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Background: Identifying priority challenges of older adults with chronic obstructive pulmonary disease (COPD) is critical to designing interventions aimed at improving their well‐being and independence. Objective: To prioritize challenges of older adults with COPD and those who care for them to guide refinement of a telephonic nurse coach intervention for patients with COPD and their family caregivers (EPIC: Empowering People to Independence in COPD). Design: Multiphase study guided by Baltes Theory of Successful Aging and the 5Ms Framework: Phase 1: Nominal group technique (NGT), a structured process of prioritizing responses to a question through group consensus. Phase 2: Rapid qualitative analysis. Phase 3: Intervention mapping and refinement. Setting: Ambulatory, virtual. Participants: Older adults with COPD, family caregivers, clinic staff (nurses, respiratory therapists), clinicians (physicians, nurse practitioners), and health system leaders. Results: NGT sessions were conducted by constituency group with 37 participants (n = 7 patients, n = 6 family caregivers, n = 8 clinic staff, n = 9 clinicians, n = 7 health system leaders) (Phase 1). Participants generated 92 statements across five themes (Phase 2): (1) "Barriers to care", (2) "Family caregiver needs", (3) "Functional status and mobility issues", (4) "Illness understanding", and (5) "COPD care complexities". Supplemental oxygen challenges emerged as a critical problem, and prioritized challenges differed by group. Patients and clinic staff prioritized "Functional status and mobility issues", family caregivers prioritized "Family caregiver needs", and clinicians and health system leaders prioritized "COPD care complexities". Intervention mapping (Phase 3) guided EPIC refinement focused on meeting patient priorities of independence and mobility but accounting for all priorities. Conclusions: Diverse constituency groups identified priority challenges for older adults with COPD. Functional status and mobility issues, particularly related to supplemental oxygen, emerged as patient prioritized challenges. Implications: Patient‐centered interventions for older adults with COPD must account for their prioritized functional and supplemental oxygen needs and explore diverse constituent perspectives to facilitate intervention enrichment. [ABSTRACT FROM AUTHOR]

Context: Patients with advanced cancer often involve family caregivers in health-related decision-making from diagnosis to end-of-life; however, few interventions have been developed to enhance caregiver decision support skills.Objectives: Assess the feasibility, acceptability, and potential efficacy of individual intervention components of CASCADE (CAre Supporters Coached to be Adept DEcision Partners), an early telehealth, palliative care coach-led decision support training intervention for caregivers.Methods: Pilot factorial trial using the multiphase optimization strategy (October 2019-October 2020). Family caregivers and their care recipients with newly-diagnosed advanced cancer (n = 46 dyads) were randomized to1 of 8 experimental conditions that included a combination of one of the following three CASCADE components: 1) effective decision support psychoeducation; 2) decision support communication training; and 3) Ottawa Decision Guide training. Feasibility was assessed by completion of sessions and questionnaires (predefined as ≥80%). Acceptability was determined through postintervention interviews and participants' ratings of their likelihood to recommend. Measures of effective decision support and caregiver and patient distress were collected at Twelve and Twenty four weeks.Results: Caregiver participants completed 78% of intervention sessions and 81% of questionnaires; patients completed 80% of questionnaires. Across conditions, average caregiver ratings for recommending the program to others was 9.9 on a scale from 1-Not at all likely to 10-Extremely likely. Individual CASCADE components were observed to have potential benefit for effective decision support and caregiver distress.Conclusion: We successfully piloted a factorial trial design to examine components of a novel intervention to enhance the decision support skills of advanced cancer family caregivers. A fully-powered factorial trial is warranted.Key Message: We pilot tested components of CASCADE, an early palliative care decision support training intervention for family caregivers of patients with advanced cancer. CASCADE components were acceptable and the trial design feasible, providing promising future directions for palliative care intervention development and testing. Pilot results will inform a fully-powered trial. [ABSTRACT FROM AUTHOR]

Recent systematic reviews and meta-analyses have reported positive benefit of multicomponent "bundled" palliative care interventions for patients and family caregivers while highlighting limitations in determining key elements and mechanisms of improvement. Traditional research approaches, such as the randomized controlled trial (RCT), typically treat interventions as "bundled" treatment packages, making it difficult to assess definitively which aspects of an intervention can be reduced or replaced or whether there are synergistic or antagonistic interactions between intervention components. Progressing toward palliative care interventions that are effective, efficient, and scalable will require new strategies and novel approaches. One such approach is the Multiphase Optimization Strategy (MOST), a framework informed by engineering principles, that uses a systematic process to empirically identify an intervention comprised of components that positively contribute to desired outcomes under real-life constraints. This article provides a brief overview and application of MOST and factorial trial design in palliative care research, including our insights from conducting a pilot factorial trial of an early palliative care intervention to enhance the decision support skills of advanced cancer family caregivers (Project CASCADE). [ABSTRACT FROM AUTHOR]

