title: Factors to inform clinicians about the end of life in severe chronic obstructive pulmonary disease.
abstract: BACKGROUND
  Palliative services have historically been offered to terminal patients with cancer, but much less so in other chronic illnesses such as chronic obstructive pulmonary disease (COPD) because of difficulties in predicting the trajectory to death.
  
  
  OBJECTIVE
  The goal of this study was to determine if the change over time of the key parameters (trajectory) in patients with severe COPD can independently predict short-term mortality.
  
  
  METHODS
  We analyzed data from 1218 patients with severe COPD. Multivariate models for trajectory change were used to forecast mortality at 12 months.
  
  
  RESULTS
  Changes in several variables by defined cutpoints increase significantly and independently the odds of dying in 12 months. The earliest and strongest predictors were the decrease in gait speed by 0.14 m/s or six-minute walk by 50 m (odds ratio [OR] 4.40, P<0.0001). Alternatively, if six-minute walk or gait speed were not used, change toward perceiving a very sedentary state using a single question (OR 3.56, P=0.0007) and decrease in maximal inspiratory pressure greater than 11 cmH2O (OR 2.19, P=0.0217) were predictive, followed by change toward feeling upset or downhearted (OR 2.44, P=0.0250), decrease in room air resting partial pressure of oxygen greater than 5 mmHg (OR 2.46, P=0.0156), and increase in room air resting partial pressure of carbon dioxide greater than 3 mmHg (OR 2.8, P=0.0039). Change over time models were more discriminative (higher c-statistics) than change from baseline models.
  
  
  CONCLUSIONS
  The changes in defined variables and patient-reported outcomes by defined cutpoints were independently associated with increased 12-month mortality in patients with severe COPD. These results may inform clinicians when to initiate end-of-life communications and palliative care.
authors.affiliation: Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA. Electronic address: benzo.roberto@mayo.edu.
authors.forename: Roberto
authors.initials: R
authors.lastname: Benzo
authors.forename: Wendy
authors.initials: W
authors.lastname: Siemion
authors.forename: Paul
authors.initials: P
authors.lastname: Novotny
authors.forename: Alice
authors.initials: A
authors.lastname: Sternberg
authors.forename: Robert M
authors.initials: RM
authors.lastname: Kaplan
authors.forename: Andrew
authors.initials: A
authors.lastname: Ries
authors.forename: Robert
authors.initials: R
authors.lastname: Wise
authors.forename: Fernando
authors.initials: F
authors.lastname: Martinez
authors.forename: James
authors.initials: J
authors.lastname: Utz
authors.forename: Frank
authors.initials: F
authors.lastname: Sciurba
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D009043:Motor Activity; D010166:Palliative Care / Q000706:statistics & numerical data*; D011379:Prognosis; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis / Q000401:mortality / Q000534:rehabilitation; D012129:Respiratory Function Tests / Q000706:statistics & numerical data*; D018570:Risk Assessment / Q000379:methods*; D015996:Survival Rate; D013727:Terminal Care / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology
keywords: Chronic obstructive pulmonary disease; end-of-life care; end-stage COPD; gait speed; mortality; palliative care; prediction tools; severe COPD