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Original article
Holistic services for people with advanced disease and chronic breathlessness: a systematic review and meta-analysis
  1. Lisa Jane Brighton1,
  2. Sophie Miller1,
  3. Morag Farquhar2,
  4. Sara Booth3,
  5. Deokhee Yi1,
  6. Wei Gao1,
  7. Sabrina Bajwah1,
  8. William D-C Man4,5,
  9. Irene J Higginson1,
  10. Matthew Maddocks1
  1. 1 Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
  2. 2 School of Health Sciences, University of East Anglia, Norwich, UK
  3. 3 Department of Oncology, University of Cambridge, Cambridge, UK
  4. 4 NIHR Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College, Harefield, UK
  5. 5 Harefield Pulmonary Rehabilitation Unit, Harefield Hospital, Harefield, UK
  1. Correspondence to Dr Matthew Maddocks, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London SE5 9PJ, UK; matthew.maddocks{at}


Background Breathlessness is a common, distressing symptom in people with advanced disease and a marker of deterioration. Holistic services that draw on integrated palliative care have been developed for this group. This systematic review aimed to examine the outcomes, experiences and therapeutic components of these services.

Methods Systematic review searching nine databases to June 2017 for experimental, qualitative and observational studies. Eligibility and quality were independently assessed by two authors. Data on service models, health and cost outcomes were synthesised, using meta-analyses as indicated. Data on recipient experiences were synthesised thematically and integrated at the level of interpretation and reporting.

Results From 3239 records identified, 37 articles were included representing 18 different services. Most services enrolled people with thoracic cancer, involved palliative care staff and comprised 4–6 contacts over 4–6 weeks. Commonly used interventions included breathing techniques, psychological support and relaxation techniques. Meta-analyses demonstrated reductions in Numeric Rating Scale distress due to breathlessness (n=324; mean difference (MD) −2.30, 95% CI −4.43 to −0.16, p=0.03) and Hospital Anxiety and Depression Scale (HADS) depression scores (n=408, MD −1.67, 95% CI −2.52 to −0.81, p<0.001) favouring the intervention. Statistically non-significant effects were observed for Chronic Respiratory Questionnaire (CRQ) mastery (n=259, MD 0.23, 95% CI −0.10 to 0.55, p=0.17) and HADS anxiety scores (n=552, MD −1.59, 95% CI −3.22 to 0.05, p=0.06). Patients and carers valued tailored education, self-management interventions and expert staff providing person-centred, dignified care. However, there was no observable effect on health status or quality of life, and mixed evidence around physical function.

Conclusion Holistic services for chronic breathlessness can reduce distress in patients with advanced disease and may improve psychological outcomes of anxiety and depression. Therapeutic components of these services should be shared and integrated into clinical practice.

Registration number CRD42017057508.

  • palliative care

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • LJB and SM are joint first authors.

  • Contributors MM and IJG designed the study, obtained funding and take overall responsibility for its content. LJB and SM conducted the searches and data extraction, MM, LJB, SM and IJH assessed study eligibility, and MM and LJB assessed study quality. MM, LJB, SM, MF and DY analysed and interpreted the data. All authors contributed to the manuscript and approved the final version.

  • Funding This review was conducted as part of a project funded by an NIHR Health Services and Delivery Research Grant (NIHR HSDR 16/02/18). MM, GW and IJH are supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London and Cicely Saunders International; MM is supported by an NIHR Career Development Fellowship (CDF-2017-009); WM is supported by the NIHR CLAHRC Northwest London, and IJH holds an NIHR Emeritus Senior Investigator Award.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Requests for additional data should be addressed to the corresponding author.

  • Correction notice This article has been corrected since it was published Online First. Sophie Miller and Lisa Jane Brighton were not originally listed joint first authors.

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