Abstract
Background:
Palliative care is essential for managing advanced chronic illnesses (ACI) but remains underused.
Objectives:
We aimed to evaluate the prevalence, associations, and outcomes of palliative care utilization (PCU) in patients with ACIs.
Design:
A prospective observational questionnaire-based study.
Methods:
The study included hospitalized patients with severe COPD (n = 53), advanced heart failure (HF; n = 56), or metastatic malignancy (n = 57). Participants were interviewed about their demographics, health status, PCU, and end-of-life decision-making.
Results:
A total of 166 subjects were included (median age: 77 years; 41% females), with a 1-year median of 2 hospital admissions. Subjects with COPD and HF had low rates of PCU compared to those with malignancy (6% and 11% vs 39%, p < 0.01). PCU occurred exclusively in patients who had visited a specialist (cardiologist, pulmonologist, or oncologist) before study inclusion. Patients with PCU were more aware of advance directives (71% vs 38%), signed advanced orders (23% vs 3%), and shared their end-of-life decisions with others (71% vs 29%). These differences remained significant after adjustment for prior specialist visits. Independent associations with PCU were self-identifying as non-religious (adjusted OR 3.41, 95% CI 1.2–9.9), above high-school education (AOR 2.84, 95% CI 1.1–7.3), and chronic pain (aOR 2.81, 95% CI 1.11–7.14), while COPD showed the opposite (aOR 0.25, 95% CI 0.07–0.96).
Conclusion:
Palliative care utilization is alarmingly low among patients with HF and COPD despite significant symptom burden. Specialists should advocate for PCU as their involvement could enhance end-of-life care planning, improve patient outcomes, and address current gaps in care.
Keywords: advance directives, COPD, end-of-life, HF, palliative care, specialist
Plain language summary
Palliative care use by patients with advanced lung and cardiac diseases
Palliative care is medical care focused on improving the quality of life for people with serious illnesses. However, many people with chronic conditions like heart failure (HF) and chronic obstructive pulmonary disease (COPD) are not receiving this type of care. This study looked at how often palliative care is used by people with severe COPD, advanced heart failure, or metastatic cancer by interviewing patients with these conditions while they were admitted to the hospital. The results showed that palliative care was much more common among cancer patients than the others. Patients who had visited a specialist doctor (such as a cardiologist, pulmonologist, or oncologist) were more likely to receive palliative care. Those who received palliative care were also more aware of end-of-life planning, more likely to have signed advance directives (legal documents that outline future medical care wishes), and more likely to have shared their end-of-life preferences with loved ones. In conclusion, many people with severe heart failure and COPD are not getting palliative care, even though they could benefit from it. Specialists play a key role in improving access to this care and more awareness and better communication between doctors and patients could improve end-of-life care for people with these chronic illnesses.
Introduction
Palliative care in patients with advanced chronic illnesses (ACI) has improved patient and healthcare system outcomes. 1 Since these patients suffer from a high disease burden, increased disability, and low quality of life, the main goal of palliative care is to reduce the suffering of patients and their families as well as to assist them with end-of-life decision-making. 2 Regarding healthcare systems, palliative care is associated with reduced costs via reduced hospitalization days and aggressive medicalization. 3 However, disparities in palliative care utilization (PCU) among different patient populations persist. Although awareness and accessibility to palliative care have increased in the last decade,4,5 there is a large discrepancy between PCU by patients with cancer and patients with other ACI.5,6 Current guidelines recommend the use of palliative care in patients with severe heart failure (HF) 7 and chronic obstructive pulmonary disease (COPD), 8 but this resource remains underused in these patient populations. Previous studies demonstrated that less than 10% of patients with HF received palliative care services, 9 and only approximately 20% of COPD patients received a referral to a palliative care specialist. 10
Primary care physicians have an integral role in managing patients with ACIs, and potentially can engage in end-of-life conversations. However, in real-life practice, this is often challenging due to time constraints and difficulty in accurately assessing patients’ prognoses.11,12 Thus, specialist physicians play a critical role in bridging this gap, both during the acute and ambulatory settings. Although PCU was investigated in different conditions, most prior studies focused on primary care physicians or included a general population suffering from each disease, without focusing on those with advanced disease, who are at the highest need of palliative care. In addition, most prior studies relied on retrospective data without interviewing patients to understand the effect of PCU on their preferences and beliefs.
