Dying COPD Patients Receive Increasing Rate of Life-Sustaining Procedures over Time

Among patients with chronic obstructive pulmonary disease (COPD) hospitalized at the end of life, the utilization of life-sustaining procedures such as mechanical ventilation and cardiopulmonary resuscitation (CPR) showed a significant interval increase from 2010 to 2014. Over the same time period, the documentation of do-not-resuscitate (DNR) status also increased significantly, while the use of palliative care consultations increased only slightly.

“To the best of our knowledge, this is the first study to report the five-year national temporal trends of life-sustaining procedures and palliative care for dying patients with COPD in US hospitals,” write the authors of a study published in the Journal of Palliative Care.

Investigators analyzed data from the National Inpatient Sample, a nationally representative database, on 38,425 adults with COPD (mean age, 73.1 years; female, 53.5%; white race, 82.5%) who died while hospitalized from 2010 to 2014. Temporal trends were quantified using the compound annual growth rate (CAGR).

Overall, 48.9% of dying COPD patients had at least one life-sustaining procedure. 38.6% received a palliative care consultation and 33.7% had a recorded DNR status. 

Key Findings:

• The rate of patients undergoing multiple life-sustaining procedures increased over time (CAGR: 6.61%), while the rate of those with no such procedures decreased (CAGR: -9.73).
• The CAGRs of all life-sustaining procedures increased (dialysis, 13.2%; CPR, 11.99%; vasopressor use, 11.95%; ventilation, 5.45%), with the exception of nutrition (-7.69%)
• Both DNR status (CAGR: 36.62%) and palliative consultation (CAGR: 5.25%) increased over time.

In multivariate analysis, occurrence of a palliative care consultation increased the likelihood of DNR status (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.44 to 1.56) and decreased likelihood of local procedures (OR, 0.72; 95% CI, 0.69 to 0.77), systemic procedures (OR, 0.69; 95% CI, 0.64 to 0.73) and surgeries (OR, 0.65; 95% CI, 0.61 to 0.70).

Increase in Aggressive Procedures

Possible reasons for the upward trend in the use of aggressive procedures, note the authors, include not only technological advancements and the increased number of available ICU beds, but also late referral to hospice or hospital based palliative care for patients admitted due to disease progression.

“Life-sustaining procedures almost always initiate until the goal of care is firmly established by the patient or by the healthcare proxy,” they write.

Challenges to timely palliative/hospice care referral of COPD patients include a lack of end-of-life communication, prognostic difficulty, diverse patient characteristics and a lack of resources, the authors note.

Limitations to their analysis noted by the authors include their inability to assess whether those patients who received palliative care consultations would choose home hospice care and whether temporal trends were influenced by the recent Medicare billing code changes that allow clinicians to bill for advance care planning discussions.

Earlier Palliative Care Needed:

According to the authors of an editorial accompanying the report, while the increase in the rate of palliative care consultations for dying COPD patients found in this study may seem encouraging, it is important to keep in mind that the presence of palliative care teams in US hospitals also increased during the study period.

What the editorial authors find “alarming” is that the rate of increase in invasive, life-sustaining procedures used for these dying COPD patients outpaced the rate of increase in palliative care delivery. Initiating a palliative care consult for patients already hospitalized near death is “too late,” they note.

“[E]xpert end-of-life care is but a drop in the ocean of what palliative care can offer for patients with COPD and their caregivers,” write the commenters. “The continuum of care model instead teaches us that palliative care should be instituted early in serious illness to provide comprehensive physical, emotional, social, and spiritual support alongside proactive end-of-life planning.”

The editorial writers conclude, “Pulmonologists who care for patients with COPD from diagnosis and through the end of life are uniquely poised to implement early palliative care in COPD to address the unmet symptom and advance care planning needs of patients with COPD and their family caregivers.”

Source: “Life-Sustaining Procedures, Palliative Care Consultation and Do-Not Resuscitate Status in Dying Patients with COPD in US Hospitals: 2010-2014,” Journal of Palliative Care; July 2018; 33(3):159-166. Shen JJ, Ko E, Yoo JW et al; Department of Healthcare Administration and Policy, University of Nevada Las Vegas, Las Vegas, NV; School of Social Work, San Diego State University, San Diego, CA; and Department of Family Medicine and Department of Internal Medicine, University of Nevada Las Vegas, LasVegas, NV.

“Easing the Tension between Palliative Care and Intensive Care in Chronic Obstructive Pulmonary Disease,” ibid.: pp. 123-124. Iyer AS et al; Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine; and Health Services, Outcomes and Effectiveness Research Training Program, University of Alabama at Birmingham, Birmingham, AL.