The goal of this webinar is to educate physicians and healthcare professionals about the medical management of advanced lung disease (ALD) and the value of advance care planning for end-of-life patients.

1. Advanced Lung Disease
at End of Life
Eric Shaban, MD
Regional Medical Director
Midwest/Northeast
The information in the pages that follow is considered by
VITAS®
Healthcare Corporation to be confidential.

2. VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through:
VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved by: Florida Board of Nursing/Florida Board of
Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling.
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through: VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number:
139000207/RT CE Provider Number: 195000028/Approved by the Illinois Division of Profession Regulation for: Licensed Nursing
Home Administrators and Illinois Respiratory Care Practitioners.
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Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and
provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing
education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2018 – 06/06/2021.
Social workers completing this course receive 1.0 continuing education credits.
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CE Credit in Illinois
06-2019
CE Provider Information

3. To accurately identify, assess and treat appropriate
patients with advanced lung disease (ALD)
Goal

4. By the end of this presentation, you should be able to:
• Define the types of advanced lung disease (ALD)
• Discuss the impact of ALD on patients, family and
the healthcare system
• Describe the symptom burden of ALD
• Appreciate factors associated with a poorer prognosis in ALD
• Identify guidelines for referral to hospice
• Review the medical management of ALD
Objectives

5. • 75-year-old veteran who was referred to VITAS following a
third hospitalization in the past three months for exacerbation
of chronic obstructive pulmonary disease (COPD).
• He was diagnosed with COPD 20 years ago and has a
60-pack-per-year smoking history. The patient also has
emphysema, HTN, diet-controlled NIDDM and PVD.
• He has been treated with Advair and Spiriva for a number
of years.
• In the past six months, he has experienced a significant clinical
decline. During each hospitalization, the COPD exacerbation was
treated with IV antibiotics, pulse steroids, and nebulized albuterol
and ipratropium.
Case Presentation

6. Talk about advanced lung disease …
• … Not about end-stage lung disease. Why? People are OK thinking of themselves
or their patients as having an advanced illness, not an end-stage disease.
• Physicians and patients think of disease as a chronic illness, not as a progressive
terminal illness!
Hospice is a package of services
• For greater impact, think of and describe hospice to others this way:
– People are not “on hospice”
– Rather, they are “receiving hospice services” or “benefiting from hospice services”
• Hospice and palliative care meet important needs with which patients and families
can easily identify—both hospice and palliative care solutions can reduce their distress
First, Some Thoughts …

7. • Another COPD exacerbation resulted in a three-day hospital
readmission, followed by a skilled nursing facility (SNF) stay.
• Continuous oxygen at 2L was initiated; patient has continued
SOB at rest and with any exertion.
• Patient shows declining activities of daily living:
– Unable to bathe or dress himself due to dyspnea
– Can ambulate 4-5 steps before resting to catch his breath
– Spends most of the day in bed or a recliner, dozing throughout
the day
– No longer leaves his home or the first floor of his house.
Case Study (Cont.)

8. • Obstructive Lung Disorders: Air cannot get out
– COPD, asthma, emphysema
• Restrictive Lung Disease: Air cannot get in
– Interstitial Lung Disorders:
• Sarcoid, idiopathic pulmonary fibrosis, interstitial pneumonia,
drug-induced, radiation-induced and many more
– Neuromuscular Disorders
• ALS, myasthenia gravis
– Thoracic/Extrathoracic Factors:
• Obesity, ascites, kyphoscoliosis
Types of Advanced Lung Disease

9. • COPD is a chronic, progressive illness characterized by airflow
limitation that is not fully reversible
• Associated with abnormal inflammatory response to particles
and gases
• Predominant cause is cigarette smoking. Other causes include:
– Occupational exposure
– Indoor/outdoor pollutants/irritants
• Other causes of chronic airflow obstruction include
– Emphysema
– Chronic bronchitis
– Asthma (in some cases)
COPD Definition & Causes

