Integrating palliative care education in pulmonary rehabilitation: a randomized controlled study protocol

BACKGROUND

Palliative care addresses multiple unmet needs of people with chronic obstructive pulmonary disease (COPD) or interstitial lung diseases (ILD) and their family and/or friend caregivers, but it remains highly underused. Pulmonary rehabilitation (PR) may provide a key opportunity to introduce palliative care. We aim to explore the effects of palliative care education as part of PR on knowledge about this field in people with COPD or ILD and their family and/or friend caregivers.

METHODS

A randomized controlled study will compare PR with palliative care education (experimental) with traditional PR (control) in people with COPD or ILD and their family and/or friend caregivers. Family and/or friend caregivers will be invited to take part in education and psychosocial support sessions. In addition to the usual educational content, the experimental group will have a session on palliative care, a "Peer-to-peer session", two "Get-apart sessions" and online sessions. The "Peer-to-peer session" and the "Get-apart sessions" will be discussions about topics suggested by participants. The "Get-apart sessions" will be dedicated to people with COPD or ILD apart from their family and/or friend caregivers and vice versa. The online sessions will be zoom meetings to discuss any health-related issues raised by participants, at a flexible time. A mixed-methods approach will be used to evaluate the outcomes. The primary outcome will be knowledge about palliative care. Secondary outcomes will include attitude towards palliative care referral, symptoms, disease impact, health-related quality of life, needs, knowledge about the disease, burden of providing care, adherence, adverse events and referral to a specialist palliative care team. Quantitative and qualitative data will be collected at baseline and end of PR. At 6-months post-PR, only patient-reported outcomes will be collected. For the primary outcome, time*group interaction will be analyzed with mixed analysis of variance.

DISCUSSION

This study aims to demonstrate the impact of integrating palliative care into the PR education program.

TRIAL REGISTRATION

The trial was registered in the ClinicalTrials.gov U.S. National Library of Medicine, on 1st September, 2023 (NCT06046547).

Development of a systematic multidisciplinary clinical and teaching model for the palliative approaches in patients with severe lung failure

Palliative medicine has traditionally focused on people affected by cancer with rapidly advancing disease progression. However, as more people live longer time with serious illnesses, including lung diseases, the need of palliative care for these patients if also increasing. There is a lack of research and clinical knowledge about what palliative care is for people affected by chronic obstructive pulmonary disease and interstitial lung disease. The aim of this paper is to describe the development process of an easy to use and clinically relevant model for the palliative care approach in people affected by severe illnesses. The developed model consists of four components, which originated the title” 4,2,4,2 model”. Each number has a specific meaning: the first 4 = the four disease trajectories that patients may experience; 2 = the two forms of knowledge, objective, and intuitive that must be achieved by the health professionals to gain an understanding of the situation; 4 = the four dimensions of suffering physically, mentally, socially and existentially/spiritually; and 2 = the two roles that health-care professionals must be able to take in when treating patients with serious illnesses. The 4-2-4-2 model proposes an easy-to-use and clinically relevant model for palliative approach and integration of PC and pulmonary medicine. Another important purpose of this model is to provide HPs with different educational backgrounds and from different medical fields with a ‘golden standard approach’ to enhance the focus of the palliative approach in both the clinic and teaching. The effect and consequences of the use of the 4-2-4-2 model should be explored in future clinical trials. Furthermore, it should be investigated whether teaching the model creates a change in clinical approach to patients with serious illnesses as well as whether these changes are long-lasting.

Comprehensive care for people living with heart failure and chronic obstructive pulmonary disease—Integration of palliative care with disease-specific care: From guidelines to practice

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are the leading global epidemiological, clinical, social, and economic burden. Due to similar risk factors and overlapping pathophysiological pathways, the coexistence of these two diseases is common. People with severe COPD and advanced chronic HF (CHF) develop similar symptoms that aggravate if evoking mechanisms overlap. The coexistence of COPD and CHF limits the quality of life (QoL) and worsens symptom burden and mortality, more than if only one of them is present. Both conditions progress despite optimal, guidelines directed treatment, frequently exacerbate, and have a similar or worse prognosis in comparison with many malignant diseases. Palliative care (PC) is effective in QoL improvement of people with CHF and COPD and may be a valuable addition to standard treatment. The current guidelines for the management of HF and COPD emphasize the importance of early integration of PC parallel to disease-modifying therapies in people with advanced forms of both conditions. The number of patients with HF and COPD requiring PC is high and will grow in future decades necessitating further attention to research and knowledge translation in this field of practice. Care pathways for people living with concomitant HF and COPD have not been published so far. It can be hypothesized that overlapping of symptoms and similarity in disease trajectories allow to draw a model of care which will address symptoms and problems caused by either condition.

