Specialised clinics needed for advanced COPD


By Nicola Garrett

8 Apr 2016

Patients with advanced lung disease need specialised care to help address issues such as end-of-life care planning, says a respiratory physician who has set up an innovative clinic in Melbourne.

Dr Natasha Smallwood and colleagues set up the clinic for patients with advanced lung disease at The Royal Melbourne Hospital in Victoria after realising that many of their patients were missing out on the opportunity to have an end-of-life discussion with their doctor.

According to Dr Smallwood, end-of-life care discussions with patients are failing to take place because busy general clinics are unable to dedicate the amount of time needed to address such a complex and delicate issue.

“An end-of-life discussion can take 45 mins to an hour so unless you have a dedicated block of time you won’t have the conversation,” Dr Smallwood told the limbic.

An end-of-life discussion with a patient is also an iterative process that really requires a continuity of care. However this is hard to achieve, particularly in a public hospital clinic, where patients may see a different doctor at each visit.

Even starting the conversation can be a process. Asking the patient for permission to talk about advance care planning is the first step, and this can be followed up with the provision of written information they can go away with to read and process.

It might not be until a few visits later that you get to actually have a detailed discussion, Dr Smallwood explains.

“It’s very rare that the first time someone sees me they’re going to sign an advance care plan such as a refusal of treatment certificate,” she says.

The multidisciplinary clinic led by Dr Smallwood addresses these issues by allowing for longer consultations so that clinicians can manage patients’ symptoms and co-morbidities as well as have the time to instigate a discussion about end-of-life-care.

Having a structure in place where patients with advanced disease can be pulled out of a general busy clinic and into a specialised service has also been crucial to ensuring they are optimally managed, Dr Smallwood says.

The doctors are already seeing results with more than 80% of patients seen in the clinic having an end-of-life discussion documented in their notes. This is in stark contrast to findings from an audit of 226 consecutive patients who died from COPD at their institution between 2004-2016 that found only 13 percent had discussed an advance care plan.

And while not every patient wants to complete a written advance care plan “at least we’ve had the conversation” said Dr Smallwood.

Dr Smallwood is presenting her findings from the clinic at this year’s European Respiratory Society in London in September.

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