Palliative care and prognosis in COPD: a systematic review with a validation cohort

Prognostic models and factors identifying end-of-life in non-cancer chronic diseases: a systematic review

BACKGROUND

Precise prognostic information, if available, is very helpful for guiding treatment decisions and resource allocation in patients with non-cancer non-communicable chronic diseases (NCDs). This study aimed to systematically review the existing evidence, examining prognostic models and factors for identifying end-of-life non-cancer NCD patients.

METHODS

Electronic databases, including Medline, Embase, CINAHL, Cochrane Library, PsychINFO and other sources, were searched from the inception of these databases up until June 2023. Studies published in English with findings mentioning prognostic models or factors related to identifying end-of-life in non-cancer NCD patients were included. The quality of studies was assessed using the Quality in Prognosis Studies tool.

RESULTS

The analysis included data from 41 studies, with 16 focusing on chronic obstructive pulmonary diseases (COPD), 10 on dementia, 6 on heart failure and 9 on mixed NCDs. Traditional statistical modelling was predominantly used for the identified prognostic models. Common predictors in COPD models included dyspnoea, forced expiratory volume in 1 s, functional status, exacerbation history and body mass index. Models for dementia and heart failure frequently included comorbidity, age, gender, blood tests and nutritional status. Similarly, mixed NCD models commonly included functional status, age, dyspnoea, the presence of skin pressure ulcers, oral intake and level of consciousness. The identified prognostic models exhibited varying predictive accuracy, with the majority demonstrating weak to moderate discriminatory performance (area under the curve: 0.5-0.8). Additionally, most of these models lacked independent external validation, and only a few underwent internal validation.

CONCLUSION

Our review summarised the most relevant predictors for identifying end-of-life in non-cancer NCDs. However, the predictive accuracy of identified models was generally inconsistent and low, and lacked external validation. Although efforts to improve these prognostic models should continue, clinicians should recognise the possibility that disease heterogeneity may limit the utility of these models for individual prognostication; they may be more useful for population level health planning.

Palliative Care Among Lung Cancer Patients With and Without COPD: A Population-Based Cohort Study

CONTEXT

Lung cancer patients with chronic obstructive pulmonary disease (COPD) may have greater palliative care needs due to poor prognosis and symptom burden.

OBJECTIVES

We sought to compare the provision of timely palliative care and symptom burden by COPD status.

METHODS

We performed a retrospective, population-based cohort study of individuals diagnosed with lung cancer in Ontario, Canada (2009-2019) using health administrative databases and cancer registries. The impact of COPD on the probability of receiving palliative care was determined accounting for dying as a competing event, overall and stratified by stage. The provision of palliative care for patients with severe symptoms (Edmonton Symptom Assessment Scale score ≥ 7), location of the first palliative care visit and symptom severity were compared by COPD status.

RESULTS

A total of 74,993 patients were included in the study (48% of patients had available symptom data). At the time of lung cancer diagnosis, 50% of patients had COPD. Stage I-III patients with COPD were more likely to receive palliative care (adjusted Hazard Ratio (HR)s: 1.05-1.31) with no difference for stage IV (1.02, 95% CI: 1.00-1.04). Despite having severe symptoms, very few patients with early-stage disease received palliative care (Stage I: COPD-23% vs. no COPD-18%, SMD = 0.12). Most patients (84%) reported severe symptoms and COPD worsened symptom burden, especially among early-stage patients.

CONCLUSION

COPD impacts the receipt of palliative care and symptom burden for patients with early-stage lung cancer. Many patients with severe symptoms did not receive palliative care, suggesting unmet needs among this vulnerable population.

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.

Voluntary Assisted Dying/Euthanasia: Will This Have an Impact on Cancer Care in Future Years?

OPINION STATEMENT

In considering the impact of medically hastened death (MHD) on cancer care, a wide range of variables needs to be considered including demographic factors, diagnoses, local cultural factors, and the legislative frameworks in place. Here, we present a synthesis of recently available published literature and empirical data collected following legislative change to enable MHD in Victoria, Australia to explore in detail the potential impact of MHD on cancer care with a focus on patients/families and professional groups. Our findings reveal that for patients and families, both physical and existential distress frequently underlie MHD requests, with the latter less readily recognised by health professionals. The responses of those around the patient making the request may have a very significant impact on relationships within families and upon the nature of the subsequent bereavement. For palliative care, while differing views may remain, it appears that there has been some accommodation of MHD into or alongside practice over time. The recognition of a shared commitment to relief of suffering of palliative care and MHD appears a helpful means of establishing how these practices may co-exist. In cancer practice more broadly, as individual professionals reflect upon their own roles, new relationships and pathways of patient movement (or referral) must be established in response to patients' requests. Our findings also highlight many unanswered questions in understanding the impact of MHD, including that upon those dying who choose not to access MHD, First Nations peoples, the participating health professionals' longer term, and the relief of suffering itself. A systematic approach to the evaluation of MHD legislation must be adopted in order to understand its full impact. Only then could it be determined if the aspirations for such legislative change were being met.

Facilitators and barriers to the delivery of palliative care to patients with Parkinson's disease: a qualitative study of the perceptions and experiences of stakeholders using the socio-ecological model

OBJECTIVE

Palliative care (PC) can improve the quality of life of Parkinson's disease (PD) patients and their carers. However, the impact of PC services on patients with PD remains unclear. This research was conducted to identify the barriers and facilitators influencing PC services for patients with PD based on the Social Ecological Model (SEM) framework.

METHODS

This research was conducted through semi-structured interviews, employing SEM to organize themes and identify potential solutions across multiple levels.