Palliative Care and Chronic Obstructive Pulmonary Disease (COPD) Readmissions: A Narrative Review

Despite all the advances in the treatment and management of chronic obstructive pulmonary disease (COPD), COPD readmissions remain a major challenge nationwide. Increasing evidence suggests that palliative care involvement with a holistic approach towards end-of-life care can significantly improve outcomes related to the quality of life and survival for late-stage cancers and chronic progressive illnesses like COPD, chronic heart failure, and end-stage renal disease. Some studies have attempted to evaluate an association between the involvement of palliative care and readmission reduction, the effect of which remains elusive, especially with regards to COPD readmissions. This review examined the existing literature to analyze the relationship between palliative care involvement for COPD patients and its effect on COPD readmissions.

Palliative Rehabilitation Improves Health Care Utilization and Function in Frail Older Adults with Chronic Lung Diseases

OBJECTIVES

The Integrated Care for Advanced REspiratory Disorders (ICARE) service is a stay-in, post-acute care program for hospitalized patients with chronic, nonmalignant lung diseases. It provides palliative rehabilitation-a novel model integrating functional rehabilitation with early palliative care. We compare reduction of health care utilization among ICARE participants vs matched controls receiving usual care.

DESIGN

This is a prospective, propensity score-matched study. Primary outcomes were reduction in hospital readmissions and length of stay and emergency department (ED) visits, comparing the period 6 months before and after ICARE, or 6 months before and after hospital discharge (for controls). Secondary outcomes included 6-minute walking distance (6MWD) and Modified Barthel Index (MBI).

SETTING

Participants were matched 1:1 to controls by age, respiratory diagnosis, socioeconomic strata, index hospitalization length of stay, frailty, and recent admissions into intensive care unit or noninvasive ventilation units.

METHODS

Multidisciplinary interventions focused on symptom relief, functional rehabilitation, targeted comorbidity management, and postdischarge care coordination.

RESULTS

One hundred pairs of patients were matched. Participants were older adults (mean age 73.9 ± 8.2 years) with prolonged index hospitalization (median 12.0 days; interquartile range 7-18). Overall, 57% had high Hospital Frailty Risk Scores and 71% had overlapping respiratory diagnoses, the most common commonest being COPD (89%), followed by interstitial lung disease (54%) and bronchiectasis (28%). Small reductions in health care utilization were observed among controls. ICARE was associated with a further 9.1 ± 19.9 days' reduction in hospitalization length of stay (P < .001), 0.8 ± 1.9 lesser admission (P < .001), and 0.6 ± 2.2 fewer ED visits (P < .02). Participants with longest index hospitalization were observed to have greatest reduction in length of stay. 6MWD and MBI scores improved by 41.0 ± 60.2 m and 12.3 ± 11.6 points, respectively (both P < .001). Greater improvement was observed in patients with lower baseline 6MWD and MBI scores. Prescription of slow-release opioids rose from 9% to 49%. Treatment for anxiety and depression rose from 5% to 19%.

CONCLUSIONS AND IMPLICATIONS

Integrating palliative care with postexacerbation functional rehabilitation was associated with short-term reduction in health care utilization, improved functional capacity, and increased treatment of dyspnea, anxiety, and depression.

Healthcare professionals' views of palliative care for American war veterans with non-malignant respiratory disease living in a rural area: a qualitative study

BACKGROUND

Chronic lung diseases, such as COPD, are a growing health concern within the veteran population. Palliative care programs have mainly focused on the needs of people with malignant disease in the past, however the majority of those worldwide needing palliative care have a non-malignant diagnosis. Additionally, palliative care provision can often be fragmented and varied dependent upon a patient's geographical location. This study aimed to explore palliative care provision for veterans with non-malignant respiratory disease, and their family carers, living in a rural area of America.

METHODS

Qualitative study involving a convenience sample of 16 healthcare professionals from a large veteran hospital in Boise, Idaho. Data collection consisted of 5 focus groups which were transcribed verbatim and analysed using thematic analysis.

