Primary and secondary palliative care integration in serious respiratory illness

This figure has three panels.

In the top panel, the x-axis denotes patient wellbeing and function, and the y-axis denotes time. The top panel illustrates the hypothetical integration of palliative care across illness trajectories of lung cancer (dashed line), pulmonary hypertension (solid line), and chronic obstructive pulmonary disease/interstitial lung disease (COPD/ILD; dotted line), each punctuated by declines in wellbeing at hospitalizations (stars) and potential lung transplant referral (diamonds). The integration of primary palliative care (squares) starts early. The integration of secondary palliative care (circles) is added later, but well before the end of life.

In the middle panel, the x-axis denotes palliative care intensity, and the y-axis denotes time. Primary palliative care increases in intensity after initiation (expanding top triangle) as serious respiratory illness worsens, and secondary palliative care starts later and also increases in intensity but layers on top of secondary palliative care (expanding bottom triangle). Through ongoing comanagement, a period of collaborative primary and secondary palliative care (overlapping triangles) should occur as illness severity worsens through the end of life.

The bottom panel illustrates how palliative care may evolve across a continuum of serious respiratory illness. When illness is less severe, palliative care occurs concurrent with illness-directed therapies and then shifts focus from cure to end-of-life care (eg, hospice and bereavement support) near and after death.