Advanced Lung Disease: Prognostication and Role of Hospice

The information in the pages that follow is considered by VITAS® Healthcare Corporation to be confidential.
Advanced Lung Disease:
Prognostication and Role
of Hospice

Advanced Lung Disease Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
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Goal
To accurately identify, assess, and treat appropriate
patients who have advanced lung disease (ALD)

Objectives
By the end of this presentation, you should be able to:
• Define the types of advanced lung disease (ALD)
• Discuss the impact of ALD on patients, their
families, and the healthcare system
• Describe the symptom burden of ALD
• Appreciate factors associated with a
poorer prognosis in ALD
• Identify guidelines for referral to hospice
• Review the medical management of ALD

Types of Advanced Lung Disease
Obstructive lung disorders: Air cannot get out
• Chronic obstructive pulmonary disease
(COPD), asthma, emphysema
Restrictive lung disease: Air cannot get in
• Interstitial lung disorders:
– Sarcoid, idiopathic pulmonary fibrosis,
interstitial pneumonia, drug-induced,
radiation-induced, and more
• Neuromuscular disorders
– ALS, myasthenia gravis
• Thoracic/extrathoracic factors:
– Obesity, ascites, kyphoscoliosis

COPD Definition and Causes
• COPD is a chronic, progressive
illness characterized by airflow
limitation that is not fully reversible
• COPD is associated with abnormal
inflammatory response to
particles and gases
• Predominant cause is cigarette
smoking. Other causes include:
– Occupational exposure
– Indoor/outdoor pollutants/irritants
• Disorders of chronic
airflow obstruction
include:
– Emphysema
– Chronic bronchitis
– Asthma

COPD Epidemiology
1
Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 2018-2021 on CDC Wonder Online Database, released in 2023.
2
American Lung Association. Pulmonary Fibrosis Types and Causes. Available at: https://www.lung.org/blog/7-things-know-pulmonary-fibrosis#:~:text=Idiopathic%20pulmonary%20fibrosis%
2C%20or%20IPF, new%20cases%20diagnosed%20each%20year.
3National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. Basics about COPD. Available at: https://www.cdc.gov/copd/basicsabout.html#:~:text=
Almost%2015.7%20million%20Americans%20(6.4,have%20been%20diagnosed%20with%20COPD.&text=More%20than%2050%25%20of%20adults, actual%20number%20may%20be%20higher
4American Lung Association. COPD Trends Brief: Mortality. Available at: https://www.lung.org/research/trends-in-lung-disease/copd-trends-brief/copd-mortality
• Chronic lower respiratory diseases
were the 5th-leading cause of
US deaths among those aged
65-84 from 2018-20211
• About 207,000 patients have
pulmonary fibrosis2
• > 50% of adults with decreased
pulmonary function are not
aware that they have COPD3
• Most (86%) COPD deaths
occur among those age
65 years or older4
• 6% of hospice admissions
in 2020 were due to ALD2

Advanced Lung Disease Clinical Presentation
Signs and Symptoms
• Dyspnea with activity
or at rest
• Cough, chest
tightness, wheezing
• Fatigue and weakness
• Anorexia
• Edema
• Excessive respiratory
mucous production
• Depression
• Anxiety
• Sleep disturbance
(often underrecognized)
• Rapid respirations
• Prolonged expirations
and pursed-lip breathing
• Muscle wasting
• Increased anterior-
posterior chest diameter
• Use of accessory
muscles of respiration

Case of JR
• 75-year-old male veteran who
was referred to VITAS following
a 3rd hospitalization in the past
5 months for exacerbation of
chronic obstructive pulmonary
disease (COPD)
• He was diagnosed with COPD
20 years ago and has a 60-pack-
per-year smoking history. The
patient also has hypertension
(HTN), diet-controlled non-insulin-
dependent diabetes mellitus
(NIDDM), and peripheral vascular
disease (PVD)
• He has been treated with
Trelegy and chronic O2 therapy
for a number of years
• 5 months ago, he was intubated
in the ICU and was treated with
IV antibiotics, steroids, and
nebulized albuterol and ipratropium.
He was discharged to a skilled
nursing facility (SNF) with O2

Case of JR (cont.)
• A subsequent COPD exacerbation resulted in another ICU
stay 2 months after his initial hospitalization. JR was:
– Treated with BiPAP therapy
– Discharged home with home
health and physical therapy

