Specialized Palliative Care Often More Effective for Advanced COPD, Study Suggests

A Swedish study published in BMC Palliative Care indicated that patient care in late-stage chronic obstructive pulmonary disease (COPD) is superior when carried out in specialized palliative care (SPC) as opposed to hospitals.

The authors asserted SPC can better focus on psychosocial and existential patient support in addition to managing their symptoms.

The Swedish National Airway Register (SNAR) and Swedish Register of Palliative Care were merged and both used to select the main criteria. From the SNAR, researchers identified 1382 patients with moderate to severe COPD and < 50% of predicted forced expiratory volume in 1 second. From those, patients who died either in inpatient or outpatient SPC (n = 159) or in a hospital (n = 439) were identified.

Bivariate and multivariate logistic regression analyses were carried out to determine predictors of place of death, and data was collected from a patient-rated questionnaire with 10 items on a 7-point scale reflecting impact on health-related quality of life.

For reference, the authors report that the majority of registrations came from primary healthcare, with only 14% in specialized pulmonary clinics. The health care professionals at the unit where patient death occurred between 2009-2016 reported characteristics of the patients, the end-of-life care, and symptoms in the last week of life.

As far as patient characteristics, the study found that patients in hospitals were older and more likely to have hypertension or heart failure, as well as more frequently reported pain, compared with those in SPC. Of the 2 locations, SPC was the more preferred place of care (P < .001), with dyspnea, anxiety, delirium, and rattle relieved more often in SPC (all P < .001).

At the Swedish SPC facilities, which are staffed by multi-professional teams, goals of care, future planning, and treatment of other aspects of a patient’s wellbeing were found to be more comprehensive than at home or in a hospital. This was also in part because death was often more expected in SPC, and thus more bereavement support was given to patients and families.

Usually, patients who died in SPC were younger than those in hospital settings, and tended to be men. Characteristics like being a woman, living alone, and having heart failure or hypertension predicted death in a hospital.

Stays in SPC lasted longer for patients than stays in hospital, with 44 days as a mean, with a median of 12 days. The higher mean time was said to be a result from certain patients enrolled for especially longer amounts of time, such that the lengths of stay ranged from 1 to 493 days. Those treated in SPC tended to stay fewer days in the setting before death when compared with those treated with palliative care at home.

More patients dying in SPC had lung cancer, while a greater percentage in hospitals had hypertension and heart failure as comorbidities. Pain medication was more often prescribed in SPC, leading to higher instances of pain relief compared with hospitals.

In general, medication for symptoms like anxiety, nausea, and rattle was distributed at greater frequency and effectiveness in SPC.

Notably, 87% of SPC patients had an end-of-life discussion with a health care provider, compared with only one-third of those hospitalized. The authors feel this may show a link with patients who have these discussions receiving more timely high-quality care.

A few limitations were present in the study. The authors stated there was no way to evaluate differences between those patients registered in the SNAR and those who were not. However, they did feel the large sample size involved was representative of conditions overall, despite the study’s observational design without any random assignment to the care settings. The data collected by the HCP was gathered retrospectively, and did not track the specialty of the hospital wards.

In the future, differences in initial factors should be examined, the authors said, such as the range of comorbidities being different between hospital and SPC groups. Additionally, patients likely had health care contacts not registered in the SNAR in the mean days between their logged visits.

Admission to SPC should be strongly considered more often, the authors asserted, as the data from their study as well as others indicates patients with COPD admitted to SPC need fewer emergency room visits, and are less likely to die in a hospital setting.

Reference

Henoch I, Ekberg-Jansson A, Löfdahl, CG. et al. Benefits, for patients with late stage chronic obstructive pulmonary disease, of being cared for in specialized palliative care compared to hospital. A nationwide register study. BMC Palliat Care. Published online August 24, 2021. doi: 10.1186/s12904-021-00826-y