Avoid unnecessary testing of people with COPD near end of life

Many patients dying from COPD in hospital continue to have diagnostic tests until close to death, even after a decision has been made to provide comfort care only, an Australia study shows.

While the prognosis of terminal COPD is challenging, there are still many missed opportunities to reduce the burden of unnecessary tests in patients who are imminently dying, say respiratory specialists in Victoria.

In a retrospective review of testing for 343 patients who died of COPD in two Victorian hospitals between 2004 and 2015, they found that most (81%) underwent diagnostic tests in the last 48 hours of life and almost a third (32%) had investigation performed on the day they died.

The study found that almost all patients with severe COPD had diagnostic tests during their terminal admission, with a median of 11 testing episodes per patient. Patients were more likely to have tests if they were younger, had ICU admission and non-invasive ventilation use.

Investigations were performed in 12% of patients after they had documented decision by clinicians to change the goal of care to provide comfort care only.

The study investigators, led by Dr Lauren Ross of the Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, acknowledged that some testing at the end of life was to be expected in patients with severe COPD and severe breathlessness because the timing of decline and death in individual patients is highly uncertain.

“During an exacerbation, it is difficult to determine which patients may die despite active treatment, as many have previously survived similar episodes,” they wrote in Internal Medicine Journal.

However they said unnecessary testing may be done at the end of life due to a lack of clinician training in diagnosing and managing active dying – and the reluctance to discuss this with patients and families.

“Given most patients in this study had severe COPD with severe breathlessness and functional limitation before their terminal admission and were well known to each hospital, the use of validated mortality predictors, together with a more proactive approach regarding end of life discussion is required to facilitate specialist palliative care review earlier,” they suggested.

The finding that some patients continued to have multiple tests even after their goal of care was changed to comfort only might be due to poor communication or junior staff not understanding that such tests can stop.

“Maintaining interventions and testing may also have a symbolic value that allows clinicians, family and patients to accept a palliative strategy and avoid the perception of abandonment,” they said.

They concluded that for patients with severe COPD admitted to hospital there is still a need to weigh up the balance of tests and treatments with choices over palliative care to focus on comfort at the end of life.

“Increased physician education regarding communication and end-of-life care, including recognising active dying may address these issues,” they said.

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