10. • 15.7 million Americans have
been diagnosed with COPD
• About 140,000 patients have
pulmonary fibrosis
• >50% of adults with decreased
pulmonary function are not
aware that they have COPD
• COPD is the third-leading cause
of death in the US
• Deaths from end-stage COPD are
higher in women than men
– Result of physical (lung size) and
hormonal (estrogen) differences
between men and women
– 2009-2014 death rates have
declined for men and are
unchanged for women
• 11% of hospice admissions in 2017
were due to ALD
COPD Epidemiology
National Hospice & Palliative Care Association (2019). Facts & Figures: 2018 Edition.

11. • Advair and Spiriva are continued without much effect.
– Patient receives some benefit from his nebulizer, which he
uses “a few” times a day
• Patient is 6 feet tall and weighs 118 pounds.
– He has lost 20 pounds since his symptoms worsened;
appetite remains poor
• The patient is admitted to hospice on discharge from the hospital.
The admissions nurse coordinates delivery of the patient’s
medications, durable medical equipment (DME) and oxygen to
the home.
Case Study (Cont.)

12. 1Kochanek K., Murphy S., Xu J., Arias E. (2017). Deaths: Final data for 2017. National Vital Statistics Reports. National Center for
Health Statistics 2019, Hyattsville, MD. (68)9.
2Rush, B. (2017). Trends and Disparities in Hospice Use Among Patients Dying of COPD in the United States [Letter to the Editor]. Chest, 151(5).
Hospice is Underutilized in Advanced Lung
Disease Patients
• COPD is the third-leading cause of
death among persons aged 65 and
over1
• Yet, only a minority of patients with
COPD die at home or with hospice
• Hospice is the only post-acute care
option that offers multiple levels of
care to match patients’ symptoms
and goals of care2
LOCATION OF DEATH2
Hospice,
5.9%
Inpatient, 33.6%
Home without
hospice, 28.6%
Nursing
Home/long-term
care, 22.5%
DOA at hospital,
0.4%
Other/Unknown,
4.5%
COPD patient deaths during study period
N=1,242,350

13. Symptoms
• Dyspnea: 78% with activity,
24% with conversation
• Cough, chest tightness,
wheezing and/or rhonchi
• Fatigue and weakness
• Anorexia
• Edema
Advanced Lung Disease Clinical Presentation
• Excessive respiratory
mucous production
• Depression
• Anxiety
• Sleep disturbance
(often under-recognized)
• Rapid respirations
• Prolonged expirations and
pursed-lip breathing
• Muscle wasting
• Increased anterior-posterior
chest diameter
• Use of accessory muscles
of respiration

14. • A survey of 1,100 COPD patients identified the following symptoms as having the
greatest impact on the patients’ perceived well-being:
– Increased coughing 42%
– Shortness of breath 37%
– Fatigue 37%
– Increased sputum production 35%
Advanced Lung Disease Symptom Impact on
Quality of Life (QOL)
Miravitlles, M., Ribera, A. (2017). Understanding the Impact of Symptoms on the Burden of COPD. Respiratory Research. 18(67)

15. Symptom Variability1
Study Patients Symptoms
Prevalence,
% Morning
Daytime Nighttime
Miravitlles et al. COPD 2016 [25] n=727 Any symptoms 81.4 82.7 63.0
Stephenson et al. Int J Chron
Obstruct Pulmon Dis. 2015 [27]
n =1239 Any symptoms 78.6 n.r. 65.9
Bateman et al. Respir Res. 2015 [29] n = 3394 Any symptoms 94.4 n.r. 88.3
Roche et al. COPD 2013 [18] n =1489 Any symptoms 39.8
2
97 58
Partridge et al. Curr Med Res Opin.
2009 [17]
n = 803 Worse symptoms
3
37 34 25
1Miravitlles, M., Ribera, A. (2017). Understanding the Impact of Symptoms on the Burden of COPD. Respiratory Research. 18(67).
2Morning symptoms were defined as those symptoms present on waking, rather than those persisting through the morning
3Defined as symptoms that were worse than usual COPD chronic obstructive pulmonary disease, n.r. not reported

