Downloaded from http://spcare.bmj.com/ on July 19, 2015 - Published by group.bmj.com
Short report
Doctors’ attitudes towards prescribing opioids for refractory dyspnoea: a single-centred study Savvas Hadjiphilippou,1 Sarah-Elizabeth Odogwu,1 Pauline Dand2
1
Department of Medicine, Kent and Canterbury Hospital, Canterbury, UK 2 Pilgrims Hospices in East Kent & East Kent University Foundation Hospital Trust, Canterbury, UK Correspondence to Dr Pauline Dand, Pilgrims Hospices in East Kent, 56 London Road, Canterbury CT2 8JA, UK; pauline.dand@ pilgrimshospices.org Received 25 July 2013 Revised 6 January 2014 Accepted 13 February 2014 Published Online First 6 March 2014
To cite: Hadjiphilippou S, Odogwu S-E, Dand P. BMJ Supportive & Palliative Care 2014;4:190–192.
190
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.
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 noncurative 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
Hadjiphilippou S, et al. BMJ Supportive & Palliative Care 2014;4:190–192. doi:10.1136/bmjspcare-2013-000565
Downloaded from http://spcare.bmj.com/ on July 19, 2015 - Published by group.bmj.com
Short report 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 nonmalignant 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 nonmalignant 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.
Figure 1 Breakdown of study sample (n=65). FY, foundation year; CT, core trainee; ST, specialist trainee; GPST, general practice specialist trainee; SpR, specialist registrar (≥ST3); SAS, staff grade and associate specialist.
Hadjiphilippou S, et al. BMJ Supportive & Palliative Care 2014;4:190–192. doi:10.1136/bmjspcare-2013-000565
191
Downloaded from http://spcare.bmj.com/ on July 19, 2015 - Published by group.bmj.com
Short report 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 contextspecific framework, may help facilitate use among hospital doctors. However, strategies are also required to address persistent concerns regarding side effects. 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. Competing interests None. 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. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage 2006;31:58–69. 2 Rocker G, Horton R, Currow D, et al. Palliation of dyspnoea in advanced COPD: revisiting a role for opioids. Thorax 2009;64:910–15.
192
3 Goodridge D, Lawson J, Rocker G, et al. Factors associated with opioid dispensation for patients with COPD and lung cancer in the last year of life: a retrospective analysis. Int J Chron Obstruct Pulmon Dis 2010;5:99–105. 4 Simon ST, Higginson IJ, Benalia H, et al. Episodic and continuous breathlessness: a new categorization of breathlessness. J Pain Symptom Manage 2013;45:1019–29. 5 Barbera L, Taylor C, Dudgeon D. Why do patients with cancer visit the emergency department near the end of life? CMAJ 2010;182:563–8. 6 Jennings AL, Davies AN, Higgins JP, et al. A systematic review of the use of opioids in the management of dyspnoea. Thorax 2002;57:939–44. 7 Currow DC, McDonald C, Oaten S, et al. Once-daily opioids for chronic dyspnea: a dose increment and pharmacovigilance study. J Pain Symptom Manage 2011;42:388–99. 8 Currow DC, Ward AM, Abernethy AP. Advances in the pharmacological management of breathlessness. Curr Opin Support Palliat Care 2009;3:103–6. 9 Rocker GM, Young J, Horton R. Using opioids to treat dyspnea in advanced COPD: a survey of Canadian clinicians [abstract]. Chest 2008;134(4_MeetingAbstracts):s29001. 10 Johnson MJ, Abernethy AP, Currow DC. Gaps in the evidence base of opioids for refractory breathlessness. A future work plan? J Pain Symptom Manage 2012;43:614–24. 11 Liverpool Care Pathway Central Team. Liverpool care pathway document (November 2005) version 11. Liverpool: Marie Curie Palliative Care Institute, 2005. 12 Abernethy AP, Currow DC, Frith P, et al. Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ 2003;327:523–8. 13 Young J, Simpson C, Farquhar M, et al. Attitudes to using opioids to treat dyspnea in advanced COPD: a qualitative study of family physicians and respiratory therapists [abstract]. Chest 2009;136(4_MeetingAbstracts):91S. 14 Rocker G, Young J, Donahue M, et al. Perspectives of patients, family caregivers and physicians about the use of opioids for refractory dyspnea in advanced chronic obstructive pulmonary disease. CMAJ 2012;184:E497–504. 15 Bennett MI, Graham J, Schmidt-Hansen M, et al. Prescribing strong opioids for pain in adult palliative care: summary of NICE guidance. BMJ 2012;344:e2806.
