Treatment decisions in end-stage COPD: who decides how? A cross-sectional survey of different medical specialties

Abstract

IntroductionEnd-stage chronic obstructive pulmonary disease (COPD) patients with acute respiratory failure are often treated by representatives from different medical specialties. This study investigates if the choice of treatment is influenced by the medical specialty.MethodsAn online cross-sectional survey among four Austrian medical societies was performed, accompanied by a case vignette of a geriatric end-stage COPD patient with acute respiratory failure. Respondents had to choose between noninvasive ventilation (NIV), a conservative treatment attempt (without NIV) and a palliative approach. Ethical considerations and their impact on decision making were also assessed.ResultsResponses of 162 physicians (67 from intensive care units (ICUs), 51 from pulmonology or internal departments and 44 from geriatric or palliative care) were included. The decision for NIV (instead of a conservative or palliative approach) was associated with working in an ICU (OR 14.9, 95% CI 1.87–118.8) and in a pulmonology or internal department (OR 9.4, 95% CI 1.14–78.42) compared with working in geriatric or palliative care (Model 1). The decision for palliative care was negatively associated with working in a pulmonology or internal department (OR 0.16, 95% CI 0.05–0.47) and (nonsignificantly) in an ICU (OR 0.41, 95% CI 0.15–1.12) (Model 2).ConclusionsDepartment association was shown to be an independent predictor for treatment decisions in end-stage COPD with acute respiratory failure. Further research on these differences and influential factors is necessary.

Chronic obstructive pulmonary disease trajectory: severe exacerbations and dynamic change in health-related quality of life

“…Chronic obstructive pulmonary disease (COPD) is common and the leading cause of severe deterioration in health-related quality of life (HRQoL) 1 2. The life trajectory of COPD has traditionally been illustrated as a continuous accelerated decay in health status known as the accelerated frailty phase 3 4. The deterioration of health status accompanied by frequent acute exacerbation (AE) and hospitalisation is thought to be an accelerated frailty phase for the natural course of patients with COPD.…”

“…The deterioration of health status accompanied by frequent acute exacerbation (AE) and hospitalisation is thought to be an accelerated frailty phase for the natural course of patients with COPD. Patients with COPD could approach the end of life owing to disease exacerbation or comorbidities 2–5 years after entering this phase 3. Suissa et al observed that patients with COPD, after their first AE requiring hospitalisation, that is, severe AE (SAE), have 5 years of stable disease between their first and second AE, called the prolonged stable phase 5.…”

“… 1 2 The life trajectory of COPD has traditionally been illustrated as a continuous accelerated decay in health status known as the accelerated frailty phase. 3 4 The deterioration of health status accompanied by frequent acute exacerbation (AE) and hospitalisation is thought to be an accelerated frailty phase for the natural course of patients with COPD. Patients with COPD could approach the end of life owing to disease exacerbation or comorbidities 2–5 years after entering this phase.…”

“…Patients with COPD could approach the end of life owing to disease exacerbation or comorbidities 2–5 years after entering this phase. 3 Suissa et al observed that patients with COPD, after their first AE requiring hospitalisation, that is, severe AE (SAE), have 5 years of stable disease between their first and second AE, called the prolonged stable phase. 5 However, the life trajectory of patients with COPD hospitalised for the first time, combined with the natural course of severe exacerbations and dynamic changes in HRQoL in reality, is unknown.…”

Older age, disease severity and co-morbidities independently predict mortality in critically ill patients with COPD exacerbation

“…Infectious exacerbations or end-stage disease have been identified as major causes of ICU admittance [12][13][14] . As yet, many studies have attempted to identify independent predictors of the outcomes of these patients in the ICU, however, the results are not consistent across studies, except for Acute Physiology and Chronic Health Evaluation (APACHE)-II score which seems to have a reproducible effect [15][16][17][18] .…”