16. Symptom Variability in Advanced Lung Disease
37%
4%
9%
21%
25%
28%
9%
46%
11%
16%
27%
34%
17%
7%
0.00
0.10
0.20
0.30
0.40
0.50
Morning Midday Afternoon Evening Night No particular time
of day
Difficult to say
All COPD patients (n=803) Severe COPD patients (n=289)
61.9
73.0 73.0
58.9
78.1 80.0
65.9
88.2 87.7
65.8
83.6 86.3
0
20
40
60
80
100
>1 nightmare symptom >1 early-morning symptom >1 daytime symptom
Mild COPD (n=63) Moderate COPD (n=265) Severe COPD (n=261) Very severe COPD (n=73)
Miravitlles, M., Ribera, A. (2017). Understanding the Impact of Symptoms on the Burden of COPD. Respiratory Research. 18(67).

17. COPD Patients Experience Aggressive
Interventions at the End of Life
CAGR=5.45%,
P=.029
CAGR=13.12%,
P<.001
CAGR=11.95%,
P<.001
CAGR=7.69%,
P=.009
CAGR=11.99%,
P<.001
• Ventilation increased from 36.99%
to 48.2% Compound Annual
Growth Rates (CAGR)
• CPR increased from 9.01
to 15.82 CAGR 11.99
Between 2010 and 2014,
a significant increase in
ventilation and CPR occurred
among COPD patients who
died in the hospital.

18. • No medications to date can modify COPD’s long, terminal decline
• Treatment regimen should be patient-specific
• Pharmacologic therapy is based upon air-flow limitations,
frequency and severity of symptom exacerbations
Pharmacologic Therapy

19. • Relaxing smooth muscles in the bronchus improves
expiratory flow and emptying of the lungs
– Improves air exchange.
• No effect at the alveolar level
• Improved O2 or decreased retained CO2 is a passive
consequence of bronchodilation
• Medications are given on either PRN or on a routine
basis to prevent or reduce symptoms
• Various forms are available
Bronchodilators

20. • Beta2
-agonist (short- and long-acting)
• Anticholinergics (short- and long-acting)
• Combination of short-acting Beta2
-agonist + anticholinergics
• Combination of long-acting Beta2
-agonist + corticosteroids
• Methylxanthines
Bronchodilator Drug Classes

21. • Albuterol: (Ventolin, Proventil) fast-acting effects
• Inhaler 4-6 hours or nebulizer 4-6 hours
• Nebulizer therapy for severe disease, exacerbations,
elderly, and dementia comorbidity
Short-Acting Beta Agonists

22. • Albuterol aerosol HFA: Cost-ineffective and delivers no added benefit
• Levalbuterol (Xopenex):
– No added benefit
– Not effective; requires 2x the dose to obtain same effect
as albuterol
– Does not decrease cardiac arrhythmias or prevent tremors,
and may lack effectiveness
• Others: Pirbuterol (Maxair)
• Oral preparations are not recommended
– They are not well absorbed and are linked to many adverse effects
Short-Acting Beta Agonists: Not Recommended

23. • Salmeterol: (Serevent Diskus) One inhalation every 12 hours
– Slow onset of action and is not for acute rescue dosing
• Others: AR formoterol (Brovana), Formoterol
(Foradil & Perforomist), and Indacaterol (Arcapta)
• Utility in hospice patients has not been studied, but any benefit is
likely limited due to requirements to hold breath after dosing
Long-Acting Beta Agonists

24. • Short-acting: Ipratropium (Atrovent) - inhaler 3-4 x a day;
nebulizer 4-6hrs
– Aerosol form cost-ineffective; no added benefit
• Long-acting: Tiotropium (Spiriva) - inhaled every 24hrs via
inhaler or inhalation device.
– In large studies, no added benefit found when added to
standard therapy.1
– These delivery systems have limited use in end-stage disease due
to patients’ poor inspiratory effort, requirement to hold breath, and
functional decline
Anticholinergics
1Fried, T., Vaz Fragoso, C., Rabow, M. (2012). Caring for the Older Person With Chronic Obstructive Pulmonary Disease. JAMA, 308)12):1254-1263.

