Supplemental Oxygen Use and High Intensity End-of-Life Healthcare Utilization in Older Adults with COPD

Supplemental oxygen use in COPD is a readily usable signal for progression to advanced disease and limited prognosis, but it is unclear whether this is reflected in different patterns of end-of-life (EOL) healthcare use or advance care planning (ACP).

To determine whether older adults with COPD using supplemental oxygen have different EOL healthcare use and ACP engagement compared to those without oxygen.

We analyzed nationally-representative Health and Retirement Survey data (2012-2018), including decedents aged ≥50 with COPD and self-reported oxygen use. Proxies completed post-death interviews about healthcare use (hospitalization, intensive care, life support equipment [e.g., mechanical ventilation], hospice, palliative care use) and ACP (durable power of attorney, advance directives, care preferences) within the last two years of life. We report adjusted probabilities derived from logistic and linear regression models adjusted for sociodemographics and comorbidities for the associations between oxygen use and EOL healthcare and ACP outcomes.

Among 848 decedents (mean age 81, 53% female, 82% White), 47% used supplemental oxygen for a median of 2 years (IQR: 1-4) before death. Compared to those without oxygen, those using oxygen had higher mean hospital days (12.4 vs 9.8 days, p = 0.03), intensive care (54% vs 40%, p = 0.001) and life support use (42% vs 27%, p < 0.001) in the last two years of life. In contrast, rates were similar for use of palliative care (26% vs 24%), hospice (48% vs 48%), and ACP, including completion of durable power of attorney (74% vs 74%) and advance directives (56% vs 56%). Among those who completed advanced directives (n = 464), decedents with and without oxygen use expressed similarly high preferences to limit care (88% vs 88%) and focus on comfort (91% vs 87%).

Supplemental oxygen use in older adults with COPD was associated with substantially higher hospital, ICU, and life support use at EOL. Yet, overall ACP engagement and palliative care use was low and those who completed advance directives had strong preferences to limit care. Supplemental oxygen may be an important and under-utilized indicator for integration of timely palliative care among older adults with COPD.