RESULTS

Healthcare professionals perceived that a lack of education regarding disease progression enhanced feelings of anxiety amongst veterans with NMRD, and their family carers. Additionally, the uncertain disease trajectory impeded referral to palliative and hospice services due to healthcare professionals own ambiguity regarding the veteran's prognosis. A particular barrier also related to this particular patient population, was a perceived lack of ability to afford relevant services and a lack of local palliative service provision. Healthcare professionals expressed that a compounding factor to palliative care uptake was the perceptions held by the veteran population. Healthcare professionals expressed that alongside aligning palliative care with dying, veterans also viewed accepting palliative care as 'surrendering' to their disease. Findings indicated that telemedicine may be a beneficial platform to which palliative care can be provided to veterans with NMRD, and their family carers, in rural areas using a digital platform.

CONCLUSION

Non-malignant respiratory disease is a life limiting condition commonly experienced within the veteran population. A new model of palliative care utilising a dynamic digital platform for this particular veteran population may provide an optimal way of providing efficient holistic care to areas with limited palliative services.

Danish respiratory society position paper: palliative care in patients with chronic progressive non-malignant lung diseases

Background: Chronic non-malignant lung diseases such as chronic obstructive pulmonary disease (COPD) and interstitial lung diseases (ILD) result in reduced quality of life (QoL), a high symptom burden and reduced survival. Patients with chronic non-malignant lung disease often have limited access to palliative care. The symptom burden and the QoL of these patients resembles patients with cancer and the general palliative approach is similar. However, the disease trajectory is often slow and unpredictable, and the palliative effort must be built on accessibility, continuity and professional competences. The Danish Health Authority as well as the WHO recommends that there is access to palliative care for all patients with life-threatening diseases regardless of diagnosis. In 2011, the Danish Health Authority requested that the national medical societies would to formulate guidelines for palliation.

Methods: In 2015, a group of members of the Danish Respiratory Society (DRS) was appointed for this purpose. It was composed of experienced ILD and COPD researchers as well as clinicians from different parts of Denmark. A literature review was made, a draft was prepared, and all recommendations were agreed upon unanimously.

Results: The Danish version of the position paper was finally submitted for review and accepted by all members of DRS.

Conclusion: In this position paper we provide recommendations on the terminology of chronic and terminal lung failure, rehabilitation and palliative care, advanced care planning, informal caregivers and bereavement, symptom management, the imminently dying patient, and organization of palliative care for patients with chronic non-malignant lung diseases.

The COPDnet integrated care model

Introduction

This research project sets out to design an integrated disease management model for patients with COPD who were referred to a secondary care setting and who qualified for pharmacological and nonpharmacological intervention options.

Theory and methods

The integrated disease management model was designed according to the guidelines of the European Pathway Association and the content founded on the Chronic Care Model, principles of integrated disease management, and knowledge of quality management systems.

Results

An integrated disease management model was created, and comprises 1) a diagnostic trajectory in a secondary care setting, 2) a nonmedical intervention program in a primary care setting, and 3) a pulmonary rehabilitation service in a tertiary care setting. The model also includes a quality management system and regional agreements about exacerbation management and palliative care.

Discussion

In the next phase of the project, the COPDnet model will be implemented in at least two different regions, in order to assess the added value of the entire model and its components, in terms of feasibility, health status benefits, and costs of care.

Conclusion

Based on scientific theories and models, a new integrated disease management model was developed for COPD patients, named COPDnet. Once the model is stable, it will be evaluated for its feasibility, health status benefits, and costs.

Palliative care and chronic obstructive pulmonary disease: where the lines meet

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide and is expected to increase as the population ages. Patients have a high symptom burden, low healthcare quality of life, and unmet needs at the end of life. This review highlights specific palliative care needs of patients with advanced COPD and opportunities to integrate palliative care into standard practice.

RECENT FINDINGS

There are many barriers to providing integrated palliative care in COPD, including difficulty with prognostication, communication barriers surrounding advance care planning, and lack of access to specialty palliative care. Because of the unique disease trajectory, emphases on early and primary palliative care are being studied in this patient population.

SUMMARY

Palliative care is appropriate for patients with COPD and should be integrated with disease-specific therapies. The line between life prolonging and palliative care undoubtedly overlaps and maximizing quality of life throughout the continuum of care should be prioritized for patients with this progressive illness.

