Dying Patients With COPD Subjected to Testing Despite Shift to Comfort Care, Study Finds

There are missed opportunities for reducing diagnostic tests and focusing on comfort at the end of life for patients with chronic obstructive pulmonary disease (COPD), according to researchers, whose study findings discovered a high burden of testing on patients dying with the disease in the hospital, even after a decision to provide comfort care only in some cases.

As a result, the researchers are calling for enhanced clinical training on end-of-life care and managing death and strategies to improve communication to address the issue.

The researchers retrospectively examined the medical record audits of 343 patients from 2 Australian hospitals over a 12-year period and identified a median of 11 diagnostic testing episodes per patient. Nearly every patient received diagnostic tests during their terminal admission.

Notably, most patients (81%) received diagnostic testing in their last 2 days of life and 12% of patients underwent ongoing investigations even after the care team had determined the patient was actively dying and had refocused the goal of care to comfort.

Slightly more than one-third, or 108 patients, had at least 1 test performed on the day of their death; of those 108 patients, 36 died on the same day they were admitted to hospital.

“Possible explanations for this practice including poor communication or limited understanding within the junior medical team that such tests can cease, family pressure to continue active management, and clinical reluctance to “give up” or remove hope,” explained the researchers. “Maintaining interventions and testing may also have a symbolic value that allows clinicians, family and patients to accept a palliative strategy and avoid the perception of abandonment.”

Younger patients (under 70 years) were significantly more likely to undergo diagnostic testing, receiving a median of 17.4 tests, compared with older patients (over 70 years), who received a median of 10 tests.

Having an increased investigational burden was significantly associated with ICU or CCU admission, as well as requiring non-invasive ventilation or intubation.

The researchers found that patients were less likely to have a high investigation burden if they had a prior admission in which their goals of care documentation indicated limited active medical treatments. Having prior admissions for COPD in the last 2 years, having a pre-admission referral to a specialist palliative care team, and using domiciliary oxygen pre-admission were also associated with a reduced investigation burden.

The burden of end-of-life testing was not significantly affected by characteristics like gender, smoking status, disease severity on spirometry, cardiac comorbidity, or pneumonia diagnosis at admission.

Reference

Ross L, Taverner J, John J, et al. The burden of diagnostic investigations at the end of life for people with COPD. Intern Med J. Published online June 16, 2020. doi:10.1111/imj.14943.