A Qualitative Study of Pulmonary and Palliative Care Clinician Perspectives on Early Palliative Care in Chronic Obstructive Pulmonary Disease

Perspectives from patients with chronic lung disease on a telehealth-facilitated integrated palliative care model: a qualitative content analysis study

BACKGROUND

Chronic lung disease affects nearly 37 million Americans and often results in significant quality of life impairment and healthcare burden. Despite guidelines calling for palliative care (PC) integration into pulmonary care as a vital part of chronic lung disease management, existing PC models have limited access and lack scalability. Use of telehealth to provide PC offers a potential solution to these barriers. This study explored perceptions of patients with chronic lung disease regarding a telehealth integrated palliative care (TIPC) model, with plans to use findings to inform development of an intervention protocol for future testing.

METHODS

For this qualitative study, we conducted semi-structured interviews between June 2021- December 2021 with patients with advanced chronic lung disease. Interviews explored experiences with chronic lung disease, understanding of PC, and perceived acceptability of the proposed model along with anticipated facilitators and barriers of the TIPC model. We analyzed findings with a content analysis approach.

RESULTS

We completed 20 interviews, with two that included both a patient and caregiver together due to patient preference. Perceptions were primarily related to three categories: burden of chronic lung disease, pre-conceived understanding of PC, and perspective on the proposed TIPC model. Analysis revealed a high level of disease burden related to chronic lung disease and its impact on day-to-day functioning. Although PC was not well understood, the TIPC model using a shared care planning approach via telehealth was seen by most as an acceptable addition to their chronic lung disease care.

CONCLUSIONS

These findings emphasize the need for a patient-centered, shared care planning approach in chronic lung disease. The TIPC model may be one option that may be acceptable to individuals with chronic lung disease. Future work includes using findings to refine our TIPC model and conducting pilot testing to assess acceptability and utility of the model.

European Respiratory Society clinical practice guideline: palliative care for people with COPD or interstitial lung disease

There is increased awareness of palliative care needs in people with COPD or interstitial lung disease (ILD). This European Respiratory Society (ERS) task force aimed to provide recommendations for initiation and integration of palliative care into the respiratory care of adult people with COPD or ILD. The ERS task force consisted of 20 members, including representatives of people with COPD or ILD and informal caregivers. Eight questions were formulated, four in the Population, Intervention, Comparison, Outcome format. These were addressed with full systematic reviews and application of Grading of Recommendations Assessment, Development and Evaluation for assessing the evidence. Four additional questions were addressed narratively. An "evidence-to-decision" framework was used to formulate recommendations. The following definition of palliative care for people with COPD or ILD was agreed. A holistic and multidisciplinary person-centred approach aiming to control symptoms and improve quality of life of people with serious health-related suffering because of COPD or ILD, and to support their informal caregivers. Recommendations were made regarding people with COPD or ILD and their informal caregivers: to consider palliative care when physical, psychological, social or existential needs are identified through holistic needs assessment; to offer palliative care interventions, including support for informal caregivers, in accordance with such needs; to offer advance care planning in accordance with preferences; and to integrate palliative care into routine COPD and ILD care. Recommendations should be reconsidered as new evidence becomes available.

Palliative Care Physicians' Perceptions of Conditions Required to Provide Early Palliative Care

CONTEXT

Early palliative care (EPC) is widely recommended but its implementation may be challenging.

OBJECTIVES

We conducted a qualitative analysis of Canadian palliative care physicians' opinions about conditions necessary to provide EPC.

METHODS

A survey assessing attitudes and opinions regarding EPC was distributed to physicians providing primary or specialized palliative care, as identified by the Canadian Society of Palliative Care Physicians. The survey included an optional final section for respondents' general comments; we screened these for relevance to our study aims and conducted a thematic analysis of relevant comments.

