Management of COPD in End-of-Life Care by Spanish Pulmonologists

ABSTRACT

Chronic obstructive pulmonary disease is progressive and in its advanced stage is associated with major disability. Previous studies suggest that patients with this disease receive little palliative care, even in very advanced stages. Given this, our objectives were to describe the clinical practice of Spanish pulmonologists in the care of patients with end-stage chronic obstructive pulmonary disease, to identify potential barriers to implementing palliative care in these patients and to correlate these responses with doctor's years of experience. A link to an online survey was sent to pulmonologists on (a) symptom management, (b) structure of their department and collaboration with other services, (c) specialized medical training in palliative care, (d) communication with patients and their families, and (e) limiting barriers identified in the management of these patients. A total of 387 responses were received. The majority used opioids to treat dyspnea (52.9%) or pain (54.2%) and many treated anxiety/depression (41%). Around half of the respondents had no established routines in their departments to offer palliative care to patients with chronic obstructive pulmonary disease. There was little communication with end-of-life patients and their families on disease course, mainly associated with a lack of medical training (83% of cases) and changes in patient wishes regarding care through the disease course (81%). In our setting, communication with end-of-life patients with chronic obstructive pulmonary disease is poor. The key challenges identified are insufficient medical training and changing desires of patients. No substantial differences in attitude were found as a function of experience.     

A Palliative Approach to Dialysis Care: A Patient-Centered Transition to the End of Life

As the importance of providing patient-centered palliative care for patients with advanced illnesses gains attention, standard dialysis delivery may be inconsistent with the goals of care for many patients with ESRD. Many dialysis patients with life expectancy of <1 year may desire a palliative approach to dialysis care, which focuses on aligning patient treatment with patients’ informed preferences. This commentary elucidates what comprises a palliative approach to dialysis care and describes its potential and appropriate use. It also reviews the barriers to integrating such an approach into the current clinical paradigm of care and existing infrastructure and outlines system-level changes needed to accommodate such an approach.     

Racial and Ethnic Variation in Pain Following Inpatient Palliative Care Consultations

Studies have documented high levels of pain in hospitalized individuals at the end of life, with minorities reporting higher levels of pain than whites. In response, inpatient palliative care (IPC) teams have grown rapidly to improve care of seriously ill individuals. Although research indicates that IPC teams effectively reduce and maintain control of pain, racial and ethnic differences in pain following IPC consultation remain unclear. This study investigated racial and ethnic pain differences after an IPC intervention in 385 seriously ill white, black, and Latino individuals aged 65 and older. Using the 11‐point Numeric Rating Scale for pain, individuals were asked to rate their pain intensity at four points during hospitalization (before IPC consultation, 2 and 24 hours after the consultation, and at hospital discharge). Results indicate that whites (F_{1.657, 173.998} = 16.528, P < .001), blacks (F_{1.800, 95.410} = 7.103, P = .002), and Latinos (F_{1.388, 73.584} = 10.902, P < .001) all experienced significant reductions in pain after the intervention. Adjusted multivariate models testing between‐group racial and ethnic differences revealed that Latinos were 62% more likely than whites to report experiencing pain at hospital discharge (relative risk = 0.38, 95% confidence interval = 0.15–0.97). Regardless of race or ethnicity, IPC effectively reduces and controls pain after consultation. Despite pain decreases, Latinos remain more likely than whites to report pain at follow‐up. Further research is needed to determine the mechanisms in operation and to better understand and address the needs of this population.     

Transitions Model: Melding of Psychotherapy and Palliative Care Using Teams

This article explains a hospital palliative model called the Transitions and Palliative Care Therapy (TPCT) and provides data. In addition, the Geriatric Interdisciplinary Team Treatment (GITT) program, using its experience with hospice and research based knowledge, applied key principles of teamwork to enhance the TPCT team approach. GITT was applied to TPCT for 1 year. The TPCT model is a transitions counselors–based model that is a hospital-centered, interdisciplinary consult service, with a focus on the patient and the family. It employs master's level counselors and mid-level providers, with a much smaller group of palliative care physicians who supervise mid-level practitioners and provide medical input and leadership. Outcomes evaluated were hospital cost, family and staff satisfaction, and number of consults that led to de-escalating treatment. In all cases the GITT model was effective; it assisted with improved cost, better satisfaction, and an increased number of consults.     

Palliative cardiovascular care: The right patient at the right time

In the increasingly complex world of modern medicine, relationship-centered, team-based care is important in geriatric cardiology. Palliative cardiovascular care plays a central role in defining the scope and timing of medical therapies and in coordinating symptom-targeted care in line with patient wishes, values, and preferences. Palliative care addresses advance care planning, symptom relief and caregiver/family support and seeks to ameliorate all forms of suffering, including physical, psychological, and spiritual. Although palliative care grew out of the hospice movement and has traditionally been associated with care at the end of life, the current model acknowledges that palliative care can be delivered concurrent with invasive, life-prolonging interventions. As the population ages, patients with serious cardiovascular disease increasingly suffer from noncardiac, multimorbid conditions and become eligible for interventions that palliate symptoms but also prolong life. Management of implanted cardiac support devices at the end of life, whether rhythm management devices or mechanical circulatory support devices, can involve a host of complexities in decisions to deactivate, timing of deactivation and even the mechanics of deactivation. Studies on palliative care interventions have demonstrated clear improvements in quality of life and are more mixed on life prolongation and cost savings. There is and will remain a dearth of clinicians with specialist palliative care training. Therefore, cardiovascular clinicians have a role to play in provision of practical, “primary” palliative care.