Dying at Home From COPD: Feasible or Fantasy?

Abstract

PURPOSE: Chronic obstructive pulmonary disease (COPD) is increasing in prevalence locally and worldwide, imposing significant burdens on patients, families and on the healthcare system. While a home death from respiratory disease is traditionally difficult to facilitate, The INSPIRED COPD Outreach Program TM implemented in Halifax, Nova Scotia in 2010 strives to alleviate burdens on patients and families by reducing facility reliance and providing supported home deaths where possible in accordance with patient preference. METHODS: Retrospective chart review of deaths attributable to COPD among INSPIRED patients (2011-2013, 2011-2015) and those outside of the program in HRM from 2011-2013. We explored local databases for available location of death data among patients with COPD/lower respiratory tract disease in Nova Scotia in 2009-2011. Our primary outcome of interest was proportion of home deaths. Secondary outcomes included length of stay (LOS) for hospital deaths, ICU/IMCU use, availability of personal directives and involvement of palliative care. RESULTS: Among INSPIRED patients in both time frames, more died at home (6/20, 30%, 23/84, 38%, p<0001) by comparison with historical controls in Nova Scotia from 2009-2011(11/129, 8.3%). Of the INSPIRED decedents who died in hospital from 2011-15 (52/84, 62%), median (Interquartile range) LOS was significantly shorter (#0.0001) at 2 (0-6) days compared to Non-INSPIRED decedents 7 (4-15) days. Fewer INSPIRED patients, were admitted to ICU or IMCU in their last hospitalization 6/84 (7%) compared to Non-INSPIRED decedents (21%). Current completion rate for personal directives within the INSPIRED program (2014-2015) is 74% CONCLUSIONS: The INSPIRED COPD Outreach Program TM facilitates quality end of life care for Nova Scotians living with COPD through: 1) Higher rates (x3-4) of home deaths versus historical data outside of the program 2) Shorter length of stay (for those dying in hospital) 3) Fewer admissions to ICU/IMCU and 4) More available personal directives CLINICAL IMPLICATIONS: Home deaths, while always difficult to facilitate for those with advanced respiratory disease, are feasible with a dedicated Pulmonology-based outreach team with training in palliative approaches These home deaths do not overburden our already stretched palliative care serices, but they are available where needed in specific cases Next Steps: Ongoing initiatives such as collaboration with Emergency Health Services to document goals of care should further help to align care provided near the end of life with preferences of patients and families

Palliative care for chronic illness: driving change

“…19 Of 84 patients enrolled in the program who died from 2011 to 2015, 32 (38%) were supported in dying at home through effective advance care planning (current completion rate of written personal directives is > 80%). 20 A mixed-method evaluation of the INSPIRED program confirmed high patient satisfaction and the program's continued impact in reducing emergency department visits, hospital admissions and days in hospital by more than 60% among participants. 21 The Canadian Foundation for Healthcare Improvement has supported the spread of the INSPIRED program to 19 teams representing 78 health care sites (academic, regional and community based) across all 10 provinces.…”

New models of care for respiratory disease: A thematic edition

“…Not only did INSPIRED show the potential to contain costs for health system administrators and policy makers, it did it in a way that prioritized dignity of the patient and their family and offered a coordinated approach to care, provided in the comfort of home, inclusive of dying at home if requested. 6 Crisis aversion showed patients and families a “new possible.” A pan-Canadian spread collaborative was born. 5 …”