Palliative care referrals after lung transplantation in major transplant centers in the United States

Objective. Although lung transplantation is a widely used treatment modality for patients with end-stage lung disease, its long-term outcomes are limited. Including palliative approaches in the care of lung transplant recipients may be beneficial; however, systematic information regarding the utilization of palliative care services for lung recipients is lacking. Design and Setting. Of the 27 transplant centers meeting the inclusion criteria (an annual lung transplant volume 2:15 for the past 5 years and the availability of palliative care or pain services at the center), 74 clinicians representing either the transplant or palliative care program from 18 centers completed surveys. Results: Both transplant and palliative care clinician respondents strongly favored the idea of integrating palliative care into lung transplant care. However, the number of palliative care referrals made during the last year was low (:55 per center). The three most frequently endorsed reasons for palliative care referrals were end-of-life planning, uncontrolled pain and symptoms, and limited functional status. The average length of survival after referral was <30 days. Palliative care clinicians considered misconceptions that palliative care meant "end-of-life care" as a major barrier, whereas transplant clinicians identified uncertainty about recipients' prognoses, the perception that palliative care precludes aggressive treatment, and difficulty in discussing palliative care with recipients and family as barriers. Conclusions: Despite clinicians' positive attitudes toward integrating palliative and lung transplant care, actual utilization of palliative care services is low. Collaborative efforts to enhance communication between the two programs are needed to clarify misconceptions and promote understanding between the programs. (Crit Care Med 2009; 37:1288-1292)