1. Identify current barriers to palliative care integration into COPD care. 2. Discuss and evaluate unique considerations of integrating palliative care into geriatric COPD populations. Despite evidence demonstrating improved chronic obstructive pulmonary disease (COPD) outcomes, palliative care in COPD is rare. Few interventions have been systematically developed and tested in community-dwelling older adults with COPD. To address this gap, we developed Project EPIC (Early Palliative Care In COPD), a series of studies following the NIH Stage Model to develop, refine, and pilot test a telephonic nurse coach–led early palliative care intervention in COPD. Pilot testing is ongoing via a single-blind, hybrid type-1 effectiveness-implementation pilot randomized control trial of the refined EPIC intervention plus usual care versus usual care alone. Sixty dyads of older adults with COPD and their care partners are being recruited from outpatient pulmonary clinics at a Southeastern academic tertiary medical center and a county clinic. Those randomized to intervention receive nurse-led, semistructured weekly coaching sessions (six sessions for patients and four sessions for care partners of problem-solving, self-care, symptom management, mobility, communication, value elicitation, and legacy building) and monthly follow-up calls. Patient eligibility criteria includes age >60 years, COPD diagnosis with FEV1/FVC<0.70 + FEV1<0.80 with severe dyspnea (Modified Medical Research Council Dyspnea Scale Score >2), >1 COPD hospitalization in last year, or on supplemental oxygen. Care partner eligibility includes >18 years old and involved with patient's medical care. Primary outcomes are feasibility (trial, intervention, and data collection) and acceptability (Likert-scale survey plus semistructured interviews). Other geriatrics-palliative care outcomes (eg, life-space mobility, quality of life, caregiver burden, anxiety, depression, loneliness, etc.) are being collected at baseline, 12 weeks, and 24 weeks to guide a future trial. The EPIC early palliative care intervention for persons with COPD and their care partners was iteratively developed and refined over multiple studies and is currently undergoing pilot acceptability and feasibility testing in older adults to prepare for a fully powered efficacy trial. [ABSTRACT FROM AUTHOR]

1. Recognize the underutilization of palliative care consultations in critically ill adults and those with palliative care consults are less likely to receive invasive procedures. 2. Understand that racial disparities exist in palliative care consultations frequency and symptom management recommendations. Palliative care (PC) is often underutilized among critically ill adults, and racial disparities exist at the end of life. (1) Examine differences in characteristics among critically ill adults who did and did not have specialist PC consults. (2) Among decedents, compare differences in invasive treatments and explore differences in PC consult characteristics and PC recommendations by race. Retrospective chart review of a cohort of adults admitted to the MICU between 2014 and 2019 who did and did not have a PC consult. In a decedent subset who received PC consultation, we conducted a content analysis of consult characteristics and compared consult characteristics by race. A total of 1,536 patients were included in the cohort (mean age: 58.6±16.0 years, 37% black, and 50% female). Those with PC consults (n=242; 15%) were older (p< 0.001) and more likely to be white (p=0.029). Among decedents (n=1,294), those who had PC consult (n=220; 17%) were less likely to have vasopressors (p=0.001), central venous lines (p=0.041), arterial lines (p=0.01), and more likely to receive opioids (p=0.001) and mechanical ventilation (p=0.014). Black decedents with PC consults (n=73; 38%), compared to white decedents (n=113; 59%), had shorter initial PC consult length (p=0.046) and were less likely to have general symptom management evaluation (p=0.009) and to have recommendations for anxiety (p=0.001), depression (p=0.045), and constipation (p=0.007). Only one in seven critically ill adults in our cohort had PC consults, and those with PC consults were less likely to receive invasive procedures. Black individuals were less likely to have PC consultation and, among decedents, had PC consults with symptom management recommendations. PC consultation remains underutilized in the ICU. Addressing racial disparities in PC consultation frequency and recommendations is crucial to ensuring equitable care for this seriously ill population. [ABSTRACT FROM AUTHOR]

Early, concurrent palliative care interventions in chronic obstructive pulmonary disease (COPD) are limited. Project EPIC (E arly Palliative Care In COPD) is a multiphase mixed methods study working to fill this gap. To conduct a formative and summative evaluation of EPIC, a telephonic nurse coach-led early palliative care intervention for COPD adapted from the ENABLE© intervention in cancer. Phase I Formative Evaluation : Patients with moderate-to-very-severe COPD, family caregivers, and pulmonary and palliative care clinicians rated the acceptability and feasibility of EPIC (≥4 out of five on a Likert-scale survey). Phase II Summative Evaluation : Patients and family caregivers in Phase I participated in a pilot of the three month EPIC prototype to evaluate intervention and data collection feasibility (≥70% completion) and to seek qualitative feedback. Phase I Formative Evaluation : Patients (n =10), family caregivers (n= 10), pulmonary clinicians (n= 6), and palliative care clinicians (n= 6) found EPIC acceptable and feasible to support adaptation, while priority early palliative care needs in COPD from our prior research mapped well to the EPIC prototype. Phase II Summative Evaluation : Patients (n= 5; ages 49–72, 40% moderate COPD, 40% Black) and their family caregivers (n= 5; ages 51–73, 40% Black) completed 100% of EPIC prototype components, including weekly telephone sessions, a one month follow-up call, Advance Directive, palliative care clinic attendance, and 95% of monthly phone data collection sessions. Feedback from participants about EPIC was all positive. EPIC was acceptable and feasible in patients with COPD and their family caregivers. Larger feasibility and effectiveness trials are warranted. [ABSTRACT FROM AUTHOR]