Palliative Care for COPD: Physicians’ Views and Treatment Patterns

Nearly 16 million Americans have a reported diagnosis of chronic obstructive pulmonary disease (COPD), making up 6.4% of the US population.¹ Although various professional guidelines recommend palliative care and advance care planning (ACP) in addition to disease-directed treatment for this population, patients with COPD rarely receive these services. According to previous findings, key barriers to access include physicians’ lack of communication and attitudes regarding such care.^2-4

In a study recently published in the Journal of Pain and Symptom Management, researchers at the Royal Melbourne Hospital in Australia noted that junior physicians often manage patients with COPD who are nearing the end of life.⁵ This highlights the critical need for these physicians to understand the role of palliative care and ACP. To that end, the authors conducted a survey to assess knowledge and attitudes regarding these services in junior physicians who were in training for internal medicine in Victoria, Australia.

The researchers created a questionnaire that “included a case vignette describing an outpatient with severe COPD, receiving maximum disease modifying therapies and worsening, severe refractory breathlessness (Modified Medical Research Council breathlessness score of 4),” the authors reported.⁶ The patient was not in the last few days of life and did not have anxiety. Physicians who took the survey were prompted to describe how they would manage such a case.

Of 822 trainees surveyed, 223 completed the questions. Approximately 77% of respondents were between 20 and 30 years of age, and roughly 46% were men. Further findings were as follows:

• 74.9% of trainees recommended referral to specialist palliative care for advice regarding breathlessness management, and this recommendation was 3 times more likely to come from women vs men (odds ratio [OR], 2.8; 95% CI, 1.2-6.8; P =.022).
• A palliative care referral for other reasons, such as access to shared care, was recommended by 10.8% of respondents, and 7.6% indicated that they would not recommend referral for the patient.
• 73.1% of trainees had reportedly managed patients with COPD who had been referred to palliative care, citing reasons such as symptom management (61.9%), community palliative care input (54.3%), end-of-life care (45.3%), and psychosocial support (20.6%).
• 53.4% of trainees disclosed that they had referred only 1 to 5 patients with COPD to palliative care.
• 48.0% of trainees estimated the patient’s prognosis to be 1 to 2 years, whereas 30.9% estimated the prognosis to be <12 months. Shorter survival estimates were reported by respondents who had been in training for a longer period. Individuals in the third year of training were 70% less likely to estimate the prognosis to be >2 years compared with those in their first year of training (OR, 0.3; 95%CI, 0.1-0.7; P =.007).
• Nearly all respondents believed that a discussion with the patient regarding ACP was appropriate. Approximately half of trainees thought the discussion should be initiated by the patient’s general practitioner, 35.9% thought it should be broached by the respiratory physician, and 7.2% suggested a multidisciplinary approach or initiation by the physician who is most familiar with the patient. No association was found between years of postgraduate training and the respondents’ indication of the need for ACP (P =.762).
• Regarding additional training, 66.4% of respondents were interested in receiving further training relevant to palliative care, and 45.7% desired more training in communication skills to discuss ACP and end-of-life care.

Overall, these findings are promising regarding future receipt of palliative care in this patient group.

“While few patients with COPD discuss advanced care planning or access specialist palliative care services, junior doctors do seem aware of the importance of advanced care planning and palliative care services for this group of patients,” Audreesh Banerjee, MD, an assistant professor of Pulmonary Medicine at the University of Pennsylvania Medical Center in Philadelphia, told Pulmonology Advisor. “One caveat is that this study used an anonymous survey with a case vignette. It would be interesting to see the actual behaviors of these physicians regarding advanced care planning and utilization of palliative care services with their patient panels.”

Dr Banerjee said that future research on this topic should include a randomized trial comparing patients with severe COPD who receive early palliative care interventions, alone or in combination with advanced care planning, vs usual care.

In addition, the study authors noted that the finding that female trainees were far more likely to refer to palliative care warrants further investigation. It would also be useful to examine the views of junior physicians in other countries regarding palliative care.

“[P]ositive views expressed by junior doctors in our study are interesting, and perhaps represents a generational swing away from nihilistic views regarding palliative care, to a greater awareness that high quality, patient-centred care should encompass both disease-directed care together with palliative care in the last few years of life,” the investigators concluded. “Optimistically, improved junior physicians’ attitudes to palliative care will translate long-term into more COPD patients accessing specialist palliative care and thus higher quality care.”

Reference

1. Centers for Disease Control and Prevention. Chronic obstructive pulmonary disease (COPD). https://www.cdc.gov/copd/index.html. Last updated August 4, 2017. Accessed on February 6, 2018.
2. Fadul, N, Elsayem A, Palmer JL, et al. Supportive versus palliative care: what’s in a name?: a survey of medical oncologists and midlevel providers at a comprehensive cancer center. Cancer. 2009;115(9):2013-2021.
3. Patel K, Janssen DJ, Curtis JR. Advance care planning in COPD. Respirology. 2012;17(1):72-78.
4. Rosenwax L, Spilsbury K, McNamara BA, et al. A retrospective population based cohort study of access to specialist palliative care in the last year of life: who is still missing out a decade on? BMC Palliat Care. 2016;15:46.
5. Smallwood N, Gaffney N, Gorelik A, Irving L, Le B, Philip J. Doctors’ attitudes to palliation and palliative care in patients with advanced chronic obstructive pulmonary disease [published online December 8, 2017]. J Pain Symptom Manage. doi: 10.1016/j.jpainsymman.2017.11.020
6. Smallwood N, Gaffney N, Gorelik A, Irving L, Le B, Philip J. Junior doctors’ attitudes to opioids for refractory breathlessness in patients with advanced chronic obstructive pulmonary disease. Intern Med J. 2017;47(9):1050-1056.