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Treatment decisions in end-stage COPD: who decides how? A cross-sectional survey of different medical specialties

Martin Gäbler, Gerald Ohrenberger, Georg-Christian Funk
ERJ Open Research 2019 5: 00163-2018; DOI: 10.1183/23120541.00163-2018
Martin Gäbler
1Institute of Preventive and Applied Sports Medicine, Krems University Hospital, Karl Landsteiner University of Health Sciences, Krems, Austria
2Dept of Respiratory and Critical Care Medicine, Otto-Wagner-Hospital, Vienna, Austria
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  • ORCID record for Martin Gäbler
  • For correspondence: martin.gaebler@kl.ac.at
Gerald Ohrenberger
3Haus der Barmherzigkeit (House of Mercy), Vienna, Austria
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Georg-Christian Funk
4Medical Dept II and Karl-Landsteiner Institute für Lungenforschung und Pneumologische Onkologie Wilheminenspital, Vienna, Austria
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  • FIGURE 1
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    FIGURE 1

    A typical life trajectory of a chronic obstructive pulmonary disease patient, who experiences a continuous physical decline due to the loss of organ function and comorbidities. Dips in the curve are caused by exacerbations and represent stages of uncertain outcome. Reproduced from [4] with permission.

  • FIGURE 2
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    FIGURE 2

    Flowchart of data acquisition. #: Austrian Society for Geriatrics and Gerontology n=310, Austrian Society for Internal and General Intensive Care and Emergency Medicine n=812, Austrian Society of Pneumology n=611, and Austrian Palliative Society n=342.

  • FIGURE 3
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    FIGURE 3

    Treatment decisions in end-stage chronic obstructive pulmonary disease by department affiliation. NIV: noninvasive ventilation. p-value obtained by the Chi-squared test.

Tables

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  • TABLE 1

    Case vignette of a chronic obstructive pulmonary disease (COPD) patient for whom a treatment pathway has to be chosen

    An 83-year-old somnolent patient with a markedly impaired general condition and very poor nutritional status is presented to you.
    The patient is tachycardic, responds only to a limited extent, has pronounced dyspnoea with paradoxical breathing, lack of lung sounds on auscultation and hypersonorous percussion sounds over both lungs. The legs are not swollen.
    Peripheral oxygen saturation (with 6 L O2·min−1) is 84%.
    Patient history reveals the development of an increasing resting dyspnoea in the last 4 days. There has been COPD (Global Initiative for Chronic Obstructive Lung Disease stage IV) and chronic heart failure (New York Heart Association functional class III) for years. One year ago, long-term oxygen therapy was initiated. Inhalation and drug therapies have already been maximised.
    In recent months, the patient has increasingly presented for respiratory distress and COPD exacerbations, and therefore has been hospitalised repeatedly.
    6 weeks ago, he had to be intubated in a critical condition and ventilated for 12 days. The patient found this intensive care unit stay to be very stressful. He subsequently refused the initiation of nocturnal home noninvasive ventilation because it would affect him too much.
    He also refused to be transferred into a nursing home. He is cared for by a home nurse several times a day.
    According to a telephone message from the family doctor, the patient has become increasingly enervated since his last stay in intensive care, and spends more and more of his days in bed due to his shortness of breath.
    Which of the specified treatment pathways would you most likely choose?
    (Regardless of your locally available options)
     Noninvasive ventilation
     Conservative treatment attempt (without ventilation)
     Palliative approach
    What additional information would you have wanted for your decision?

    The complete survey (in German) is available in the supplementary material.

    • TABLE 2

      Sociodemographic characteristics stratified by department

      TotalIntensive care unitPulmonology or internal medicineGeriatric or palliative carep-value
      Total respondents16267 (41)51 (32)44 (27)
      Age (range) years49±10 (27–65)47±9 (32–63)47±11 (27–65)53±8 (30–65)0.009#
       No answer15 (9)3 (5)5 (10)7 (16)
      Sex0.034¶
       Male89 (55)37 (55)32 (63)20 (46)
       Female69 (43)30 (45)19 (37)20 (46)
       No answer4 (2)0 (0)0 (0)4 (8)
      Education<0.001¶
       Physician in training12 (7)3 (5)8 (16)1 (2)
       General physician18 (11)2 (3)2 (4)14 (32)
       Specialist132 (82)62 (93)41 (80)29 (66)
      Experience in this field ≥10 years110 (68)43 (64)37 (73)30 (68)0.991¶

      Data are presented as n, mean±sd or n (%), unless otherwise stated. #: p-value obtained by ANOVA; ¶: p-value obtained by the Chi-squared test.

      • TABLE 3

        Model 1: independent predictors for a decision for (or against) noninvasive ventilation (NIV)

        OR for NIV (95% CI)p-value
        Department
         Geriatric or palliative careReference
         Intensive care unit14.9 (1.87–118.8)0.011
         Pulmonology or internal medicine9.4 (1.14–78.42)0.038
        Physician recommends living will#0.57 (0.34–0.97)0.038
        Age of the physician (per year)0.96 (0.92–1.00)0.052

        Odds ratios were obtained by multivariable logistic regression. OR >1 shows a higher probability for NIV. #: physicians with a positive answer to: “Do you advise patients with a foreseeably severe disease progression and/or limited life expectancy to draw up a living will?”.

        • TABLE 4

          Model 2: independent predictors for a decision for (or against) a palliative approach

          OR for palliative care (95% CI)p-value
          Department
           Geriatric or palliative careReference
           Intensive care unit0.41 (0.15–1.12)0.081
           Pulmonology or internal medicine0.16 (0.05–0.47)0.001
          Concerns of other professional groups#0.26 (0.12–0.60)0.001
          Guardianship¶2.69 (1.10–6.58)0.030

          OR <1 shows a lower probability for a palliative approach. #: these respondents stated that the concerns of other professional groups (e.g. nurses) involved in patient care had influenced their decision in the specific case they were asked to recall; ¶: these respondents stated that they actively asked if a guardianship was in place in the specific case they were asked to recall.

          Supplementary Materials

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          • Supplementary Material

            Please note: supplementary material is not edited by the Editorial Office, and is uploaded as it has been supplied by the author.

            Questionnaire 00163-2018.supp1

            Questions and results 00163-2018.supp2

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          Treatment decisions in end-stage COPD: who decides how? A cross-sectional survey of different medical specialties
          Martin Gäbler, Gerald Ohrenberger, Georg-Christian Funk
          ERJ Open Research Jul 2019, 5 (3) 00163-2018; DOI: 10.1183/23120541.00163-2018

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          Treatment decisions in end-stage COPD: who decides how? A cross-sectional survey of different medical specialties
          Martin Gäbler, Gerald Ohrenberger, Georg-Christian Funk
          ERJ Open Research Jul 2019, 5 (3) 00163-2018; DOI: 10.1183/23120541.00163-2018
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