Confidential and Proprietary Content
Advanced Lung Disease Is your patient hospice-eligible? VITAS can help.
Case of JR:
Two Pathways

Case Study of JR (cont.): Pathway #1 - Hospital
• Missed opportunities for goals-of-care conversation and introduction
of hospice services
3 weeks later
• JR not tolerating PT. Experiences
another exacerbation and goes
to the ED
• He is readmitted to the ICU and
put on a ventilator, where he
remains for 8 days
• NG feedings initiated
• Dependent in 6/6 ADLs
1 week later
• Wife wants to focus on
comfort care for JR
• Wife approves DNR
• JR is extubated and dies
in ICU 30 minutes later
• Family receives no
bereavement support

Between 2010 and 2014, a
significant increase in ventilation
and CPR occurred among COPD
patients who died in the hospital.
COPD Patients Experience Aggressive Interventions
at the End of Life
Shen, J. et al. (2018). Life-sustaining procedures, palliative care consultation, and do-not resuscitate status in dying patients with COPD in US hospitals: 2010-2014. Journal of Palliative Care, 33(3):159-166.
• Ventilation increased from
36.99% to 48.2% compound
annual growth rate (CAGR)
• CPR increased from 9.01
to 15.82 CAGR 11.99
CAGR=5.4
5%,
P=.02
9
CAGR=13.
12%,
P<.001
CAGR=11.
95%,
P<.001
CAGR=7.6
9%,
P=.00
9
CAGR=11.
99%,
P<.001

Case Study of JR (cont.): Pathway #2 - Hospice
• 3 weeks later post-hospital D/C,
JR is not tolerating PT
• Visits ED with SOB, cough,
dehydration, and anxiety
• Patient is discharged home with
recommendation for follow-up
with his pulmonologist
– Pulmonologist and PCP collaborate
to evaluate potential effectiveness
of curative treatments
• JR experiences worsening
symptoms 2 days later
• After telehealth goals-of-care discussion
with pulmonologist, JR and wife express
their wishes for JR to remain at home
• He is not ready to sign a DNR and
wants full code but is open to a hospice
discussion; a hospice consult is made
• JR is admitted to hospice on Intensive
Comfort Care®
(ICC) level of care to
manage his acute symptoms
• JR remains on this level of care for 2
days until his symptoms are brought
under control; he is then D/C to routine
level of hospice care

Hospice Is Underutilized in Patients
With Advanced Lung Disease
1Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 2018-2021 on CDC Wonder Online Database, released in 2023.
2Yaqoob, Z., et al. (2017). Trends and disparities in hospice use among patients dying of COPD in the United States. Chest, 151(5), 1183-1184.
• COPD is the 5th-leading cause
of death among persons aged
65 and over1
• Yet only a minority of patients with
COPD die at home or with hospice
• Hospice is the only post-acute care
option that offers multiple levels of
care to match patients’ symptoms
and goals of care2
Hospice,
5.9%
Inpatient
without
hospice,
33.6%
Home without
hospice, 28.6%
NH/LTC
without
hospice,
22.5%
DOA at
hospital, 0.4%
LOCATION OF DEATH2
Other/Unknown,
4.5%
COPD patient deaths during study period
N=1,242,350

Trends for Lung Disease in Places of Death
1
Cross, S., et al. (2020). Place of death for individuals with chronic lung disease: trends and associated factors from 2003 to 2017 in the United States. Chest, 158(2), 670-680.
• Between 2003-2017, home and
hospice facility deaths increased
while deaths in the hospital and
nursing facilities decreased1:
– Hospital = 44% to 28%
– Home = 23.4% to 34.7%
– Nursing Home = 22.6% to 19.7%
– Hospice Facility = 0.1% to 9.1%
• Home surpassed hospital as the
most common place of death in
2014, driven largely by deaths
caused by COPD1

1
Cross, S. et al. (2020). Place of death for individuals with chronic lung disease: trends and associated factors from 2003 to 2017 in the United States. Chest, 158(2), 670-680.
2Iyer, A. et al. (2019). A formative evaluation of patient and family caregiver perspectives on early palliative care in chronic obstructive pulmonary disease across disease severity.
Annals of the American Thoracic Society, 16(8), 1024-1033.
3Lindell, K. et al.(2015). Palliative care and location of death in decedents with idiopathic pulmonary fibrosis. Chest, 147(2), 423-429.
• A greater proportion of decedents from
pulmonary disease die in the hospital
than individuals dying of cancer,
cardiovascular disease, cerebrovascular
disease, or dementia1
• Because lung disease deaths occur
more frequently at home, unpaid
caregivers⏤typically relatives⏤will
be responsible for more and more
patient care, making the need for
caregiver support more critical1
• In a study of patients with COPD and
their caregivers, fewer than one-third
of respondents had heard of
palliative care
• Another study indicated that only a
minority of patients with chronic lung
disease receive formal palliative care
referrals, and many of these referrals
are only following ICU admission or
prior to initiation of hospice
Trends for Lung Disease in Places of Death (cont.)