The provision of generalist and specialist palliative care for patients with non-malignant respiratory disease in the North and Republic of Ireland: a qualitative study

Background

Previous research and key guidelines have suggested potential models of palliative care for patients with COPD and interstitial lung disease. However, these recommendations are often not effectively implemented in clinical practice and are void of guidance regarding palliative care for patients with bronchiectasis, another form of non-malignant respiratory disease. The aim of this research was to explore generalist and specialist palliative care service provision for people with non-malignant respiratory disease in the North and Republic of Ireland.

Methods

Qualitative study involving a convenience sample of 17 bereaved carers and 18 healthcare professionals recruited from 2 rural and 2 urban sites on the Island of Ireland. Data collection consisted of semi-structured interviews with carers of patients with COPD, interstitial lung disease or bronchiectasis who had died 3–18 months previously; and 4 focus groups with healthcare professionals. Data analysed using thematic analysis.

Results

Findings highlighted the lack of a clear model of holistic care delivery for patients with non-malignant respiratory disease and illuminated the varying levels of palliative care provision this client group experienced. Additionally, ambiguity amongst healthcare professionals regarding prognostication illuminated the importance of the provision of palliative care being based on patient need, not prognosis. This research developed a potential model of palliative care which may help healthcare professionals introduce palliative care, and specialist respiratory care, early in the disease trajectory of non-malignant respiratory disease, whilst also encouraging the involvement of specialist palliative care for complex symptom management.

Conclusion

This research provides an important insight into a potential model of palliative care for people with non-malignant respiratory disease, inclusive of bronchiectasis. However, the feasibility of integrating this model into clinical practice requires further exploration.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-017-0220-1) contains supplementary material, which is available to authorized users.

Palliative care in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is the only major worldwide cause of mortality that is currently increasing in prevalence. Furthermore, COPD is incurable, and the only therapy that has been shown to increase survival is oxygen therapy in selected patients. Compared to patients with cancer, patients with COPD experience similar levels of pain, breathlessness, fatigue, depression, and anxiety and have a worse quality of life but have comparatively little access to palliative care. When these patients do receive palliative care, they tend to be referred later than patients with cancer. Many disease, patient-, and provider-related factors contribute to this phenomenon, including COPD's unpredictable course, misperceptions of palliative care among patients and physicians, and lack of advance care planning discussions outside of crisis situations. A new paradigm for palliative care would introduce palliative treatments alongside, rather than at the exclusion of disease-modifying interventions. This integrated approach would circumvent the issue of difficult prognostication in COPD, as any patient would receive individualized palliative interventions from the time of diagnosis. These points will be covered in this review, which discusses the challenges in providing palliative care to COPD patients, the strategies to mitigate the challenges, management of common symptoms, and the evidence for integrated palliative care models as well as some suggestions for future development.

Pulmonary Rehabilitation and Palliative Care for the Lung Cancer Patient

Pulmonary rehabilitation, as a quality of life intervention, has a role to play in palliative care for lung cancer patients. Combining the art and skills of clinical care, physiological, and behavioral tools, pulmonary rehabilitation can serve to rebuild the functional capacity of patients limited by breathlessness and deconditioning. Exercise programs are the primary tool used to restore and rebuild the patient's endurance by challenging the entire pathway of oxygen transport and improving gas exchange. Other tools of pulmonary rehabilitation include breathing retraining, self-management skills, airway clearance techniques, bronchodilitation, smoking cessation and oxygen therapy. Pulmonary rehabilitation is now becoming a part of supportive care for patients undergoing chemotherapy and radiation therapy. The ability to be more active without suffering the consequences of dyspnea on exertion boosts the patient's self-efficacy and allows for an improved quality of life, so that lung cancer patients can participate in their family lives during this therapeutic challenge.