RESULTS

Of 531 completed surveys, 129 (24%) respondents provided written comments, of whom 104 mentioned conditions they felt to be necessary to provide EPC. Four key themes were identified: 1) Clear delineation of roles of primary and specialized palliative care physicians-all physicians should be empowered to provide primary palliative care, with specialists providing additional support; 2) Shared care with needs-dependent referral-primary and specialized palliative care physicians should work collaboratively, with referral to specialized palliative care based on need rather than on prognosis; 3) Adequate resources to support primary palliative care-education, financial incentives, and collaboration with interdisciplinary team members such as nurses and specialized providers were specifically mentioned; 4) Addressing the misconception that palliative care equals end-of-life care-there was particular emphasis on education of both healthcare providers and the public.

CONCLUSION

Changes are necessary at the level of palliative care referral systems, providers, resources, and policy to enable implementation of EPC.

Differences in Palliative Care Provision by Primary and Specialist Providers Supporting Patients With COVID-19: A Qualitative Study

Objectives: To describe the delivery of palliative care by primary providers (PP) and specialist providers (SP) to hospitalized patients with COVID-19. Methods: PP and SP completed interviews about their experiences providing palliative care. Results were analyzed using thematic analysis. Results: Twenty-one physicians (11 SP, 10 PP) were interviewed. Six thematic categories emerged. Care provision: PP and SP described their support of care discussions, symptom management, managing end of life, and care withdrawal. Patients provided care: PP described patients at end of life, with comfort-focused goals; SP included patients seeking life-prolonging treatments. Approach to symptom management: SP described comfort, and PP discomfort in providing opioids with survival-focused goals. Goals of care: SP felt these conversations were code status-focused. Supporting family: both groups indicated difficulties engaging families due to visitor restrictions; SP also outlined challenges in managing family grief and need to advocate for family at the bedside. Care coordination: internist PP and SP described difficulties supporting those leaving the hospital. Conclusion: PP and SP may have a different approach to care, which may affect consistency and quality of care.

Rehabilitation for People with Respiratory Disease and Frailty: An Official American Thoracic Society Workshop Report

People with respiratory disease have increased risk of developing frailty, which is associated with worse health outcomes. There is growing evidence of the role of rehabilitation in managing frailty in people with respiratory disease. However, several challenges remain regarding optimal methods of identifying frailty and delivering rehabilitation for this population. The aims of this American Thoracic Society workshop were to outline key definitions and concepts around rehabilitation for people with respiratory disease and frailty, synthesize available evidence, and explore how programs may be adapted to align to the needs and experiences of this population. Across two half-day virtual workshops, 20 professionals from diverse disciplines, professions, and countries discussed key developments and identified opportunities for future research, with additional input via online correspondence. Participants highlighted a "frailty rehabilitation paradox" whereby pulmonary rehabilitation can effectively reduce frailty, but programs are challenging for some individuals with frailty to complete. Frailty should not limit access to rehabilitation; instead, the identification of frailty should prompt comprehensive assessment and tailored support, including onward referral for additional specialist input. Exercise prescriptions that explicitly consider symptom burden and comorbidities, integration of additional geriatric or palliative care expertise, and/or preemptive planning for disruptions to participation may support engagement and outcomes. To identify and measure frailty in people with respiratory disease, tools should be selected on the basis of sensitivity, specificity, responsiveness, and feasibility for their intended purpose. Research is required to expand understanding beyond the physical dimensions of frailty and to explore the merits and limitations of telerehabilitation or home-based pulmonary rehabilitation for people with chronic respiratory disease and frailty.

Project EPIC (Early Palliative Care In COPD): A Formative and Summative Evaluation of the EPIC Telehealth Intervention

CONTEXT

Early, concurrent palliative care interventions in chronic obstructive pulmonary disease (COPD) are limited. Project EPIC (Early Palliative Care In COPD) is a multiphase mixed methods study working to fill this gap.

OBJECTIVES

To conduct a formative and summative evaluation of EPIC, a telephonic nurse coach-led early palliative care intervention for COPD adapted from the ENABLE© intervention in cancer.