25. • Tiotropium: Modest improvement in lung function, fewer
hospitalizations and thus improved quality of life for stable COPD.
- Tiotropium costs more than 10x ipratropium.
• Other product in class: Aclidinium (Tudzora and Pressair)
• No data to guide treatment in hospice-eligible patients
Cheyne, L., Irvin-Sellers, M., White, J. (2013) Tiotropium versus Ipratropium in the Management of COPD. Cochrane Database of Systemic Reviews, Issue 9.
Ipratropium vs. Tiotropium

26. • Albuterol + Ipratropium Nebulizer (DuoNeb):
– One unit dose every 4-6 hours
– Preferred substitute in hospice-eligible patients
• Albuterol + Ipratropium Inhalation Spray (Combivent Respimat):
– One inhalation every 6 hours
Combination of Short-Acting
Beta2-agonist + Anticholinergics

27. • Salmeterol + Fluticasone (Advair Diskus)
– Inhaled every 12 hours
– Lung function is so compromised that patients cannot inhale the med
properly (can lead to thrush due to fluticasone)
• Requires holding breath for 10 seconds
– Dementia and severe COPD limit ability to deliver medication
• Other product: Budesonide/Formoterol (Symbicort)
Combination Long-Acting
Beta2-agonist + Corticosteroids

28. • Corticosteroids:
• Routine usage improves symptoms, lung function and quality
of life
• Does not modify decline or mortality and has significant
side effects
• Discontinuation may evoke symptom exacerbations1
• For end-stage disease and hospice, benefits of oral systemic
therapy often outweigh the risks
Anti-Inflammatory Agents
1Vestbo, et al. (2013). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease.
American Journal of Critical Care Medicine, 187(4).

29. • If patient is able to effectively take medication!
• These are not additive!
– Inhaled Corticosteroid: Unclear effect
– LABA: 15%-20%
– LABA + Inhaled Steroid: 25%
– Tiotropium: 14%-25%
– Phosphodiesterase four inhibitors: 17% reduction for Roflumilast
– Azithromycin: 25%, but increased risk of cardiac death
– Fluticasone/Salmeterol vs. Tiotropium: No difference
Percentage of Exacerbation Prevention
Marchetti, N., Criner, G. J., & Albert, R. K. (2013). Preventing Acute Exacerbations and Hospital Admissions in COPD. Chest, 143(5), 1444-1454.
doi:10.1378/chest.12-1801.

30. • Fluticasone/Salmeterol (Advair) + Tiotropium (Spiriva):
– 50% reduction with combination of three medications
– There was no combined reduction in exacerbation rates when
compared to use of each product individually!1
• These medications often are not appropriate for hospice
patients when:
– Lung function is so compromised they cannot inhale the med properly
– Patient is not able to inhale and hold breath for ten seconds
– Patients have other comorbidities (e.g., dementia) that make
administration difficult
Hospitalization Prevention: The Challenge
in the Literature
1Marchetti, N., Criner, G. J., & Albert, R. K. (2013). Preventing Acute Exacerbations and Hospital Admissions in COPD. Chest, 143(5), 1444-1454.
doi:10.1378/chest.12-1801.

