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Kathleen O. Lindell, PhD, RN; Margaret Q. Rosenzweig, PhD, ACNP; Joseph Pilewski, MD; Leslie A. Hoffman, PhD, RN; Kevin Gibson, MD; Naftali Kaminski, MD
Author and Funding Information

From the University of Pittsburgh Dorothy P. & Richard P. Simmons Center for Interstitial Lung Disease at UPMC (Drs Lindell and Gibson), the Division of Pulmonary, Allergy, and Critical Care Medicine (Drs Lindell, Pilewski, and Gibson), and School of Nursing (Drs Rosenzweig and Hoffman), University of Pittsburgh; and Pulmonary, Critical Care, and Sleep Medicine (Dr Kaminski), Yale School of Medicine.

CORRESPONDENCE TO: Kathleen O. Lindell, PhD, RN, University of Pittsburgh, Dorothy P. & Richard P. Simmons Center for Interstitial Lung Disease, UPMC, 3459 Fifth Ave, Pittsburgh, PA 15213; e-mail: lindellko@upmc.edu


Drs Gibson and Kaminski are senior authors.

FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following conflicts of interest: Dr Pilewski has contracts with Vertex Pharmaceuticals Inc, N30 Pharmaceuticals LLC, Constellation Pharmaceuticals, and, previously, with KalaBios Pharmaceuticals Inc. Dr Gibson is a consultant for Gilead Sciences Inc. Dr Kaminski is a consultant to InterMune Inc, Sanofi-Aventis LLC, Biogen Idec Inc, Vertex Pharmaceuticals Inc, Takeda Pharmaceutical Co Ltd, Promedior Inc, Moerae Matrix Inc, and Boehringer Ingelheim GmbH; a past recipient of grants from Gilead Sciences Inc and Celgene Corp; and inventor on patent applications on the use of microRNAs in IPF and on peripheral blood biomarkers in IPF. Drs Lindell, Rosenzweig, and Hoffman have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

FUNDING/SUPPORT: This study was supported by the Dorothy P. and Richard P. Simmons endowed chair for Interstitial Lung Disease and the National Institutes of Health [Grant UL1TR000005].

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


Chest. 2015;148(2):e57-e58. doi:10.1378/chest.15-0772
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To the Editor:

We thank Dr Wijsenbeek and colleagues for the information they provided regarding the European experience of location of death for patients with idiopathic pulmonary fibrosis (IPF). One of the aims of our recent article in CHEST1 was to draw attention to this relatively neglected aspect in the care of patients with IPF, the need for palliative care. The data Dr Wijsenbeek and colleagues provide complement our study, add a global perspective, and, most importantly, support our notion that more research and clear guidelines need to be provided regarding palliative care for patients with IPF.

Overall, the numbers by Dr Wijsenbeek and colleagues are concurrent with our observation. The majority of their patients (59%) died in the hospital, as did the majority of the patients in our study (57%). The general value of this observation is highlighted by the fact that, in response to a question, 70% of European experts on IPF from 15 countries responded that the majority of their patients die in the hospital. Considering the progressive nature of IPF and the limited value of hospitalization in the absence of a transplant option during the final stages of the disease, it is obvious that this number is too high, and other options should be considered and actively advocated.

An interesting difference between our results and those of Dr Wijsenbeek and colleagues has to do with location of death in the hospital. Although in our study, of those who died in our hospital, 33% died in the ICU, in the report by Dr Wijsenbeek and colleagues only 7% died in the ICU. It is hard to assess the reason for this large difference, but it is not surprising considering the difference in ICU bed numbers and their use between different countries.2 As an example, the United States has seven times more ICU beds per capita compared with the United Kingdom. A large study that assessed the impact of these numbers found significant differences in patterns of admissions of medical patients to the ICU between the United States and the United Kingdom and suggested that the threshold for admission of a medical patient to the ICU in the United States is substantially lower than in the United Kingdom.3 Generally, patients in the United States had a significantly lower severity of illness, were significantly more likely to be admitted directly from the ED, and included a much larger proportion of the very elderly. Thus, the location of death within the hospital is probably reflective of local practice patterns and availability of ICU beds.

In this context, it is worth mentioning that the Simmons Center is affiliated with a very active, high-volume (> 100 per year in the last decade) lung transplant program. Patients with IPF who are pursuing transplant may, in some instances, receive a transplant during or following their ICU admission, and, thus, it is likely that critical care measures would be appropriate and more frequently offered to this population.

A very impressive aspect of the correspondence by Dr Wijsenbeek and colleagues is the implementation of a palliative program that reduced the rate of patients with IPF dying in the hospital by close to 50% to 28%. This is an important finding, because it suggests that active implementation of palliative care may reduce deaths in the hospital, improve the management of the symptoms of patients with IPF in the final stages of their disease, and eventually address the preferences of the patients and their families in the best possible way.

In summary, the correspondence by Dr Wijsenbeek and colleagues reinforces our notion that palliative care has been underused in patients with IPF. We believe that active implementation of palliative care for patients with IPF and discussion of palliative care with patients as soon as the diagnosis is made is critically important. Studies that assess the best ways to educate patients about the disease course and assess patient and family preferences regarding symptom management and palliative care are needed. Perhaps most importantly, a paradigm shift from an afterthought to a foundation of care is required in our approach to palliative care for patients with IPF.

Acknowledgments

Role of sponsors: The sponsors had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

Lindell KO, Liang Z, Hoffman LA, et al. Palliative care and location of death in decedents with idiopathic pulmonary fibrosis. Chest. 2015;147(2):423-429. [CrossRef] [PubMed]
 
Murthy S, Wunsch H. Clinical review: international comparisons in critical care - lessons learned. Crit Care. 2012;16(2):218. [CrossRef] [PubMed]
 
Wunsch H, Angus DC, Harrison DA, Linde-Zwirble WT, Rowan KM. Comparison of medical admissions to intensive care units in the United States and United Kingdom. Am J Respir Crit Care Med. 2011;183(12):1666-1673. [CrossRef] [PubMed]
 

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References

Lindell KO, Liang Z, Hoffman LA, et al. Palliative care and location of death in decedents with idiopathic pulmonary fibrosis. Chest. 2015;147(2):423-429. [CrossRef] [PubMed]
 
Murthy S, Wunsch H. Clinical review: international comparisons in critical care - lessons learned. Crit Care. 2012;16(2):218. [CrossRef] [PubMed]
 
Wunsch H, Angus DC, Harrison DA, Linde-Zwirble WT, Rowan KM. Comparison of medical admissions to intensive care units in the United States and United Kingdom. Am J Respir Crit Care Med. 2011;183(12):1666-1673. [CrossRef] [PubMed]
 
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