The integration of palliative care in cancer care is an emerging trend driven by data on the benefits of palliative care intervention in the care of patients with terminal malignancies. Although studies have shown that patients with end-stage organ disease tend to develop similar symptoms and issues as those of cancer patients, the use of palliative care services among patients with end-stage organ disease seems to be limited.1 The clinical course of terminal malignancy is usually marked by a consistent decline, whereas organ failure is usually marked by periods of exacerbations in relation to decompensation.2 Patients with organ failure often exhibit a gradual and subtle decline over time, making it more challenging to predict the disease course.2
Woo and colleagues studied patients with chronic illnesses and showed that, similar to patients diagnosed with cancer, symptoms of fatigue, pain, and dyspnea were common.3 They also found that caregivers of patients with chronic illness reported suboptimal physical and emotional well-being as well as moderate levels of stress.3 These findings suggest that caregivers for cancer and noncancer patients will benefit from the support inherent in an interdisciplinary approach to palliative care.3 According to the CDC, the second leading cause of death in the U.S. in 2011 was cancer followed by chronic respiratory disease.4
The authors conducted a quality improvement (QI) initiative to explore the benefits of integrating palliative care in the care of patients with chronic obstructive pulmonary disease (COPD) and share outcomes of improved palliative care education at John D. Dingell VAMC (JDDVAMC) in Detroit, Michigan, for care of patients with COPD.
Background
Chronic obstructive pulmonary disease is a progressive, incurable lung disease.5 It also has been referred to as chronic bronchitis, emphysema, or chronic asthma.5 The degree of severity of COPD is determined by measuring the degree of air flow obstruction by conducting a spirometry test.5 Common symptoms associated with COPD include dyspnea, cough, wheezing, recurring respiratory infections, and generalized weakness.5
Compared with terminally ill patients with lung cancer, patients with COPD were found to have a poorer quality of life as well as more anxiety and depression.6 In a study to evaluate for breathlessness among patients with severe COPD and advanced cancer, Bausewein and colleagues found that both groups reported moderately distressing physical symptoms.7 Both groups also reported shortness of breath as their most distressing physical symptom and worrying as the most common psychological symptom.7 The study also identified a 50% commonality among the participants on palliative care needs.7
The common palliative care needs that were identified were the need for symptom management for breathlessness, access to information, ability to share feelings, a sense of wasted time, and assistance with practical matters.7 During the study’s 6-month data collection period, 61% of the patients with cancer and 10% of the patients with COPD died.7 Median survival for both groups showed that the patients with COPD had a significantly longer median survival of 589 days compared with 107 days for the patients with cancer.7
A retrospective review of patient records from 2010 to 2013 showed that providers referred only 5% of patients with COPD for palliative care.8 In the United Kingdom, the 5-year survival rate among patients diagnosed with severe COPD is 24% to 30%.9 Chronic obstructive pulmonary disease is one of the most common causes of hospital admissions, and treatments are aimed toward palliation of symptoms.9 As COPD reaches its end stage, incorporation of end-of-life (EOL) care should be considered. Signs that may indicate EOL care is needed include long-term oxygen therapy, depression, hospitalization for exacerbations at a rate of 2 or more a year, evidence of right-sided heart failure, cortisone treatment for > 6 weeks, and a history of noninvasive ventilation or admission to the intensive care unit (ICU).9
Nguyen and colleagues conducted a study in Montreal, Canada, among patients with moderate-to-severe COPD.10 The participants watched a DVD on EOL topics as well as life support measures and their implications.10 After watching the DVD, the researchers conducted interviews with the participants’ about their beliefs and experiences with regards to advance care planning.10 In conducting advance care planning, the participants identified having a relationship with the medical team and appropriate timing for the discussion as important.10
Crucial topics identified by participants included life expectancy, availability of medications to treat symptoms, different treatment options, stages of disease progression, and quality of EOL care.10 Other findings from the study included the participants’ desire to consider their families in the decision-making process.10 Becoming a burden to their families due to their need for physical and financial assistance and the inability to establish clear health care directives were identified as sources of concern.10 Many of the participants also shared a preference to die rather than to give up quality of life or mental capacity.10 Nguyen and colleagues also found that the severity of illness was not a good predictor of the participants’ readiness to engage in advance care planning.10