Coordination of end-of-life care for patients with lung cancer and those with advanced COPD: a letter of response.

Dear Sirs,

The paper by Epiphaniou et al.[1] provides an interesting insight into the inequality of experience that exists between patients with lung cancer and those with chronic obstructive pulmonary disease (COPD) perceived to be approaching the end of their life.

The authors make reference to the ‘prognostic paralysis’ that makes planning time-appropriate care for patients with COPD such a challenge and their own study illustrates this point. Recruiting clinicians were asked to identify patients who were felt to be in the final year of their life. Despite using Supportive and Palliative Care Indicators Tool criteria, the ‘surprise’ question and individual clinical judgement in combination, all seven of the patients with COPD included in the study were alive at the end of the 12-month study period. This compares to the lung cancer group, half of whom had died by the end of the same period. This highlights the current difficulty in the identification of patients with COPD approaching the end of their life.

This prognostic challenge will be familiar to many primary and secondary care physicians dealing with patients with advanced COPD on a regular basis. A study by Pinnock et al.[2] gives some insight into potential reasons behind these difficulties. It identified problems in defining a transition point for the initiation of end-of-life care services in patients with COPD because of the lack of a clear beginning to their disease and an often chaotic, unpredictable end. This is in contrast to patients with cancer who mostly experience a clear trajectory of worsening symptoms leading ultimately to their death.

In addition, prognostication in terminal illness has never been the domain of non-oncology physicians with one study demonstrating that the ability of clinicians to predict mortality in patients suffering from a range of chronic illnesses including cancer was poor.[3]

In a health-care system where access to palliative care is limited in its availability, identifying approaching end of life in these patients is not merely academic—it is of critical importance. The Global Initiative for Chronic Obstructive Lung Disease global strategy for the diagnosis, management and prevention of COPD[4] impresses on the clinician involved in the care of the patient with advanced COPD the need to identify those who would benefit from palliative care services. Clarity of prognosis may ease the current difficulties clinicians face with regard to identification of these patients and with the timing of end-of-life discussions.

Although the Supportive and Palliative Care Indicators Tool mentioned in this study has a relatively high sensitivity, its use specifically in COPD may fail to identify patients appropriate for end-of-life care discussions. We feel that in addition to Supportive and Palliative Care Indicators Tool and the ‘surprise’ question, more specific markers of end-stage COPD need to be explored to determine their prognostic significance in these patients. Examples could include use of long-term oxygen therapy, hospital admissions with hypercapnic respiratory failure requiring ventilation, body mass index, Medical Research Council dyspnoea score and number of hospital admissions with exacerbations in the previous 12 months. A more exhaustive list including measures of disability and physiological impairment may give increasing confidence to the respiratory specialist, general practitioner or key worker contemplating end-of-life care discussions with their patients.