# Comparison of Palliative Care Models in Idiopathic Pulmonary Fibrosis
## 4 Discussion  
Improving access to PC and EOL care is an important goal in management of IPF patients who experience serious health-related suffering throughout their illness and especially near the end of life. Comprehensive patient centered care in IPF and ILD, therefore, requires a focus on symptoms, support, and ACP in practice [14]. Such a comprehensive approach extends routine care beyond making accurate and timely diagnosis and instituting disease-specific medical management to provide comprehensive support for living and coping well [15]. [PERSON] and colleagues' systematic review identified diverse ILD/IPF patient needs ranging from psychological, physical, daily living, information, and education to preparing for EOL [2]. Patients also desire organized follow-up and better care coordination [16]. Integration of a PC approach in routine care by ILD experts, general pulmonologists, internists, and family physicians offers the possibility to meet these needs while simultaneously delivering evidence-based disease-targeted therapies. There is universal agreement on the need for PC access, but delivery of PC remains challenging. Currently, the gold-standard model of PC delivery is unknown [10; 17]. [PERSON] and colleagues suggest that the PC needs for many chronic diseases can be safely met through a primary PC model where the healthcare professionals themselves provide a PC approach with specialist consultations reserved only for challenging issues. There are no assessments of this approach in ILD/IPF. Our study addresses this evidence gap by describing primary PC and specialist PC referral models in real-world IPF cohorts and the impact of each model on care. Our work suggests that a primary PC approach is feasible in IPF when adequate resources and infrastructure are in place and can result in early and concurrent delivery of PC. Whereas reliance on specialist PC referral may result in fewer patients receiving PC and a significant delay in PC interventions. EC model sought specialist PC for hospice referrals and the collaborative PIP multidisciplinary team in BC integrated psychology and specialist PC with pulmonologists and community teams to meet PC needs of IPF/ILD patients [13]. Specialist PC referral rates observed in QC are similar to those described in the literature, where 15% were referred to PC [18]. When a primary PC approach is undertaken by pulmonologists, more patients receive symptom management and ACP early in the disease course, concurrent with IPF-specific care (antifibrotics and transplant assessments). It is particularly striking to note the high uptake of non-pharmacog dyspnea management strategies seldom used in traditional clinical practice. Additionally, primary PC models also improved access to rehabilitation, support groups, and home care services (where available) and led to early engagement of family caregivers. EOL care in IPF is generally poor with inadequate and delayed symptom management; there is a lack of timely EOL conversations, less family engagement, and limited support, with majority of patients dying in less desired acute care settings [18; 19; 20]. Primary PC models with systematic ACP improve EOL care, with \(>90\%\) of EC and BC decedents receiving PC. This is a substantial improvement from current practice, where PC is not integrated. Systematic ACP led to more patients dying in their preferred location in the primary PC models. Lack of EOL data in the specialist PC model (QC) hampered further comparisons. Even though the specialist PC referral model (QC) had fewer patients receiving PC, the majority of those referred received symptom management and engaged in ACP. From a patient perspective, the primary PC model has many advantages. Many patients with progressive dyspnea, fatigue, and high flow oxygen may not be willing or able to attend another clinic appointment. This was noted in a feasibility trial of PC referral in IPF patients, where 60% were reluctant to attend PC clinics outside their regular ILD visits.