RESULTS

A total of 29 interviewees (5 PD clinicians, 7 PD registered nurses, 8 patients, 5 caregivers, and 4 policy makers) completed the interviews. Facilitators and barriers were identified according to the levels of the SEM. Several facilitators were identified, i.e., (1) individual level: the critical needs among PD patients and their relatives and the desire for PC knowledge among health professionals; (2) interpersonal level: social support; (3) organizational level: the investments towards systematization of PC; and nurses are the bridge between patients and doctors; (4) community level: the convenience of community services; and hospital-community-family-based services; (5) culture and policy level: existing policy.

CONCLUSION

The social-ecological model proposed in this study helps illuminate the complex and multilevel factors that may influence PC delivery to PD patients.

Caring for patients with advanced COPD: beyond the inhalers…

COPD affects millions of people worldwide. Patients with advanced COPD have a high symptom burden. Breathlessness, cough and fatigue are frequent daily symptoms. Guidelines often focus on pharmacological treatment, especially inhaler therapy, but other approaches in combination with medications offer symptomatic benefit. In this review, we take a multidisciplinary approach with contributions from pulmonary physicians, cardiothoracic surgeons and a physiotherapist. The following areas are addressed: oxygen therapy and noninvasive ventilation (NIV), dyspnoea management, surgical and bronchoscopic options, lung transplantation and palliative care. Oxygen therapy prescribed within guidelines improves mortality in patients with COPD. NIV guidelines offer only low-certainty instruction on the use of this therapy on the basis of the limited available evidence. Dyspnoea management can take place through pulmonary rehabilitation. Specific criteria aid decisions on referral for lung volume reduction treatments through surgical or bronchoscopic approaches. Lung transplantation requires precise disease severity assessment to determine which patients have the most urgent need for lung transplantation and are likely to have the longest survival. The palliative approach runs in parallel with these other treatments, focusing on symptoms and aiming to improve the quality of life of patients and their families facing the problems associated with life-threatening illness. In combination with appropriate medication and an individual approach to symptom management, patients' experiences can be optimised.

Educational aims

To understand the multidisciplinary approach to management of patients with advanced COPD.To recognise the parallel approaches to oxygen, NIV and dyspnoea management with consideration of more interventional options with lung volume reduction therapy or lung transplantation.To understand the high level of symptomatology present in advanced COPD and the relevance of palliative care alongside optimal medical management.

Triggering palliative care referrals through the identification of poor prognosis in older patients presented to emergency departments in rural Australia

Background: Without objective screening for risk of death, the palliative care needs of older patients near the end of life may be unrecognised and unmet. Aim: This study aimed to estimate the usefulness of the Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL) tool in determining older patients' risk of death within 3-months after initial hospital admission. Methods: A prospective cohort study of 235 patients aged 70+ years, who presented to two rural emergency departments in two adjacent Australian states, was utilised. The 'risk of death' of each patient was screened with the CriSTAL prognostic tool. Their 3-month follow-up outcomes were assessed through telephone interviews and a clinical record review. Findings: A CriSTAL cut-off score of more than 7 yielded a sensitivity of 80.7% and specificity of 70.81% for a 3-month risk of death. Palliative care services were only used by 31% of the deceased in their last trimester of life. Conclusion: Prognostic tools provide a viable means of identifying individuals with a poor prognosis. Identification can trigger an earlier referral to palliative care, which will benefit the patient's wellbeing and quality of life.

Implementation of an integrated respiratory palliative care service for patients with advanced lung disease

Objectives This study describes the model of care provided by an integrated respiratory and palliative care service for patients with advanced lung disease, and assesses the potential impact of the service on acute hospital utilisation and cost. Methods This study implemented an integrated specialist care service at a single tertiary teaching hospital in Melbourne, Victoria, Australia. The service provided disease-orientated care, alongside symptom management and advance care planning, and comprised both outpatient clinic (OPC) and home visit (HV) capacity for those with barriers to accessing OPC. Acute hospital utilisation and hospital cost were analysed with a paired t -test 90 days before/after the first physician review. Results Between April 2017 and 2019, 51 patients received 59 HVs, whereas between July 2018 and 2020, 58 patients received 206 OPC reviews. Acute hospital admissions decreased by 51% in the HV cohort (P  < 0.05) and by 46% in the OPC cohort (P  = 0.01); total bed days of acute admissions decreased by 29% in the HV cohort (P  = n.s.), and by 60% in the OPC cohort (P  < 0.05); and specialist outpatient clinic attendances decreased in the OPC cohort by 55% (P  < 0.01). There was a decrease in hospital cost for the HV cohort by 3% (cost savings of A$18 579), and in the OPC cohort by 23% (cost savings of A$109 149). Conclusions This model of care provided specialist respiratory management with seamless integration of palliative care, with the capacity for home visits. There was a decrease in acute hospital utilisation and overall cost savings observed in both HV and OPC cohorts.

Grupo de síntomas de enfermedad pulmonar obstructiva crónica y cuidados paliativos: una revisión sistemática

La enfermedad pulmonar obstructiva crónica (EPOC) es una entidad patológica que se caracteriza por una serie de manifestaciones físicas persistentes como tos, fatiga, disnea y producción de esputo; síntomas que generan malestar en el paciente desde el momento del diagnóstico y que, al ser una enfermedad irreversible por el daño tisular que causa, progresivamente va incidiendo de manera negativa en la calidad de vida. De otra parte, se ha reportado presencia de síntomas psicológicos como depresión, inseguridad, ansiedad y alteraciones emocionales en los pacientes diagnosticados con EPOC. Así mismo, los pacientes con este diagnóstico tienden a desarrollar comportamientos que alteran sus relaciones sociales familiares y laborales, por cuanto tienden a aislarse debido a la sintomatología, especialmente física. La situación planteada genera la necesidad de desarrollar un trabajo de investigación con el objetivo de reconocer el clúster de síntomas físicos, psicológicos y sociales de los pacientes diagnosticados con EPOC, e identificar si se plantea un abordaje desde la atención paliativa. El estudio se desarrolló mediante una revisión sistemática de literatura en la que se identificaron 1776 artículos, de los que se evaluaron 41 para la identificación del clúster de síntomas. Se identificó el binomio disnea y tos, fatiga y expectoración como el clúster de síntomas físicos; la depresión y la ansiedad constituyen el clúster de síntomas psicológicos, y el impacto en la calidad de vida y la percepción de aislamiento o exclusión social.