METHODS

Phase I Formative Evaluation: Patients with moderate-to-very-severe COPD, family caregivers, and pulmonary and palliative care clinicians rated the acceptability and feasibility of EPIC (≥4 out of five on a Likert-scale survey). Phase II Summative Evaluation: Patients and family caregivers in Phase I participated in a pilot of the three month EPIC prototype to evaluate intervention and data collection feasibility (≥70% completion) and to seek qualitative feedback.

RESULTS

Phase I Formative Evaluation: Patients (n=10), family caregivers (n=10), pulmonary clinicians (n=6), and palliative care clinicians (n=6) found EPIC acceptable and feasible to support adaptation, while priority early palliative care needs in COPD from our prior research mapped well to the EPIC prototype. Phase II Summative Evaluation: Patients (n=5; ages 49-72, 40% moderate COPD, 40% Black) and their family caregivers (n=5; ages 51-73, 40% Black) completed 100% of EPIC prototype components, including weekly telephone sessions, a one month follow-up call, Advance Directive, palliative care clinic attendance, and 95% of monthly phone data collection sessions. Feedback from participants about EPIC was all positive.

CONCLUSION

EPIC was acceptable and feasible in patients with COPD and their family caregivers. Larger feasibility and effectiveness trials are warranted.

Global Research Trend and Bibliometric Analysis of Current Studies on End-of-Life Care

The growing emphasis on evidence-based practice has led to a need for more research on healthcare disciplines, and for the synthesis and translation of that research into practice. This study explored the global research trend in regard to End-of-Life Care (EoLC), and assessed the impact and influence, on the scientific community, of relevant EoLC publications EoLC. Over 350,000 related publications on EoLC were retrieved from three databases (PubMed, Scopus, and Web of Science). Our analysis of the global research trend revealed an exponential rise in the number of related publications on EoLC since the year 1837. This study assessed the bibliometric information of 547 current journal publications on EoLC, sorted by relevance, from the three databases. The USA (47.3%) and the UK (16.1%) were the most productive countries, in terms of the number of relevant publications. The bibliometric analysis also revealed which EoLC research was most impactful and influential, from different parameters including documents, authors, sources, and organisations. The keyword analysis further suggested the growing importance of advance care planning and decision-making in regard to EoLC, as well as an episodic upsurge of EoLC publications related to the COVID-19 pandemic. There were few collaborations among the prolific research on EoLC. This study recommends increased research collaboration across the globe, for wider wisdom-sharing on EoLC issues.

Identifying barriers and facilitators to palliative care integration in the management of hospitalized patients with COVID-19: A qualitative study

BACKGROUND

Palliative care is well suited to support patients hospitalized with COVID-19, but integration into care has been variable and generally poor.

AIM

To understand barriers and facilitators of palliative care integration for hospitalized patients with COVID-19.

METHODS

Internists, Intensivists and palliative care physicians completed semi-structured interviews about their experiences providing care to patients with COVID-19. Results were analysed using thematic analysis.

RESULTS

Twenty-three physicians (13 specialist palliative care, five intensivists, five general internists) were interviewed; mean ± SD age was 42 ± 11 years and 61% were female. Six thematic categories were described including: patient and family factors, palliative care knowledge, primary provider factors, COVID-19 specific factors, palliative care service factors, and leadership and culture factors. Patient and family factors included patient prognosis, characteristics that implied prognosis (i.e., age, etc.), and goals of care. Palliative care knowledge included confidence in primary palliative care skills, misperception that COVID-19 is not a 'palliative diagnosis', and the need to choose quantity or quality of life in COVID-19 management. Primary provider factors included available time, attitude, and reimbursement. COVID-19 specific factors were COVID-19 as an impetus to act, uncertain illness trajectory, treatments and outcomes, and infection control measures. Palliative care service factors were accessibility, adaptability, and previous successful relationships. Leadership and culture factors included government-mandated support, presence at COVID planning tables, and institutional and unit culture.

CONCLUSION

The study findings highlight the need for leadership support for formal integrated models of palliative care for patients with COVID-19, a palliative care role in pandemic planning, and educational initiatives with primary palliative care providers.

