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Original Research: Transplantation |

Barriers to Optimal Palliative Care of Lung Transplant CandidatesPalliative Care in Lung Transplant Candidates

Rebecca E. Colman, MD; J. Randall Curtis, MD, FCCP; Judith E. Nelson, MD, FCCP; Linda Efferen, MD, FCCP; Denis Hadjiliadis, MD, FCCP; Deborah J. Levine, MD; Keith C. Meyer, MD, FCCP; Maria Padilla, MD, FCCP; Mary Strek, MD, FCCP; Basil Varkey, MD, FCCP; Lianne G. Singer, MD, FCCP
Author and Funding Information

From the Division of Respirology, Department of Medicine (Drs Singer and Colman), University of Toronto; and the Toronto Lung Transplant Program (Dr Singer), University Health Network, Toronto, ON, Canada; the Division of Pulmonary and Critical Care Medicine (Dr Curtis), Harborview Medical Center, University of Washington, Seattle, WA; the Division of Pulmonary, Critical Care, and Sleep Medicine and the Hertzberg Palliative Care Institute (Dr Nelson), and the Department of Medicine (Dr Padilla), Mount Sinai School of Medicine, New York, NY; the Department of Medicine (Dr Efferen), South Nassau Communities Hospital, Oceanside, NY; the Division of Pulmonary and Critical Care Medicine (Dr Hadjiliadis), University of Pennsylvania School of Medicine, Philadelphia, PA; the Division of Pulmonary and Critical Care Medicine and CT Surgery (Dr Levine), University of Texas Heath Center, San Antonio, TX; the Department of Medicine (Dr Meyer), University of Wisconsin School of Medicine and Public Health, Madison, WI; the Division of Pulmonary and Critical Care Medicine (Dr Varkey), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI; and the Section of Pulmonary and Critical Care Medicine (Dr Strek), Department of Medicine, University of Chicago, Chicago IL.

Correspondence to: Lianne G. Singer, MD, FCCP, University Health Network, Toronto Lung Transplant Program, Toronto General Hospital, 585 University Ave, NCSB 11C-1194, Toronto, ON, Canada M5G 2N2; e-mail: lianne.singer@uhn.ca


Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(3):736-743. doi:10.1378/chest.12-0830
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Background:  The provision of effective palliative care is of great importance to patients awaiting lung transplantation. Although the prospect of lung transplantation provides hope to patients and their families, these patients are usually very symptomatic from their underlying disease.

Methods:  An e-mail questionnaire was sent to members of the American College of Chest Physicians’ Transplant NetWork and the Pulmonary Council of the International Society for Heart and Lung Transplantation (ISHLT). The survey included questions about barriers to providing palliative care, the availability of palliative care services, and recommended strategies to improve palliative care for lung transplant candidates.

Results:  The 158 respondents represented approximately 65% of transplant programs in the ISHLT registry. Respondents were in practice a mean of 11.3 (± 9) years, 70% were pulmonologists, 17% were surgeons, and 13% were other care providers. Barriers were classified into domains including patient factors, family factors, physician factors, and institutional/transplant program/lung allocation system factors. Significant patient/family barriers included unrealistic patient/family expectations about survival, unwillingness to plan end-of-life care, concerns about abandonment or inappropriate care after enrollment in a palliative care program, and family disagreements about care goals. For institutional/program/allocation system barriers, only the requirement for weight loss or gain to meet program-specific BMI requirements was identified. Significant physician barriers included competing time demands and the seemingly contradictory goals of transplant vs palliative care. Strategies recommended to improve palliative care included routine advance care planning for patients awaiting transplantation, access to palliative care specialists, training of transplant physicians in symptom management, and regular meetings among transplant physicians, nurses, patients, and families.

Conclusions:  Physicians providing care to lung transplant candidates reported considerable barriers to the delivery and acceptance of palliative care and identified specific strategies to improve palliative care for lung transplant candidates.


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