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

Challenges of symptom management in interstitial lung disease: dyspnea, cough, and fatigue

INTRODUCTION

Interstitial lung disease (ILD) is a broad group of conditions characterized by fibrosis of the lung parenchyma. Idiopathic pulmonary fibrosis (IPF) is the most common subvariant. IPF is marked by considerable symptom burden of dyspnea, cough and fatigue that is often refractory to optimal disease-directed treatment.

AREAS COVERED

In this narrative review, we searched MEDLINE for articles related to the current evidence regarding management of chronic dyspnea, cough, and fatigue as three of the most prevalent and distressing symptoms associated with IPF and other ILDs. Each symptom shares common features of multi-factorial etiology and a lack of safe and effective pharmacological therapies. Both corticosteroids and opioids have been utilized in this context, yet there is insufficient evidence of therapeutic benefit and considerable risk of harms. Whilst some may benefit from symptom-directed pharmacological management, usage must be carefully monitored. Use of non-pharmacological strategies, such as breathing techniques and speech therapy represent low risk and low-cost option, yet broader validation of these therapies' effectiveness is needed.

EXPERT OPINION

Symptom management in IPF and other ILDs requires an iterative and individualized approach. Leveraging the expertise of multidisciplinary teams within an integrated care setting is an important opportunity to maximize health outcomes.

A self-management package for pulmonary fibrosis: A feasibility study

Background and objective

There is currently no self-management package designed to meet the needs of people with pulmonary fibrosis (PF). This study evaluated the feasibility and acceptability of a PF-specific self-management package.

Methods

Adults with PF were randomly allocated (1:1) to either receive the self-management package with healthcare professional (HCP) support or standardised PF information. Primary outcomes were feasibility and acceptability of the intervention. Secondary outcomes included health-related quality of life, self-efficacy, breathlessness, daily steps, use of PF-related treatments, and healthcare utilisation. Participants' experiences of using the package were explored using qualitative interviews.

Results

Thirty participants were included. Recruitment rate was 91% and 100% of those recruited were randomised. Eighty-seven percent of participants who received the package read ≥1 module and set a goal. Secondary outcomes were feasible to collect with high assessment completion rates (87%). Most participants reported the package was easy to use and enhanced knowledge, but suggested some improvements, while HCP support was highly valued.

Conclusion

A PF-specific self-management package was feasible to deliver and requires further testing in a trial powered to detect changes in clinical outcomes.

Innovation

This is the first self-management package designed specifically for people with PF, informed by patient experience and expert consensus.

Early palliative care program in idiopathic pulmonary fibrosis patients favors at-home and hospice deaths, reduces unplanned medical visits, and prolongs survival: A pilot study

BACKGROUND

Idiopathic Pulmonary Fibrosis (IPF) is a lethal disease; most patients die in hospitals because palliative care (PC) is not wildly and early available. We aimed to determine the impact of an early PC program in IPF patients on place of death, emergency department (ED) admission, unplanned medical visits and survival before and after its implementation at our clinic.

METHODS

IPF patients from our ILD clinic who died between January 1st, 2018 and December 31th, 2023 were included in the analysis. Primary outcomes were location of death, number of ED access and unplanned medical visits; secondary outcomes was survival from diagnosis.

RESULTS

A total of 46 decedents between 2018 and 2023 were analysed: (median age 71,5 ± 5,5 years, 89 % male): 26 died before the implementation of the early PC program and 20 after. Through χ2 test, location of death resulted significantly different in the two groups, showing the capacity of early PC to favor at home or in hospice death (p = 0,02); similarly, the number of unplanned visits was significantly lower (p = 0,03). Finally, survival was significantly lower in patients not receiving the early PC program (p = 0,01).

CONCLUSION

The availability of an early PC program since the diagnosis significantly reduced both the death rate in hospital settings, favoring dying in hospice or at home, and the number of unplanned medical visits. Furthermore, IPF patients receiving early PC showed a longer survival than those who did not.

Palliative care in advanced pulmonary fibrosis

PURPOSE OF REVIEW

Updated clinical practice guidelines for pulmonary fibrosis recommend early integrated palliative care using a primary palliative approach. Clinicians need to be aware of the various palliative interventions in order to implement guidelines' recommendations. This review provides an update on evidence-based palliative therapies.

