Chronic Obstructive Pulmonary Disease (COPD) affects 19 million Americans and is the 4th leading cause of death in the U.S. The age-adjusted mortality is increasing. COPD is a common problem in the VA setting with more than a million outpatient and 127,000 inpatient primary or secondary ICD-9 diagnoses in 1996. COPD contributes to 33% of admissions to VA medical facilities and 16% of all hospital admissions. In addition, treatment of COPD is expensive with an estimated 24 billon dollars spent in the U.S. in 1993.

Discussing treatment preferences in the context of the burden of treatment and the likelihood of a desirable outcome is an essential part of providing quality end-of-life care and increases the probability that care is in general agreement with a patient’s wishes. Despite evidence that suggests patients with COPD would like to have end-of-life discussions, communication with COPD patients about end-of-life care occurs infrequently. The objective of the study is to evaluate an intervention to improve the quality of end-of-life discussions between patients with COPD and their primary care providers. Because primary care clinicians and pulmonologists treat most patients with advanced COPD, interventions that are designed to improve communication about end-of-life care and treatment preferences for COPD patients will have to address factors that serve as obstacles to communication about end-of-life care. The intervention is based on self-efficacy theory and includes provider education, local champions and role models, determination of patients’ individual barriers and facilitators regarding communication about end-of-life care, preferences for communication about end-of-life care and preferences for end-of-life care and using this information to activate patients, family members, and healthcare providers.

As secondary aims, we will 1) assess whether the intervention resulted in an increase in provider-patients discussions about end-of-life care, patient-surrogate discussion about end-of-life care or improved patient’s satisfaction with COPD care; 2) assess the desire of COPD patients to discuss preferences about end-of-life care, preferences about dying and death, and the quality of patient-clinician communication about end-of-life care; 3) assess barriers and facilitators to high quality end-of-life communication for patients with COPD and their providers; 4) examine the utilization of VA services by these patients for up to ten years after the study start date to describe whether the intervention influenced the care actually received.

This is a multifaceted randomized trial that is grounded in self-efficacy theory and is designed to improve the quality of communication of end-of-life care for patients with COPD. The intervention will be evaluated using a randomized controlled trial design with the providers as the unit of randomization and the primary outcome being a previously developed and validated questionnaire assessing the occurrence and quality of communication about end-of-life care. We will enroll approximately 120 providers and 450 patients from General Internal Medicine, Geriatrics and Pulmonary clinics at the VA Puget Sound Health Care System. Eligible subjects must have a future visit scheduled in a participating clinic and have airflow limitation on spirometry or pulmonary function testing.

Genders Eligible for Study:  Both

Criteria

Inclusion Criteria:

• Have a future visit scheduled in one of the eligible primary care or chest clinics.
• Have moderate to severe airflow limitation on spirometry or pulmonary function testing defined as an FEV1 of <50% predicted.

Plus one or more of the following:

• Have 3 or more outpatient clinics visits for COPD (ICD-9) in the two years prior to enrollment.
• Have been hospitalized with a primary discharge diagnosis (ICD-9) for COPD.
• Have received, on average, 1 canister/month of an inhaled beta-agonist and ipratrapropium bromide (or the equivalent amount in combination inhalers like Combivent™) for 9 of 12 consecutive months prior to enrollment