Strategies for knowledge translation of a palliative approach outside specialized palliative care services: a scoping review

Objectives

Research suggests palliative care to be translated and integrated in non-specialized palliative care services throughout the palliative care continuum across populations and settings. A need has been identified to build on the existing research literature in order to design strong knowledge translation strategies that can be evaluated in future research. The aim was to map strategies for knowledge translation of a palliative approach to care into non-specialized palliative care services for adult patients. The objectives were to explore the primary research activities, the specific type of knowledge translation strategies used, the research designs and study settings for such evaluations along with the major results thereof, and to identify major research gaps in this area.

Methods

A scoping review was performed to map the volume and characteristics of research literature (project registered in PROSPERO #2018 CRD42018100663). The ten-year period 2010 to 2019 was searched in six major databases for original articles published in English in which the knowledge translation of a palliative approach for adult patients was evaluated in non-specialized palliative healthcare settings, and all type of empirical data-based research designs. We excluded non-English, non-empirical articles, non-evaluation of knowledge translations, specialized palliative care settings, and other types of publications (i.e. non-original articles).

Results

Most of the 183 included articles focused on patients with cancer who were dying in hospitals and in high income countries. Only 13 articles focused on early palliative care. A palette of different strategies was used to implement palliative care in non-specialist palliative settings; no strategy was identified as outstanding. The majority of the articles had unspecified essential components of the research designs.

Conclusion

Previous suggestions for utilization of implementation science for knowledge translation of a palliative approach to care into non-specialized palliative care services are confirmed, and established knowledge translation theories can strengthen the field. To advance this specific field of knowledge, meticulously detailed reporting of studies is required as related to research designs, clarifications of contextual influences and mechanisms at work. Specific systematic reviews and meta-syntheses in the field are merited.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00929-0.

Patient-Centered Discussion on End-of-Life Care for Patients with Advanced COPD

Exacerbations of chronic obstructive pulmonary disease (COPD) may lead to a rapid decline in health and subsequent death, an unfortunate tyranny of having COPD-an irreversible health condition of 16 million individuals in the USA totaling 60 million in the world. While COPD is the third largest leading cause of death, causing 3.23 million deaths worldwide in 2019 (according to the WHO), most patients with COPD do not receive adequate treatment at the end stages of life. Although death is inevitable, the trajectory towards end-of-life is less predictable in severe COPD. Thus, clinician-patient discussion for end-of-life and palliative care could bring a meaningful life-prospective to patients with advanced COPD. Here, we summarized the current understanding and treatment of COPD. This review also highlights the importance of patient-centered discussion and summarizes current status of managing patients with advanced COPD.

Stakeholders' Views on Reducing Psychological Distress in Chronic Obstructive Pulmonary Disease

CONTEXT

Psychological distress is highly prevalent among patients with chronic obstructive pulmonary disease (COPD), the top palliative care priority identified by such patients, and associated with poor outcomes. However, patients with COPD rarely receive care for psychological distress.

OBJECTIVES

To identify the barriers and opportunities to reducing psychological distress among patients with COPD in the specialty pulmonary setting.

METHODS

We conducted semi-structured interviews based on Consolidated Framework for Implementation Research constructs with key stakeholders at two pulmonary clinics, including clinicians, staff, patients, and caregivers. We focused on the relevance, identification, and management of psychological distress in COPD care. We identified emergent patterns and concepts, developed and applied codes to the text, and examined the content in each code to identify key themes.

RESULTS

Thirty-one stakeholders participated in interviews (RR=64.6%). Nearly all pulmonary clinicians felt that psychological well-being was a critical, unmet patient need. Yet, most pulmonary clinicians reported that they lacked sufficient training and available resources to support patients, prioritized physical symptoms and medication management over emotional concerns, and perceived limited cultural support for such efforts in the pulmonary clinic setting. Patient and caregiver participants desired integration and prioritization of care addressing psychological distress into routine pulmonary care.

