A Palliative Approach is Adopted for Many Patients Dying in Hospital with Chronic Obstructive Pulmonary Disease

Figures & data

Figure 1. Study participants’ eligibility.

Table 1. Patients’ clinical characteristics.

Characteristic	All (n = 343		RMH (n = 221)		NHW (n = 122)		Statistical difference between sites
Age (years)*	79.4	(71.4–85.0)	80.0	(72–85)	76.5	(70.0–84.3)	–
Male	217	(63.3%)	136	(61.5%)	81	(66.4%)	–
Ex-smoker	225	(65.6%)	156	(70.6%)	69	(56.6%)	p < 0.0001
Current smoker	80	(23.3%)	55	(24.9%)	25	(20.5%)	–
Never smoked	38	(11.1%)	10	(4.5%)	28	(23.0%)	–
Coexisting respiratory disease	113	(32.9%)	65	(29.4%)	48	(39.3%)	p < 0.0001
Bronchiectasis	18	(5.2%)	13	(5.9%)	5	(4.1%)	–
Asthma	38	(11.1%)	8	(3.6%)	30	(24.6%)	–
Pulmonary embolism	8	(2.3%)	8	(3.6%)	0		–
Pulmonary fibrosis	15	(4.4%)	6	(2.7%)	9	(7.4%)	–
Other respiratory disease	34	(9.9%)	30	(13.6%)	4	(3.3%)	–
Cor pulmonale	101	(29.4%)	94	(42.5)	7	(5.7%)	p < 0.0001
Comorbidities present	313	(91.3%)	197	(89.1%)	116	(95.1%)	–
Mean number of comorbidities**	3	(1.7%)	3	(1.5)	4	(1.8)	–
Cardiac disease	195	(56.9%)	113	(51.1%)	82	(67.2%)	p = 0.005
Pulmonary function tests	166	(48.4%)	125	(56.6%)	41	(33.6%)	–
FEV1 (L)*	0.80	(0.61–1.22)	0.82	(0.63–1.08)	0.87	(0.65–1.30)	–
FEV1 % predicted**	42	(16)	43	(17)	42	(15)	–
FVC (L)*	2.02	(1.62–2.57)	2.00	(1.61–2.66)	1.95	(1.59–2.66)	–
FVC % predicted**	73	(23)	74	(21)	70	(27)	–
DLco*(ml/min/mmHg)	9.00	(6.35–12.85)	8.04	(6.01–11.04)	11.70	(7.10–18.55)	–
DLco % predicted**	42	(17)	41	(17)	44	(17)	–
6MWT distance (m)**	170	(122)	170	(127)	171	(116)	–
BMI**	24.6	(8.4)	24.3	(5.8)	25.7	(13.7)	–
Domiciliary oxygen	164	(47.8%)	109	(49.3%)	55	(45.1%)	–

Date are presented as counts with frequencies, medians* with IQRs or means** with SDs. FEV₁= Forced expiratory volume in 1 second, FVC = Forced vital capacity, DLco = Diffusing capacity of the lung for carbon monoxide, 6MWT = Six minute walk test, BMI = Body mass index, and ‘–’ = no significant difference in patient characteristic between sites.

Table 2. Previous outpatient care and admissions.

	All (n = 343)		RMH (n = 221)		NHW (n = 122)		Statistical difference between sites
Outpatient care	195	(56.6%)	113	(51.1%)	82	(67.2%)	p < 0.0001
Hospital respiratory clinic	51	(14.9%)	51	(23.1%)	N/A	N/A	–
Advanced Lung Disease clinic	9	(2.6%)	9	(4.1%)	N/A	N/A	–
Hospital general medicine clinic	67	(19.5%)	27	(12.2%)	40	(32.8%)	–
Other medical clinic at RMH/NHW	13	(3.8%)	13	(5.9%)	N/A	N/A	–
Private respiratory clinic	55	(16.0%)	13	(5.9%)	42	(34.4%)	–
Mean number of public (RMH) or private (NHW) respiratory clinic visits per patient**	4.1	(3.3)	3.9	(2.8)	4.4	(3.9)	–
Community palliative care	30	(8.7%)	18	(9.1%)	12	(9.8%)	–
Any previous palliative contact	60	(17.5%)	45	(20.3%)	15	(12.3%)	–
Advance directive (AD) written	17	(5.0%)	13	(5.9%)	4	(3.3%)	–
Discussed advance care planning as outpatient but no AD written	35	(10.2%)	26	(11.8%)	9	(7.4%)	–
Time from writing AD or discussing ACP to death (days) (n = 52)*	179	(65–439)	152	(56–303)	462	(233–614)	p = 0.042
Opioids prescribed for breathlessness as an outpatient	21	(6.1%)	15	(6.8%)	6	(4.9%)	–
Respiratory physician commenced opioids	13	(3.8%)	13	(5.9%)	N/A	N/A	–
General physician commenced opioids	4	(1.2%)	2	(0.9%)	2	(1.6%)	–
Palliative care specialist commenced opioids	3	(0.9%)	0	0	3	(2.5%)	–
GP commenced opioids	1	(0.3%)	0	0	1	(0.8%)	–
Time from starting outpatient opioids to death (days) (n = 21)*	47	(14–346)	48	(14–365)	36	(12–271)	–
Past RMH or NHW admissions	195	(56.9%)	129	(58.3%)	66	(54.1%)	–
Number of admissions per patient*	2	(1–3)	2	(1–3)	2.5	(2–4)	–
Palliative treatments given in a previous admission	23	(6.6%)	16	(7.2)%	7	(5.7%)	–
Previous admission with palliation documented as the goal of care	17	(5.0%)	13	(5.9%)	4	(3.3%)	–
Palliative care referral made in a past admission	21	(6.1%)	18	(8.1%)	3	(2.5%)	–
‘Not for resuscitation’ documented during a past admission	106	(30.9%)	81	(36.7%)	25	(20.4%)	p = 0.001
Time from previous admission with ‘Not for resuscitation’ documented to death (days) (n = 106)*	145.5	(48.3–370.3)	156	(70–383)	140	(48.5–461.5)	–

