Palliative care and prognosis in COPD: a systematic review with a validation cohort

Abstract

Current recommendations to consider initiation of palliative care (PC) in COPD patients are often based on an expected poor prognosis. However, this approach is not evidence-based, and which and when COPD patients should start PC is controversial. We aimed to assess whether current suggested recommendations for initiating PC were sufficiently reliable. We identified prognostic variables proposed in the literature for initiating PC; then, we ascertained their relationship with 1-year mortality, and finally, we validated their utility in our cohort of 697 patients hospitalized for COPD exacerbation. From 24 articles of 499 screened, we selected 20 variables and retrieved 48 original articles in which we were able to calculate the relationship between each of them and 1-year mortality. The number of studies where 1-year mortality was detailed for these variables ranged from 9 for previous hospitalizations or FEV1 ≤30% to none for albumin ≤25 mg/dL. The percentage of 1-year mortality in the literature for these variables ranged from 5% to 60%. In the validation cohort study, the prevalence of these proposed variables ranged from 8% to 64%; only 10 of the 18 variables analyzed in our cohort reached statistical significance with Cox regression analysis, and none overcame an area under the curve ≥0.7. We conclude that none of the suggested criteria for initiating PC based on an expected poor vital prognosis in COPD patients in the short or medium term offers sufficient reliability, and consequently, they should be avoided as exclusive criteria for considering PC or at least critically appraised.

The potential of palliative care for patients with respiratory diseases

“…Palliative care along with disease-focused evidence-based care with ongoing patient education and support are needed [ 41 ]. Studies have documented that palliative care in COPD is more effective when offered earlier in the trajectory, rather than waiting for referrals at the end of life [ 40 , 42 ].…”

Low uptake of palliative care for COPD patients within primary care in the UK

“…However, compared with patients with lung cancer who suffer from a similar burden of disabling symptoms and psychological distress, small studies or studies using select COPD cohorts have found over the past decade that COPD patients often have limited access to palliative care services [ 9 – 13 ], even when compared with patients with other chronic terminal diseases [ 14 ]. It is likely that a major reason for this is the difficulty in predicting when to initiate PCS; current recommendations are to deliver PCS during the last year of life, but prognosticating the life expectancy of individuals with COPD has proven to be extremely difficult [ 1 , 15 , 16 ]. Consequentially, there is no commonly accepted definition of “end-stage COPD”.…”

Letter to the editor regarding: "Development of the ProPal-COPD tool to identify patients with COPD for proactive palliative care"

“…They worried that patients in need of PCC would be missed out, because a recent review showed that existing prognostic criteria were not sufficiently reliable. 2 However, as mentioned in our article, prediction of mortality or identification of the terminal phase was never our objective. Our actual objective was to develop a tool as an additional aid to identify patients with COPD who are in need of PPC.…”

“…Nevertheless, its exclusive use may exclude many patients who could benefit from PPC. 2 For instance, in the model proposed by Duenk et al, seven dichotomic predictor variables were suggested to consider PPC based on their relationship with 1-year mortality. However, it seems clear that a COPD patient with severe airflow obstruction, disabling dyspnea, and several previous hospitalizations, although strictly not meeting all the recommended criteria, is a candidate for PPC.…”