CONCLUSION

Mitigating psychological distress is a palliative care priority in COPD. Integrating efficient, effective resources, such as tools or programs that address psychological distress, into pulmonary clinic settings serving a high volume of patients with COPD may improve the provision of supportive care to patients typically underserved by specialty palliative care.

The Role of Palliative Care in COPD

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States and is a serious respiratory illness characterized by years of progressively debilitating breathlessness, high prevalence of associated depression and anxiety, frequent hospitalizations, and diminished wellbeing. Despite the potential to confer significant quality of life benefits for patients and their care partners and to improve end-of-life care, specialist palliative care is rarely implemented in COPD and when initiated it often occurs only at the very end of life. Primary palliative care delivered by frontline clinicians is a feasible model, but is not routinely integrated in COPD. In this review, we discuss the following: 1) the role of specialist and primary palliative care for patients with COPD and the case for earlier integration into routine practice; 2) the domains of the National Consensus Project Guidelines for Quality Palliative Care applied to people living with COPD and their care partners; and, 3) triggers for initiating palliative care and practical ways to implement palliative care using case-based examples. In the end, this review solidifies that palliative care is much more than hospice and end-of-life care and demonstrates that early palliative care is appropriate at any point during the COPD trajectory. We emphasize that palliative care should be integrated long before the end of life to provide comprehensive support for patients and their care partners and to better prepare them for the end of life.

Supportive and palliative care for people with chronic respiratory disease and frailty

PURPOSE OF REVIEW

Frailty is a multidimensional syndrome associated with increased risk of poor outcomes. It is estimated that at least one in five people with chronic respiratory disease is also living with frailty. In this review, we consider recent advances in how frailty can be recognized, and its associated impact on people with chronic respiratory disease. We then discuss advances in supportive and palliative care for those with both chronic respiratory disease and frailty.

RECENT FINDINGS

The interconnectedness of chronic respiratory disease and frailty is being better understood. An increasing number of factors associated with frailty in respiratory disease have been identified, from increased symptom burden (e.g. breathlessness, fatigue) to increased exacerbations and higher mortality. These contribute to accumulating multidimensional losses in reserve, and unpredictable health. Recent advances in respiratory research, while not always with people with frailty, may inform supportive and palliative care to address frailty in chronic respiratory disease. These include rehabilitation interventions to strengthen reserves, advance care planning interventions to help manage unpredictable trajectories, and integrated models of care (e.g. incorporating respiratory, geriatric, and palliative care) to address multidimensional needs.

SUMMARY

Recent evidence supporting the role of rehabilitation, advance care planning, and early palliative care, may be of benefit to people living with chronic respiratory disease and frailty. Models showing integration across multiple specialities and professionals may have the most potential to meet the multidimensional needs of this group. Future research should develop and test models of care that address frailty and/or explore the role of frailty in triggering integrated multidisciplinary input.

Top Ten Tips Palliative Care Clinicians Should Know About Prognostication in Oncology, Dementia, Frailty, and Pulmonary Diseases

Prognostication has been described as "Medicine's Lost Art." Taken with diagnosis and treatment, prognostication is the third leg on which medical care rests. As research leads to additional beneficial treatments for vexing conditions like cancer, dementia, and lung disease, prognostication becomes even more difficult. This article, written by a group of palliative care clinicians with backgrounds in geriatrics, pulmonology, and oncology, aims to offer a useful framework for consideration of prognosis in these conditions. This article will serve as the first in a three-part series on prognostication in adults and children.

Exploring Culturally Responsive Religious and Spirituality Health Care Communications among African Americans with Advanced Heart Failure, Their Family Caregivers, and Clinicians

