Chest
Volume 139, Issue 5, May 2011, Pages 1081-1088
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Original Research
COPD
A Call for High-Quality Advance Care Planning in Outpatients With Severe COPD or Chronic Heart Failure

https://doi.org/10.1378/chest.10-1753Get rights and content

Background

Patients with severe COPD or chronic heart failure (CHF) are often confronted with decisions concerning life-sustaining treatments. The aim of this prospective, observational study was to assess life-sustaining treatment preferences, advance care planning, and the quality of end-of-life care communication in Dutch outpatients with clinically stable but severe COPD or CHF.

Methods

The following outcomes were assessed in outpatients with severe COPD (n = 105) or CHF (n = 80): life-sustaining treatment preferences (CPR and mechanical ventilation; Willingness to Accept Life-sustaining Treatment instrument), advance care planning, and quality of end-of-life care communication (Quality of Communication questionnaire).

Results

Most patients asserted that in their current health status, they would prefer CPR (COPD, 70.5%; CHF, 62.5%) and/or mechanical ventilation (COPD, 70.5%; CHF, 66.3%). Patients' treatment preferences were influenced by burden of treatment, outcome of treatment, and likelihood of outcome. Advance directives were discussed with the physician specialist by 5.9% of patients with COPD and 3.9% of patients with CHF. Patients rated quality of patient-physician end-of-life care communication as poor. Physicians rarely discussed prognosis, dying, and palliative care.

Conclusions

Despite the fact that patients are able to indicate their preferences regarding life-sustaining treatments, based on burden of treatment, outcome of treatment, and likelihood of outcome, these preferences are rarely discussed with their physician specialist. This study shows a need for advance care planning, taking into account the burden of treatment, outcome of treatment, and likelihood of outcome, in patients with severe COPD or CHF. Finally, the quality of patient-physician end-of-life care communication needs to improve.

Section snippets

Design

This prospective cross-sectional study is part of a longitudinal study concerning self-perceived symptoms and care needs in patients with severe COPD or CHF and the consequences for their closest relatives.19 The methodology of this study was described previously,19 and details are provided in e-Appendix 1. The Medical Ethical Commission of the Maastricht University Medical Centre + (MUMC+), Maastricht, The Netherlands, approved this study (MEC 07-3-054).

Study Population

The study population consisted of a

General Patient Characteristics

One hundred five patients with COPD and 80 patients with CHF were included. The proportion of eligible patients who participated in the study was 62.9% for patients with COPD and 46.0% for patients with CHF (P < .05). Chest physicians referred a median of five (one to 10) patients, and cardiologists referred two (one to three) participating patients. Most patients with COPD had very severe COPD (GOLD stage IV, 73.3%). Patients with CHF were classified mainly as NYHA class III (92.5%). On

Discussion

The present study shows that the majority of Dutch outpatients with clinically stable severe COPD or CHF are able to indicate their preferences regarding life-sustaining treatments, depending on burden of treatment, outcome of treatment, and likelihood of outcome. Despite the fact that patients can indicate preferences regarding life-sustaining treatments and end-of-life care, these preferences are rarely discussed with their physician specialist. Indeed, patients rate quality of

Conclusions

To conclude, the current findings emphasize the lack of advance care planning in Dutch clinically stable outpatients with severe COPD or CHF. Increased awareness among chest physicians and cardiologists that advance care planning is an essential component of care for patients with severe COPD or CHF is necessary. Finally, the quality of patient-physician end-of-life care communication needs to improve.

Acknowledgments

Author contributions: Dr Janssen had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Janssen: contributed to the study concept and design, acquisition of data, analysis and interpretation of data, drafting of the article, critical revision of the article for important intellectual content, and final approval of the version to be published.

Dr Spruit: contributed to the study concept and design, acquisition

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    Funding/Support: This project was supported by Proteion Thuis and CIRO+, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands; The Netherlands Asthma Foundation, Leusden, The Netherlands [Grant 3.4.06.082]; and Stichting Wetenschapsbevordering Verpleeghuiszorg (SWBV), Utrecht, The Netherlands.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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