Integration or Empowerment of Respiratory Physicians? What is the Best Fit for Providing Palliative Care for Advanced Respiratory Diseases in the Indian Context?

INTEGRATION

An integrated care plan focuses on the needs through coordinated care to ensure the continuity of care as patients often require a transfer between different disciplines, such as pulmonary and palliative care.^[1] There are varied models of integrated care which could be considered based on the type of service provision such as OPD, inpatient, hospice and community care.^[2,3] This survey participants are largely practicing at private hospitals; therefore, the findings reflect the opinion of physicians from this health sector. Including a varied sample from different health-care sectors, public and private hospitals and types of service provision such as primary, secondary and tertiary care could be helpful to have a broader understanding. This would facilitate the implementation of integrated care across varied healthcare sectors. While majority of the study participants agree with the early integration, nearly 24% wanted to refer only for terminal care. Around 80% wanted to initiate the talk or referral to palliative care when there is a decline in health and/or when the physician perceives the need to talk about advance care or the family asks for it. All of these factors may hinder early integration, which needs to be addressed.

EMPOWERMENT

A considerable number (62.21%) of physicians were not comfortable referring their patients to palliative care due to the feeling of loss of control over patient care. The reason for non-referral could also be due to lack of awareness and mutual professional understanding and networking, which is essential for integration. In contrast, a survey conducted to study the patients and their carers’ experience of integrated care showed that less than half of the patients did not visit palliative care physician at the integrated clinic.^[4] This indicates the need for training and empowerment of the respiratory physicians to enable them to provide palliative care for their patients. This could facilitate providing comprehensive care for those who do not wish to consult palliative care. Furthermore, lack of palliative care in the respiratory care clinics across India might challenge integration. In this context, trained respiratory physicians can consider referring only those patients who need specialised palliative care consultation to the nearest palliative care. Further, this may minimise the sense of abandonment of patients by respiratory physicians, as identified in this current study. A previous study showed that most participants with breathlessness in advanced COPD required emergency admission.^[5] Empowering may help minimising ambiguity in treatment decisions during emergency admissions with acute breathlessness, as respiratory physicians would be able to identify whether or not people need palliative care or intensive care along with on-going respiratory care. These factors indicate that empowering respiratory physicians would facilitate the provision of palliative care at the earliest point as identified by the respiratory physicians.

TRAINING

Training respiratory physicians are essential for empowering and will facilitate the provision of comprehensive care to their patients. This survey identified lack of time and training of physicians as major barriers for initiating discussions on palliative care. This relates to the findings from a study conducted to understand the experience of hospitalisation in people with advanced COPD in a South Indian hospital that the patient participants had limited opportunity to discuss palliative care while being hospitalised in the advanced stage of COPD.^[5] Further, this previous study also showed that the participants wanted their physician to initiate end-of-life care discussion. This particular finding needs to be considered alongside the opinion of the respiratory physician of this present study, while considering training of respiratory physicians. Respiratory physicians (70.35%) of this survey expressed the need for training in pain and symptom management, followed by communication skills and end-of-life care; however, they did not identify the need to address psycho-spiritual issues. A previous study conducted in India with advanced COPD patient participants showed considerable psychological and spiritual distress.^[5] Therefore, training of respiratory physicians needs to consider the inclusion of identifying psycho-spiritual issues.

This study is an eye-opener for integration of palliative care in non-malignant diseases in India. Integration or empowerment in the Indian context needs a careful consideration which depends on several factors discussed here. Particularly, integration requires further exploration with inclusion of a broader sampling covering varied health sectors and the types of service provision.