Fibrosis. London. 2013. Available from: https://www.nice.org.uk/guidance/cg163 Last accessed February 2016[Link] Guidelines for the Use of Oxygen in Palliative Care Date of Production September 2013 Date of Review September 2017

Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines

27. Leadership Alliance for the Care of Dying People. One Chance to Get It Right: Improving people’s experience of care in the last few days and hours of life. London. 2014.[Link] 28. British Thoracic Society Working Group on Home Oxygen Services. Clinical component for the home oxygen service in England and Wales. London. 2006.[Link] 29. Murabit A, Tredget EE. Review of burn injuries secondary to home oxygen. J Burn Care Res 2012; 33(2): 212-217.[PubMed] 30. Litt EJ, Ziesche R, Happak W, Lumenta DB. Burning HOT: revisiting guidelines associated with home oxygen therapy. Int J Burns Trauma 2012; 2(3): 167-170.[PubMed]

Guidelines for the Use of Oxygen in Palliative Care Date of Production September 2013 Date of Review September 2017

Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines

Appendix 1: Systematic Review Summary Form Guideline Title: Guidelines for the Use of Oxygen In Palliative Care Reviewers: CL Robinson, AA Scott, H Bonwick, A Thompson I D E N T I F I C A T I O N

S C R E E N I N G

Clinical Question – To investigate the role of oxygen in palliative care

Databases NHS Evidence Healthcare Database and Cochrane. Terms ‘palliative’ ‘terminal’ ‘end of life’ AND ‘oxygen’ were searched in the title.

Records identified AMED, EMBASE, HMIC, Ovid MEDLINE, PsychINFO, BNI, CINAHL, Health Business ELITE and Cochrane databases (n = 372)

Records after duplicates removed (n = 134)

Foreign language = 10 Records screened (n = 134)

E L I G I B I L I T Y I N C L U D E D

Records excluded (n = 113)

Inappropriate topic = 101 Full text not available = 2

Full-text articles assessed for eligibility

Full-text articles excluded (n = 4)

(n = 21)

Review article (n = 4)

Studies included in final literature review (n = 17 )

Guidelines for the Use of Oxygen in Palliative Care Date of Production September 2013 Date of Review September 2017