In the current study, we sought to evaluate the prevalence, determinants, and associations with outcomes of PCU in patients with ACI. Our analysis focuses on three patient groups: those with COPD, HF, and cancer. These groups represent varying symptom burdens, care trajectories, and end-of-life challenges, making them ideal for investigating disparities in PCU.
Methods
Study design, population, and data collection
We conducted a prospective questionnaire-based study enrolling consecutive patients with ACI hospitalized in an internal medicine ward of a tertiary hospital between October 2021 and October 2022. The study used a questionnaire that included domains regarding symptom burden, healthcare utilization, advance directive awareness, and end-of-life decision-making preferences (Supplemental Appendix). The questionnaire was developed by part of the research team (L.Z., O.F., and R.T.), reviewed by four additional physicians specialized in internal medicine and palliative medicine, and revised accordingly. 13 All included patients met the following criteria: (1) signed an informed consent form, (2) suffered from an ACI, (3) were adults above 18 years old, (4) had medical capacity for decision-making as assessed by the treating physicians and the research team, and (5) completed all parts of the interview. Patients were excluded for one of the following: (1) second concurrent ACI diagnosis or suspicion, (2) unavailable access to medical records, and (3) unwillingness or inability to sign informed consent. The study was reported in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist (See Supplemental Material). 14
For this study, we included only patients with one of the following ACIs: (1) HF with New-York Heart Association (NYHA) functional status 3–4, 15 (2) COPD with GOLD severity group C-D and at least one severe exacerbation in the prior year, 16 or (3) Metastatic cancer. To verify that patients did not have a second concurrent ACI out of the above, the research team evaluated prior echocardiographic examinations (performed by all COPD patients) and pulmonary functions, and assessed symptoms, treatments (diuretics and inhalers), and prior expert visits for validation. We obtained prior PCU information from patients’ answers, with validation from patients’ medical records (including all prior 1-year admission notes and summaries). PCU is defined as one of the following occurring in the 1-year prior to inclusion: (1) visiting a palliative care clinic, (2) receiving a palliative care consultation during hospitalization, and (3) home palliative care visit. End-of-life-related outcomes were evaluated in the questionnaire as yes/no questions. They include advanced directive awareness, filling advanced directive orders, sharing with others about end-of-life decisions, current life satisfaction, and decisions about mechanical ventilation in hypothetical scenarios of reversible and irreversible acute respiratory failure. Prior 1-year specialist visit is defined for patients with HF who visited a cardiologist, patients with COPD who visited a pulmonologist, and patients with malignancy who visited an oncologist.
Rates of 1-year PCU between patients with metastatic cancer and either COPD or HF were the primary outcome for this trial. Based on prior research,17–19 we conservatively assumed a 1-year PCU rate of 30% in the cancer group and 8% in either the COPD or HF groups. Considering the above, to achieve a two-sided alpha of 0.05 and a power of 80%, there was a need for 49 patients in each group. To account for the possible effect of the COVID-19 pandemic on the study outcome, we performed a sub-analysis between patients enrolled before and after March 1st, 2022, as the last lockdown due to COVID-19 occurred in February 2021 in Israel. Of note, all patients were hospitalized in non-COVID wards at their inclusion.
Statistical analysis
We compared baseline demographic and clinical characteristics between the three study groups (HF, COPD, and malignancy). Mann-Whitney U tests were used to compare continuous variables between groups, and chi-squared tests were used to compare categorical variables. Considering the identified strong association between prior specialist visits and PCU, we evaluated the associations between each end-of-life-related outcome and PCU after adjusting for prior specialist visits. This adjustment was performed using multivariate logistic regression analysis for each of the end-of-life outcomes. Multivariate logistic analysis with backward multiple regression was used to identify independent associations with PCU, which included variables associated with PCU in univariate analysis. For analyses, p < 0.05 was defined as statistically significant. All analyses were performed in SPSS version 28.0.