Advanced Lung Disease Symptom Impact
on Quality Life (QOL)
1
Miravitlles, M., et al. (2017). Understanding the impact of symptoms on the burden of COPD. Respiratory Research, 18(1), 1-11.
2Suen, et al. (2023) National Prevalence of Social Isolation and Loneliness in Adults with Chronic Obstructive Pulmonary Disease. Annals of the American Thoracic Society.
A survey of 1,100 patients with COPD identified the
following symptoms as having the greatest impact
on patients’ perceived well-being1:
• Increased coughing: 42%
• Shortness of breath: 37%
• Fatigue: 37%
• Increased sputum production: 35%
Nearly 1 in 6 adults with COPD experience social
isolation, and 1 in 5 experience loneliness, with almost
twice the prevalence among those on supplemental
oxygen compared to the general population2

Pharmacologic Therapy
• No medications to date can modify COPD’s
long, terminal decline
–Treatment regimen should be patient-specific
• Pharmacologic therapy is based on air-flow
limitations and the frequency and severity
of symptom exacerbations

Bronchodilators
• Relaxation of smooth muscles in the bronchus
improves expiratory flow and emptying of
the lungs
– Improves air exchange
• No effect at the alveolar level
• Improved O2 or decreased retained CO2 are
passive consequences of bronchodilation
• Medications are given on either PRN or on
a routine basis to prevent or reduce symptoms
• Various forms are available

Bronchodilator Drug Classes
• Beta2-agonist (short- and long-acting)
• Anticholinergics (short- and long-acting)
• Combination of short-acting Beta2-agonist
+ anticholinergics
• Combination of long-acting Beta2-agonist
+ corticosteroids
• Methylxanthines

Bronchodilator Drug Classes: Short-Acting Beta2 Agonists
Class Name Type/Method
Recommended for
Hospice Patients?
Reasoning
Short-acting
Beta2 Agonists
(SABA)
Albuterol Neb
• Fast-acting
• Nebs q4h-q6h
Yes
• Works well for those with severe
disease, exacerbations, elderly, and
dementia comorbidity
Albuterol
Aerosol HFA
Metered dose inhaler No
• Cost-ineffective
• Delivers no added benefit
Levalbuterol
(Xopenex)
• No added benefit
• Not effective (requires 2x dose to
obtain same effect as Albuterol)
• Does not decrease cardiac
arrhythmias or prevent tremors
Pirbuterol
(Maxair)
• Complexity of use and difficult
administration for patients
nearing the end of life
• Requires dexterity and timing
of activation with inspiration
of deep breath
Oral preparations are not recommended
• They are not well absorbed and are linked to many adverse effects

Bronchodilator Drug Classes: Long-Acting Beta2 Agonists
Recommended for
Hospice Patients?
Reasoning
Long-acting
Beta2 Agonists
(LABA)
Salmeterol
(Serevent Diskus)
One inhalation
every 12 hours
Utility in hospice patients
has not been studied,
but any benefit is
likely limited due to
requirements for patients
to hold their breath
after dosing
•Slow onset of action
•Not intended for
acute rescue dosing
Arformoterol
(Brovana)
Dose
inhalation
Formoterol
(Foradil, Perforomist)
Dose
inhalation
Indacaterol (Arcapta)
Dose
inhalation

Bronchodilator Drug Classes: Anticholinergics
Recommended for
Hospice Patients?
Reasoning
Short-acting
Anticholinergics
Ipratropium
(Atrovent)
Inhaled
3-4 times a day Utility in hospice patients
has not been studied,
but any benefit is
likely limited due to
requirements for
patients to hold their
breath after dosing
• Aerosol form cost-ineffective
• No added benefit
• No added benefit when
added to standard therapy
• Delivery systems have limited
use in end-stage disease because
of functional decline and patients’
inability to inspire and hold breath
Long-acting
Anticholinergics
Tiotropium
(Spiriva)
Inhaled every
24 hours via inhaler
or inhalation device

