2.2.1 Aims & hypotheses
To determine if patients dying from COPD in two Australian hospitals received symptom palliation or palliative care at the end of life, or within the two years before death.
Hypotheses
1. Most patients within the cohort did not access symptom palliation, advance care planning opportunities, and generalist or specialist palliative care in the two years before death occurred
2. During the terminal admission in which death occurred in hospital, most patients within the cohort did not access symptom palliation, advance care planning opportunities, and generalist or specialist palliative care
3. There was no difference between the two hospital sites in the provision of symptom palliation, advance care planning opportunities, and generalist or specialist palliative care either in the terminal admission or the preceding two years
2.2.2 Study sites
Ethics approval was granted for this study by the Melbourne Health Research Office (Approval number: QA2014171) and by the Northeast Health Wangaratta Human Research Ethics Committee (Project number: 169). As 72% of patients with COPD die in hospital in Australia (18), this study focussed on the provision of symptom palliation, advance care planning opportunities, and generalist or specialist palliative care to a cohort of patients who died in hospital. Two different types of hospital (teaching hospital or regional district hospital) located in different parts of the state of Victoria (Australia) and serving different populations were purposefully chosen for this study to provide comparison.
The Royal Melbourne Hospital (RMH) is an Australian, metropolitan, teaching hospital with 450 acute beds. The hospital provides care to patients living within the inner city local catchment area, as well as offering specialist quaternary services to patients from across the state of Victoria. Both respiratory medicine and palliative care services (including specialist medical and nursing staff) are available. Multiple specialty outpatient clinics are available, including an integrated respiratory and palliative care clinic (the Advanced Lung Disease Service) established in 2013 for patients with non-malignant, respiratory disease (461). Inpatient care for respiratory patients is provided on medical wards or the respiratory ward, with non-invasive ventilation (NIV) available in the Respiratory Care Unit (RCU), Intensive Care Unit (ICU) or High Dependency Unit (HDU). Additionally there is an inpatient palliative care unit onsite.
Northeast Health Wangaratta (NHW) is a major, regional hospital in in the north of the state of Victoria and serves a widely dispersed rural population. The hospital has 140 acute beds. There is no specialist respiratory service or clinic. Outpatient care occurs through the NHW general medicine clinic or privately. A specialist palliative care nurse is available for consultation. Inpatient care is provided by general physicians on medical wards, with NIV available in the Critical Care Unit, which offers ICU and HDU level care.
2.2.3 Study design
Retrospective medical record audits were completed at RMH and NHW of all patients who died at each site over twelve years between 1st January 2004 and 31st December 2015, with
COPD listed in one of the first five diagnoses at death. Only those patients who died as a consequence of COPD (including respiratory infections) and not from other comorbidities were included. Patients with any co-existing malignancy were excluded as these patients may have accessed palliative care for their malignancy and not COPD. Only patients with a
confirmed diagnosis of COPD (based on the history and previous spirometric testing confirming obstruction) were included.
COPD deaths were identified from each site’s mortality database using the International Classification of Diseases codes: J43-44. Medical records (paper files and electronic records), administrative and clinical databases were examined to explore how clinical care was delivered, and to determine the use and duration of treatments with preventive, therapeutic and palliative intent during the final admission in which death occurred. Using definitions developed by Philip et al (462), preventive treatments include those given for comorbidities such as hypercholesterolaemia, therapeutic interventions included (but were not limited to) antibiotics, oral steroids, and non-invasive ventilation, and palliative treatments included opioids and benzodiazepines to palliate symptoms. Offering a palliative approach was defined as any of: initiating palliative treatments, discussing or documenting advance care planning, documenting that the goal of care in the terminal admission was to provide comfort care (palliation), completing a resuscitation status form or referral to specialist palliative care.
Comprehensive data (Appendix 3) were collected regarding five main themes: 1. Demographic data, comorbidities and pre-admission disease severity
2. Previous outpatient hospital care including any access to specialist palliative care 3. Previous inpatient episodes including any access to specialist palliative care 4. Management during the final admission: preventive, therapeutic and palliative 5. Specialists involved in care at the end of life and place of death
Whilst all patients had spirometry results available, only results within two years of death were included.
Electronic databases accessed (in addition to paper files) for data collection included:
1. Electronic medical files (which came into use in November 2015, so that paper medical files were discontinued)
2. Hospital administration database to determine past admissions, length of admissions, treating team, and outpatient appointments (attended or failed to attend)
3. Pathology database 4. Radiology database
5. Medical transcription database to access clinic letters
2.2.4 Statistical analysis
Data are reported descriptively using counts and frequencies, with median values and interquartile ranges reported for variables with significant distribution skew. Data from each site were compared using Student’s t test for continuous variables and the Chi Square test for categorical variables. The twelve years included in the study period were divided into three 4-year blocks: 2004-2007, 2008-2011 and 2012-2015. Logistic regression was then used to examine associations between palliative care provision and year of admission. Statistical analyses were performed using IBM SPSS Statistics version 24. Statistical significance was indicated by p<0.05.
2.3 RESPIRATORY MEDICINE AND PALLIATIVE CARE PHYSICIANS’ ATTITUDES AND