Geriatric rehabilitation for patients with advanced chronic obstructive pulmonary disease: a naturalistic prospective cohort study on feasibility and course of health status

In view of the worldwide aging population, disease-specific geriatric rehabilitation (GR) programs are needed. Therefore, we developed and implemented a postacute GR program for patients with advanced chronic obstructive pulmonary disease (COPD) (the GR-COPD program). The aim of this study is to investigate the feasibility of the GR-COPD program and to present clinical data on patient characteristics and course of functional capacity and health status. This is a naturalistic prospective cohort study of patients with advanced COPD. A total of 61 patients entered the GR-COPD program and were eligible to participate in this study. All patients suffered from advanced COPD, and comorbidities were frequent. On admission, functional capacity and health status were severely limited but showed significant and clinically relevant improvement during the GR-COPD program. Patients with advanced COPD admitted to hospital for an acute exacerbation suffer from severely impaired functional capacity and poor health status. Development and implementation of a postacute GR program for these patients are feasible and likely to offer substantial improvements. Further research is essential and should focus on designing a controlled intervention trial to investigate the efficacy of the program.

Can we predict which hospitalised patients are in their last year of life? A prospective cross-sectional study of the Gold Standards Framework Prognostic Indicator Guidance as a screening tool in the acute hospital setting

BACKGROUND

Screening to identify hospital inpatients with a short life expectancy may be a way to improve care towards the end of life. The Gold Standards Framework Prognostic Indicator Guidance is a screening tool that has recently been advocated for use in the hospital setting.

AIM

To assess the clinical utility of the Gold Standards Framework Prognostic Indicator Guidance as a screening tool in an acute hospital setting.

MAIN OUTCOME MEASURES

Mortality at 6 and 12 months and sensitivity, specificity and predictive value of the Gold Standards Framework Prognostic Indicator Guidance at 1 year.

DESIGN, SETTING AND PARTICIPANTS

Prospective cross-sectional study of 501 adult inpatients in a tertiary New Zealand teaching hospital screened utilising the Gold Standards Framework Prognostic Indicator Guidance.

RESULTS

A total of 99 patients were identified as meeting at least one of the Gold Standards Framework Prognostic Indicator Guidance triggers. In this group, 6-month mortality was 56.6% and 12-month mortality was 67.7% compared with 5.2% and 10%, respectively, for those not identified as meeting the criteria. The sensitivity and specificity of the Gold Standards Framework Prognostic Indicator Guidance at 1 year were 62.6% and 91.9%, respectively, with a positive predictive value of 67.7% and a negative predictive value of 90.0%.

CONCLUSION

The sensitivity, specificity and predictive values of the Gold Standards Framework Prognostic Indicator Guidance in this study are comparable to, or better than, results of studies identifying patients with a limited life expectancy in particular disease states (e.g. heart failure and renal failure). Screening utilising the Gold Standards Framework Prognostic Indicator Guidance in the acute setting could be the first step towards implementing a more systematic way of addressing patient need--both current unrecognised and future anticipated--thereby improving outcomes for this population.

The Benefits of Rehabilitation for Palliative Care Patients

Palliative care requires an interdisciplinary team approach to provide the best care for patients with life-threatening illnesses. Like palliative medicine, rehabilitation also uses an interdisciplinary approach to treating patients with chronic illnesses. This review article focuses on rehabilitation interventions that can be beneficial in patients with late stage illnesses. Rehabilitation may be useful in improving the quality of life by palliating function, mobility, activities of daily living, pain relief, endurance, and the psyche of a patient while helping to maintain as much independence as possible, leading to a decrease in burden on caregivers and family. Rehabilitative services are underutilized in the palliative care setting, and more research is needed to address how patients may benefit as they approach the end of their lives.

Palliative care in COPD--web survey in Sweden highlights the current situation for a vulnerable group of patients

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a common cause of death. Despite the heavy symptom burden in late stages, these patients are relatively seldom referred to specialist palliative care.

METHODS

A web-based survey concerning medical and organizational aspects of palliative care in COPD was distributed to respiratory physicians in Sweden. There were 93 respondents included in the study.

RESULTS

Palliative care issues were regularly discussed with the patients according to a third of the respondents. About half of the respondents worked in settings where established routines for co-operation with palliative units were available at least to some extent. Less than half of the respondents (39%) were aware of current plans to develop palliative care, either as a co-operative effort or within the facility. Palliative care is focused on physical, psychological, social, and existential dimensions, and the proportions of respondents providing support within these dimensions, 'always' or 'often', were 83%, 36%, 32%, and 11%, respectively. Thus, to treat the physical dimensions was perceived as much more obvious than to address the other dimensions.

CONCLUSIONS

The survey indicates that the priorities and resources for palliative care in COPD are insufficient in Sweden. The data, despite limitations, reveal a lack of established team-work with specialized palliative care units and actual plans for such co-operation.