Ipratropium vs. Tiotropium
Cheyne, L., et al. (2013). Tiotropium versus ipratropium bromide for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews, (9).
Tiotropium Modest improvement in lung function,
fewer hospitalizations, and thus improved quality of
life for stable COPD
• Tiotropium costs more than 10x ipratropium
Other product in class: Aclidinium (Tudorza Pressair)
• No data to guide treatment in hospice-eligible patients

Combination Inhalation Medications
Recommended for
Hospice Patients?
Reasoning
Short-acting
Beta2 Agonists +
Anticholinergics
Albuterol + Ipratropium
Nebulizer (DuoNeb)
One-unit dose
every 4-6 hours
Yes
• Preferred substitute
in hospice-eligible patients
• Availability, efficacy, and
ease of use for patients
nearing end of life
Albuterol + Ipratropium
Inhalation Spray
(Combivent Respimat)
One inhalation
every 6 hours
Not typically
• Difficult administration for
patients nearing end of life
• Complexity of use
Long-acting
Beta2 Agonists +
Corticosteroids
Salmeterol + Fluticasone
(Advair Diskus)
Inhaled every
12 hours
No
• Lung function is so
compromised that patients
cannot inhale the med
properly (can lead to
thrush due to Fluticasone)*
• Difficult administration
for patients nearing
end of life
• Complexity of use
Budesonide/
Formoterol (Symbicort)
Metered dose inhaler,
2 inhalations BID
No

Anti-Inflammatory Agents
1
Vestbo, J., et al. (2013). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. American Journal of Respiratory and Critical Care Medicine, 187(4), 347-365.
2Woods, J., (2014). Corticosteroids in the treatment of acute exacerbations of chronic obstructive pulmonary disease. International Journal of Chronic Obstructive Pulmonary Disease, 9, 421.
Corticosteroids
• Routine usage improves symptoms, lung function, and quality of life
• Do not modify decline or mortality and has significant side effects
• Discontinuation may evoke symptom exacerbations1
• For end-stage disease and hospice, benefits of oral systemic therapy
often outweigh the risks
• Have been shown to reduce rehospitalizations and duration
of hospital stay2

Percentage of Exacerbation Prevention
Marchetti, N., et al. (2013). Preventing acute exacerbations and hospital admissions in COPD. Chest, 143(5), 1444-1454.
• If patient is able to take medication effectively!
• These are not additive!
– Inhaled corticosteroid Unclear effect
– LABA 15%-20%
– LABA + Inhaled steroid 25%
– Tiotropium 14%-25%
– Phosphodiesterase-4 inhibitor
17% reduction for Roflumilast
– Azithromycin 25%, but increased risk of cardiac death
– Fluticasone/Salmeterol vs. Tiotropium No difference

Hospitalization Prevention: The Challenge in the Literature
Fluticasone/Salmeterol (Advair) + Tiotropium (Spiriva):
• 50% reduction with combination of 3 medications
• There was no combined reduction in exacerbation rates
when compared to use of each product individually!1
These medications often are not appropriate for hospice
patients when:
• Lung function is so compromised they cannot inhale
the med properly
• Patient is not able to inhale and hold breath for 10 seconds
• Patients have other comorbidities (e.g., dementia) that
make administration difficult
Marchetti, N., et al. (2013). Preventing acute exacerbations and hospital admissions in COPD. Chest, 143(5), 1444-1454.

Advanced Therapies
• All advanced therapies are approved on a case-by-case
basis and would require discussion with VITAS medical
director, GM, and PCA
• BiPAP, Trilogy, and other forms of mechanical ventilation
– Often used as bridging therapy
• Primary pulmonary hypertension medications
– Prostacyclin agonists: epoprostenol, treprostinil
– Endothelin agonists: ambisetron, bosentan
– Nitric oxide enhancers: sildenafil, tadalafil

Typical Hospice Presentations of COPD
The Mild Exacerbation Patient:
• More difficult to prognosticate, subtle functional
declines, and prognosis closer to 6 months or
perhaps greater
• Persistent symptoms with little activity or at rest
• Can transition to moderate or severe exacerbation
The Moderate Exacerbation Patient:
• Clearly unstable, exacerbates easily,
persistent symptoms
The Acute Severe Exacerbation Patient:
• Unstable and may be actively dying

