Abstract and Introduction
Abstract
Introduction: ICU admission is required in more than 25% of patients with chronic obstructive pulmonary disease (COPD) at some time during the course of the disease. However, only limited information is available on how physicians communicate with COPD patients about ICU admission.
Methods: COPD patients and relatives from 19 French ICUs were interviewed at ICU discharge about their knowledge of COPD. French pulmonologists self-reported their practices for informing and discussing intensive care treatment preferences with COPD patients. Finally, pulmonologists and ICU physicians reported barriers and facilitators for transfer of COPD patients to the ICU and to propose invasive mechanical ventilation.
Results: Self-report questionnaires were filled in by 126 COPD patients and 102 relatives, and 173 pulmonologists and 135 ICU physicians were interviewed. For 41% (n = 39) of patients and 54% (n = 51) of relatives, ICU admission had never been expected prior to admission. One half of patients were not routinely informed by their pulmonologist about possible ICU admission at some time during the course of COPD. Moreover, treatment options (that is, non-invasive ventilation, intubation and mechanical ventilation or tracheotomy) were not explained to COPD patients during regular pulmonologist visits. Pulmonologists and ICU physician have different perceptions of the decision-making process pertaining to ICU admission and intubation.
Conclusions: The information provided by pulmonologists to patients and families concerning the prognosis of COPD, the risks of ICU admission and specific care could be improved in order to deliver ICU care in accordance with the patient's personal values and preferences. Given the discrepancies in the decision-making process between pulmonologists and intensivists, a more collaborative approach should probably be discussed.
Introduction
Chronic obstructive pulmonary disease (COPD) is an increasingly common cause of death. At severe stages of the disease, episodes of acute respiratory failure often require intensive care unit (ICU) admission. Although the corresponding acute mortality is relatively low and lower than that of other diseases, outcomes after an exacerbation are poor. Disease severity, comorbidities, and impairment of activities of daily living are salient prognostic factors. Of note, intubation and invasive ventilation during an episode of exacerbation are associated with longer durations of stay and increased in-hospital and post-hospital mortality rates. In this context, the American Thoracic Society/European Respiratory Society task force on COPD diagnosis and management has recommended that 'Healthcare providers should assist patients during stable periods of health to think about their advance care planning by initiating discussions about end-of-life care' and stated that 'these discussions should prepare patients with advanced COPD for a life-threatening exacerbation of their chronic disease …' while '…providing information on probable outcomes and the existence of palliative interventions…'
Despite more stays in ICU and more resource-intensive care than patients with cancer, COPD patients are not always well informed about their disease in general and about the risk of ICU admission in particular. They are also poorly informed about what an ICU stay entails. Semi-structured interviews conducted in 21 patients with advanced COPD revealed that many of them were unaware of the progressive nature of the condition and few were aware that they could die from their disease. Conversations about ICU care with COPD patients and their relatives during or after an acute episode are frequently conducted by intensivists rather than attending pulmonologists, in a context in which ICU stressors and post-traumatic disorders can interfere with decisions, preferences and values. In addition, COPD patients are particularly prone to psychiatric disorders, with a high prevalence of anxiety. As previously implemented in cancer patients, advance care planning could therefore improve the patient's quality of life without inducing higher rates of major depressive disorder.
The first objective of this study was to provide a description of the information provided by pulmonologists to their COPD patients at regular follow-up visits and of the information received by COPD patients and their relative about COPD-related ICU stays. Because decision-making processes are bound to influence the information given to patients, we aimed to describe how pulmonologists based their decisions for ICU admission and intubation in comparison with intensivists.