Respiratory Nurses Have Positive Attitudes But Lack Confidence in Advance Care Planning for Chronic Obstructive Pulmonary Disease

Abstract

Chronic obstructive pulmonary disease (COPD) is a progressive, life-limiting illness. Despite significant symptom burden, access to advance care planning (ACP) and palliative care are limited. Early initiation of ACP enables patients to articulate the values that underpin the decisions they would make if, in the future, they are unable to speak for themselves. Nurses constitute the majority of health care workforce and are well placed to initiate these discussions. This study explored knowledge, attitudes, and practice regarding ACP for patients with COPD among Australian and New Zealand respiratory nurses. A cross-sectional online survey tested knowledge about ACP and canvassed attitudes about current practice. Data were analyzed using descriptive statistics and content analysis of text data. The 112 participating respiratory nurses had substantial knowledge and positive attitudes regarding ACP in COPD; however, they lacked confidence and clarity regarding their role. Despite advances in end-of-life care provision for chronic disease, well-established barriers remained (inadequate training, fear of distressing patients, and time), and discussion triggers were still linked to acute deterioration, diagnosis of severe disease, and patient initiation. Better articulating the role of the respiratory nurse in ACP and building capacity and confidence within this workforce may improve ACP access for people living with COPD.

Knowledge and Attitudes of Allied Health Professionals Towards End-Of-Life and Advance Care Planning Discussions With People With COPD: A Cross-Sectional Survey Study

“…Indeed, the importance of initiating these discussions early in the disease trajectory to prevent decisional crises and improve patient and families’ satisfaction with care was well recognised within this cohort. This is consistent with surveys of respiratory nurses 29 and pulmonary rehabilitations clinicians. 30 Despite each of these professions being well placed to initiate early ACP discussions in advanced lung disease clinics and pulmonary rehabilitation services, 31 many were under the impression that other health professionals were managing these conversations.…”

“…These findings are in line with international literature on perceived barriers to ACP, 5,27,28 as well as recent data on respiratory and palliative care nurses. 19,20 Uncertainty around which specialty and discipline should shoulder the responsibility for EOL and ACP discussions has been a consistent finding in previous studies across disease groups and presents recurrent 'missed opportunities' for engaging patients with chronic disease. Indeed, the importance of "Fear, reality, family understanding" (P.26 OT) "The clients readiness to accept their diagnosis and its ramifications" (P.109 OT) "In the group setting, I have had feedback that some patients find it "depressing" to talk about ACP; Some patients state they "trust the doctors to make the decision" (P.53 social worker)…”

“…These findings are in line with international literature on perceived barriers to ACP, 5,27,28 as well as recent data on respiratory and palliative care nurses. 19,20…”

“…18 In Australia and New Zealand (NZ), past research has shown that respiratory nurses have positive views and good knowledge of ACP practice and EOL discussions, although lack confidence and appropriate training to effectively utilise this in their practice. 19 Palliative care nurses similarly show substantial knowledge and positive beliefs regarding ACP, but many highlighted a lack of consensus regarding when to initiate ACP in the disease trajectory and which specialty and discipline should lead this. 20 A commonly cited barrier is the relapsing-remitting nature and uncertain prognosis of COPD with many emphasising the importance of a cross-disciplinary approach towards early engagement.…”