Complementary frailty and mortality prediction models on older patients as a tool for assessing palliative care needs

Palliative care (PC) has demonstrated benefits for life-limiting illnesses. Bad survival prognosis and patients' decline are working criteria to guide PC decision-making for older patients. Still, there is not a clear consensus on when to initiate early PC. This work aims to propose machine learning approaches to predict frailty and mortality in older patients in supporting PC decision-making. Predictive models based on Gradient Boosting Machines (GBM) and Deep Neural Networks (DNN) were implemented for binary 1-year mortality classification, survival estimation and 1-year frailty classification. Besides, we tested the similarity between mortality and frailty distributions. The 1-year mortality classifier achieved an Area Under the Curve Receiver Operating Characteristic (AUC ROC) of 0.87 [0.86, 0.87], whereas the mortality regression model achieved an mean absolute error (MAE) of 333.13 [323.10, 342.49] days. Moreover, the 1-year frailty classifier obtained an AUC ROC of 0.89 [0.88, 0.90]. Mortality and frailty criteria were weakly correlated and had different distributions, which can be interpreted as these assessment measurements are complementary for PC decision-making. This study provides new models that can be part of decision-making systems for PC services in older patients after their external validation.

Spanish COPD Guideline (GesEPOC) Update: Comorbidities, Self-Management and Palliative Care

The current health care models described in GesEPOC indicate the best way to make a correct diagnosis, the categorization of patients, the appropriate selection of the therapeutic strategy and the management and prevention of exacerbations. In addition, COPD involves several aspects that are crucial in an integrated approach to the health care of these patients. The evaluation of comorbidities in COPD patients represents a healthcare challenge. As part of a comprehensive assessment, the presence of comorbidities related to the clinical presentation, to some diagnostic technique or to some COPD-related treatments should be studied. Likewise, interventions on healthy lifestyle habits, adherence to complex treatments, developing skills to recognize the signs and symptoms of exacerbation, knowing what to do to prevent them and treat them within the framework of a self-management plan are also necessary. Finally, palliative care is one of the pillars in the comprehensive treatment of the COPD patient, seeking to prevent or treat the symptoms of a disease, the side effects of treatment, and the physical, psychological and social problems of patients and their caregivers. Therefore, the main objective of this palliative care is not to prolong life expectancy, but to improve its quality. This chapter of GesEPOC 2021 presents an update on the most important comorbidities, self-management strategies, and palliative care in COPD, and includes a recommendation on the use of opioids for the treatment of refractory dyspnea in COPD.

Cardiac and Pulmonary Diagnoses and Advance Care Planning in Home Health

Chronic cardiovascular and pulmonary diseases are prevalent in the US home health population. Heart failure and chronic obstructive pulmonary disease are both chronic and terminal, but they are not always perceived as serious illnesses with imminent death. Therefore, they provide a context for advance care planning that is distinct from the diagnostic contexts of cancer, end-stage renal disease, or dementia. Advance care planning is defined as a process that supports adults at any age or stage of health in understanding and sharing their goals, values, and preferences about future medical care, including the designation of a surrogate decision-maker. This study tests the hypothesis that US home health agencies with higher percentages of patients with chronic cardiovascular and pulmonary conditions have less robust advance care planning protocols. The Spearman correlation coefficient was r = 0.22 ( S = 74684, P = .025, 1-tailed), which was statistically significant and an unexpected finding. The greater percentage of patients with chronic cardiac and pulmonary diagnoses in an agency, the more robust the advance care planning protocol was. This supports our previous findings and existing literature indicating that agencies may be using exacerbation events marked by acute care use as opportunities to initiate or repeat advance care planning.

Development and validation of a prediction index for recent mortality in advanced COPD patients

The primary barrier to initiating palliative care for advanced COPD patients is the unpredictable course of the disease. We enroll 752 COPD patients into the study and validate the prediction tools for 1-year mortality using the current guidelines for palliative care. We also develop a composite prediction index for 1-year mortality and validate it in another cohort of 342 patients. Using the current prognostic models for recent mortality in palliative care, the best area under the curve (AUC) for predicting mortality is 0.68. Using the Modified Medical Research Council dyspnea score and oxygen saturation to define the combined dyspnea and oxygenation (DO) index, we find that the AUC of the DO index is 0.84 for predicting mortality in the validated cohort. Predictions of 1-year mortality based on the current palliative care guideline for COPD patients are poor. The DO index exhibits better predictive ability than other models in the study.