31. • All advanced therapies are approved on a case-by-
case basis and would require discussion with
VITAS medical director and PCA
• BiPAP, Trilogy and other forms of mechanical
ventilation
– Often used as bridging therapy
• Primary pulmonary hypertension medications
– Prostacyclin agonists: epoprostenol, treprostinil
– Endothelin agonists: ambisetron, bosentan
– Nitric oxide enhancers: sildenafil, tadalafil
Advanced Therapies

32. • 24 hours after admission to hospice, the patient wakes up in severe
respiratory distress. He is short of breath and wheezing. 911 is called
and the patient transported to the Emergency Department (ED)
• A relative sees the ambulance next door and calls VITAS Telecare,
which provides 24/7/365 phone access to clinicians. The family and
hospice nurse meet the patient at the ED
• The patient is receiving BiPAP and nebulized bronchodilator therapy
– He improves two hours later, and BiPAP is discontinued
• Patient is transferred home on VITAS Intensive Comfort Care®
(ICC, or continuous care) for dyspnea and exacerbation
Case Study (Cont.)

33. • The Mild Exacerbation Patient:
– More difficult to prognosticate, subtle functional declines,
and prognosis closer to six months, or perhaps greater
– Persistent symptoms with little activity or at rest
– Can transition to moderate or severe exacerbation
• The Moderate Exacerbation Patient:
– Clearly unstable, exacerbates easily, persistent symptoms
• The Acute Severe Exacerbation Patient:
– Unstable and may be actively dying
Typical Hospice Presentations of COPD

34. • Energy-conserving techniques and limited exposure to sick contacts
• All nebulizer therapy for inhaled meds
• Oral steroids as tolerated
• Low-dose continuous and PRN opiates for dyspnea
• Low-dose BDZ if patient has worsening anxiety
– Caution: May potentiate opiate sedating effects
Treatment of the Moderate Exacerbation
Hospice Patient

35. • Prior history of exacerbations and particularly the need for
hospitalization
• Previous mechanical ventilation
• Significant comorbidities
• Significant new symptoms and treatment plan changes
Acute Exacerbations Are Likely When:

36. Treatment options:
• Evaluate for Inpatient or ICC status, given severity
and response to acute management
• Home treatment is as effective as hospitalization
when no change in mentation
Pharmacology:
• Nebulized short-acting bronchodilators
• Corticosteroids
• Antibiotics
Acute Exacerbations

37. • Morphine IV or subcutaneous (subQ) -- immediate onset
• To "break" acute dyspnea: 2-5 mg q5-10 for 1-2 doses before
transitioning to a scheduled q4h opiate (or LA formulation)
and q1h PRN
• Similar methodology can be used with oral medications if needed,
but at a dose of 5-10 mg q15
• Nebulized opioids, including morphine, have insufficient supporting
data and thus are not recommended .
– Not cost-effective
Dyspnea Management

38. Hospice-eligible COPD patients
• Have advanced disease
• Have more frequent COPD exacerbations
• Are often dyspneic and tachypneic
• Are often O2-dependent, steroid-dependent, and poorly
responsive to bronchodilators
• Often do not have inspiratory velocity to effectively use
dry powder inhalers and MDIs
• Present to hospice following functional decline, cachexia,
and/or severe disease exacerbation
The Hospice COPD Patient

39. • Presents like patients in a persistent exacerbation
• Breathlessness is the hallmark symptom of COPD
– Cough, sputum production, wheeze and chest tightness
• Increasing evidence base demonstrates that the overall
symptomatic burden has a detrimental impact on:
– Health status
– Quality of life
– ADLs
– Increased anxiety and depression
– Increased risk of exacerbations
– Worse disease prognosis
The Hospice COPD Patient (Cont.)

40. Disabling dyspnea as demonstrated by:
• Dyspnea at rest and/or with minimal exertion
• Dyspnea poorly responsive to bronchodilators
– FEV-1 < 30% predicted, post-bronchodilator
Progressive pulmonary disease as manifested by:
• Multiple hospitalizations, ER visits or doctor’s office visits
• Cor pulmonale
• Recent intubation
• Recurrent exacerbations with bronchitis or pneumonia
End-Stage Pulmonary Disease
Wright, J., Kinzbrunner, B. Predicting Prognosis: How to decide when end-of life care is needed. Chapter 1 in End-of-Life Care: A Practical Guide.
New York: McGraw Hill. P. 16.

