Table 5.
Summary of Palliative Care Interventions for Patients with Pulmonary Disease
| Study | Study objective | Study setting | Sample | Mean age (years) | Study design | Findings |
|---|---|---|---|---|---|---|
| Individual studies | ||||||
| Higginson et al.83 | Assessing the effectiveness of early palliative care integrated with respiratory services for patients with advanced disease and refractory breathlessness. | Patients were enrolled from three large teaching hospitals and through general practitioners in South London, UK. | 105 patients enrolled, 83 completed assessment at six weeks | 67 | Randomized, controlled, parallel group, pragmatic, single-blind fast-track trial | Mastery of breathlessness improved in the intervention compared with the control. |
| Survival rate from randomization to six months was better in the breathlessness support service group than in the control group. | ||||||
| Detering et al.88 | Investigating the impact of advance care planning on end-of-life care in elderly patients. | Patients admitted under internal medicine, cardiology, or respiratory medicine in a large university hospital in Melbourne, Australia. | 309 legally competent medical inpatients who were >80 years old | Median intervention group 85; control group 84 | Prospective, randomized controlled trial | Intervention reduced proportion of patients admitted to the ICU and resulted in high levels of family satisfaction and lower levels of family symptoms of anxiety and depression. |
| Rocker and Verma107 | Commentary describing a pan-Canadian quality improvement program (INSPIRED) supporting multidisciplinary healthcare teams to bridge the chasm between evidence and practice, focused on enhancing patient confidence to manage their illness more effectively in their homes and communities. | First implemented at Queen Elizabeth II Health Sciences Centre (QEII HSC) in Halifax, Nova Scotia, Canada. | 257 patients enrolled; 131 patients completed the program | Not included | Observational cohort study using patients as their own controls | Patients who completed the full program had fewer ED visits, fewer hospital admissions, fewer days in hospital compared with their utilization before enrollment and these reductions persisted for an additional subset of patients in a 12-month pre–post comparison. |
| Au et al.87 | Assessing whether an intervention using patient-specific feedback about preferences for discussing end-of-life care would improve the occurrence and quality of communication between patients with COPD and their clinicians. | Outpatient clinics at the Veterans Affairs Puget Sound Healthcare System | 376 randomized; 306 completed the study | 69.4 | Cluster-randomized trial that was randomized by clinicians | Patients in the intervention arm reported a nearly threefold higher rate of discussions about end-of-life care and also higher quality end-of-life communication. |
| Currow et al.108 | Assessing if oxygen administration results in symptomatic benefit of breathlessness. | Outpatients; Perth, Western Australia | 413 outpatients | 69.7 | Consecutive cohort of patients seen over a four-year period (post hoc analysis of prospectively collected data) | No clinically significant improvement in breathlessness. |
| Currow et al.109 | Describing the pattern of response of breathlessness intensity to morphine dose escalation to inform dose titration in people who have responded in routine clinical care. | Outpatients with multiple morbidities; Perth, Western Australia | 17 patients with multiple conditions who required a morphine dose greater than 10 mg daily | Median 82 | Secondary data analysis | Improvement in breathlessness was greatest in the first 24 hours of response after dose escalation with continued improvement for six more days, suggesting that further dose increases should not occur for at least one week. |
| Abernethy et al.110 | Assessing the effectiveness of oxygen compared with room air delivered by nasal cannula for relief of breathlessness. | Outpatients with multiple morbidities in Australia, USA, and UK | 239 patients with multiple conditions | 73 | Randomized, controlled double-blind trial | Oxygen delivered by nasal cannula provides no additional symptomatic benefit for relief of refractory dyspnea compared with room air. Room air delivered by nasal cannula can be considered an intervention. |
| Currow, et al.86 | Determining the minimum effective once-daily dose of sustained-release morphine and whether net clinical benefits are sustained safely. | Palliative Care service outpatients and inpatients with multiple morbidities | 83 patients with dyspnea caused by multiple conditions | 74.6 | Pharmacovigilance study (Phase II dose increment study and Phase IV effectiveness/safety study at 10% dyspnea improvement dose) | Ten milligrams of sustained-release oral morphine once daily is safe and effective for most people who respond. |
| Systematic reviews | ||||||
| Rabow et al.111 | To review the evidence surrounding outpatient palliative care | Four well-designed randomized trials of interventions of in-home palliative care, palliative care consultation in a primary care clinic, early palliative care comanagement or telephone, advance practice nurse-led psychoeducational intervention | Four well-designed randomized interventions in patients with COPD, advanced cancer, and other chronic conditions | N/A | Systematic review | Outpatient palliative care services can (1) improve patient satisfaction, (2) improve symptom control and quality of life, (3) reduce healthcare utilization, and (4) lengthen survival in a population of lung cancer patients. |
| Gomes et al.112 | Quantifying the effect of home palliative care services for adult patients with advanced illness and their family caregivers; examining the clinical effectiveness of home palliative care services on other outcomes | 12 electronic databases up to November 2012: 23 studies (16 RCTs, 6 of high quality) | 37,561 patients and 4042 family caregivers, patients largely not only with advanced cancer but also CHF, COPD, HIV/AIDS, and MS, among others | N/A | Systematic review | The results show home palliative care increases the chance of dying at home and reduces symptom burden in particular for patients with cancer, without negatively impacting caregiver grief |
| Barnes et al.113 | Determining the effectiveness of opioid drugs in relieving the symptom of breathlessness in people with advanced disease receiving palliative care | 26 studies; double-blind RCTs only reviewed | Total of 526 participants | N/A | Systematic review | The mean change from baseline dyspnea score was better in the opioid group compared with the placebo group for breathlessness; the four-minute walk evidence was conflicting with no significant changes in quality of life and with patients more likely to experience adverse effects in opioid group |
COPD, chronic obstructive pulmonary disease; CHF, congestive heart failure; ED, emergency department; MS, multiple sclerosis; N/A, not applicable; RCTs, randomized controlled trials.