Spanish Nurses' Knowledge about Palliative Care. A National Online Survey

(1) Background: Nurses can find people with advanced diseases or in their last days of life during their professional careers and in many different care settings. For this reason, they need to have at least a basic level of palliative care education since they are the professional cohort treating these patients in a very close way. This research aims to determine the level of knowledge in palliative care of Spanish nurses and establish any possible difference based on their experience and training in palliative care. (2) Methods: A cross-sectional design using survey methods (distributed an online questionnaire) aimed at Spanish registered nurses. A validated questionnaire (PCQN-SV) was used to determine the level of knowledge in palliative care; information on some variables to characterize the population was also collected (experience and education in palliative care, years of professional experience, academic level, and others). Uni and bivariate descriptive analyses were performed. A binary logistic regression model was also developed to identify those variables that influenced obtaining results higher than the population’s average. (3) Results: Spanish nurses have a medium–low level of knowledge in palliative care, higher in those who have previous experience or education in this area. Statistically significant differences were also found according to the area in which their caring activity was developed. (4) Conclusions: It is necessary to implement strategies for the basic training of nursing professionals in palliative care to offer quality care to people in advanced stages of illnesses or at the end of their lives.

End-of-life use of antibiotics: a survey on how doctors decide

OBJECTIVES

Infections are the main complications in terminal diseases. Many patients die using antibiotics, which raises questions about their real usefulness and role in unnecessary prolongation of suffering. This survey evaluated how doctors use antibiotics in palliative care.

METHODS

From June to August of 2016, an online survey was conducted with 224 doctors who provide palliative care. They had to decide whether to initiate antibiotics in fictitious scenarios involving patients with suspected infections (urinary tract infection, pneumonia, sepsis) in end-of-life (from cancer, dementia, malignant stroke with sequelae, advanced COPD, multiple organ failure). Then, they had to decide whether to stop, maintain, or extend antibiotics after non-response in 72 hours.

RESULTS

88-100% of doctors decided to initiate antibiotics in all situations, except in advanced dementia (55%), and most of them decided to maintain/extend antibiotics inadequately. Factors associated with maintaining/extending antibiotics inadequately were: longer time since graduation (over 13 years; significant in all 7 clinical situations; OR range: 2.45-10.11), and not having formal specialization in palliative care (statistically significant in 3 of 7 situations).

CONCLUSIONS

Most palliative care physicians in this study decided to initiate and maintain/extend antibiotics at the end-of-life.

Communicating uncertainty: contrasting the communication experiences of patients with advanced COPD and incurable lung cancer

BACKGROUND

Due to the uncertain disease trajectory and variable rate of progression in chronic obstructive pulmonary disease (COPD), health care professionals (HCPs) are challenged in explaining what the future may hold for patients compared to those with lung cancer (LC). Support and communication of timely information can significantly improve health outcomes.

OBJECTIVE

This study sought to identify factors that impact communication and support and recommend ways to improve patients' understanding of living with life-threatening illness.

METHODS

Semi-structured interviews with patients with LC (n = 22) and advanced COPD (n = 18), their informal carers (21 LC and 18 COPD) and HCPs (n = 51). Patients were recruited from primary and secondary care in the East of England, UK, during 2010-12.

RESULTS

Directness and clarity characterized communication in LC, whereas uncertainty and limited explanations predominated in COPD. Discussions on how the disease might impact on decisions and preferences to be made in the future were less common in COPD. Information for LC patients was mainly from hospital clinicians and any information for COPD patients mainly from primary care clinicians.

CONCLUSIONS

The experience of COPD patients could be improved by professionals soon after diagnosis explaining to them the typical pattern of decline in COPD, highlighting the inherent uncertainties about when exacerbations and death may occur. This conversation should lead to planning for the different challenges that the patient and informal carer recognize as most important to them. This contrasts with the 'breaking bad news' conversation that oncologists are highly trained to deliver.

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.

Chronic obstructive pulmonary disease and lung cancer: access to palliative care, emergency room visits and hospital deaths

Background

Despite the severe symptoms experienced by dying COPD patients, specialized palliative care (SPC) services focus mainly on cancer patients. We aimed to study the access to SPC that COPD and lung cancer (LC) patients receive and how that access affects the need for acute hospital care.

Methods

A descriptive regional registry study using data acquired through VAL, the Stockholm Regional Council’s central data warehouse, which covers nearly all healthcare use in the county of Stockholm. All the patients who died of COPD or LC from 2015 to 2019 were included. T-tests, chi-2 tests, and univariable and multivariable logistic regression analyses were performed on the accumulated data.

Results

In total, 6479 patients, (2917 with COPD and 3562 with LC) were studied. The patients with LC had more access to SPC during the last three months of life than did those with COPD (77% vs. 18%, respectively; p < .0001), whereas patients with COPD were more likely to be residents of nursing homes than those with LC (32% vs. 9%, respectively; p < .0001). Higher socioeconomic status (SES) (p < .01) and patient age < 80 years (p < .001) were associated with increased access to SPC for LC patients. Access to SPC correlated with fewer emergency room visits (p < .0001 for both COPD and LC patients) and fewer admissions to acute hospitals during the last month of life (p < .0001 for both groups). More COPD patients died in acute hospitals than lung cancer patients, (39% vs. 20%; χ² = 287, p < .0001), with significantly lower figures for those who had access to SPC (p < .0001).

Conclusions

Compared to dying COPD patients, LC patients have more access to SPC. Access to SPC reduces the need for emergency room visits and admissions to acute hospitals.

Referral criteria to palliative care for patients with respiratory disease: a systematic review

BACKGROUND

Advanced non-malignant respiratory diseases are associated with significant patient morbidity, yet access to palliative care occurs late, if at all.

AIM

To examine referral criteria for palliative care among patients with advanced non-malignant respiratory disease, with a view to developing a standardised set of referral criteria.

DESIGN

Systematic review of all studies reporting on referral criteria to palliative care in advanced non-malignant respiratory disease, with a focus on chronic obstructive pulmonary disease and interstitial lung disease.