RECENT FINDINGS

Literature review indicates early integration of palliative care in pulmonary fibrosis is feasible and meets patient needs. Key components of a primary palliative approach include comprehensive symptoms and needs screening, systematic symptom management using nonpharmacologic interventions, supplemental oxygen and opioids for dyspnea and cough. Patient-centered communication is essential for successful integration of palliative care. Early, iterative advance care planning in clinic to understand patient goals, values and preferences for current and future care, improves patient care and satisfaction. Prioritizing caregiver inclusion in clinics can address their needs. Collaborating with a multidisciplinary allied team facilitates integration of palliative care and supports patients throughout the disease course. Different models of palliative care delivery exist and can be adapted for local use. The use of artificial intelligence algorithms and tools may improve care and continuity.

SUMMARY

Clinicians must develop competency in palliative care. Organizational and policy support is essential to enable seamless integration of palliative care throughout the care continuum.

An update of palliative care in lung transplantation with a focus on symptoms, quality of life and functional outcomes

PURPOSE OF REVIEW

Palliative care (PC) in lung transplantation is increasingly acknowledged for its important role in addressing symptoms, enhancing functionality, and facilitating advance care planning for patients, families, and caregivers. The present review provides an update in PC management in lung transplantation.

RECENT FINDINGS

Research confirms the effectiveness of PC for patients with advanced lung disease who are undergoing transplantation, showing improvements in symptoms and reduced healthcare utilization. Assessment tools and patient-reported outcome measures for PC are commonly used in lung transplant candidates, revealing discrepancies between symptom severity and objective measures such as exercise capacity. The use of opioids to manage dyspnea and cough in the pretransplant period is deemed safe and does not heighten risks posttransplantation. However, the integration of PC support in managing symptoms and chronic allograft dysfunction in the posttransplant period has not been as well described.

SUMMARY

Palliative care support should be provided in the pretransplant and select peri-operative and posttransplant periods to help support patient quality of life, symptoms, communication and daily function.

The Impact of Integrated Palliative Care on Survival in Idiopathic Pulmonary Fibrosis: A Retrospective Multicenter Comparison

Background: Early and integrated palliative care is recommended for patients with idiopathic pulmonary fibrosis. Unfortunately, palliative care delivery remains poor due to various barriers in practice. This study describes various palliative care delivery models in a real-world cohort of patients with idiopathic pulmonary fibrosis, examines the predictors of survival in this cohort of patients, and explores the impact of palliative care on survival. Design: Charts were reviewed retrospectively and analyzed. The primary outcome was survival during a 4-year follow-up period. Two multivariable models were created to examine the impact of therapeutic strategies including palliative intervention on survival. Results: 298 patients with idiopathic pulmonary fibrosis were enrolled from 3 interstitial lung disease clinics with different palliative care models in Edmonton, Canada; Bristol, UK; and Kingston, Canada. 200 (67%) patients received palliative care and 119 (40%) died during follow up. Primary palliative care models (Edmonton and Bristol) delivered palliative care to 96% and 100% respectively compared 21% in the referral model (Queens). Palliative care [adjusted hazard ratio (aHR) .28 (.12-.65)] along with the use of antifibrotics [aHR .56 (.37-.84)], and body mass index >30 [aHR .47 (.37-.85)] reduced the risk of death in our idiopathic pulmonary fibrosis cohort. Opioid use was associated with worse survival [aHR 2.11 (1.30-23.43)]. Conclusions: Both palliative care and antifibrotic use were associated with survival benefit in this cohort of patients with idiopathic pulmonary fibrosis after adjusting for covariates. The benefit was seen despite differences in disease severity and different palliative care delivery models.

Prognostic Factors of Mortality in Nonchronic Obstructive Pulmonary Disease Chronic Lung Disease: A Scoping Review