Results
During the study period, 187 subjects were approached by the study team, 172 agreed to participate, and 166 patients completed the interview and were included in our cohort (median age 77 years (IQR: 70–83); 41% females). Fifty-three patients (32%) had COPD, 56 (34%) had HF, and 57 (34%) had metastatic cancer. Characteristics of the study cohort and comparison of different patient groups are presented in Table 1. The overall disease burden was high, represented by only 37% of patients with the ability to perform daily activity, 21% who are able to climb more than one staircase, 40% with home oxygen use, and a median of two admissions per patient in the past year. Patients with HF were older than patients with COPD or malignancy (83 vs 75 and 74 years old, respectively; p = 0.01). The rate of patients with cancer who saw a specialist in the year prior to inclusion was higher than that of patients with COPD or HF (88% vs 47% and 70%, respectively; p = 0.001 and p = 0.02). Among patients with a specialist visit, there was a higher number of visits in patients with malignancy (median 2, IQR 2-3) compared to either COPD (1, IQR 1–2) or HF (2, IQR 1–2). The rate of patients with COPD who underwent prior mechanical ventilation (MV) was higher than that of patients with HF and malignancy (17% vs 4% and 4%, respectively; p = 0.02).
Table 1.
Comparison of baseline characteristics between subjects with COPD, HF, and cancer.
| Variables | COPD n = 53 (%) |
Malignancy n = 57 (%) |
HF n = 56 (%) |
p1 a | p2 b | p3 c |
|---|---|---|---|---|---|---|
| Age | 75 (69–80) | 74 (65–80) | 83 (75–87) | 0.48 | 0.01 | <0.01 |
| Female sex | 22 (42) | 28 (49) | 18 (32) | 0.42 | 0.31 | 0.07 |
| Non-religious | 33 (62) | 36 (63) | 29 (52) | 0.92 | 0.27 | 0.22 |
| Above high-school education | 22 (42) | 32 (56) | 26 (46) | 0.13 | 0.61 | 0.30 |
| Living alone | 13 (25) | 14 (25) | 15 (27) | 0.99 | 0.79 | 0.79 |
| Self-reported above-average financial status | 23 (43) | 31 (54) | 38 (68) | 0.25 | 0.01 | 0.14 |
| Obese (BMI > 30) | 13 (25) | 8 (14) | 16 (29) | 0.16 | 0.63 | 0.06 |
| Psychiatric comorbidity | 11 (21) | 7 (12) | 8 (14) | 0.23 | 0.37 | 0.75 |
| # Admissions, past year | 2 (1-2) | 2 (1-3) | 2 (1-3) | 0.06 | 0.03 | 0.80 |
| Seen specialist in past year d | 25 (47) | 50 (88) | 39 (70) | <0.01 | 0.02 | 0.02 |
| 1y specialist visits, # | 1 (1–2) | 2 (2–3) | 2 (1–2) | <0.01 | 0.608 | <0.01 |
| Self-reported high health awareness | 35 (66) | 47 (83) | 42 (75) | 0.05 | 0.30 | 0.33 |
| Prior intubation | 9 (17) | 2 (4) | 2 (4) | 0.02 | 0.02 | 0.99 |
| Able to walk >500 m | 33 (62) | 30 (53) | 19 (34) | 0.31 | <0.01 | <0.05 |
| Able to perform daily activities | 27 (51) | 21 (37) | 14 (25) | 0.14 | <0.01 | 0.17 |
| Able to climb >1 staircase without stop | 8 (15) | 20 (35) | 6 (11) | 0.02 | 0.50 | <0.01 |
| >5% weight loss in 6 months | 19 (36) | 39 (68) | 4 (7) | <0.01 | <0.01 | <0.01 |
| Home oxygen use | 35 (66) | 11 (19) | 21 (38) | <0.01 | <0.01 | 0.03 |
| Chronic pain | 21 (40) | 41 (72) | 18 (32) | <0.01 | 0.42 | <0.01 |
| Opioids use | 3 (6) | 24 (42) | 5 (9) | <0.01 | 0.51 | <0.01 |
p-Value for the comparison between subjects with COPD and malignancy.
p-Value for the comparison between subjects with COPD and heart failure.
p-Value for the comparison between subjects with heart failure and malignancy.