41. Other indicators of a poor prognosis
• Body weight
– < 90% ideal body weight or
– > 10% weight loss
• Resting tachycardia > 100/min
• Abnormal ABGs or O2 saturation
– pO2 < 55 mm Hg
– O2 saturation < 88%
– pCO2 > 50 mm Hg
• Continuous oxygen therapy
End-Stage Pulmonary Disease (Cont.)

42. • Gait speed decline
• PaCO2 increases, PaO2 declines
• Disability chair, recliner or bed owing to COPD
• Maximal inspiratory pressure decrease
• Maximum work decline
• Depression and/or isolation
• Weight loss
Other Factors to Consider

43. • Prognosis is quite variable
• Hospice guidelines are accurate at 6-month prognosis about
50% of the time
• It is important to look at disease status, symptoms, functional
status and nutritional decline to support the prognosis
Advanced Lung Disease/COPD Prognosis

44. • Functional decline (e.g., homebound, confined to room,
bedbound, limited ADLs)
• Respiratory function decline is progressive despite aggressive
medical management
• Depression
• Weight loss
• Isolation
• All factors are associated with a limited prognosis
Prognosis: Important Factors

45. • On ICC, patient’s wheezing continues with moderate SOB.
• The hospice physician evaluates the patient the next day and prescribes
oral steroids and IV antibiotics.
• After a discussion about the patient’s use of dry powder inhalers and their
effectiveness, the inhalers are discontinued.
• The patient and family agree to scheduled nebulizer therapy plus a long-acting
opioid to manage his symptoms. The patient and family are encouraged to rely
on Telecare.
• He spends two days on ICC and is returned to routine level of hospice care.
Case Study (Cont.)

46. Patients with Advanced Illness Prefer:
• Pain and symptom control
• Avoidance of inappropriate prolongation of the dying process
• A sense of control
• Relief of burdens on family
• Strengthened relationships with loved ones
What Do Hospice Patients Want?

47. • COPD is the third-leading cause of death in America. Among
chronic COPD patients, the disease negatively affects or interferes
with quality of life on many levels:
– 70% normal activities
– 56% household chores
– 53% social activities
– 51% work
– 50% sleeping
– 46% family activities
• Virtually all hospice-appropriate patients have most or all of
these factors affecting their lives!
Burden of COPD and Other Advanced Lung Diseases

48. • In 2010, COPD cost the US medical system $36 billion,
estimated to rise to $49 billion by 2020!
– $32.1 billion direct healthcare expenditures
– $3.9 billion in worker absenteeism
– Estimated 16.4 million lost work days
• Most COPD patients are 65 or older and living with many
other chronic illnesses, including diabetes, cardiac disease
and dementia
– They have high overall healthcare utilization, especially at
the end of their lives and especially for EOL care in the last
month of life
Financial Cost and Cost to Healthcare System

49. • Hospital Readmission Reduction Program
– Reduction in all-cause hospital readmissions by aligning
payments with outcomes
– Applied following admission for COPD, PNA AMI, CHF,
and total hip or knee replacement to patients who readmit
within 30 days
– Penalties to Medicare billing
• 2015: up to 3% of a hospital’s total Medicare billing
COPD and Readmissions

50. • Patients with ALD and their families experience:
– ↑ overall satisfaction with their care
– ↑ symptom control, QOL
– ↓ unnecessary, invasive procedures and interventions
near the end of life
- ↑ CHANCE OF DYING AT HOME
– Improved communication with healthcare providers
– Earlier referral to hospice may actually prolong survival
(average 81 days for some CA pts)
Palliative Care and Hospice Improve
Clinical Outcomes
Adler, ED. (2009). Palliative care in the treatment of advanced heart failure. Circulation, 120(25): 2597-606.

