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

1. Advanced Lung Disease:
Prognostication and
Role of Hospice
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Healthcare Corporation to be confidential.

2. Satisfactory Completion
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in the entire activity as partial credit is not available. If you are seeking continuing education credit for
a specialty not listed below, it is your responsibility to contact your licensing/certification board to
determine course eligibility for your licensing/certification requirement.
Physicians
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Physicians should claim only the credit commensurate with the extent of their participation in the activity.
CME Provider Information

3. 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.
VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB)
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

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

5. 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

6. • 75-year-old male 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

7. 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 …

8. • 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 of JR (cont.)

9. 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

10. • 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 and Causes

11. • 16.4 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 but
has only a 20-day median
length of stay (LOS)
• 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 2018 were due to ALD
COPD Epidemiology
National Hospice & Palliative Care Association (2018). Facts & Figures: 2020 Edition.
COPD Data and Statistics. U.S. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/copd/data.html
Learn About COPD. Retrieved from American Lung Association: https://www.lung.org/lung-health-diseases/lung-disease-lookup/copd/learn-about-copd

12. • 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 hospice admissions nurse coordinates delivery
of the patient’s medications, home medical equipment
(HME), and oxygen to the home.
Case Study of JR (cont.)

13. 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.
2Yaqoob, Z. J., Al-Kindi, S. G., & Zein, J. G. (2017). Trends and disparities in hospice use among patients dying of COPD in the United States. Chest, 151(5), 1183-1184.
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
Hospice,
5.9%
Inpatient,
33.6%
Home without
hospice, 28.6%
Nursing
Home/long-
term care,
22.5%
DOA at
hospital, 0.4%
LOCATION OF DEATH2
Other/Unknown,
4.5%
COPD patient deaths during study period
N=1,242,350

14. 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

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

16. 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).
Symptom Variability1
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

17. Miravitlles, M., Ribera, A. (2017). Understanding the Impact of Symptoms on the Burden of COPD. Respiratory Research. 18(67).
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 65.8
88.2 83.6 86.3
Very severe COPD (n=73)
87.7
80
60
40
20
0
100
>1 nightmare symptom >1 early-morning symptom >1 daytime symptom
Mild COPD (n=63) Moderate COPD (n=265) Severe COPD (n=261)

18. 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
Between 2010 and 2014,
a significant increase in
ventilation and CPR occurred
among COPD patients who
died in the hospital.
COPD Patients Experience Aggressive Interventions at the End of Life
• Ventilation increased
from 36.99% to 48.2%
Compound Annual
Growth Rates (CAGR)
• CPR increased from 9.01
to 15.82 CAGR 11.99
Shen, et. al. (2018). Life-sustaining procedures, palliative care consultation, and do-not resuscitate status in dying patients with COPD in US hospitals: 2010-2014. Journal of Palliative Care, 33(3):159-
166.

19. • 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

20. • 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 are
passive consequences of bronchodilation
• Medications are given on either PRN or on
a routine basis to prevent or reduce symptoms
• Various forms are available
Bronchodilators

21. -• 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

22. Bronchodilator Drug Classes: Short-Acting Beta2 Agonists
Class Name Type/Method
Recommended for
Hospice Patients?
Reasoning
Short-
acting
Beta2
Agonists
(SABA)
Albuterol
(Ventolin, Proventil)
• Fast-acting
• Inhaler q4h-q6h
or Nebs q4h-q6h
Yes
• Works well for those with severe
disease, exacerbations, elderly, and
dementia comorbidity
Albuterol
aerosol HFA
Metered dose inhaler No
• Cost-ineffective
• Delivers no added benefit
Levalbuterol
(Xopenex)
Metered dose inhaler No
• No added benefit
• Not effective (requires 2x dose
to obtain same effect as Albuterol)
• Does not decrease cardiac
arrhythmias or prevent tremors
Pirbuterol
(Maxair)
Metered dose inhaler No
• Complexity of use and difficult
administration for patients nearing
end of life
• Requires dexterity and timing of
activation with inspiration of deep breath
Oral preparations are not recommended
• They are not well absorbed and are linked to many adverse effects

23. Class Name Type/Method
Recommended for
Hospice Patients?
Reasoning
Long-acting
Beta2 Agonists
(LABA)
Salmeterol
(Serevent Diskus)
One inhalation
every 12 hours
Utility in hospice
patients has not been
studied, but any benefit
is likely limited due to
requirements to hold
breath after dosing
• Slow onset of action
• Not intended for acute
rescue dosing
AR Formoterol
(Brovana)
Dose inhalation
Formoterol
(Foradil, Perforomist) Dose inhalation
Indacaterol
(Arcapta)
Dose inhalation
Bronchodilator Drug Classes: Long-Acting Beta2 Agonists