Data are presented as counts with frequencies, medians* with IQRs or means ** with SDs. Data refer to outpatient and inpatient activity in the 2 years before death. N/A = clinic or personnel no available at that site and ‘- ‘= no significant difference in patient characteristic between sites. Any previous palliative care contact includes from the Advanced Lung Disease clinic (RMH only), community or inpatient palliative care teams.

Table 3. Terminal admission care.

	All (n = 343)		RMH (n = 221)		NHW (n = 122)		Statistical difference between sites
Admitting team							p < 0.0001
Respiratory medicine	61	(17.8%)	61	(27.6%)	N/A	N/A
General medicine	254	(74.1%)	134	(60.6%)	120	(98.4%)
Palliative medicine	9	(2.6%)	9	(4.1%)	N/A	N/A
Other medical team	17	(5.0%)	17	(7.7%)	N/A	N/A
General practitioner	2	(0.6%)	N/A	N/A	2	(1.6%)
Admitted to ICU or HDU or RCU	194	(56.6%)	134	(60.6%)	60	(49.1%)	p = 0.04
Treating time at time of death							p < 0.0001
Respiratory Medicine	59	(17.2%)	59	(26.7%)	N/A	N/A
General Medicine	235	(68.5%)	115	(52.0%)	120	(98.4%)
Palliative Medicine	33	(9.6%)	33	(14.9%)	N/A	N/A
Other medical team	14	(4.1%)	14	(6.3%)	N/A	N/A
General Practitioner	2	(0.6%)	N/A	N/A	2	(1.6%)
End-of-life care
Referred to palliative care*	99	(28.9%)	92	(41.6%)	7	(5.7%)	p < 0.0001
Goal of care documented as palliation	252	(73.5%)	187	(84.6%)	65	(53.3%)	p < 0.0001
‘Not for resuscitation’ documented	236	(68.8%)	131	(59.3%)	105	(86.1%)	p < 0.0001
Opioids prescribed	294	(85.7%)	187	(84.6%)	107	(87.7%)	–
Number of opioid drugs (mean)	1	(0.6)	1	(0.6)	1	(0.6)	–
Opioid name							p = 0.020
Morphine	286	(83.4%)	182	(82.3%)	104	(85.2%)
Oxycodone	52	(15.2%)	24	(10.9%)	28	(23.0%)	–
Other opioid	10	(2.9%)	7	(3.2%)	3	(2.4%)	–
Benzodiazepines prescribed	226	(65.9%)	146	(66.1%)	80	(65.6%)
Place of death							p < 0.0001
ICU/HDU/RCU	105	(30.6%)	70	(31.7%)	35	(28.7%)
Medical ward	188	(54.8%)	107	(48.4%)	81	(66.4%)
Palliative care ward	31	(9.0%)	31	(14.0%)	N/A	N/A
Emergency department	19	(5.5%)	13	(5.9%)	6	(4.9%)

Data are presented as counts with frequencies. N/A = clinical team or ward not available at that site and ‘–’=no significant difference in patient characteristic between sites. *For RMH the total number of patients eligible for referral to palliative medicine was 212, as 9 were admitted under palliative care initially.

Figure 2. Initiation and continuation of treatments during the terminal admission for the whole cohort (n = 343). NIV = Non-invasive ventilation and LMWH = Low molecular weight heparin. Steroids refers to oral steroids, not inhaled steroid use. Statins and anti-platelet medications had been initiated prior to the terminal admission.

Figure 3. Initiation and continuation of terminal admission treatments by site. Each block of 4 bars represents one treatment, with initiation and continuation shown for RMH in the first 2 bars as dark blue and dark red and NHW in the second 2 bars as light blue and light red. NIV = Non-invasive ventilation, BD = Nebulised bronchodilators and LMWH = Low molecular weight heparin. * represents a significant difference in practice between RMH and NHW.

Figure 4. Timeline of admission events (n = 343).

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