Proactive palliative care for patients with COPD (PROLONG): a pragmatic cluster controlled trial

International Journal of COPD Dovepress open access to scientific and medical research Original Research International Journal of Chronic Obstructive Pulmonary Disease downloaded from https://www.dovepress.com/ by 37.59.46.207 on 12-Jul-2018 For personal use only. Open Access Full Text Article Proactive palliative care for patients with COPD (PROLONG): a pragmatic cluster controlled trial This article was published in the following Dove Press journal: International Journal of COPD 28 September 2017 Number of times this article has been viewed RG Duenk 1 C Verhagen 1 EM Bronkhorst 2 PJWB van Mierlo 3,4 MEAC Broeders 5 SM Collard 6 PNR Dekhuijzen 7 KCP Vissers 1 Y Heijdra 7,* Y Engels 1,* Department of Anesthesiology, Pain and Palliative Medicine, 2Department of Health Evidence, Radboud University Medical Center, Nijmegen, 3 Department of Supportive and Palliative Medicine, 4Department of Geriatric Medicine, Rijnstate Hospital, Arnhem, 5Department of Pulmonary Diseases, Jeroen Bosch Hospital, ‘s-Hertogenbosch, 6Department of Pulmonary Diseases, Meander Medical Center, Amersfoort, 7Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands 1 *These authors contributed equally to this work Background and aim: Patients with advanced chronic obstructive pulmonary disease (COPD) have poor quality of life. The aim of this study was to assess the effects of proactive palliative care on the well-being of these patients. Trial registration: This trial is registered with the Netherlands Trial Register, NTR4037. Patients and methods: A pragmatic cluster controlled trial (quasi-experimental design) was performed with hospitals as cluster (three intervention and three control) and a pretrial assessment was performed. Hospitals were selected for the intervention group based on the presence of a specialized palliative care team (SPCT). To control for confounders, a pretrial assessment was performed in which hospitals were compared on baseline characteristics. Patients with COPD with poor prognosis were recruited during hospitalization for acute exacerbation. All patients received usual care while patients in the intervention group received additional proactive palliative care in monthly meetings with an SPCT. Our primary outcome was change in quality of life score after 3 months, which was measured using the St George Respiratory Questionnaire (SGRQ). Secondary outcomes were, among others, quality of life at 6, 9 and 12 months; readmissions: survival; and having made advance care planning (ACP) choices. All analyses were performed following the principle of intention to treat. Results: During the year 2014, 228 patients (90 intervention and 138 control) were recruited and at 3 months, 163 patients (67 intervention and 96 control) completed the SGRQ. There was no significant difference in change scores of the SGRQ total at 3 months between groups (−0.79 [95% CI, −4.61 to 3.34], p=0.70). However, patients who received proactive palliative care experienced less impact of their COPD (SGRQ impact subscale) at 6 months (−6.22 [−11.73 to −0.71], p=0.04) and had more often made ACP choices (adjusted odds ratio 3.26 [1.49–7.14], p=0.003). Other secondary outcomes were not significantly different. Conclusion: Proactive palliative care did not improve the overall quality of life of patients with COPD. However, patients more often made ACP choices which may lead to better quality of care toward the end of life. Keywords: COPD, proactive palliative care, quality of life, advance care planning, readmission, survival Introduction Correspondence: RG Duenk Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, the Netherlands Tel +31 24 366 6254 Fax +31 24 361 3585 Email 2795 submit your manuscript | www.dovepress.com International Journal of COPD 2017:12 2795–2806 Dovepress © 2017 Duenk et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). http://dx.doi.org/10.2147/COPD.S141974 Powered by TCPDF (www.tcpdf.org) Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide and caused 3.1 million deaths (5.6% of total deaths) in 2012.1,2 This progressive life-threatening lung disease has an unpredictable course characterized by episodes of gradual decline punctuated by acute severe exacerbations.3 After the first hospitalization for an acute exacerbation of COPD (AECOPD), 50% of patients die within 3.6 years.4 Patients with advanced COPD have a high symptom burden, Dovepress International Journal of Chronic Obstructive Pulmonary Disease downloaded from https://www.dovepress.com/ by 37.59.46.207 on 12-Jul-2018 For personal use only. Duenk et al including breathlessness, fatigue, cough, and anxiety.5 Their quality of life is poor and often even worse than patients with lung cancer.6 Early or proactive palliative care can improve the quality of life of patients with cancer7–9 and heart failure.10,11 This kind of care is not restricted to end-of-life care but can be delivered earlier in the disease course by anticipating on wishes and needs of patients, in order to prevent and relieve suffering from problems in the physical, psychosocial, and spiritual domain.2 Patients with lung cancer receiving proactive palliative care even had longer survival while receiving less aggressive treatments.8 Prolonged survival has also been observed in patients with refractory breathlessness (cancer, COPD, chronic heart failure [CHF], and interstitial lung disease).12 In this study of Higginson et al,12 early introduction of a palliative breathlessness support service improved breathlessness mastery, a quality of life domain of the Chronic Respiratory Disease Questionnaire. Although proactive palliative care has been shown to improve the quality of life and prolong survival of patients with various life-threatening diseases, it is still not common for patients with COPD to receive this care.13 Since little is known about the effects of proactive palliative care in COPD, research is needed to be able to improve care for this patient group.13 We report a pragmatic cluster controlled trial of proactive palliative care in patients with COPD. A cluster design was chosen to prevent contamination and to minimize ethical concerns of patients and clinicians with respect to randomization and gate keeping. We h (...truncated)