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Integrated respiratory and palliative care may improve outcomes in advanced lung disease

Natasha Smallwood, Michelle Thompson, Matthew Warrender-Sparkes, Peter Eastman, Brian Le, Louis Irving, Jennifer Philip
ERJ Open Research 2018 4: 00102-2017; DOI: 10.1183/23120541.00102-2017
Natasha Smallwood
1Dept of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Parkville, Australia
2Dept of Medicine, University of Melbourne, Melbourne, Australia
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  • For correspondence: Natasha.smallwood@mh.org.au
Michelle Thompson
1Dept of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Parkville, Australia
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Matthew Warrender-Sparkes
1Dept of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Parkville, Australia
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Peter Eastman
3Dept of Palliative Care, The Royal Melbourne Hospital, Parkville, Australia
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Brian Le
3Dept of Palliative Care, The Royal Melbourne Hospital, Parkville, Australia
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Louis Irving
1Dept of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Parkville, Australia
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Jennifer Philip
2Dept of Medicine, University of Melbourne, Melbourne, Australia
4Centre for Palliative Care, St Vincent's Hospital, Fitzroy, Australia
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Figures

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  • FIGURE 1
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    FIGURE 1

    Hospital admissions and emergency department presentations (without admission) for respiratory illness. Data are presented as mean±sem.

  • FIGURE 2
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    FIGURE 2

    Advanced Lung Disease Service advance care planning activities.

  • FIGURE 3
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    FIGURE 3

    Advanced Lung Disease Service patients' place of death.

Tables

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  • TABLE 1

    Advanced Lung Disease Service key components

    1)Respiratory and palliative care offered together, to provide individualised care which addresses the underlying respiratory disease, symptoms and psychosocial issues
    2)Disease treatment optimisation including: optimising inhaler therapy and device technique, smoking cessation support, pulmonary rehabilitation referral, and domiciliary oxygen therapy assessment, education and management
    3)Comprehensive management of refractory breathlessness, with nonpharmacological strategies (such as breathing techniques, recovery breathing positions, the use of a handheld fan) and opioids as required; individualised written breathlessness plans and written breathlessness resources provided
    4)Self-management support including patient and family education regarding disease and symptom management, with provision of written exacerbation action plans
    5)Routine discussions regarding goals of care and advance care planning
    6)Patient- and family-focused care including extended 1-h consultations, urgent reviews and rapid access (<1 week) for new referrals as needed
    7)Specific carer support including facilitating access to respite care and bereavement support
    8)Long-term follow-up with continuity of care in clinic and nonabandonment
    9)Telephone support and home visits provided by a respiratory nurse consultant
    10)Early access to “Hospital in the Home” care to avoid respiratory admissions
    11)Respiratory care and service coordination, and integration with other community services, including aged care assessment services
    12)Focus on early communication with, and support of, general practitioners and other health professionals, including teleconferences
  • TABLE 2

    Patient characteristics and diagnoses

    Patients171
    Male97 (56.7)
    Age years (mean (range))75.9 (42.8–91.8)
    Ex-smoker134 (78.4)
    Lives alone45 (26.3)
    Lives in nursing home19 (11.1)
    Primary respiratory diagnosis
     COPD142 (83.0)
     Pulmonary fibrosis14 (8.9)
     Bronchiectasis7 (4.1)
     Coexisting second respiratory condition107 (62.6)
    Comorbidities (mean (range))6.8 (0–14)
     Anxiety65 (38.0)
     Depression51 (29.8)
     Cardiac disease119 (69.6)
     Cardiac comorbidities (mean (range))1.5 (0–5)
    Pulmonary function n=169
     FEV1 L (median (IQR))0.8 (0.6–1.1)
     FEV1 % pred (median (IQR))41.5 (32.0–55.8)
     FVC L (median (IQR))2.2 (1.7–2.7)
     FVC % pred (median (IQR))83 (65.3–101.8)
     DLCO (median (IQR))8 (6–10)
     DLCO % pred (median (IQR))37.5 (29.0–48.0)
     6MWD on air m (median (IQR)) n=16380 (0–222.5)
     PaO2 mmHg (median (IQR)) n=11557.1 (51.1–64.0)
     PaCO2 mmHg (median (IQR)) n=11545.0 (39.3–50.9)
     Domiciliary oxygen use111 (64.9)
     mMRC Dyspnoea scale score (median (IQR))4 (2–4)
      mMRC Dyspnoea scale score 1–248 (26.9)
      mMRC Dyspnoea scale score 3–4123 (73.1)

    Data are presented as n or n (%), unless otherwise stated. COPD: chronic obstructive pulmonary disease; FEV1: forced expiratory volume in 1 s; IQR: interquartile range; FVC: forced vital capacity; DLCO: diffusing capacity of the lung for carbon monoxide; 6MWD: 6-min walk distance; PaO2: arterial oxygen tension; PaCO2: arterial carbon dioxide tension; mMRC: modified Medical Research Council.

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      N. Smallwood 00102-2017_Smallwood

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    Integrated respiratory and palliative care may improve outcomes in advanced lung disease
    Natasha Smallwood, Michelle Thompson, Matthew Warrender-Sparkes, Peter Eastman, Brian Le, Louis Irving, Jennifer Philip
    ERJ Open Research Jan 2018, 4 (1) 00102-2017; DOI: 10.1183/23120541.00102-2017

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    Integrated respiratory and palliative care may improve outcomes in advanced lung disease
    Natasha Smallwood, Michelle Thompson, Matthew Warrender-Sparkes, Peter Eastman, Brian Le, Louis Irving, Jennifer Philip
    ERJ Open Research Jan 2018, 4 (1) 00102-2017; DOI: 10.1183/23120541.00102-2017
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