Seen a specialist relevant to the severe chronic disease, that is, a pulmonologist, cardiologist, or an oncologist.
COPD, chronic obstructive pulmonary disease; HF, heart failure.
Palliative care utilization and end-of-life decisions
Comparisons of PCU and end-of-life related outcomes between the different ACIs are shown in Figure 1. Patients with cancer had the highest 1-year PC utilization (39%), which was significantly higher than among subjects with COPD (6%, p < 0.01) or HF (11%, p < 0.01). This group of patients also had the highest advance-directives awareness, shared with others regarding end-of-life decisions, and predicted a worsening in their condition in the following year. All groups had low rates of signed advance directives (ranges 4%–9%). When questioned about MV in a hypothetical scenario of irreversible respiratory failure, 48% of subjects with COPD opted for MV, higher than cancer (28%, p = 0.09) and HF (23%, p = 0.03). Of note, with regards to COVID-19, there were no differences in PCU in subjects recruited before or after March 1, 2022.
Figure 1.
Comparison of palliative care and end-of-life outcomes between the study groups.
p1, COPD versus malignancy; p2, COPD versus HF; p3, malignancy versus HF.
aShared close person or physician on end-of-life choices.
bWould want to be mechanically ventilated if needed in an irreversible condition (small chance to be weaned off the ventilator, with probable deterioration if general and medical state compared to current).
*p < 0.05. **p < 0.01.
CHF, chronic heart failure; PC, palliative care.
Associations between palliative care utilization and outcomes
Associations between PCU and outcomes are shown in Figure 2. Subjects with 1-year PCU compared to subjects who did not use PC services were more aware of the possibility of advance directives (71% vs 38%), signed advanced directive orders more frequently (3% vs 23%), and shared more about their end-of-life decisions (71% vs 29%).
Figure 2.
End-of-life outcomes in patients with and without palliative care utilization.
*p < 0.05.
PCU occurred only in patients who saw a specialist (cardiologist, pulmonologist, or oncologist) in the prior year. We therefore analyzed the associations between PCU and the mentioned outcomes after adjusting for 1-year specialist visits (Table 2). Following the adjustment, all associations between PC utilization and outcomes remained significant. PCU was also associated with higher odds of opioid use (adjusted OR 4.10, 95% CI 1.53–11.1).
Table 2.
Associations between outcomes and palliative care utilization, adjusted for 1-year specialist visits.
| Variable | PC utilization | |
|---|---|---|
| aOR (95% CI) a | p | |
| Self-reported high health awareness | 1.49 (0.45–4.89) | 0.51 |
| Advanced directive awareness | 3.19 (1.31–7.76) | 0.01 |
| Advanced directive orders | 11.8 (2.30–60.6) | <0.01 |
| Shared about end of life b | 4.32 (1.76–10.6) | <0.01 |
| life satisfaction | 0.69 (0.29–1.50) | 0.25 |
| Opioids use | 4.10 (1.53–11.1) | <0.01 |
Each odds ratio is adjusted for visiting a relevant specialist (pulmonologist, cardiologist, or an oncologist) in the past year.
Shared close person or physician on end-of-life choices.
AOR, adjusted odds ratio; PC, palliative care.
Associations with palliative care utilization
Considering the strong correlation between PCU and end-of-life-related outcomes, we evaluated associations between patients’ characteristics and PCU in univariate (Table S1) and multivariate (Table 3) analyses. Independent associations for PCU included a higher 1-year admissions (aOR 1.36 for every 1 additional admission, 95% CI 1.06–1.75), self-defining as non-religious (aOR 3.41, 95% CI 1.16–9.98), and chronic pain (aOR 2.81, 95% CI 1.11–7.14). COPD had an independent association with lack of PC utilization (aOR 0.25, 95% CI 0.07–0.96). As mentioned above, seeing a specialist was strongly associated with PCU, although we did not include it in our multivariate analysis given the high collinearity with other variables. In addition, there was no association between the number of 1-year specialist visits and PCU.
Table 3.
