Qualitative Study of Refractory Dyspnea
The study selected for review covers the effects of nebulized opioids on refractory dyspnea in a 10-year-old boy. This paper will examine the study with regard to data collection methods and ethical treatment of the human subject involved. This study is representative of most in this area of research insomuch as it is a case study with limited variable control. As such, there is a nothing conclusive that can be said about the effectiveness of nebulized opioids as compared to other treatments for refractory dyspnea, and further research is required.
This paper will review the work published by Cohen and Dawson (2002) with regards to protection of human participants, data collection, data management, and findings / interpretations of the data.
Protection of Participants
The benefits of this treatment are purely palliative. Dyspnea is a problem affecting the quality of life in patients with end stage cystic fibrosis in which the lungs cannot oxygenate properly causing sensations of breathlessness and panic in the individual. These symptoms cause patients to feel anxiety and depression as they consistently feel as though they cannot get enough air. It is deemed important by medical professionals to lessen the suffering of these patients by researching ways to improve the symptoms of dyspnea.
The article makes no mention of informed consent or voluntary participation. The treatment itself was not done for the purpose of study, but to alleviate symptoms. Even so, it was a palliative treatment and the patient’s guardian was most likely made aware of the situation and gave permission. The guardian would also needed to give permission for the the patient’s information to be used in the study, though again, no mention is made of this. It is also not made clear if an institutional review board was involved in this study.
The research is a case study and as such, much of the data gathered in the study is qualitative, but tried to use quantitative data whenever possible to support the qualitative results. Nebulized morphine was administered in incremental doses ranging from 2.5 mg to 12.5 mg in a 10-year-old, 20-kg boy for three days until the patient’s death. After each dose of morphine, the following parameters were recorded: visual analog "dyspnea" scores, vital signs, venous blood gases, and blood levels of morphine. Patient was monitored for signs of physical or mental distress and was routinely asked to describe his comfort level.
Researchers’ rationale for collecting this data was in part due to a need to uphold the hippocratic oath and do no harm. Since the patient has a lung condition and opioids suppress respiratory function, the researchers had to be sure that the treatment was only alleviating the patient’s symptoms and not technically contributing to his death. The laboratory tests administered were partly to ensure the patient was not deteriorating as a result of the nebulized morphine. The stable blood chemical levels compared against the improved symptoms demonstrate the positive correlation between non-lethal opioid doses and diminished sensations of dyspnea.
The paper does not adequately explain the many variables at play such as the lateness with which treatment began. The ambiguous results of the study which could only show mild improvement may be due to beginning the treatment after sufficient damage to his breathing system had already occurred. There is no way to say, but the research makes no note of possible confounds.
Data Management and Analysis
This study makes very little mention of the rigors of analysis methods of the data management, which can be worrisome. At the same time, this study serves as a sort of proof of concept, attempting to document any indication that nebulized opioids are useful in treating refractory dyspnea. The condition and treatment occur rarely enough that there is little evidence on the subject, and the researches seem to be taking what they can get. While this is understandable, it still does not change the fact that very little scientific rigor is present with regard to drawing correlations or controlling for confounding variables.
Findings and Interpretations
The nebulized morphine was found to have a modest effect on the patient's dyspnea, with no significant differences found between the varying doses. Researches made several speculations as to why this “saturation effect” seems to have occurred. These findings, while simple, were presented in the article in a logical fashion. The researchers’ cautious interpretations of a modest effect are valid and accurately reflect what was observed, as does their discussion on potential extraneous factors which will help future studies by giving researchers an idea of what these could be.
These results offer support for the use of nebulized morphine as an effective palliative treatment for refractory dyspnea. The implications for the nursing community are relatively minor as it will not necessarily impact the way nurses do their jobs, however, the study’s place in the larger framework of palliative care for patients with cystic fibrosis may affect nurses as a shift from life-prolonging measures to palliative care may be seen. The debate between these two forms of care is pervasive throughout the medical community and affects nurses in many ways, including how they are taught, how they practice, and how administration forms policies.
No specific suggestions are made for future study. Rather, the researchers simply conclude that some form of further inquiry into the topic is needed in order to draw any sort of strong conclusion. They make no indication of what methods these potential studies should use.
Congruity between what is objectively observed and how the researcher chooses to interpret and report this data is paramount in scientific endeavor. Cohen and Dawson (2002) follow all reasonable scientific parameters as they observe the final days of a patient with the targeted condition for study and see minor improvement in his condition. They attempt to account for confounds by measuring vital signs and laboratory work to ensure that the medication is only doing the job intended for it. They report very little, which is appropriate for a study that observed very little effect. These observations are nevertheless important as they build on each other to lead to stronger scientific consensus.
Cohen, S. P., & Dawson, T. C. (2002). Nebulized morphine as a treatment for dyspnea in a child with cystic fibrosis. Pediatrics, 38, 110-113.