Choosing wisely - when to mend a broken heart with ECMO?

Outcomes of lung transplant candidates referred for co-management by palliative care: A retrospective case series

BACKGROUND

Lung transplant candidates experience important symptoms, but they are rarely referred for palliative care consultation until they are deemed ineligible for transplant. Our lung transplant service has a high rate of palliative care referral for patients awaiting transplant.

AIM

We reviewed the characteristics, interventions, and outcomes of lung transplant candidates referred for co-management by palliative care, to determine whether they safely received opioids and went on to transplantation.

DESIGN AND PARTICIPANTS

Retrospective review of lung transplant candidates referred to our palliative care consultation service between January 2010 and May 2012.

RESULTS

Of 308 lung transplant candidates, 64 (20.7%) were referred to palliative care. Most had interstitial lung disease and were referred for dyspnea and a rapidly deteriorating course. A total of 59 (92%) were prescribed opioids for dyspnea, 55/59 used the opioids more than once, and 38/59 were maintained on standing opioids. There were no episodes of clinically important opioid toxicity or respiratory depression, and there was a trend toward increased exertion during exercise sessions post-opioid versus pre-opioid (19.3 vs 17.0 kcal, respectively, p = 0.06). At last follow-up, 30 (47%) had been transplanted, 23 (36%) had died while on the wait-list, 9 (14%) had died after delisting, and 2 (3%) were still awaiting transplantation. Of the 30 patients who underwent lung transplantation, only 7 (23%) still required an opioid prescription 1 month post-discharge.

CONCLUSION

In lung transplant candidates, palliative care and opioids in particular can be safely provided without compromising eligibility for transplantation. Palliative care should not be delayed until a patient is deemed ineligible for transplant.