Chest
Volume 127, Issue 6, June 2005, Pages 2188-2196
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Ethics in Cardiopulmonary Medicine
Barriers and Facilitators to End-of-Life Care Communication for Patients with COPD

https://doi.org/10.1378/chest.127.6.2188Get rights and content

Objective

Patients with COPD frequently do not discuss end-of-life care with physicians; therefore, we sought to identify the barriers and facilitators to this communication as a first step to overcoming barriers and capitalizing on facilitators.

Design

Fifteen barriers and 11 facilitators to patient-physician communication about end-of-life care were generated from focus groups of patients with COPD. We subsequently conducted a cross-sectional study of 115 patients with oxygen-dependent COPD and their physicians to identify the common barriers and facilitators and examine the association of these barriers and facilitators with communication about end-of-life care.

Participants and setting

Patients with oxygen-dependent COPD were recruited from clinics at a university, county, and Veterans Affairs teaching hospital, and an oxygen delivery company. We also recruited the physician identified by each patient as the doctor primarily responsible for their lung disease.

Measurements and results

Patients were interviewed by trained research interviewers. Physician data collection was completed by mail survey. Participation rates were 40% for patients and 86% for physicians. Only 32% of patients reported having a discussion about end-of-life care with their physician. Two of 15 barriers and 8 of 11 facilitators were endorsed by > 50% of patients. The most commonly endorsed barriers were “I'd rather concentrate on staying alive,” and “I'm not sure which doctor will be taking care of me.” Two barriers were significantly associated with lack of communication, as follows: “I don't know what kind of care I want,” and “I'm not sure which doctor will be taking care of me.” The greater the number of barriers endorsed by patients, the less likely they were to have discussed end-of-life care with physicians (p < 0.01), suggesting the validity of these barriers. Conversely, the more facilitators, the more likely patients were to report having had end-of-life discussions with their physicians (p < 0.001).

Conclusion

Although patients endorsed many barriers and facilitators, few barriers were endorsed by most patients. Barriers and facilitators associated with communication are targets for interventions to improve end-of-life care, but such interventions will likely need to address the specific barriers relevant to individual patient-physician pairs.

Section snippets

Participant Recruitment and Enrollment

We report results of a cross-sectional analysis of a prospective study of patients with oxygen-dependent COPD recruited from ambulatory clinics at a university, county, and Veterans Affairs (VA) teaching hospital, and an oxygen delivery company in Seattle, WA. The methods have been described previously in an article10 describing the quality of communication about end-of-life care and an article11 describing the role of depression and quality of life on treatment preferences for life-sustaining

Results

Of the 295 eligible patients contacted, 118 patients were initially enrolled in the study for 40% participation. Of the 118 enrolled patients, 3 patients were unable to complete interviews due to fatigue, leaving a sample size of 115 patients. At the two study sites where a clinician familiar with the patient introduced the study, 78 eligible patients were identified, and 50 patients were enrolled for a participation rate of 64%. At the two study sites where patients were sent a mailing

Occurrence of Communication About End-of-Life Care

This study suggests that only one third (32%) of the patients with oxygen-dependent COPD discuss with their physicians the type of care they would want if they were too sick to speak for themselves. Even the lower limit of the 95% confidence interval around this proportion (24%) is higher than the 19% found by Heffner and colleagues45 in a study of patients with COPD enrolled in a pulmonary rehabilitation program. The increase likely represents temporal changes, with an increase in emphasis on

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  • Cited by (0)

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

    This project was supported by a Career Investigator Award from the American Lung Association and the American Lung Association of Washington (Dr. Curtis).

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