Typical Hospice Presentations of COPD (cont.)
Currow, D., et al. (2020). Regular, sustained-release morphine for chronic breathlessness: a multicentre, double-blind, randomised, placebo-controlled trial. Thorax, 75(1), 50-56.
Exacerbation Type Presentation Treatments/Pharmacology
Mild
• Shortness of breath at rest and/or
with minimal exertion
• Poorly responsive to bronchodilator therapy
• Increased healthcare utilization
• Frequent episodes of bronchitis or pneumonia
• Continuous chronic oxygen therapy
• Increasing need for assistance in ADLs
• Declining PPS
• Energy-conserving techniques and limited exposure
to sick contacts
• All nebulizer therapy for inhaled meds
• Based on patient symptom burden:
– Oral steroids PRN
– Low-dose continuous and PRN opiates for dyspnea
– Low-dose BDZ if patient has worsening anxiety*
Moderate
Presentations included in mild, plus:
• Pulmonary cachexia
• Steroid-dependent
• Cyanosis
• Dependence in 3/6 ADLs
• Energy-conserving techniques and limited
exposure to sick contacts
• All nebulizer therapy for inhaled meds
• Oral steroids as tolerated
• Low-dose continuous and PRN opiates for dyspnea
• Low-dose BDZ if patient has worsening anxiety*
Acute
• Prior history of exacerbations and
particularly the need for
hospitalization
• Previous mechanical ventilation
• Significant comorbidities
• Significant new symptoms and
treatment plan changes
• Evaluate for inpatient or ICC status given
severity and response to acute management
• Home treatment is as effective as
hospitalization when there is no change
in mentation
• Nebulized short-acting bronchodilators
• Corticosteroids
• Antibiotics

Dyspnea Management
• Morphine IV or subcutaneous (SubQ) ⏤ immediate onset
• To “break” acute dyspnea: 2-5 mg q 5-10 minutes for
1-2 doses before transitioning to a scheduled q 4h
opiate (or LA formulation) and q 1h PRN
• Similar methodology can be used with oral medications
if needed, but at a dose of 5-10 mg q 15 minutes
• Nebulized opioids, including morphine, have insufficient
supporting data and thus are not recommended
• Not cost-effective

• After receiving 6 weeks of routine
hospice care, over the weekend,
JR’s wife notices increased
lethargy and SOB
• Wife calls hospice 24/7/365 live
clinical support line
• Hospice clinician dispatches after-
hours clinician for assessment
of JR at home and contacts on-call
VITAS physician; orders are obtained
• Intensive Comfort Care®
initiated
at home for symptoms of SOB and
COPD exacerbation:
– Antibiotics for 7 days for management
of COPD exacerbation
– Oral steroids
– O2 titrated to comfort
• JR and wife elect DNR status
• JR’s symptoms improve and Intensive
Comfort Care® is discontinued
• JR remains on routine level of
hospice care for the next 2 months

The Hospice-Eligible COPD Patient
Hospice-eligible COPD patients:
• Have advanced disease
• Have more frequent
COPD exacerbations
• Are often dyspneic and tachypneic
• Are often O2-dependent, steroid-
dependent, and poorly responsive
to bronchodilators
• Often do not have inspiratory
velocity to effectively use dry
powder inhalers and MDIs
• Present to hospice following
functional decline,
cachexia, and/or severe
disease exacerbation

• Presents like patients in a
persistent exacerbation
• Breathlessness is the hallmark
symptom of COPD
– Cough, sputum production,
wheeze, and chest tightness
The Hospice-Eligible COPD Patient (cont.)
• Increasing evidence base demonstrates
that the overall symptomatic burden
has a detrimental impact on:
– Health status
– Quality of life
– ADLs
– Increased anxiety and depression
– Increased risk of exacerbations
– Worse disease prognosis

End-Stage Pulmonary Disease
Wright, J., Kinzbrunner, B. Predicting Prognosis: How to decide when end-of life care is needed. Chapter 1 in End-of-Life Care: A Practical Guide. New York: McGraw Hill. P. 16.
Disabling dyspnea as
demonstrated by:
• Dyspnea at rest and/or with
minimal exertion
• Dyspnea poorly responsive
to bronchodilators
– FEV-1 < 30% predicted,
post-bronchodilator
Progressive pulmonary disease
as manifested by:
• Multiple hospitalizations, ED
visits, or doctor’s office visits
• Cor pulmonale
• Recent intubation
• Recurrent exacerbations with
bronchitis or pneumonia
• Inability to wean or increased
need for chronic O2/oral steroids

Other indicators of a poor prognosis:
• Body weight
– < 90% ideal body weight or
– > 10% weight loss
• Resting tachycardia > 100/min
• Abnormal ABGs or O2 saturation
– pO2 < 55 mmHg
– O2 saturation < 88%
– pCO2 > 50 mmHg
• Continuous oxygen therapy
End-Stage Pulmonary Disease (cont.)

