Earlier palliative home care is associated with patient-centred medical resource utilisation and lower costs in the last 30 days before death in COPD: a population-level decedent cohort study

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.

Early Integration of Palliative Care in Nononcological Patients: A Systematic Review

INTRODUCTION

Palliative care (PALC) is traditionally linked to end-of-life cancer care but also benefits advanced nononcological diseases.

OBJECTIVES

This systematic review evaluated the impact of early PALC on quality of life (QOL), symptom management, advance care planning (ACP), and healthcare resource utilization (HRU) among nononcological patients.

METHODS

PubMed, Web of Science, and Scopus databases were searched for randomized controlled trials and clinical studies published between January 2018 and April 2023. Participants were adult patients with nononcological diseases exposed to PALC interventions compared to usual care. Outcomes included QOL, symptom management, ACP, and HRU. The risk of bias was assessed using Cochrane tools.

RESULTS

Seven studies were included involving 1118 patients. Early PALC positively affects pain interference and fatigue in heart failure (HF) patients and time until first readmission and days alive outside the hospital in end-stage liver disease (ESLD) patients. Benefits were noted in symptom burden for patients with Human Immunodeficiency Virus (HIV), anxiety and depression in stroke patients, and ACP in chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis (IPF) patients. However, results for anxiety and depression in HF patients are inconsistent, and no significant differences in QOL were observed in HF, ESLD, IPF, and COPD. The intervention did not improve overall QOL in HIV.

CONCLUSIONS

The impact of early PALC on health outcomes in nononcological diseases is inconsistent. Addressing barriers to early PALC integration and conducting further high-quality research are essential for optimizing care pathways and enhancing patient outcomes.

Reverse Time-to-Death as Time-Scale in Time-to-Event Analysis for Studies of Advanced Illness and Palliative Care

Incidence of adverse outcome events rises as patients with advanced illness approach end-of-life. Exposures that tend to occur near end-of-life, for example, use of wheelchair, oxygen therapy and palliative care, may therefore be found associated with the incidence of the adverse outcomes. We propose a concept of reverse time-to-death (rTTD) and its use for the time-scale in time-to-event analysis based on partial likelihood to mitigate the time-varying confounding. We used data on community-based palliative care uptake (exposure) and emergency department visits (outcome) among patients with advanced cancer in Singapore to illustrate. We compare the results against that of the common practice of using time-on-study (TOS) as time-scale. Graphical analysis demonstrated that cancer patients receiving palliative care had higher rate of emergency department visits than non-recipients mainly because they were closer to end-of-life, and that rTTD analysis made comparison between patients at the same time-to-death. In analysis of a decedent cohort, emergency department visits in relation to palliative care using TOS time-scale showed significant increase in hazard ratio estimate when observed time-varying covariates were omitted from statistical adjustment (% change-in-estimate = 16.2%; 95% CI 6.4% to 25.6%). There was no such change in otherwise the same analysis using rTTD (% change-in-estimate = 3.1%; 95% CI -1.0% to 8.5%), demonstrating the ability of rTTD time-scale to mitigate confounding that intensifies in relation to time-to-death. A similar pattern was found in the full cohort. Simulations demonstrated that the proposed method had smaller relative bias and root mean square error than TOS-based analysis. In conclusion, use of rTTD as time-scale in time-to-event analysis provides a simple and robust approach to control time-varying confounding in studies of advanced illness, even if the confounders are unmeasured.

Early, integrated palliative care for people with chronic respiratory disease: lessons learnt from lung cancer

Lung cancer and chronic non-malignant respiratory disease cause pervasive, multifactorial suffering for patients and informal carers alike. Palliative care aims to reduce suffering and improve quality of life for patients and their families. An established evidence base exists that has demonstrated the essential role of specialist palliative care for people with lung cancer. Emerging evidence supports similar benefits among people with chronic respiratory disease. Many lessons can be learnt from lung cancer care, particularly as the model of care delivery has transformed over recent decades due to major advances in the diagnostic pathway and the development of new treatments. This narrative review aims to summarize the evidence for specialist palliative care in lung cancer and chronic respiratory disease, by highlighting seven key lessons from lung cancer care that can inform the development of proactive, integrated models of palliative care among those with chronic respiratory disease. These seven lessons emphasize (1) managing challenging symptoms; (2) the efficacy of specialist palliative care; (3) the importance of providing specialist palliative care integrated with disease-directed care according to patients' needs not prognosis; (4) the need for new models of collaborative palliative care, (5) which are culturally appropriate and (6) able to evolve with changes in disease-directed care. Finally, we discuss (7) some of the critical research gaps that persist and reduce implementation in practice.