Introduction: Patients with chronic lung disease (CLD) experience a heavy symptom burden at the end of life, but their uptake of palliative care is notably low. Having an understanding of a patient's prognosis would facilitate shared decision making on treatment options and care planning between patients, families, and their clinicians, and complement clinicians' assessments of patients' unmet palliative needs. While literature on prognostication in patients with chronic obstructive pulmonary disease (COPD) has been established and summarized, information for other CLDs remains less consolidated. Summarizing the mortality risk factors for non-COPD CLDs would be a novel contribution to literature. Hence, we aimed to identify and summarize the prognostic factors associated with non-COPD CLDs from the literature. Methods: We conducted a scoping review following published guidelines. We searched MEDLINE, Embase, PubMed, CINAHL, Cochrane Library, and Web of Science for studies published between 2000 and 2020 that described non-COPD CLD populations with an all-cause mortality risk period of up to three years. Only primary studies which reported associations with mortality adjusted through multivariable analysis were included. Results: Fifty-five studies were reviewed, with 53 based on interstitial lung disease (ILD) or connective tissue disease-associated ILD populations and two in bronchiectasis populations. Prognostic factors were classified into 10 domains, with pulmonary function and disease being the largest. Older age, lower forced vital capacity, and lower carbon monoxide diffusing capacity were most commonly investigated and associated with statistically significant increases in mortality risks. Conclusions: This comprehensive overview of prognostic factors for patients with non-COPD CLDs would facilitate the identification and prioritization of candidate factors to predict short-term mortality, supporting tool development for decision making and to identify high-risk patients for palliative needs assessments. Literature focused on patients with ILDs, and more studies should be conducted on other CLDs to bridge the knowledge gap.

Self-management interventions for people with pulmonary fibrosis: a scoping review

BACKGROUND

The most effective method for encouraging self-management in individuals with pulmonary fibrosis (PF) is unclear. This review aimed to identify common self-management components, the outcome measures used and the impact of these components in PF.

METHODS

A scoping review was conducted according to the Joanna Briggs Institute Manual for Evidence Synthesis using Medline, Embase, PsychInfo, CINAHL and the Cochrane Central Register of Controlled Trials. Eligible studies included those with educational, behavioural or support components aimed at facilitating self-management among adults with PF and employed quantitative and/or qualitative methods.

RESULTS

87 studies were included. Common self-management components included education (78%), managing physical symptoms (66%) and enhancing psychosocial wellbeing (54%). Components were predominantly delivered in a pulmonary rehabilitation setting (71%). No studies tested a PF-specific self-management package. Common outcome measures were 6-min walk distance (60%), St George's Respiratory Questionnaire (37%) and the Medical Research Council Dyspnoea scale (34%). Clinically significant improvements in these outcomes were seen in ≥50% of randomised controlled trials. Qualitative data highlighted the importance of healthcare professional and peer support and increased confidence in managing PF.

CONCLUSION

Self-management components are commonly incorporated into pulmonary rehabilitation programmes rather than being offered as standalone packages. Future research should focus on testing PF-specific self-management packages and employ standardised outcome assessments that include self-efficacy and health-related behaviours.

Clinical Characteristics of Individuals with Interstitial Lung Diseases and Indication of End-of-Life Care

End-of-life care (EOLC) is palliative support provided in the last 6 months to 1 year of a patient's life. Although there are established criteria for its indication, few studies describe the clinical and functional characteristics of individuals with interstitial lung diseases (ILD) in EOLC. ILD individuals underwent various assessments, including lung function, exercise capacity (6 min walk test), physical activity in daily life (PADL), peripheral muscle strength, maximal respiratory pressures, body composition, quality of life (SGRQ-I), symptoms of anxiety and depression, dyspnea (MRC scale), and sleep quality. Fifty-eight individuals were included and divided into two groups according to the indication for commencing EOLC (ILD with an indication of EOLC (ILD-EOLC) or ILD without an indication of EOLC (ILD-nEOLC). There were differences between the groups, respectively, for steps/day (2328 [1134-3130] vs. 5188 [3863-6514] n/day, p = 0.001), time spent/day carrying out moderate-to-vigorous physical activities (1 [0.4-1] vs. 10 [3-19] min/day, p = 0.0003), time spent/day in standing (3.8 [3.2-4.5] vs. 4.8 [4.1-6.7] h/day, p = 0.005), and lying positions (5.7 [5.3-6.9] vs. 4.2 [3.6-5.1] h/day, p = 0.0004), the sit-to-stand test (20 ± 4 vs. 26 ± 7 reps, p = 0.01), 4 m gait speed (0.92 ± 0.21 vs. 1.05 ± 0.15 m/s, p = 0.02), quadriceps muscle strength (237 [211-303] vs. 319 [261-446] N, p = 0.005), SGRQ-I (71 ± 15 vs. 50 ± 20 pts, p = 0.0009), and MRC (4 [3-5] vs. 2 [2-3] pts, p = 0.001). ILD individuals with criteria for commencing EOLC exhibit reduced PADL, functional performance, peripheral muscle strength, quality of life, and increased dyspnea.