Multivariate model of associations with 1-year palliative care utilization.
| Variable | Adjusted OR | 95% CI | p | |
|---|---|---|---|---|
| Lower | Upper | |||
| # 1-year admissions | 1.359 | 1.055 | 1.750 | 0.018 |
| Non-religious | 3.407 | 1.164 | 9.977 | 0.025 |
| Above high-school education | 2.843 | 1.102 | 7.333 | 0.031 |
| Chronic pain | 2.810 | 1.106 | 7.140 | 0.030 |
| COPD | 0.251 | 0.065 | 0.964 | 0.044 |
Discussion
In the current study, we evaluated different aspects of PCU and its association with end-of-life decisions in patients with COPD, HF, and cancer. Our main findings are as follows: (1) Although disease burden among patients with advanced HF and COPD is high, PCU in this population is extremely low; (2) Most patients with HF and COPD do not prepare for the end-of-life in terms of advanced directives; (3) Meeting a HF, COPD, or cancer specialist is strongly associated with PCU and (4) PCU correlated with patients’ end-of-life-related outcomes.
Awareness and accessibility to palliative care services in noncancer patients have recently increased in high-income countries, yet it is still heavily underused. 6 The low rates of PCU among COPD and HF patients in our study are overall in line with prior results. A recent nationwide study from Denmark demonstrated that only 6% and 2% of patients with lung and cardiovascular diseases, respectively, were referred to palliative care. Other studies have also shown rates lower than 10% in severe COPD and HF patients. 18 These results should raise concern given the high disease and social burden inflicted by HF and COPD.20,21 Several factors might explain these low rates, especially compared to patients with cancer. First, the relatively unpredictable course of COPD or HF limits timely referrals for PC services. 22 Second, practitioners might believe that PC is relevant only for end-stage HF or COPD, limiting its use for less severe cases. 23 Third, pain is often the main reason for referral to PC, especially among physicians less experienced with PC, which is not frequent in HF or COPD compared to cancer. 24 The above issues are emphasized given that most patients were admitted to the hospital in the previous year, yet few in-patient PC services were utilized. As we experienced by ourselves, internal medicine physicians who treat patients with HF or COPD exacerbations focus on treating the acute condition and miss the opportunity to order PC consultation. 25 Low awareness of PC, physical barriers for patients with HF or COPD (e.g., lack of mobility and oxygen requirement), and low availability of PC services 25 are additional barriers. Lastly, the COVID-19 pandemic, which affected all aspects of patient care until recently, could have exacerbated the barriers mentioned above and partly contributed to our results.
Current guidelines recognize the importance of palliative care in noncancer patients. The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure recommends referring patients with advanced HF to palliative care specialists and hospice when appropriate. 7 Similarly, in patients with COPD, the 2024 Global Initiative for Chronic Obstructive Lung Disease (GOLD) statement recommends discussing end-of-life care with patients and administering palliative care. 16 Despite these recommendations, a multicenter study in the United States of patients with cardiovascular disease referred to palliative care found that only 12% of referrals were made by cardiologists. 26 In a survey of 551 cardiologists in Canada, up to 64% of cardiologists were unaware of referral criteria to palliative care services, and almost half of the physicians believed that palliative care services prioritize cancer patients. 27 Pulmonologists’ referral rates to palliative care are low as well. A survey in Dutch pulmonologists demonstrated that only 31% of them referred COPD patients to palliative care 28 and in patients with idiopathic pulmonary fibrosis, these rates were even lower at 12%. 29 Considering these previously published low referral rates, specialist involvement was highly associated with PCU in our study. This finding highlights the need for targeted educational initiatives aimed at increasing awareness and guideline adherence among cardiologists and pulmonologists, who often serve as gatekeepers to palliative care referrals. In addition, the in-patient setting could also be used to facilitate PCU, with consultations (when available) prior to hospital discharge or referrals to the palliative clinic at discharge, increasing the above rates of PCU.
Advance directives lead to improved patient-physician communication, better patient-caregiver congruence, and reduced healthcare costs.30–32 The low rates of advanced directives awareness or completion and the high rates of patients opting for MV in hypothetical non-reversible respiratory failure emphasize that the role of specialists in palliative care goes beyond referral to palliative care services. These results might signify a gap in patients’ understanding of their prognosis, a lack of discussion on end-of-life goals, and on the probable sequela of their diseases in a case of deterioration. Physicians should engage patients in meaningful end-of-life discussions, including prognosis, goals of care, and preferred place of dying.
