Palliative care for elderly patients with advanced lung disease

The November 2024 issue of Annals of Palliative Medicine features 7 Original Articles, 1 Review Article, and 1 Letter to the Editor, as well as an Editorial serving as an introductory article for the impactful special series entitled, “Radiotherapy for Oncologic Emergencies”.

This Message from the Editor-in-Chief focuses on the Review Article by Chen and O’Mahony on the role of palliative care in elderly patients with advanced lung disease (1). This article is the most current and perhaps the most comprehensive article in this patient population on pulmonary diseases that remain a major cause of morbidity and mortality worldwide. While several articles in Annals of Palliative Medicine have focused on pulmonary compromise from malignancy and cancer treatment complications (2,3) or from sequela of COVID-19 infection (4,5), there has been less focus on historically common causes of non-malignant lung symptomatology in elderly patients, including chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD). In their review article, Chen and O’Mahony focus on those common disabling respiratory conditions that predominantly afflict the elderly.

As people age, their likelihood of developing an advanced lung disease increases. The resulting quality-of-life-limiting symptoms of such lung diseases can often be compounded by increase in other comorbidities seen in the elderly, including cardiac disease. Advanced lung diseases are typically categorized as obstructive or restrictive, and both groups can profoundly impact patient’s quality of life.

COPD is an obstructive lung disease, which is defined as a decrease in post-bronchodilator forced expiratory volume in 1 second (FEV1) over forced vital capacity (FVC) ratio. COPD is caused by tobacco smoke or other noxious particles and gases that lead to an inflammatory response in the airways, which cause a progressive destruction of alveoli and loss of airway recoil. Patients with COPD often exhibit a gradual decline in lung function over many years and intermittent acute exacerbations that may result in frequent hospitalizations. COPD is increasing in prevalent in older adults and represents the leading cause of respiratory-related mortality in the elderly. In fact, it is consistently one of the top four causes of death globally (6).

ILD, on the other hand, is a restrictive lung disease that results in decreases in FEV1, FVC, total lung capacity (TLC), and diffusion capacity of lung for carbon monoxide (DLCO). ILD is a heterogenous group of diseases affecting the interstitium of the lungs and that is characterized by inflammation and fibrosis of the interstitial space. Common ILDs include idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, drug-induced pneumonitis, autoimmune-associated lung diseases, and sarcoidosis. Additionally, cancer treatments like radiation therapy and systemic therapy can also induce ILDs. ILD is increasing in prevalence, especially among the elderly (7). Prognosis and survival with ILDs are poor, with progressive fibrotic changes being permanent, with occasional acute exacerbations compounding progressive symptoms, and with survival typically measured in a few years (8,9).

Palliative care is a critical but historically underutilized component of care for patients with progressive pulmonary diseases like COPD and ILD, as these patients often have unmet needs in symptom relief, understanding their disease state and prognosis, and health services following hospital discharges after acute exacerbations (10). Despite this, however, patients with these non-malignant pulmonary conditions are significantly less likely to receive palliative care than those with pulmonary symptoms from lung cancer (11). Chen and O’Mahony recommend palliative care initiation at the time of ILD diagnosis. They call for primary palliative care to be provided by the pulmonary team, with the incorporation of an interprofessional palliative care team as needs escalate.

Beyond pulmonary symptoms, Chen and O’Mahony highlight several unique challenges facing the elderly patient population with advanced pulmonary disease. They highlight additional challenges such concomitant comorbidities, caregiver burden, and mental health complications like depression and anxiety. They also note that the elderly to a greater extent may experience non-pulmonary manifestations of COPD, including loss of body mass index and cachexia, as well as side effects from medications, and that they may have more difficulty with medication administration and compliance (12).

Chen and O’Mahony then provide a detailed summary and recommendations for the management of dyspnea, including nonpharmacological approaches and pharmacologic management for the subjective experience of breathing discomfort and breathlessness that patients with advanced lung disease face. They also detail management approaches for depression and anxiety that are common in patients with advanced lung disease (13).

The authors next describe how palliative care is important for advance care planning and end-of-life preparations. Prior studies have reported that patients with advanced lung disease prefer earlier discussions on advanced care planning (14-17).

Chen and O’Mahony emphasize prior findings (17) calling for health care providers to gain additional training and guidance to improve their advance care planning skills, and they recommend decision support tools to help patients facing end-of-life treatment choices. They endorse pulmonary rehabilitation groups, often critical for the management of advanced lung disease, as an appropriate setting for the delivery of advance care planning. The authors also make calls for improving terminal care in this patient population.

Advanced lung diseases like COPD and ILD have both high symptom burdens and high mortality rates. Chen and O’Mahony should be commended for their thorough review and highlighting how palliative care is important for both symptom management as well as advanced care planning and end-of-life preparations in patients with advanced lung disease.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-25-28/coif). The author serves as the co-Editor-in-Chief of Annals of Palliative Medicine from April 2014 to April 2027. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

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