DATA SOURCES

A systematic review conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses guideline was undertaken using electronic databases (Ovid, MEDLINE, Ovid Embase, and PubMed).

RESULTS

Searches yielded 2052 unique titles, which were screened for eligibility resulting in 62 studies addressing referral criteria to palliative care in advanced non-malignant respiratory disease. Of 18 categories put forward for referral to palliative care, the most commonly discussed factors were hospital use (69% of papers), indicators of poor respiratory status (47%), physical and emotional symptoms (37%), functional decline (29%), need for advanced respiratory therapies (27%), and disease progression (26%).

CONCLUSION

Clinicians consider referral to specialist palliative care for a wide range of disease- and needs-based criteria. Our findings highlight the need to standardise palliative care access by developing consensus referral criteria for patients with advanced non-malignant respiratory illnesses.

Palliative Care Needs and Integration of Palliative Care Support in COPD: A Qualitative Study

BACKGROUND

The provision of palliative care for severe COPD remains low, resulting in unmet needs in patients and carers.

RESEARCH QUESTIONS

What are the palliative care needs of patients living with severe COPD and their caregivers? What views of accessing and providing palliative care and factors influence these experiences. To what extent have palliative care and COPD services been integrated?

STUDY DESIGN AND METHODS

A multicentre qualitative study was undertaken in COPD services and specialist palliative care in the United Kingdom involving patients with severe COPD, their carers, and health professionals. Data were collected using semistructured interviews and were analyzed using framework analysis. Themes were integrated using the constant comparison process, enabling systematic data synthesis.

RESULTS

Four themes were generated from interviews with 20 patients, six carers, and 25 health professionals: management of exacerbations, palliative care needs, access to palliative care and pathways, and integration of palliative care support. Uncertainty and fear were common in patients and carers, with identified needs for reassurance, rapid medical access, home care, and finance advice. Timely palliative care was perceived as important by health professionals. Palliative care was integrated into COPD services, although models of working varied across regions. Reliable screening tools and needs assessment, embedded psychological care, and enhanced training in palliative care and communication skills were perceived to be important by health professionals for timely palliative care referrals and optimized management.

INTERPRETATION

Palliative care increasingly is being implemented for nonmalignant diseases including COPD throughout the United Kingdom, although models of working vary. A theoretical model was developed to illustrate the concept and pathway of the integration of palliative care support. A standardized screening and needs assessment tool is required to improve timely palliative care and to address the significant needs of this population.

The determinants of dyspnoea evaluated by the mMRC scale: The French Palomb cohort

INTRODUCTION AND OBJECTIVE

Dyspnoea is a major symptom in COPD patients, but the determinants that could be associated with a higher dyspnoea mMRC score in COPD patients remain unclear. Our research aimed to study the determinants of dyspnoea at the threshold of 1, 2, 3 and 4 mMRC.

PATIENTS AND METHODS

Diagnosis of COPD was made using spirometry with post-bronchodilator FEV₁FVC<70%. An online questionnaire has been employed by pulmonologists to recruit COPD patients. The following variables were collected: age, gender, BMI, FEV₁, RV, IC, TLC, FRC, mMRC, frequency of exacerbations and comorbidities. The LASSO was used to select the variables associated with the mMRC dyspnoea scale in a subgroup (who had no missing IC, RV and FRC values) of 421 COPD patients defined by the previously mentioned variables.

RESULTS

One thousand nine hundred and sevety-three patients (65.3% males, average age=66±10, 38% current smokers) were included. Dyspnoea was correlated with a low FEV₁ and with the number of exacerbations in the past 12 months. Multivariate analysis showed that the determinants of dyspnoea(mMRC≥2) are: FEV₁: OR=3.71[2.86-4.82]; anxiety: OR=2.52[1.82-3.47]; cough: OR=1.94[1.57-2.40]; bronchiectasis: OR=1.84[1.03-3.29]; age: OR=1.80[1.45-2.24]; hyperinflation (RV/TLC): OR=1.68[1.34-2.11]; ischemic cardiopathy: OR=1.63[1.22-2.18]; hypertension: OR=1.52[1.21-1.91]; exacerbations (≥2): OR=1.41[1.10-1.81]; women: OR=1.39[1.10-1.74] and overweight: OR=1.33[1.06-1.67]. The subgroup analysis showed that: FEV₁: OR=3.47[1.96-6.12]; exacerbations (≥2) OR=2.31[1.33-4.17] and hyperinflation (IC/TLC) OR=0.57[0.35-0.85] were associated with higher dyspnoea (mMRC≥2).

CONCLUSION

Our results showed that dyspnoea is related to the severity of airflow limitation, gender, exacerbations, comorbidities and hyperinflation.

Prevalence and Mortality of Patients with Palliative Needs in an Acute Respiratory Setting

INTRODUCTION

NECPAL is a tool for identification of patients with advanced chronic disease in need of palliative care. The main objective of the study is to know the prevalence of patients with palliative needs in an acute respiratory ward in a Spanish tertiary hospital using NECPAL. A second objective of the study is to know the annual mortality rate of these patients.

MATERIALS AND METHODS

Cross sectional study and prospective monitoring of a cohort identified as palliative patients with the NECPAL tool for 12 months. Patient identification was performed in patients admitted to the respiratory ward of our hospital for longer than 3 days. We have assessed the annual vital status (deceased or not deceased) of patients and have recorded demographics, clinical and functional data, as well as the use of healthcare resources.

RESULTS

We monitored a cohort of 363 patients. Of them, 87 patients (24.3%) (IC 95% 19-30) were identified as NECPAL positive. 60% of patients (n = 64) died within 12 months of their admission. There was no significant difference in the mortality ratio of oncologic versus non oncologic patients. In a multivariable analysis, mortality was associated with demand by patients or relatives for palliative care and with the presence of specific disease progression markers or indicators.

