Dying with lung cancer or chronic obstructive pulmonary disease: Insights from SUPPORT

CONTEXT: Many are calling for patients with advanced chronic obstructive pu lmonary disease (COPD) to receive hospice care, but the traditional hospice model may be insufficient. OBJECTIVE: To compare the course of illness and patterns of care for patien ts with non-small cell lung cancer and severe COPD. DESIGN: Prospective cohort study of seriously ill, hospitalized adults. SETTING: Five teaching hospitals in the United States. PATIENTS: Patients with Stage III or TV non-small cell lung cancer (n = 939 ) or acute exacerbation of severe COPD (n = 1008). MAIN OUTCOME MEASURES: Patients' preferences for pattern of care and for ve ntilator use; symptoms; life-sustaining interventions; and survival prognos es. RESULTS: Sixty percent in each group wanted comfort-focused care; 81% with lung cancer and 78% with COPD were extremely unwilling to have mechanical v entilation indefinitely. Severe dyspnea occurred in 32% of patients with lu ng cancer and 56% of patients with COPD and severe pain in 28% of patients with lung cancer and 21% of patients with COPD. Patients with COPD who died during index hospitalization were more likely than patients with lung canc er to receive mechanical ventilation (70.4% vs 19.8%), tube feeding (38.7% vs 18.5%), and cardiopulmonary resuscitation (25.2% vs 7.8%). Mechanical ve ntilation had greater short term effectiveness in patients with COPD, based on survival to hospital discharge (76% vs 38%). Patients with COPD maintai ned higher median 2-month and 6-month survival prognoses, even days before death. CONCLUSIONS: Hospitalized patients with lung cancer or COPD preferred comfo rt-focused care, yet dyspnea and pain were problematic in both groups. Pati ents with COPD were more often treated with life-sustaining interventions, and short-term effectiveness was comparatively better than in patients with lung cancer. In caring for patients with severe COPD, consideration should be given to implementing palliative treatments more aggressively, even whi le remaining open to provision of life-sustaining interventions.