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The burden of diagnostic investigations at the end of life for people with COPD

Dr Lauren Ross MBBS,

Corresponding Author

Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Parkville, Victoria, 3050 Australia

Correspondence

Department of Respiratory and Sleep Medicine The Royal Melbourne Hospital Parkville, Victoria 3050, Australia.

Email: laurenross@gmail.com

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Dr John Taverner MBBS,

Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Parkville, Victoria, 3050 Australia

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Jennifer John BDS MPH,

Department of Rural Health, University of Melbourne, Northeast Health Wangaratta, 35–47 Green St, Wangaratta, Victoria, 3677 Australia

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Dr Andreas Baisch MBBS MD FRACP,

Department of Medicine, Northeast Health Wangaratta, 35–47 Green St, Wangaratta, Victoria, 3677 Australia

The Department of Rural Health, University of Melbourne

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A/Prof Louis Irving MBBS FRCGP FRCP,

Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Parkville, Victoria, 3050 Australia

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Prof Jennifer Philip PhD FAChPM MMed MBBS,

Chair of Palliative Medicine, University of Melbourne, St Vincent's Hospital and Victorian Comprehensive Cancer Centre

St Vincent's Hospital, Victoria Parade, Fitzroy, Victoria, 3065 Australia

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A/Prof Natasha Smallwood BMedSci MBBS SpecCertPallCare MSc MRCP FRACP PhD,

Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Royal Parade, Parkville, Victoria, 3050 Australia

Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, Victoria, 3050 Australia

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First published: 16 June 2020
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This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/imj.14943.

Abstract

Background

Chronic obstructive pulmonary disease (COPD) is an incurable, chronic condition that leads to significant morbidity and mortality, with most patients dying in hospital. While diagnostic tests are important for actively managing patients during hospital admissions, the balance between benefit and harm should always be considered. This is particularly important when patients reach the end-of-life, when the focus is to reduce burdensome interventions. This study aimed to examine the use of diagnostic testing in a cohort of people with COPD who died in hospital.

Methods

Retrospective medical record audits were completed at two Australian hospitals (Royal Melbourne Hospital and Northeast Health Wangaratta), with all patients who died from COPD over twelve years between 1/1/2004 and 31/12/2015 included.

Results

Three hundred and forty-three patients were included, with a median of 11 diagnostic testing episodes per patient. Undergoing higher numbers of diagnostic tests was associated with younger age, ICU admission and non-invasive ventilation use. Reduced testing was associated with recent hospital admission for COPD, domiciliary oxygen use and a prior admission with documentation limiting medical treatment. Most patients underwent diagnostic tests in the last two days of life, and 12% of patients had ongoing diagnostic tests performed after a documented decision was made to change the goal of care to provide comfort care only.

Conclusion

There were missed opportunities to reduce the burden of diagnostic tests and 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.

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