Hadjiphilippou S, et al. BMJ Supportive & Palliative Care 2014;4:190–192. doi:10.1136/bmjspcare-2013-000565
Downloaded from http://spcare.bmj.com/ on July 19, 2015 - Published by group.bmj.com
Doctors' attitudes towards prescribing opioids for refractory dyspnoea: a single-centred study Savvas Hadjiphilippou, Sarah-Elizabeth Odogwu and Pauline Dand BMJ Support Palliat Care 2014 4: 190-192 originally published online March 6, 2014
doi: 10.1136/bmjspcare-2013-000565 Updated information and services can be found at: http://spcare.bmj.com/content/4/2/190
These include:
References Email alerting service
This article cites 14 articles, 6 of which you can access for free at: http://spcare.bmj.com/content/4/2/190#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Short report
Doctors’ attitudes towards prescribing opioids for refractory dyspnoea: a single-centred study Savvas Hadjiphilippou,1 Sarah-Elizabeth Odogwu,1 Pauline Dand2
1
Department of Medicine, Kent and Canterbury Hospital, Canterbury, UK 2 Pilgrims Hospices in East Kent & East Kent University Foundation Hospital Trust, Canterbury, UK Correspondence to Dr Pauline Dand, Pilgrims Hospices in East Kent, 56 London Road, Canterbury CT2 8JA, UK; pauline.dand@ pilgrimshospices.org Received 25 July 2013 Revised 6 January 2014 Accepted 13 February 2014 Published Online First 6 March 2014
To cite: Hadjiphilippou S, Odogwu S-E, Dand P. BMJ Supportive & Palliative Care 2014;4:190–192.
190
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.
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 noncurative 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
Hadjiphilippou S, et al. BMJ Supportive & Palliative Care 2014;4:190–192. doi:10.1136/bmjspcare-2013-000565
Downloaded from http://spcare.bmj.com/ on July 19, 2015 - Published by group.bmj.com
Short report 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 nonmalignant 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 nonmalignant 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.
Figure 1 Breakdown of study sample (n=65). FY, foundation year; CT, core trainee; ST, specialist trainee; GPST, general practice specialist trainee; SpR, specialist registrar (≥ST3); SAS, staff grade and associate specialist.
Hadjiphilippou S, et al. BMJ Supportive & Palliative Care 2014;4:190–192. doi:10.1136/bmjspcare-2013-000565
191
Downloaded from http://spcare.bmj.com/ on July 19, 2015 - Published by group.bmj.com
Short report 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 contextspecific framework, may help facilitate use among hospital doctors. However, strategies are also required to address persistent concerns regarding side effects. 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. Competing interests None. 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. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage 2006;31:58–69. 2 Rocker G, Horton R, Currow D, et al. Palliation of dyspnoea in advanced COPD: revisiting a role for opioids. Thorax 2009;64:910–15.
192
3 Goodridge D, Lawson J, Rocker G, et al. Factors associated with opioid dispensation for patients with COPD and lung cancer in the last year of life: a retrospective analysis. Int J Chron Obstruct Pulmon Dis 2010;5:99–105. 4 Simon ST, Higginson IJ, Benalia H, et al. Episodic and continuous breathlessness: a new categorization of breathlessness. J Pain Symptom Manage 2013;45:1019–29. 5 Barbera L, Taylor C, Dudgeon D. Why do patients with cancer visit the emergency department near the end of life? CMAJ 2010;182:563–8. 6 Jennings AL, Davies AN, Higgins JP, et al. A systematic review of the use of opioids in the management of dyspnoea. Thorax 2002;57:939–44. 7 Currow DC, McDonald C, Oaten S, et al. Once-daily opioids for chronic dyspnea: a dose increment and pharmacovigilance study. J Pain Symptom Manage 2011;42:388–99. 8 Currow DC, Ward AM, Abernethy AP. Advances in the pharmacological management of breathlessness. Curr Opin Support Palliat Care 2009;3:103–6. 9 Rocker GM, Young J, Horton R. Using opioids to treat dyspnea in advanced COPD: a survey of Canadian clinicians [abstract]. Chest 2008;134(4_MeetingAbstracts):s29001. 10 Johnson MJ, Abernethy AP, Currow DC. Gaps in the evidence base of opioids for refractory breathlessness. A future work plan? J Pain Symptom Manage 2012;43:614–24. 11 Liverpool Care Pathway Central Team. Liverpool care pathway document (November 2005) version 11. Liverpool: Marie Curie Palliative Care Institute, 2005. 12 Abernethy AP, Currow DC, Frith P, et al. Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ 2003;327:523–8. 13 Young J, Simpson C, Farquhar M, et al. Attitudes to using opioids to treat dyspnea in advanced COPD: a qualitative study of family physicians and respiratory therapists [abstract]. Chest 2009;136(4_MeetingAbstracts):91S. 14 Rocker G, Young J, Donahue M, et al. Perspectives of patients, family caregivers and physicians about the use of opioids for refractory dyspnea in advanced chronic obstructive pulmonary disease. CMAJ 2012;184:E497–504. 15 Bennett MI, Graham J, Schmidt-Hansen M, et al. Prescribing strong opioids for pain in adult palliative care: summary of NICE guidance. BMJ 2012;344:e2806.
Hadjiphilippou S, et al. BMJ Supportive & Palliative Care 2014;4:190–192. doi:10.1136/bmjspcare-2013-000565
Downloaded from http://spcare.bmj.com/ on July 19, 2015 - Published by group.bmj.com
Doctors' attitudes towards prescribing opioids for refractory dyspnoea: a single-centred study Savvas Hadjiphilippou, Sarah-Elizabeth Odogwu and Pauline Dand BMJ Support Palliat Care 2014 4: 190-192 originally published online March 6, 2014
doi: 10.1136/bmjspcare-2013-000565 Updated information and services can be found at: http://spcare.bmj.com/content/4/2/190
These include:
References Email alerting service
This article cites 14 articles, 6 of which you can access for free at: http://spcare.bmj.com/content/4/2/190#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