Other Factors to Consider
• Gait speed decline
• PaCO2 increases, PaO2 declines
• Disability: spends majority of time in
a chair, recliner, or bed owing to COPD
• Maximal inspiratory pressure decrease
• Maximum work decline
• Depression and/or isolation
• Weight loss

Prognosis: Advanced Lung Disease/COPD
• Prognosis is quite variable
• Hospice guidelines are accurate at 6-month
prognosis about 50% of the time
• It is important to look at disease status,
symptoms, functional status, and nutritional
decline to support the prognosis

Prognosis: Important Factors
• Functional decline (e.g., homebound,
confined to room, bedbound,
limited ADLs)
• Respiratory function decline
is progressive despite aggressive
medical management
• Anxiety/depression
• Weight loss
• Isolation
• All factors are associated
with a limited prognosis

What Do Hospice Patients Want?
Patients with advanced illness prefer:
• Pain and symptom control
• Avoidance of inappropriate
prolongation of the dying process
• A sense of control
• Relief of burdens on family
• Strengthened relationships
with loved ones

Burden of COPD and Other Advanced Lung Diseases
1Iyer, A. S., et al. (2022). The Role of Palliative Care in COPD. Chest, 161(5), 1250–1262. https://doi.org/10.1016/j.chest.2021.10.032
2Singer, P. (1999). Quality end-of-life care: patients' perspectives. JAMA, 281(2), 163-168.
COPD is the 4th-leading cause of death in America1.
Among chronic COPD patients, the disease negatively
affects or interferes with quality of life on many levels2:
• 70% - normal activities
• 56% - household chores
• 53% - social activities
• 51% - work
• 50% - sleeping
• 46% - family activities
Virtually all hospice-eligible patients have most
or all of these factors affecting their lives!

Financial Cost and Cost to Healthcare System
Løkke A., et al. Economic burden of COPD by disease severity—Anationwide cohort study in Denmark. Int J Chron Obstruct Pulmon Dis. March 10, 2021.
• In the US, direct costs associated
with COPD amount to $32 billion
– Exacerbation-related costs
– Hospitalizations
– Outpatient follow-up care
– General practitioner visits
– Medications
– Laboratory tests
– Rehabilitation programs
• Most COPD patients are 65 or
older and living with many other
chronic illnesses, including diabetes,
cardiac disease, and dementia
– They have high overall healthcare
utilization, especially at the end of
their lives and especially for EOL
care in the last month of life

COPD and Readmissions
• Hospital Readmission Reduction Program
– Reduction in all-cause hospital readmissions
by aligning payments with outcomes
– Applied following admission for COPD, pneumonia
(PNM), acute myocardial infarction (AMI), congestive
heart failure (HF), and total hip or knee replacement
to patients who readmit within 30 days
– Penalties to Medicare billing
• Now up to 3% of a hospital’s total Medicare billing

Palliative Care and Hospice Improve Clinical Outcomes
Adler, E. et al. (2009). Palliative care in the treatment of advanced heart failure. Circulation, 120(25), 2597-2606.
Patients with ALD and their families experience:
↑ Overall satisfaction with their care
↑ Symptom control, QOL
↓ Unnecessary, invasive procedures and
interventions near the end of life
↑ CHANCE OF DYING AT HOME
Improved communication with healthcare providers
Earlier referral to hospice may actually prolong
survival (average 81 days for some CA pts)

Case Study of JR Concludes: Pathway #2 - Hospice
• 2 months later, JR’s symptoms worsen
• Continuous care initiated for symptoms
of altered mental status, fever,
congestion, and SOB
• Medication and treatments ordered, and
adjustments made to comfort meds
• 3 days later, JR passes away with dignity
in the comfort of his home, surrounded by
his wife, family, friends, and hospice staff