Understanding Nonpharmacologic Palliative Care for People With Serious COPD: The Individual and Organizational Perspective

TOPIC IMPORTANCE

This narrative review emphasizes the growing interest in palliative care for people with serious lung diseases such as COPD. It reflects on recent publications from the American Thoracic Society, the World Health Organization, and European Respiratory Society, with a focus on nonpharmacologic palliative care for people with COPD from both the health care professional and organizational perspective.

REVIEW FINDINGS

The concept of palliative care has changed over time and is now seen as applicable throughout the entire disease trajectory according to need, in conjunction with any disease-modifying therapies. Palliative care should pay attention to the needs of the person with COPD as well as the informal caregiver. Timely integration of palliative care with disease-modifying treatment requires assessment of needs at the individual level as well as organizational changes. High-quality communication, including advance care planning, is a cornerstone of palliative care.

SUMMARY

Therefore, services should be based on the understanding that palliative care is not only specific standardized actions and treatments, but rather a holistic approach that includes compassionate communication, treatment, and care addressing the patient and informal and formal caregivers. Living with and dying of COPD is much more than objective measurements. It is the sum of relationships with others and the experience of living in the best possible harmony with one's own values and hopes, despite having a serious illness.

A narrative review of proactive palliative care models for people with COPD

Chronic obstructive pulmonary disease (COPD) refers to a group of lung diseases that are distinct in underlying aetiology but share a common disease course of persistent and progressive airflow restriction. People living with COPD, as well as the people who care for them, frequently have severe and unmet physical and psychosocial needs, including breathlessness, fatigue, cough, anxiety and depression. Early proactive palliative care is well placed to address these needs, yet it is frequently under-utilised in this group. This narrative review aimed to identify core components of palliative care and examine how existing models of care are implemented to better understand which models can best serve the needs of people with COPD. Symptom palliation, advance care planning, and support for caregivers emerged as the common components underpinning both generalist and specialist models of palliative care. Models of proactive palliative care were diverse in terms of where and how care was delivered as well as which health professionals were involved. Five key models of palliative care were identified: (1) multi-disciplinary integrated services, (2) nurse-led care, (3) hospice and residential aged care, (4) home-based care, and (5) telemonitoring and telehealth. Each model describes a diverse set of interventions and many of these share common elements, including the normalisation of palliative principles within routine care and the provision of diverse delivery settings to accommodate individual preferences and needs. Successful palliative care models must be practical, accessible and innovative to respond to individuals' complex and evolving needs, foster multi-disciplinary collaboration and input and optimally utilise local healthcare resources.

Effectiveness of the integration of a palliative care team in the follow-up of patients with advanced chronic obstructive pulmonary disease: The home obstructive lung disease study

BACKGROUND

Access to palliative care for patients with end-stage chronic obstructive pulmonary disease (COPD) is still very poor.

OBJECTIVES

Evaluate our palliative care program for patients with advanced COPD by assessing whether the referral criteria for advanced COPD patients were adequate in identifying patients in end-of-life care and determine the results of the palliative care team's intervention METHODS: This was a prospective observational study of patients admitted to a multidisciplinary unit for advanced COPD. Data on sociodemographic variables, survival, symptomatology, quality of life, ACP, and health resource utilization were analyzed.