CONCLUSIONS

prevalence of patients with palliative needs in acute respiratory wards is high (one out of four patients). 60% of the patients identified as NECPAL positive in our cohort died in the first 12 months. Training of healthcare professionals as well as availability of appropriate resources are indispensable factors to improve care of this population.

Mapping non-malignant respiratory palliative care services in Australia and New Zealand

Objective Despite needs, people with advanced non-malignant respiratory disease are infrequently referred to palliative care services. Integrated models of palliative care and respiratory service delivery have been advocated to address this inequity of access. This study mapped current ambulatory palliative care service provision for patients with advanced non-malignant respiratory disease in Australia and New Zealand. Methods An online survey was distributed to the palliative care physician membership of the Australian and New Zealand Society of Palliative Medicine. Information was sought regarding access to specific breathlessness and integrated respiratory and palliative care services, and their operation. Data were described using descriptive statistics. Results In all, 133 respondents (93 from Australia, 40 from New Zealand; representing 55 Australian and 26 New Zealand discrete sites) with complete data were available for analysis. More than half the respondents reported seeing patients with advanced non-malignant respiratory disease frequently (56/97; 58%), and 18 of 81 services (22%) reported having breathlessness or integrated respiratory and palliative care services caring for this patient group. Such services were mostly staffed by respiratory and palliative care doctors and nurses and based in the clinic environment, with limited support available outside this setting. Of the 63 respondents without existing breathlessness or integrated services, 49 (78%) expressed interest in their establishment, with limited resources cited as the most common barrier. Conclusions There is limited availability of integrated respiratory and palliative care or specialised breathlessness services in Australia and New Zealand despite widespread support by palliative care physicians. This study provides a snapshot to inform strategic service development. What is known about the topic? People with advanced respiratory disease have very significant morbidity with complex needs equivalent to, and in many cases more intense than, people with end-stage lung cancer; they also have significant mortality. Yet, these people frequently do not access palliative care services. The establishment of integrated respiratory and palliative care services has been advocated as an effective means to overcome the barriers to palliative care access. Such services have demonstrated improved patient and family-reported outcomes, as well as service-level improvements. What does this paper add? This paper maps the availability of integrated respiratory palliative care services in Australia and New Zealand. We reveal that although most palliative care physicians report seeing patients with advanced respiratory disease in practice, just one-fifth of services report having an integrated service approach. There was high interest and enthusiasm for such services (78%), but resources limited their establishment. What are the implications for practitioners? Palliative care services recognise the needs of patients with advanced respiratory disease and the benefits of integrated respiratory and palliative care services to address these needs, but scarcity of resources limits the ability to respond accordingly. This study provides a snapshot of current service level to inform strategic development.

Comparison of end-of-life care in people with chronic obstructive pulmonary disease or lung cancer: A systematic review

BACKGROUND

Palliative care has been widely implemented in clinical practice for patients with cancer but is not routinely provided to people with chronic obstructive pulmonary disease.

AIM

The study aims were to compare palliative care services, medications, life-sustaining interventions, place of death, symptom burden and health-related quality of life among chronic obstructive pulmonary disease and lung cancer populations.

DESIGN

Systematic review with meta-analysis (PROSPERO: CRD42019139425).

DATA SOURCES

MEDLINE, EMBASE, PubMed, CINAHL and PsycINFO were searched for studies comparing palliative care, symptom burden or health-related quality of life among chronic obstructive pulmonary disease, lung cancer or populations with both conditions. Quality scores were assigned using the QualSyst tool.

RESULTS

Nineteen studies were included. There was significant heterogeneity in study design and sample size. A random effects meta-analysis (n = 3-7) determined that people with lung cancer had higher odds of receiving hospital (odds ratio: 9.95, 95% confidence interval: 6.37-15.55, p < 0.001) or home-based palliative care (8.79, 6.76-11.43, p < 0.001), opioids (4.76, 1.87-12.11, p = 0.001), sedatives (2.03, 1.78-2.32, p < 0.001) and dying at home (1.47, 1.14-1.89, p = 0.003) compared to people with chronic obstructive pulmonary disease. People with lung cancer had lower odds of receiving invasive ventilation (0.26, 0.22-0.32, p < 0.001), non-invasive ventilation (0.63, 0.44-0.89, p = 0.009), cardiopulmonary resuscitation (0.29, 0.18-0.47, p < 0.001) or dying at a nursing home/long-term care facility (0.32, 0.16-0.64, p < 0.001) than people with chronic obstructive pulmonary disease. Symptom burden and health-related quality of life were relatively similar between the two populations.

CONCLUSION

People with chronic obstructive pulmonary disease receive less palliative measures at the end of life compared to people with lung cancer, despite a relatively similar symptom profile.

Palliative Care Initiation in Chronic Obstructive Pulmonary Disease: Prognosis-Based, Symptoms-Based or Needs-Based?