Background: Religion and spirituality (R/S) impact how African Americans (AAs) cope with serious illness, yet are infrequently addressed in patient-clinician communication. Objectives: To explore AAs with advanced heart failure and their family caregivers' (FCGs) preferences about R/S in patient-clinician communication. Methods: An embedded qualitative interview within a parent randomized trial about the role of R/S in the illness experience and in clinician interactions with patients and FCGs in a Southern U.S. state. Transcribed interviews were analyzed using constant comparative analysis to identify emergent themes. Results: AA participants (n = 15) were a mean age of 62 years, were female (40%), and had >high school diploma/GED (87%). AA FCGs (n = 14) were a mean age of 58; were female (93%); had >high school diploma/General Education Development (GED) (93%); and were unemployed (86%). Most (63%) were patients' spouses/partners. All patients and FCGs were Protestant. Participants reported the critical role of R/S in living with illness; however, patients' and FCGs' perspectives related to inclusion of R/S in health care communications differed. Patients' perspectives were as follows: (1) R/S is not discussed in clinical encounters and (2) R/S should be discussed only if patient initiated. FCGs' perspectives about ideal inclusion of R/S represented three main diverging themes: (1) clinicians' R/S communication is not a priority, (2) clinicians should openly acknowledge patients' R/S beliefs, and (3) clinicians should engage in R/S conversations with patients. Conclusion: Key thematic differences about the role of R/S in illness and preferences for incorporating R/S in health care communications reveal important considerations about the need to assess and individualize this aspect of palliative care research and practice.

Ten minutes to midnight: a narrative inquiry of people living with dying with advanced copd and their family members

Purpose: To explore how people with end stage chronic obstructive pulmonary disease and their family members describe living in the face of impending death.

Methods: A narrative inquiry was undertaken using a social constructionist perspective. Data were collected in 2017–18 in two in-depth interviews, lasting 90 to 120 minutes approximately 3–4 months apart, with a telephone follow-up 2–3 months later. Thematic analysis was conducted including analysis within and across participants.

Results: Sixteen people with advanced chronic obstructive pulmonary disease and seven family members participated. For both people with the disease and family members, six key themes/storylines emerged including missing life, being vigilant, hope and realism, avoiding death talk, the scary dying process, and need to prepare.

Conclusion: This study highlighted six key storylines about death and dying with advanced chronic obstructive pulmonary disease for people with the illness and their family members. The participants with the illness and their family members held similar perceptions about end of life. More supports are needed for people with advanced chronic obstructive pulmonary disease and their family members in living with their illness while ensuring that they experience a “good death.”

End-of-Life Spending and Healthcare Utilization Among Older Adults with Chronic Obstructive Pulmonary Disease

BACKGROUND

End-of-life spending and healthcare utilization among older adults with COPD have not been previously described.

METHODS

We examined data on Medicare beneficiaries aged 65 years or older with chronic obstructive pulmonary disease (COPD) who died during the period of 2013-2014. End-of-life measures were retrospectively reviewed for 2 years prior to death. Hospital referral regions (HRRs) were categorized into quintiles of age-sex-race-adjusted overall spending during the last 2 years of life. Geographic quintile variation in spending and healthcare utilization was examined across the continuum.

RESULTS

We investigated data on 146,240 decedents with COPD from 306 HRRs. Age-sex-race-adjusted overall spending per decedent during the last 2 years of life varied significantly nationwide ($61,271±$11,639 per decedent; range: $48,288±$3,665 to $79,453±$9,242). Inpatient care accounted for 40.2% of spending ($24,626±$6,192 per decedent). Overall, 82%±4% of decedents were admitted to the hospital for 13.7±3.1 days, and 55%±11% were admitted to an intensive care unit for 5.4±2.5 days. Compared with HRRs in the lowest spending quintile, HRRs in the highest spending quintile had a 1.5-fold longer hospital length of stay. Skilled nursing facilities accounted for 11.6% of spending ($7101±$2403 per decedent), and these facilities were utilized by 38%±7% of decedents for 18.7±4.9 days. Hospice accounted for 10.3% of spending ($6,307±$2,201 per decedent) and was utilized by 47%±9% of decedents for 39.7±14.8 days. Significant geographic variation in hospice utilization existed nationwide.

CONCLUSIONS

End-of-life spending and healthcare utilization among older adults with COPD varied substantially nationwide. Decedents with COPD frequently utilized acute care near the end of life. Hospice utilization was higher than expected, with significant geographic disparities.