51. • Two months later, the patient becomes acutely short of
breath and is wheezing again.
• He has developed ascites and lower-extremity edema,
indicating the development of right heart failure. His wife
calls Telecare, and ICC is initiated.
• He continues to exhibit SOB and wheezing after two days,
despite nebulizer therapy, as-needed opioids and diuretics
for his edema.
Case Study (Cont.)

52. • His symptoms continue to worsen. The decision is made to
transfer him to the VITAS inpatient unit. After transfer to the IPU, IV
therapies are initiated.
• After three hours of intensive symptom management, he becomes
comfortable and is no longer responsive. He dies peacefully a few
hours later, with his family at bedside.
• The family receives standard bereavement support for 13 months.
Case Concludes

53. 1Fulmer, T., Escobedo, M., Berman, A., Koren, A., Hernandez, S., Hult, A. (2018). Physicians’ views on advance care planning and end-of-life care
conversations. JAGS, 66(6):
2Jabbarian, et al. (2018). Advance care planning for patients with chronic respiratory diseases: a systematic review of preferences and practices.
Thorax, 73:222-230
Clinician Must Explore Advance Care
Planning (ACP) Opportunities
ACP is uncommon in chronic
respiratory disease
• 99% of clinicians say it is important
to have ACP conversations1
• In ALD, ACP happens rarely
• On average2:
– About 20% of patients engage in
ACP conversations
– Almost 30% of these conversations
occur in the last 3 days of life
Somewhat
important, 10%
Very
important,
38%
Extremely
important,
51%
Not too/not at all
important, 1%

54. • Hospice alleviates symptom burden and improves quality of life
for patients suffering from ALD
• Hospice helps to maximize patients’ time at home and increases
their chances of dying in their home
• Hospice can support the healthcare system by improving:
– Readmissions
– High-acuity healthcare utilization
Conclusion

55. Adler, E., Goldfinger, J., Kalman, J., Park, M., & Meier, D. (2009). Palliative care in the treatment of advanced heart
failure. Circulation, 120(25), 2597-2606.
Centers for Disease Control (2015). COPD Prevalence in Adults by State. (CDC, BRFSS).
Cheyne, L., Irvin-Sellers, M., White, J. Tiotropium versus Ipratropium in the Management of COPD. Cochrane Database
of Systemic Reviews, September 2013, Issue 9
Deaths from Chronic Obstructive Pulmonary Disease --- United States (n.d.). Retrieved from
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a4.htm
Ford, E., Murphy, L., Khavjou, M., Giles, W., Holt, J., Croft, J. (2015). Total and State-Specific Medical and Absenteeism
Costs of COPD Among Adults Aged 18 Years in the United States for 2010 and Projections Through 2020. CHEST,
147(1); 31-45.
Fried, T., Vaz Fragoso, C., Rabow, M. (2012). Caring for the Older Person With Chronic Obstructive Pulmonary Disease.
JAMA, (308)12):1254-1263.
Fulmer, T., Escobedo, M., Berman, A., Koren, A., Hernandez, S., Hult, A. (2018). Physicians’ views on advance care planning
and end-of-life care conversations. JAGS, 66(6):1201-1205.
Jabbarian, et al.(2018). Advance care planning for patients with chronic respiratory diseases: a systematic review of preferences and
practices. Thorax, 73:222-230
Kochanek K., Murphy S., Xu J., Arias E. (2017). Deaths: Final data for 2017. National Vital Statistics Reports. National Center for Health
Statistics 2019, Hyattsville, MD. (68)9.
References

56. Marchetti, N., Criner, G. J., & Albert, R. K. (2013). Preventing Acute Exacerbations and Hospital Admissions in COPD. Chest,143(5),
1444-1454. doi:10.1378/chest.12-1801.
Miravitlles, M., Ribera, A. (2017). Understanding the Impact of Symptoms on the Burden of COPD. Respiratory Research. 18(67).
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References

57. Questions

58. Advanced Lung Disease
at End of Life
Eric Shaban, MD
Regional Medical Director
Midwest/Northeast
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