Overview
Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in older Americans. COPD increases in frequency with age, and older adults with COPD often have significant unmet geriatrics-palliative care needs that results in reduced quality of life, high healthcare utilization, and care at the end of life that does not align with the values and wishes of patients and their care partners. Older adults with COPD could benefit from proactive geriatrics-palliative care before the end of life. However, no geriatrics-palliative care interventions have been systematically developed and tested in community-dwelling older adults with COPD and their care partners. As the number of older adults with COPD increases to levels unmatched by current palliative care workforce trends, innovative strategies are desperately needed to improve the delivery of geriatrics-palliative care in COPD before the end of life.
Project EPIC (Empowering People to Independence in COPD) is a multiphase study to refine and pilot test the EPIC telephonic nurse coaching intervention in older adults with COPD and their care partners. EPIC is informed by the ENABLE (Educate, Nurture, Advise Before Life Ends) early palliative care intervention that improved quality of life and mood for patients with advanced cancer and has been iteratively refined over decades and rigorous randomized controlled trial testing. In the intervention, palliative care-trained nurse coaches deliver the Charting Your Course Curriculum over the phone to patients (six sessions) and their care partners (four sessions), with activities and monthly telephone follow-up following a manualized curriculum. We conducted a formative evaluation in a diverse and multidisciplinary group of stakeholders to refine ENABLE for patients with COPD and pilot tested the potential feasibility of the refined intervention, EPIC, in patients and their care partners.
The current study summatively evaluates EPIC through a hybrid effectiveness-implementation pilot randomized controlled trial in dyads of community-dwelling older adults with moderate to very severe COPD and their care partners randomized to usual COPD care (control) versus usual COPD care + EPIC (intervention). The primary outcomes are trial and intervention feasibility and acceptability. Secondary geriatrics-palliative care outcomes include Life-Space mobility, quality of life, cognitive impairment, functional status, healthcare utilization, palliative care uptake, and care partner burden.
Eligibility
Patients
Inclusion criteria (must meet ALL of the following):
- ≥60 years;
- COPD on routinely collected spirometry (FEV1/FVC <0.70 + FEV1<80%);
- Able to speak English;
- At least one of the following:
4a) Severe breathlessness as defined by a documented modified Medical Research Council
(mMRC) Dyspnea Scale Score >2 in the medical record or any of the following levels of
severe breathlessness by medical review: breathless after walking about 100 yards,
breathless after a walking few minutes on level ground, or too breathless to leave the
house or when dressing); OR, 4b) ≥1 hospitalization in the year prior but >30 days from
enrollment; OR, 4c) On supplemental oxygen (exertional or continuous).
Exclusion criteria (can be excluded for ANY of the following):
1. No access to a dedicated telephone service;
2. Recent hospitalization for any reason or exacerbation of COPD in the past 30 days or
ongoing exacerbation symptoms requiring treatment with antibiotics and steroids;
3. Treated within the past 60 days for an advanced cancer defined as metastatic and/or
recurrent/progressive stage III/IV cancer, including brain, lung, breast, gynecologic,
head and neck, gastrointestinal, genitourinary cancer, and hematologic malignancies by
self report or chart review;
4. Active schizophrenia, major depressive disorder, bipolar disorder, suicidal ideations,
or substance abuse by self-report or chart review (Active means currently being
treated for schizophrenia, bipolar disorder, or suicidal ideations or having active
and untreated major depressive disorder, i.e. not under the care of a clinician or not
on medications such as antidepressants or mood stabilizers, or having active and
untreated substance abuse, i.e. not on medication or enrolled in a substance abuse
program);
5. Non-correctable hearing impairment (i.e. hearing impairment despite hearing aids);
6. Severe cognitive impairment (score ≤3 points on 6-item Callahan Screener): a)
Correctly identify current year (1 point); b) Correctly identify current month (1
point); c) Correctly identify current day (1 point); d) Correctly recall "apple" after
5 minutes (1 point); e) Correctly recall "table" after 5 minutes (1 point); f)
Correctly recall "penny" after 5 minutes (1 point).
Care partners
Inclusion criteria (must meet ALL of the following):
1. ≥18 years;
2. Self-reporting as "an unpaid spouse or care partner, relative, or friend who knows
[the patient] well and is involved in their medical care";
3. Able to speak English.
Exclusion criteria (can be excluded for ANY of the following):
1. No access to a dedicated telephone service;
2. Active schizophrenia, major depressive disorder, bipolar disorder, suicidal ideation,
or substance abuse by self-report (Active schizophrenia, major depressive disorder,
bipolar disorder, suicidal ideation, or substance abuse by self-report or chart review
(Active means currently being treated for schizophrenia, bipolar disorder, or suicidal
ideations or having active and untreated major depressive disorder, i.e. not under the
care of a clinician or not on medications such as antidepressants or mood stabilizers,
or having active and untreated substance abuse, i.e. not on medication or enrolled in
a substance abuse program);
3. Non-correctable hearing impairment (i.e. hearing impairment despite hearing aids);
4. Severe cognitive impairment (score ≤3 points on a 6-item Callahan screener): a)
Correctly identify current year (1 point); b) Correctly identify current month (1
point); c) Correctly identify current day (1 point); d) Correctly recall "apple" after
5 minutes (1 point); e) Correctly recall "table" after 5 minutes (1 point); f)
Correctly recall "penny" after 5 minutes (1 point)