24. Anticholinergics
Class Name Type/Method
Recommended for
Hospice Patients?
Reasoning
Short-acting
Anticholinergics
Ipratropium
(Atrovent)
Inhaled
3-4 times a day
Utility in hospice
patients has not been
studied, but any benefit
is likely limited due to
requirements to hold
breath after dosing
• Aerosol form cost-ineffective
• No added benefit
Long-acting
Anticholinergics
Tiotropium
(Spiriva)
Inhaled every
24 hours via inhaler
or inhalation device
• No added benefit when added
to standard therapy
• Delivery systems have limited
use in end-stage disease because of
functional
decline and patients’ inability
to inspire and hold breath

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
Ipratropium vs. Tiotropium
Cheyne, L., Irvin-Sellers, M., White, J. (2013) Tiotropium versus Ipratropium in the Management of COPD. Cochrane Database of Systemic Reviews, Issue 9.

26. *Requires holding breath for 10 seconds, limiting ability to deliver medication to patients with dementia and severe COPD
Combination Inhalation Medications
Class Name Type/Method
Recommended for
Hospice Patients?
Reasoning
Short-acting
Beta2 Agonists +
Anticholinergics
Albuterol + Ipratropium
Nebulizer (DuoNeb)
One-unit dose
every 4-6 hours
Yes
• Preferred substitute in
hospice-eligible patients
• Availability, efficacy, and ease of
use for patients nearing end of life
Albuterol + Ipratropium
Inhalation Spray
(Combivent Respimat)
One inhalation
every 6 hours
Not typically
• Difficult administration for
patients nearing end of life
• Complexity of use
Long-acting
Beta2 Agonists +
Corticosteroids
Salmeterol + Fluticasone
(Advair Diskus)
Inhaled
every 12 hours
No
• Lung function is so compromised
that patients cannot inhale the med
properly (can lead to thrush due
to Fluticasone)*
• Difficult administration for patients
nearing end of life
• Complexity of use
Budesonide/Formoterol
(Symbicort)
Metered dose inhaler,
2 inhalations BID
No

27. 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).

28. • If patient is able to take medication effectively!
• 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.

29. 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 10 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.

30. • All advanced therapies are approved on a case-by-case
basis and would require discussion with VITAS
medical director, GM, 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

31. • 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 is 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 of JR (cont.)

32. 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

33. Typical Hospice Presentations of COPD (cont.)
Currow D, Louw S, McCloud P On behalf of the Australian National Palliative Care Clinical Studies Collaborative (PaCCSC), et al Regular,
sustained-release morphine for chronic breathlessness: a multicentre, double-blind, randomised, placebo-controlled trial Thorax 2020;75:50-56.
Exacerbation Type Presentation Treatments/Pharmacology
Mild
• Shortness of breath at rest and/or with
minimal exertion
• Poorly responsive to bronchodilator therapy
• Increased healthcare utilization
• Frequent episodes of bronchitis or pneumonia
• Continuous chronic oxygen therapy
• Increasing need for assistance in ADLs
• Declining PPS
• Energy-conserving techniques and limited exposure to sick contacts
• All nebulizer therapy for inhaled meds
• Based on patient symptom burden:
– Oral steroids PRN
– Low-dose continuous and PRN opiates for dyspnea
– Low-dose BDZ if patient has worsening anxiety*
Moderate
Presentations included in mild, plus:
• Pulmonary cachexia
• Steroid-dependent
• Cyanosis
• Dependence in 3/6 ADLs
• 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*
Acute
• Prior history of exacerbations and
particularly the need for hospitalization
• Previous mechanical ventilation
• Significant comorbidities
• Significant new symptoms and treatment
plan changes
• Evaluate for Inpatient or ICC status, given severity and
response to acute management
• Home treatment is as effective as hospitalization when
there is no change in mentation
• Nebulized short-acting bronchodilators
• Corticosteroids
• Antibiotics

34. • 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

35. 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

36. • 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.)

37. 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, ED 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.

38. 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 mmHg
– O2 saturation < 88%
– pCO2 > 50 mmHg
• Continuous oxygen therapy
End-Stage Pulmonary Disease (cont.)

39. • 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

40. • 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

41. • 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

42. • 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 of JR (cont.)

43. Patients with advanced iIllness 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?

44. 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-eligible patients have most or all of these
factors affecting their lives!
Burden of COPD and Other Advanced Lung Diseases
Singer, P.A., Martin, D.K., & Kelner, M. (2019). Quality end-of-life care: patients’ perspectives. Journal of the American Medical Association, 281(2):163-8.