Clinicians Must Explore Advance Care Planning
(ACP) Opportunities
1Fulmer, T., et al. (2018). Physicians’ views on advance care planning and end-of-life care conversations. JAGS, 66(6):
2Jabbarian, L., et al. (2018). Advance care planning for patients with chronic respiratory diseases: a systematic review of preferences and practices. Thorax, 73:222-230
ACP is uncommon in chronic
respiratory disease:
• 99% of clinicians say it is important
to have ACP conversations1
• In ALD, ACP happens rarely
On average2:
• About 20% of patients engage in
ACP conversations
• Almost 30% of these conversations
occur in the last 3 days of life
Somewhat
important, 10%
Very
important,
38%
Extremely
important,
51%
Not too/not at all
important, 1%

ACP: Typically Provided Too Late, If At All
*FT stands for full-treatment intervention
Lee, R., et al. (2020). Association of physician orders for life-sustaining treatment with ICU admission among patients hospitalized near the end of life. JAMA, 323(10), 950-960.
• Fewer ICU admissions:
– Limited intervention: 46% vs. 62% FT*
– Comfort-only: 31% vs. 62%
• Fewer life-sustaining treatments:
– Limited intervention: 20% vs. 43% FT*
– Comfort-only: 14% vs. 43%
• Lower likelihood of mechanical ventilation,
vasoactive infusions, or CPR
aAdjusted for age at admission, race/ethnicity, education, log-transformed
days from POLST completion to study admission, history of cancer with
poor prognosis, history of dementia, and POLST signatory.

Goals of Care (GOC) and ACP in COPD
Andreas S, et al. (2018). Advance care planning in severe COPD: it is time to engage with the future. ERJ Open Res. 2018 Feb 16;4(1).
COPD patients receive costly care
between exacerbations but get lost
in the primary care cycle between
these admissions.
• Majority of DNR decisions are
made during admission
• Key opportunities for clarification
of GOC and ACP are missed in
the community
• Hospice can help address and
conduct GOC conversations
Limited/no GOC/ACP leads to
increased healthcare utilization
near the end of life, highlighting the
importance of early hospice referrals
for patients with advanced ALD/COPD.
Without hospice, they are:
• More likely to die in hospital/ICU
without benefit of hospice services
• Not receiving care based on their
goals and values

Conclusion
• Hospice alleviates symptom burden and improves
quality of life for patients suffering from ALD
• Hospice helps to maximize patients’ time at
home and increases their chances of dying in
their home or preferred setting for end-of-life care
• Hospice helps promote goal-concordant
care with:
–Decrease in readmissions
–Reduction in in-hospital mortality
–Lower Medicare spend per-beneficiary
–Improvement in patient satisfaction

Confidential and Proprietary Content
Advanced Lung Disease Is your patient hospice-eligible? VITAS can help.
Questions?

Additional Hospice Resources
The VITAS mobile app includes helpful
tools and information:
• Interactive Palliative Performance
Scale (PPS)
• Body-Mass Index (BMI) calculator
• Opioid converter
• Disease-specific hospice
eligibility guidelines
• Hospice care discussion guides
We look forward to having you attend
some of our future webinars!
Scan now to
download the
VITAS app.

References
Adler, E., et al.. (2009). Palliative care in the treatment of advanced heart failure. Circulation, 120(25), 2597-2606.
American Lung Association. COPD Trends Brief: Mortality. Available at: https://www.lung.org/research/trends-in-lung-disease/copd-
trends-brief/copd-mortality
American Lung Association. Pulmonary Fibrosis Types and Causes. Available at: https://www.lung.org/blog/7-things-know-pulmonary-
fibrosis#:~:text=Idiopathic%20pulmonary%20fibrosis%2C%20or%20IPF,new%20cases%20diagnosed%20each%20year.
Andreas, S, et al. (2018). Advance care planning in severe COPD: it is time to engage with the future. ERJ Open Res. 2018;4(1):00009-2018.
Centers for Disease Control (2015). COPD Prevalence in Adults by State. (CDC, BRFSS).
Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 2018-2021 on
CDC Wonder Online Database, released in 2023.
Cheyne, L., et al. Tiotropium versus Ipratropium in the Management of COPD. Cochrane Database of Systemic Reviews, September 2013, Issue 9
COPD Data and Statistics. U.S. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/copd/data.html
Cross, S., et al. (2020). Place of death for individuals with chronic lung disease: trends and associated factors from 2003 to 2017 in the
United States. Chest, 158(2), 670-680.
Currow D., et al. (2020). On behalf of the Australian National Palliative Care Clinical Studies Collaborative (PaCCSC), et al. Regular,
sustained-release morphine for chronic breathlessness: a multicentre, double-blind, randomised, placebo-controlled trial. Thorax, 75:50-56.
Deaths from Chronic Obstructive Pulmonary Disease --- United States (n.d.). Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a4.htm