The absence or late initiation of palliative care (PC) in chronic obstructive pulmonary disease (COPD) is multidimensional. To provide palliative care from the moment of COPD diagnosis remains utopic. Even the advanced forms or the end-of-life stages benefit late or never from these services. In this context, the research questions for the present systematic review were focused on the prognosis variables or multicomponent indices in COPD patients alongside the symptoms and unmet needs, which may be useful for the palliative care initiation. The aim was to help clinicians to identify not only the tools reliable to predict poor survival in COPD patients but also to identify the criteria for appropriateness for early palliative care onset. The search included systematic reviews and reviews published in English in the PUBMED database from Jan 1, 2015 to Jan 6, 2020. From a total of 202 findings, after applying filters, using additional sources, and eliminating duplicates, the search strategy screened 16 articles, out of which 10 were selected and included. A Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) flow diagram was constructed. The main domains identified as barriers in providing palliative care in COPD patients were complex: from the prognosis difficulties to the prognostic variables and scores proposed for initiating PC; from the troublesome symptoms or the unidimensional symptom tools to the unmet needs of COPD patients. The review concluded that none of the existing prognostic variables and multicomponent indices are reliable enough to exclusively predict poor survival in COPD patients and the decision to initiate PC should be rather based on the presence of refractory symptoms and patients’ unmet needs and preferences. Despite the current advances, the ideal model to initiate palliative care from the moment COPD is diagnosed is a goal for clinicians trained in, and capable of providing palliative care in any COPD patient.

Preferences for Predictive Model Characteristics among People Living with Chronic Lung Disease: A Discrete Choice Experiment

Background. Patients may find clinical prediction models more useful if those models accounted for preferences for false-positive and false-negative predictive errors and for other model characteristics. Methods. We conducted a discrete choice experiment to compare preferences for characteristics of a hypothetical mortality prediction model among community-dwelling patients with chronic lung disease recruited from 3 clinics in Philadelphia. This design was chosen to allow us to quantify "exchange rates" between different characteristics of a prediction model. We provided previously validated educational modules to explain model attributes of sensitivity, specificity, confidence intervals (CI), and time horizons. Patients reported their interest in using prediction models themselves or having their physicians use them. Patients then chose between 2 hypothetical prediction models each containing varying levels of the 4 attributes across 12 tasks. Results. We completed interviews with 200 patients, among whom 95% correctly chose a strictly dominant model in an internal validity check. Patients' interest in predictive information was high for use by themselves (n = 169, 85%) and by their physicians (n = 184, 92%). Interest in maximizing sensitivity and specificity were similar (0.88 percentage points of specificity equivalent to 1 point of sensitivity, 95% CI 0.72 to 1.05). Patients were willing to accept a reduction of 6.10 months (95% CI 3.66 to 8.54) in the predictive time horizon for a 1% increase in specificity. Discussion. Patients with chronic lung disease can articulate their preferences for the characteristics of hypothetical mortality prediction models and are highly interested in using such models as part of their care. Just as clinical care should become more patient centered, so should the characteristics of predictive models used to guide that care.

Prognostic models for outcome prediction in patients with chronic obstructive pulmonary disease: systematic review and critical appraisal

OBJECTIVE

To map and assess prognostic models for outcome prediction in patients with chronic obstructive pulmonary disease (COPD).

DESIGN

Systematic review.

DATA SOURCES

PubMed until November 2018 and hand searched references from eligible articles.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Studies developing, validating, or updating a prediction model in COPD patients and focusing on any potential clinical outcome.

RESULTS

The systematic search yielded 228 eligible articles, describing the development of 408 prognostic models, the external validation of 38 models, and the validation of 20 prognostic models derived for diseases other than COPD. The 408 prognostic models were developed in three clinical settings: outpatients (n=239; 59%), patients admitted to hospital (n=155; 38%), and patients attending the emergency department (n=14; 3%). Among the 408 prognostic models, the most prevalent endpoints were mortality (n=209; 51%), risk for acute exacerbation of COPD (n=42; 10%), and risk for readmission after the index hospital admission (n=36; 9%). Overall, the most commonly used predictors were age (n=166; 41%), forced expiratory volume in one second (n=85; 21%), sex (n=74; 18%), body mass index (n=66; 16%), and smoking (n=65; 16%). Of the 408 prognostic models, 100 (25%) were internally validated and 91 (23%) examined the calibration of the developed model. For 286 (70%) models a model presentation was not available, and only 56 (14%) models were presented through the full equation. Model discrimination using the C statistic was available for 311 (76%) models. 38 models were externally validated, but in only 12 of these was the validation performed by a fully independent team. Only seven prognostic models with an overall low risk of bias according to PROBAST were identified. These models were ADO, B-AE-D, B-AE-D-C, extended ADO, updated ADO, updated BODE, and a model developed by Bertens et al. A meta-analysis of C statistics was performed for 12 prognostic models, and the summary estimates ranged from 0.611 to 0.769.

CONCLUSIONS

This study constitutes a detailed mapping and assessment of the prognostic models for outcome prediction in COPD patients. The findings indicate several methodological pitfalls in their development and a low rate of external validation. Future research should focus on the improvement of existing models through update and external validation, as well as the assessment of the safety, clinical effectiveness, and cost effectiveness of the application of these prognostic models in clinical practice through impact studies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017069247.

Mortality attributable to high temperatures over the 2021-2050 and 2051-2100 time horizons in Spain: Adaptation and economic estimate

BACKGROUND

In recent years, a number of studies have been conducted with the aim of analysing the impact that high temperatures will have on mortality over different time horizons under different climate scenarios. Very few of these studies take into account the fact that the threshold temperature used to define a heat wave will vary over time, and there are practically none which calculate this threshold temperature for each geographical area on the assumption that there will be variations at a country level.

OBJECTIVE

To analyse the impact that high temperatures will have on mortality across the periods 2021-2050 and 2051-2100 under a high-emission climate scenario (RCP8.5), in a case: (a) where adaptation processes are not taken into account; and (b) where complete adaptation processes are taken into account.

