Figures
- 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
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
Treatment decisions in end-stage chronic obstructive pulmonary disease by department affiliation. NIV: noninvasive ventilation. p-value obtained by the Chi-squared test.
Tables
- 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
Total Intensive care unit Pulmonology or internal medicine Geriatric or palliative care p-value Total respondents 162 67 (41) 51 (32) 44 (27) Age (range) years 49±10 (27–65) 47±9 (32–63) 47±11 (27–65) 53±8 (30–65) 0.009# No answer 15 (9) 3 (5) 5 (10) 7 (16) Sex 0.034¶ Male 89 (55) 37 (55) 32 (63) 20 (46) Female 69 (43) 30 (45) 19 (37) 20 (46) No answer 4 (2) 0 (0) 0 (0) 4 (8) Education <0.001¶ Physician in training 12 (7) 3 (5) 8 (16) 1 (2) General physician 18 (11) 2 (3) 2 (4) 14 (32) Specialist 132 (82) 62 (93) 41 (80) 29 (66) Experience in this field ≥10 years 110 (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 care Reference Intensive care unit 14.9 (1.87–118.8) 0.011 Pulmonology or internal medicine 9.4 (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 care Reference Intensive care unit 0.41 (0.15–1.12) 0.081 Pulmonology or internal medicine 0.16 (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 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
