Palliative Care For Patients With Advanced Chronic Obstructive Pulmonary Disease (COPD) Remains Underutilized

P atients with advanced chronic obstructive pulmonary disease (COPD) have a high burden of distressing symptoms and poor quality of life. Palliative care strategies can address this; however, robust research in the use of these strategies is lacking, including studies to comprehensively assess the utilization of palliative care services in advanced COPD. This study examines the rates of formal palliative care consultation, opioid use, and long-term oxygen therapy (LTOT) for patients with advanced COPD in Ontario over a period of 10 years. The authors conducted a population-based repeated crosssectional study using health administrative data from Ontario, Canada. Health administrative databases were used to provide basic demographic data, services provided by physicians, a prescription medication for those 65 years of age or older, and the use of LTOT from 2004 to 2014, in patients with a diagnosis of COPD. Patients with advanced COPD were identified on the basis of those with ≥ 1 hospitalizations for COPD and/or the use of LTOT in those with COPD. Given that COPD is difficult to prognosticate compared with other disease groups that utilize palliative care services frequently,1 this study was unique in that it did not limit assessment of patients within their last year of life, but rather any palliative care service use during the defined study period. For this study, about 25% of patients with advanced COPD had a COPD-related hospitalization, with a mortality rate of around 18%. This study demonstrated that there was an increase in the use of formal palliative care services from 5% in 2004 to 14% in 2014 for their patient population with advanced COPD. They found that 42% of their cohort received formal palliative care services within the last 6 months of life. Although this is an important trend, it suggests that formal palliative care services are still underutilized, given the high burden of symptoms reported by patients with COPD, and the potential to expand end-of-life series to this population. Opioid use in patients with advanced COPD can alleviate severe dyspnea.2 However, numerous studies have shown relatively low use of opioids in patients with COPD even in the last year of their life, from 10% to 25% in various international studies. This has been attributed to lack of knowledge, education, and lack of guidelines. In this study, which did not define the indication for opioid prescription, 40% of patients with advanced COPD had a prescription for opioids in any given year. This is higher than has been found in other studies, but, again, it suggests underutilization, given the high reports of symptoms such as breathlessness in COPD patients. LTOT can also alleviate dyspnea and can be considered part of a palliative care strategy for patients with advanced COPD. This study found an increase in the rate of LTOT use of about 1% per year to 35% use in the final year of the study. Again, while this is an important trend, it suggests that there may be an underutilization of LTOT for symptom relief in patients with advanced COPD. In summary, this study provides a more comprehensive assessment of palliative care utilization for patients with advanced COPD. Although there has been an increase in the use of palliative care strategies, it suggests an underutilization of these strategies, which may help alleviate significant symptom burden and suffering for patients with advanced COPD.