RESULTS

Eighty-three patients were included in this study. By the end of the follow-up period, 69 (83%) patients had died, mainly due to respiratory failure (96%). The median duration of survival from the start of follow-up was 4.27 months (95% confidence interval, 1.97-16.07). Most patients (94%) had a dyspnea level of 4. Sixty (72%) patients required opioids for dyspnea control. There were no significant differences in the quality of life of the patients during follow-up. Thirty (43%) patients died at home, 26 (38%) in a palliative care unit, and 13 (19%) in an acute care hospital. ACP was performed for 50 (72%) patients. Forty (57%) patients required palliative sedation during follow-up. Dyspnea was the reason for sedation in 34 (85%) patients. Hospital admissions and emergency room visits decreased significantly (p = 0.01) during follow-up.

CONCLUSIONS

Our integrated model allows for adequate selection of patients, facilitates symptom control and ACP, reduces resource utilization, and favors death at home.

Palliative care interventions in chronic respiratory diseases: A systematic review

INTRODUCTION

Chronic respiratory diseases represent a significant burden of disease globally, with high morbidity and mortality. Individuals living with these conditions, as well as their families, face considerable physical, emotional and social challenges. Palliative care might be a valuable approach to address their complex needs, but evidence to prove this is still scarce.

OBJECTIVES

This systematic review aimed to study the effectiveness of palliative care interventions in health-related outcomes (quality of life, symptom control, symptom burden, psychological well-being, advance care planning, use of health services, and survival) in chronic respiratory patients.

METHODS

Pubmed, Cochrane and Web of Science were searched for trials published in the last 10 years, comparing palliative care interventions to usual care, in patients with chronic respiratory diseases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed.

RESULTS

Eight studies were included, seven randomized controlled trials and one cluster-controlled trial; the former with moderate risk of bias and the latter with high risk of bias. Findings revealed that palliative interventions improve breathlessness control and advance care planning. There were no significant differences for the other outcomes.

CONCLUSIONS

Palliative care appears to have a beneficial effect on breathlessness, one of the most distressing symptoms in patients suffering from chronic respiratory diseases and allows for advanced care planning. Additional research, with more robust trials, is needed to draw further conclusions about other health-related outcomes.

Perspectives of Respiratory Physicians toward Need and Integration of Palliative Care in Advanced Respiratory Diseases

Objectives:

Patients with chronic life-limiting or advanced respiratory diseases often suffer from high symptom burden, requiring palliative care to alleviate symptoms, improve quality of life and restore dignity. The present study explored the perception of respiratory physicians and their current practice of integrating palliative care for adult patients with chronic advanced respiratory diseases.

Materials and Methods:

An exploratory survey method using Google survey forms and SurveyMonkey was emailed to respiratory physicians between December 2020 and May 2021.

Results:

One hundred and seventy-two respiratory physicians responded to the survey. The majority of respiratory physicians (n = 153; 88.9%) thought that early integration of palliative care early was beneficial. They did not feel referring to palliative care would result in loss of control on patient care (n = 107; 62.21%) and 66 (38.37%) strongly disagreed that the referral would result in a loss of hope in patients. Further exploration into the training needs of respiratory physicians revealed that 121 (70.35%) felt the need for training in end-of-life care.

Conclusion:

Respiratory physicians in our study had an inclination toward palliative care integration into their routine clinical practice. A majority of them expressed the need to enhance their skills in palliative care. Therefore, concerted efforts at integration and a mutual exchange of knowledge between respiratory physicians and palliative care physicians will ensure that patients with advanced respiratory diseases are provided high-quality palliative care.

Nasal High Flow Therapy For Symptom Management in People Receiving Palliative Care

For patients with chronic non-malignant lung disease, severe chronic breathlessness can significantly impact quality of life, causing significant disability, distress, social isolation, and recurrent hospital admissions. Caregivers for people with challenging symptoms, such as severe breathlessness, are also profoundly impacted. Despite increasing research focused on breathlessness over recent years, this symptom remains extremely difficult to manage, with no effective treatment that completely relieves breathlessness. A new potential treatment for relieving breathlessness in patients at home is nasal high flow (NHF) therapy. NHF therapy is a respiratory support system that delivers heated, humidified air (together with oxygen if required) with flows of up to 60 L/min. This case describes a patient with very severe chronic obstructive pulmonary disease who received domiciliary NHF therapy (approximately 8 hours/day, flow rate of 20 L/min) over twelve months with good effect for the relief of severe chronic breathlessness. We discuss the management principles for severe chronic breathlessness, the physiological effects of NHF therapy and the evidence for long-term use in the community setting. With the support of respiratory and palliative care clinicians together, domiciliary NHF therapy has great potential for improving current symptom management approaches in people with life-limiting illnesses.