45. • 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
COPD Costs. U.S. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/copd/infographics/copd-costs.html

46. • 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
• Now up to 3% of a hospital’s total Medicare billing
COPD and Readmissions

47. 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.

48. • 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
VITAS Intensive Comfort Care® (continuous
care) 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 of JR (cont.)

49. • 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

50. 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
Clinicians 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%

51. Recent study looked at POLST utilization in
1,818 ICU decedents, of whom 712 had COPD
• 286 (40%) of decedents were “full code”
at time of death
• 212 had limited interventions enacted
•Only 134 (19%) received comfort measures
There was a clear missed opportunity prior to
hospital admission for these patients to have
been referred to hospice care, able to access
the benefit
ACP: Typically Provided Too Late, If At All
Lee RY, Brumback LC, Sathitratanacheewin S, et al. Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Among
Patients Hospitalized Near the End of Life [published online ahead of print, 2020 Feb 16]. JAMA. 2020;323(10):950-960.
doi:10.1001/jama.2019.22523
aAdjusted for age at admission, race/ethnicity, education, log-transformed
days from POLST completion to study admission, history of cancer with
poor prognosis, history of dementia, and POLST signatory.

52. COPD patients receive costly care between exacerbations but
get lost in the primary care cycle between these admissions.
• Majority of DNR decisions are made during admission
• Key opportunities for clarification of GOC and ACP are missed
in the community
• Hospice can help address and conduce GOC conversations
Limited/no GOP/ACP leads to increased healthcare utilization
near the end of life, highlighting the importance of early hospice
referrals for advanced ALD/COPD patients.
Without hospice, they are:
• More likely to die in hospital/ICU without benefit of hospice services
• Not receiving care based on their goals and values
Goals of Care (GOC) and ACP in COPD
Andreas S, Alt-Epping B. Advance care planning in severe COPD: it is time to engage with the future.
ERJ Open Res. 2018;4(1):00009-2018. Published 2018 Feb 16. doi:10.1183/23120541.00009-2018

53. • 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 helps promote goal-concordant care,
with resultant:
• Decrease in readmissions
• Reduction in in-hospital mortality
• Lower Medicare spend per-beneficiary
• Improvement in patient satisfaction
Conclusion

54. Questions?

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.
Andreas S, Alt-Epping B. Advance care planning in severe COPD: it is time to engage with the future. ERJ Open Res.2018;4(1):00009-2018.
Published 2018 Feb 16. doi:10.1183/23120541.00009-2018
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
COPD Costs. U.S. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/copd/infographics/copd-costs.html
COPD Data and Statistics. U.S. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/copd/data.html
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 andpractices.
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. Learn About COPD. Retrieved from American Lung Association: https://www.lung.org/lung-health-diseases/lung-disease-lookup/copd/learn-about-copd
Lee RY, Brumback LC, Sathitratanacheewin S, et al. Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Among Patients
Hospitalized Near the End of Life [published online ahead of print, 2020 Feb 16]. JAMA. 2020;323(10):950-960. doi:10.1001/jama.2019.22523
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).
Miravitlles, M., Anzueto, A., Legnani, D., Forstmeier, L., & Fargel, M. (2007). Patients perception of exacerbations of COPD—the PERCEIVE study.
Respiratory Medicine,101(3), 453-460. doi:10.1016/j.rmed.2006.07.010
National Hospice & Palliative Care Association (2019). Facts & Figures: 2018Edition.
Shen, et. al. (2018). Life-Sustaining Procedures, Palliative Care Consultation, and Do-Not Resuscitate Status in Dying Patients With COPD in
US Hospitals: 2010-2014. Journal of Palliative Care, 33(3):159-166.
Singer, P., Martin, D., Kelner, M. (1999). Quality End-of-Life Care. JAMA, 281(2), 163. doi:10.1001/jama.281.2.163
Vestbo, et al. (2013). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. American Journal
of Critical Care Medicine. 187(4).
Wright J, Kinzbrunner B. (2011). Predicting Prognosis: How to decide when end-of life care is needed. Chapter 1, End-of-Life Care: A Practical Guide.
New York: McGraw Hill, p. 16.
Yaqoob, Z. J., Al-Kindi, S. G., & Zein, J. G. (2017). Trends and disparities in hospice use among patients dying of COPD in the United States.
Chest, 151(5), 1183-1184.
References

57. This document contains confidential and proprietary business information and
may not be further distributed in any way, including but not limited to email.
This presentation is designed for clinicians and healthcare professionals.
While it cannot replace professional clinical judgment, it is intended to guide
clinicians and healthcare professionals in establishing hospice eligibility for
patients through evaluation and management of advanced lung disease. It is
provided for general educational and informational purposes only, without a
guarantee of the correctness or completeness of the material presented.