The study has several limitations. First, although the cohort is from a large tertiary center, it mostly represents an urban, Jewish, non-orthodox population, possibly leading to a selection bias. Patients with different backgrounds might have had other perceptions regarding palliative care, affecting the generalizability of our results. Second, PCU was assessed by patients’ answers, and although validated by medical records, it was not collected prospectively, hence leading to a possible reporting and recall bias. Third, while the sample size was powered for the primary outcome, it might not be the case for the secondary analyses, which should be further validated by larger studies. Fourth, the study tool was not based on a validated questionnaire, which might have affected participants’ answers. Fifth, specific treatments for each ACI and its association with PCU were beyond the study scope. Finally, considering the study design, all associations between PCU and end-of-life outcomes could not be inferred on causality. Future prospective multicenter randomized controlled trials are needed to conclude on the effect of palliative care utilization.
Conclusion
Palliative care utilization and advance-directives awareness among patients with HF and COPD are exceedingly low. The strong association between specialist visits and PCU highlights their important role and possibly low awareness among other caregivers for palliative care. Increasing awareness and incorporating end-of-life discussions into routine care could help bridge the mentioned gaps. Future randomized controlled trials are needed to assess the effect of PCU on patients’ outcomes and the effect of interventions to increase PCU.
Supplemental Material
Supplemental material, sj-docx-1-tar-10.1177_17534666251364056 for Underutilization of palliative care in advanced COPD and heart failure: associations, disparities, and the role of specialists by Lior Zornitzki, Neta Sror, Amir Bar-Shai, Rotem Tellem, Shmuel Banai, Shir Frydman, Gil Bornstein and Ophir Freund in Therapeutic Advances in Respiratory Disease
Acknowledgments
None.
Footnotes
ORCID iD: Ophir Freund 
https://orcid.org/0000-0002-7272-5284
Supplemental material: Supplemental material for this article is available online.
Contributor Information
Lior Zornitzki, Internal Medicine B, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.
Neta Sror, Internal Medicine B, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Amir Bar-Shai, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Institute of Pulmonary Medicine, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.
Rotem Tellem, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Palliative Care Unit, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.
Shmuel Banai, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.
Shir Frydman, Internal Medicine B, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.
Gil Bornstein, Internal Medicine B, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Ophir Freund, Internal Medicine B, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street Tel Aviv 6423906, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Institute of Pulmonary Medicine, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.
Declarations
Ethics approval and consent to participate: The study was approved by the Tel Aviv Sourasky Medical Center review board (0812-20-TLV) and conducted per the Declaration of Helsinki and GCP Guidelines. All patients signed an informed consent form.
Consent for publication: No personal images or data are being presented. All participants signed informed consent, including the approval of publication.
Author contributions: Lior Zornitzki: Conceptualization; Data curation; Writing – original draft.
Neta Sror: Data curation; Investigation; Writing – review & editing.
Amir Bar-Shai: Formal analysis; Methodology; Writing – review & editing.
Rotem Tellem: Formal analysis; Methodology; Writing – review & editing.
Shmuel Banai: Formal analysis; Methodology; Writing – review & editing.
Shir Frydman: Data curation; Investigation; Writing – review & editing.
Gil Bornstein: Formal analysis; Methodology; Supervision; Writing – review & editing.
Ophir Freund: Conceptualization; Data curation; Writing – original draft.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
Competing interests: The authors declare that there is no conflict of interest.
Availability of data and materials: All relevant data to this work appear within the submitted materials of this paper.
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Supplementary Materials
Supplemental material, sj-docx-1-tar-10.1177_17534666251364056 for Underutilization of palliative care in advanced COPD and heart failure: associations, disparities, and the role of specialists by Lior Zornitzki, Neta Sror, Amir Bar-Shai, Rotem Tellem, Shmuel Banai, Shir Frydman, Gil Bornstein and Ophir Freund in Therapeutic Advances in Respiratory Disease