Investigation burden for patients with fibrotic interstitial lung disease at the end of life

The use of specialist palliative care services differs in chronic obstructive pulmonary disease and interstitial lung disease: A national cohort study

BACKGROUND

High symptom burden and psychosocial needs in chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD) warrant palliative care. We assessed the use of specialist palliative care (SPC) and its association with the use of emergency department (ED) and hospital inpatient days in COPD and ILD.

METHODS

A retrospective cohort study of all Finnish decedents who died of COPD (n = 1189) or ILD (n = 382) in 2019. Data was gathered from the registries of the Finnish Institute of Health and Welfare. Demographics, the use of SPC, the use of ED, and hospital inpatient days during the last six months of life were evaluated.

RESULTS

During the last six months of life, ILD patients used more ED (92 % vs. 84 %, p < 0.001) and spent more time at the hospital (median of 19 vs. 12 days, p < 0.001) compared to COPD. Overall, 12 % and 8 % of the ILD and COPD patients had contact with SPC, respectively (p = 0.012). During the last month of life, SPC reduced the use of ED both in COPD (57 % vs. 68 %, p = 0.036) and ILD (58 % vs. 74 %, p = 0.021), as well as the number of days spent in secondary care hospitals in ILD (median of 0 vs. 2 days, p = 0.011). Also in multivariate analysis, SPC reduced the use of ED. Most patients (72 %) died in a hospital.

CONCLUSIONS

ILD patients received more SPC than COPD patients, yet the numbers were low in both patient groups. Using acute hospital resources was common during the last months of life, but SPC reduced this.

Impact of Palliative Care in End-of-Life of Fibrotic Interstitial Lung Disease Patients

Background: Interstitial lung disease (ILD) is associated with poor quality of life (QoL) and high symptom burden. Studies evaluating the benefits of palliative care examined mainly idiopathic pulmonary fibrosis (IPF) patients. We aim to examine the impact of palliative care on a broader group of fibrotic ILD patients. Methods: Single center retrospective cohort study comparing deceased ILD patients who received outpatient palliative care services (palliative-intervention group) against a usual care group. Results: Of 63 subjects, 26 (41%) were in the palliative-intervention group and 37 (59%) in the usual care group. Median time to palliative care referral was 8.6 (IQR .3-21.2) months. Dyspnea-related disability was greater in the palliative-intervention group [mMRC dyspnea score 3.5(IQR 2-4) vs 2(IQR 2-4), P = .039], with more patients requiring long term oxygen therapy (70% vs 30%, P < .001). There was no difference in the median number of hospitalizations or length of stay in the last 6 months of life. Patients in the palliative-intervention group had a higher uptake of advance care planning (ACP) (39% vs 11%, P = .014), lower frequency of intensive care unit (ICU) admissions (5% vs 19%, P = .102) and were prescribed more opioids (96% vs 27%, P < .001) and benzodiazepines (39% vs 14%, P = .022). The palliative-intervention group experienced a longer median survival of 23.9 months (95% confidence interval [CI] 14.1-33.7) compared to the usual group (11.4 months [95% CI 5.4-17.3] (log-rank test: P = .023). Male gender was a strong predictor of 1-year mortality. Conclusions: The palliative-intervention group received earlier pharmacologic intervention for symptom relief. Healthcare utilization was not increased despite greater dyspnea-related disability.

Which factors influence the quality of end-of-life care in interstitial lung disease? A systematic review with narrative synthesis

BACKGROUND

People dying from interstitial lung disease experience considerable symptoms and commonly die in an acute healthcare environment. However, there is limited understanding about the quality of their end-of-life care.

AIM

To synthesise evidence about end-of-life care in interstitial lung disease and identify factors that influence quality of care.

DESIGN

Systematic literature review and narrative synthesis. The review protocol was prospectively registered with PROSPERO (CRD42020203197).

DATA SOURCES

Five electronic healthcare databases were searched (Medline, Embase, PubMed, Scopus and Web of Science) from January 1996 to February 2021. Studies were included if they focussed on the end-of-life care or death of patients with interstitial lung disease. Quality was assessed using the Critical Appraisal Skills Programme checklist for the relevant study design.

RESULTS

A total of 4088 articles were identified by initial searches. Twenty-four met the inclusion criteria, providing evidence from 300,736 individuals across eight countries. Most patients with interstitial lung disease died in hospital, with some subjected to a high burden of investigations or life-prolonging treatments. Low levels of involvement with palliative care services and advance care planning contributed to the trend of patients dying in acute environments. This review identified a paucity of research that addressed symptom management in the last few days or weeks of life.

CONCLUSIONS

There is inadequate knowledge regarding the most appropriate location for end-of-life care for people with interstitial lung disease. Early palliative care involvement can improve accordance with end-of-life care wishes. Future research should consider symptom management at the end-of-life and association with location of death.