Expectations of respiratory physicians from psychologists in palliative care for patients with non-cancer respiratory diseases

BACKGROUND

Psychological symptoms are common in patients with non-malignant respiratory disease (NMRD). Psychologists can likely play a role in NMRD palliative care. We aimed to explore the expectations of respiratory physicians from psychologists in NMRD palliative care.

METHODS

An ad hoc questionnaire was developed based on a free-descriptive questionnaire survey among respiratory physicians from four hospitals in Japan. Using this questionnaire, we surveyed respiratory physicians from eight hospitals in Japan and assessed their expectations of psychologists' support and outcomes. Expectations were compared between physicians with and without experience of working with psychologists.

RESULTS

The quantitative questionnaire was completed by 129 physicians. Data analysis from 108 participants revealed that the highly expected support included "getting early information on patients' psychological distress" (97.2%) and "counseling family members regarding anxiety caused by changes in patient's condition" (96.3%). Physicians also expected "relief in patient's psychological distress" (96.3%) and "providing the psychological support that families need" (95.4%) from psychologists. Compared to physicians with experience of working with psychologists, those without expected more in terms of "giving specific advice on the way of communication and psychological support" (p = 0.035) and "providing psychological support for difficult-to-handle patients and families on behalf of other medical staff" (p = 0.036).

CONCLUSIONS

Respiratory physicians may expect relief of psychological distress experienced by patients and their families from psychologists by getting information about their distress and providing psychological support. These results may be useful for psychologists to provide palliative care for patients with NMRD in collaboration with respiratory physicians.

Home Based Palliative Care: Known Benefits and Future Directions

Purpose of Review

To summarize key recent evidence regarding the impact of Home-Based Palliative Care (HBPalC) and to highlight opportunities for future study.

Recent Findings

HBPalC is cost effective and benefits patients and caregivers across the health care continuum.

Summary

High-quality data support the cost effectiveness of HBPalC. A growing literature base supports the benefits of HBPalC for patients, families, and informal caregivers by alleviating symptoms, reducing unwanted hospitalizations, and offering support at the end of life. Numerous innovative HBPalC models exist, but there is a lack of high-quality evidence comparing specific models across subpopulations. Our wide literature search captured no research regarding HBPalC for underserved populations. Further research will also be necessary to guide quality standards for HBPalC.

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.

Association between Palliative Care, Days at Home, and Health Care Use in Patients with Advanced COPD: A Cohort Study

RATIONALE

Palliative care focuses on improving quality of life for patients with life-limiting conditions. While previous studies have shown palliative care to be associated with reduced acute health care use in people with cancer and other illnesses, these findings may not generalize to patients with COPD.

OBJECTIVES

We examined the association between palliative care and rates of days at home, location of death, and acute health care use in patients with COPD.

METHODS

We used health administrative databases in Ontario, Canada to identify patients with advanced COPD hospitalized between April 2010 and March 2017 and followed until March 2018. Patients who received palliative care were matched 1:1 to those who did not on age, sex, long-term oxygen, previous COPD hospitalizations and propensity scores. Rate ratios (RR) were estimated using Poisson models with generalized estimating equations to account for matching.

RESULTS

Among 35,492 patients, 1,788 (5%) received palliative care. In the matched cohort (1,721 pairs), people with COPD receiving palliative care had similar rates of days at home (RR=1.01, 95% CI [0.97, 1.05]) but were more likely to die at home (16.4% vs. 10.0%, p<0.001) compared to those who did not receive palliative care. Rates of healthcare utilization were similar except for increased hospitalizations in the palliative care group (RR=1.09, 95% CI [1.01, 1.18]).

CONCLUSIONS

Receipt of palliative care did not reduce days at home or healthcare utilization but was associated with a modest increase in proportion dying at home. Future work should evaluate palliative care strategies designed specifically for patients with COPD.