Underutilization of palliative care in advanced COPD and heart failure: associations, disparities, and the role of specialists

Abstract

Background: Palliative care is essential for managing advanced chronic illnesses (ACI) but remains underused. Objectives: We aimed to evaluate the prevalence, associations, and outcomes of palliative care utilization (PCU) in patients with ACIs. Design: A prospective observational questionnaire-based study. Methods: The study included hospitalized patients with severe COPD (n = 53), advanced heart failure (HF; n = 56), or metastatic malignancy (n = 57). Participants were interviewed about their demographics, health status, PCU, and end-of-life decision-making. Results: A total of 166 subjects were included (median age: 77 years; 41% females), with a 1-year median of 2 hospital admissions. Subjects with COPD and HF had low rates of PCU compared to those with malignancy (6% and 11% vs 39%, p < 0.01). PCU occurred exclusively in patients who had visited a specialist (cardiologist, pulmonologist, or oncologist) before study inclusion. Patients with PCU were more aware of advance directives (71% vs 38%), signed advanced orders (23% vs 3%), and shared their end-of-life decisions with others (71% vs 29%). These differences remained significant after adjustment for prior specialist visits. Independent associations with PCU were self-identifying as non-religious (adjusted OR 3.41, 95% CI 1.2–9.9), above high-school education (AOR 2.84, 95% CI 1.1–7.3), and chronic pain (aOR 2.81, 95% CI 1.11–7.14), while COPD showed the opposite (aOR 0.25, 95% CI 0.07–0.96). Conclusion: Palliative care utilization is alarmingly low among patients with HF and COPD despite significant symptom burden. Specialists should advocate for PCU as their involvement could enhance end-of-life care planning, improve patient outcomes, and address current gaps in care.