References
Fulmer, T., et al. (2018). Physicians’ views on advance care planning and end-of-life care conversations. JAGS, 66(6):1201-1205.
Iyer, A. et al. (2019). A formative evaluation of patient and family caregiver perspectives on early palliative care in chronic obstructive
pulmonary disease across disease severity. Annals of the American Thoracic Society, 16(8), 1024-1033.
Iyer, A. S., et al. (2022). The Role of Palliative Care in COPD. Chest, 161(5), 1250–1262. https://doi.org/10.1016/j.chest.2021.10.032
Jabbarian, L., et al.(2018). Advance care planning for patients with chronic respiratory diseases: a systematic review of preferences and practices.
Thorax, 73:222-230
Learn About COPD. Retrieved from American Lung Association: https://www.lung.org/lung-health-diseases/lung-disease-lookup/copd/learn-about-copd
Lee, R., et al. Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Among Patients Hospitalized Near the End of Life
[published online ahead of print, 2020 Feb 16]. JAMA. 2020;323(10):950-960. doi:10.1001/jama.2019.22523
Lindell, K., et al.(2015). Palliative care and location of death in decedents with idiopathic pulmonary fibrosis. Chest, 147(2), 423-429.
Løkke A., et al. Economic burden of COPD by disease severity—Anationwide cohort study in Denmark. Int J Chron Obstruct Pulmon Dis.
March 10, 2021.
Marchetti, N., et al. (2013). Preventing Acute Exacerbations and Hospital Admissions in COPD. Chest,143(5), 1444-1454. doi:10.1378/chest. 12-1801.
Miravitlles, M., et al. (2007). Patients' perception of exacerbations of COPD—the PERCEIVE study. Respiratory Medicine,101(3), 453-460.
doi:10.1016/j.rmed.2006.07.010

References
Miravitlles, M., et al. (2017). Understanding the Impact of Symptoms on the Burden of COPD. Respiratory Research. 18(67).
National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. Basics about COPD. Available at:
https://www.cdc.gov/copd/basicsabout.html#:~:text=Almost%2015.7%20million%20Americans%20(6.4,have%20been%20diagnosed%
20with%20COPD.&text=More%20than%2050%25%20of%20adults,actual%20number%20may%20be%20higher
National Hospice & Palliative Care Association (2020). Facts and Figures: 2020 Edition.
Shen, J., et. al. (2018). Life-Sustaining Procedures, Palliative Care Consultation, and Do-Not Resuscitate Status in Dying Patients
With COPD in US Hospitals: 2010-2014. Journal of Palliative Care, 33(3):159-166.
Singer, P., et al. (1999). Quality End-of-Life Care. JAMA, 281(2), 163. doi:10.1001/jama.281.2.163
Suen, et al. (2023) National Prevalence of Social Isolation and Loneliness in Adults with Chronic Obstructive Pulmonary Disease.
Annals of the American Thoracic Society.
Vestbo, J., et al. (2013). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease:
GOLD executive summary. American Journal of Respiratory and Critical Care Medicine, 187(4), 347-365.
Woods, J., (2014). Corticosteroids in the treatment of acute exacerbations of chronic obstructive pulmonary disease. International
Journal of Chronic Obstructive Pulmonary Disease, 9, 421.
Wright J., et al. (2011). Predicting Prognosis: How to decide when end-of life care is needed. Chapter 1, End-of-Life Care: A Practical Guide.
New York: McGraw Hill, p. 16.
Yaqoob, Z., et al. (2017). Trends and disparities in hospice use among patients dying of COPD in the United States. Chest, 151(5), 1183-1184.

This document contains confidential and proprietary business information and
may not be further distributed in any way, including but not limited to email.
This presentation is designed for clinicians and healthcare professionals.
While it cannot replace professional clinical judgment, it is intended to guide
clinicians and healthcare professionals in establishing hospice eligibility for
patients through evaluation and management of advanced lung disease. It is
provided for general educational and informational purposes only, without a
guarantee of the correctness or completeness of the material presented.

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