MATERIAL AND METHODS

Based on heat-wave definition temperature (T_threshold) values previously calculated for the reference period, 2000-2009, for each Spanish provincial capital, and their impact on daily mortality as measured by population attributable risk (PAR), the impact of high temperatures on mortality will be calculated for the above-mentioned future periods. Two hypotheses will be considered, namely: (a) that T_threshold does not vary over time (scenario without adaptation to heat); and, (b) that T_threshold does vary over time, with the percentile to which said T_threshold corresponds being assumed to remain constant (complete adaptation to heat). The temperature data were sourced from projections generated by Coupled Model Intercomparison Project (CMIP5) climate models adapted to each region's local characteristics by the State Meteorological Agency (Agencia Estatal de Meteorología/AEMET). Population-growth projections were obtained from the National Statistics Institute (Instituto Nacional de Estadística/INE). In addition, an economic estimate of the resulting impact will be drawn up.

RESULTS

The mean value of maximum daily temperatures will rise, in relation to those of the reference period (2000-2009), by 1.6⁰C across the period 2021-2050 and by 3.3⁰C across the period 2051-2100. In a case where there is no heat-adaptation process, overall annual mortality attributable to high temperatures in Spain would amount to 1414 deaths/year (95% CI: 1089-1771) in the period 2021-2050, rising to 12,896 deaths/year (95% CI: 9852-15,976) in the period 2051-2100. In a case where there is a heat-adaptation process, annual mortality would be 651 deaths/year (95% CI: 500-807) in the period 2021-2050, and 931 deaths per year (95% CI: 770-1081) in the period 2051-2100. These results display a high degree of heterogeneity. The savings between a situation that does envisage and one that does not envisage an adaptive process is €49,100 million/year over the 2051-2100 time horizon.

CONCLUSION

A non-linear increase in maximum daily temperatures was observed, which varies widely from some regions to others, with an increase in mean values for Spain as a whole that is not linear over time. The high degree of heterogeneity found in heat-related mortality by region and the great differences observed on considering an adaptive versus a non-adaptive process render it necessary for adaptation plans to be implemented at a regional level.

External Validation and Recalculation of the CODEX Index in COPD Patients. A 3CIAplus Cohort Study

The CODEX index was developed and validated in patients hospitalized for COPD exacerbation to predict the risk of death and readmission within one year after discharge. Our study aimed to validate the CODEX index in a large external population of COPD patients with variable durations of follow-up. Additionally, we aimed to recalculate the thresholds of the CODEX index using the cutoffs of variables previously suggested in the 3CIA study (mCODEX). Individual data on 2,755 patients included in the COPD Cohorts Collaborative International Assessment Plus (3CIA+) were explored. A further two cohorts (ESMI AND EGARPOC-2) were added. To validate the CODEX index, the relationship between mortality and the CODEX index was assessed using cumulative/dynamic ROC curves at different follow-up periods, ranging from 3 months up to 10 years. Calibration was performed using univariate and multivariate Cox proportional hazard models and Hosmer-Lemeshow test. A total of 3,321 (87.8% males) patients were included with a mean ± SD age of 66.9 ± 10.5 years, and a median follow-up of 1,064 days (IQR 25-75% 426-1643), totaling 11,190 person-years. The CODEX index was statistically associated with mortality in the short- (≤3 months), medium- (≤1 year) and long-term (10 years), with an area under the curve of 0.72, 0.70 and 0.76, respectively. The mCODEX index performed better in the medium-term (<1 year) than the original CODEX, and similarly in the long-term. In conclusion, CODEX and mCODEX index are good predictors of mortality in patients with COPD, regardless of disease severity or duration of follow-up.

Low uptake of palliative care for COPD patients within primary care in the UK

Mortality and symptom burden from chronic obstructive pulmonary disease (COPD) and lung cancer are similar but there is thought to be an inequality in palliative care support (PCS) between diseases. This nationally representative study assessed PCS for COPD patients within primary care in the UK.This was a cohort study using electronic healthcare records (2004-2015). Factors associated with receiving PCS were assessed using logistic regression for the whole cohort and deceased patients.There were 92 365 eligible COPD patients, of which 26 135 died. Only 7.8% of the whole cohort and 21.4% of deceased patients received PCS. Lung cancer had a strong association with PCS compared with other patient characteristics, including Global Initiative for Chronic Obstructive Lung Disease stage and Medical Research Council Dyspnoea score (whole cohort, lung cancer: OR 14.1, 95% CI 13.1-15; deceased patients, lung cancer: OR 6.5, 95% CI 6-7). Only 16.7% of deceased COPD patients without lung cancer received PCS compared with 56.5% of deceased patients with lung cancer. In patients that received PCS, lung cancer co-diagnosis significantly increased the chances of receiving PCS before the last month of life (1-6 versus ≤1 month pre-death: risk ratio 1.4, 95% CI 1.3-1.7).Provision of PCS for COPD patients in the UK is inadequate. Lung cancer, not COPD, was the dominant driver for COPD patients to receive PCS.

The potential of palliative care for patients with respiratory diseases

Based on the demonstrated effectiveness of palliative care in the alleviation of symptoms and enhancement of life quality, it is important to incorporate palliative care early in the respiratory disease trajectory. Quality palliative care addresses eight domains that are all patient and family centred. Palliative care interventions in respiratory conditions include management of symptoms such as dyspnoea, cough, haemoptysis, sputum production, fatigue and respiratory secretion management, especially as the end-of-life nears. A practical checklist of activities based on the domains of palliative care can assist clinicians to integrate palliative care into their practice. Clinical management of patients receiving palliative care requires consideration of human factors and related organisational characteristics that involve cultural, educational and motivational aspects of the patient/family and clinicians.

Early palliative care can relieve suffering and provide support for people with respiratory diseaseshttp://ow.ly/z0Hd30jpsb4