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A recent study by Atreya et al. in Palliative Care examined the viewpoints of respiratory care physicians regarding integrated palliative care for advanced respiratory diseases [1]. The results of an online survey indicated that 88.95% of respiratory physicians perceive early integration as crucial, highlighting the necessity of palliative care in advanced respiratory diseases. While this finding is promising for the advancement of palliative care in non-malignant conditions in India, there may be challenges in implementing integration. Integrated care plans prioritize coordinated care to address patient needs during transitions between various disciplines, such as pulmonary and palliative care. Different models of integrated care exist, depending on the type of service provision, including outpatient, inpatient, hospice, and community care [2,3]. The participants in this survey were predominantly practicing at private hospitals, which mean the findings mainly reflect the opinions of physicians from this healthcare sector. To enhance the breadth of knowledge on the subject, it would be advantageous to incorporate a wide-ranging sample from diverse healthcare sectors, including both public and private hospitals. Additionally, considering various types of service provision, such as primary, secondary, and tertiary care, would contribute to a more comprehensive understanding. This would facilitate the implementation of integrated care across different healthcare sectors. Although the majority of participants supported early integration, approximately 24% preferred to refer patients only for terminal care. Additionally, around 80% indicated the need to initiate discussions or referrals to palliative care when there is a decline in health, when the physician deems it necessary to discuss advance care, or when the family requests it. These factors could potentially hinder early integration and should be addressed.

A significant proportion (62.21%) of physicians expressed discomfort in referring their patients to palliative care, citing concerns about losing control over patient care. Non-referral may also be attributed to a lack of awareness, limited professional understanding, and insufficient networking, all of which are vital for successful integration. Conversely, a survey assessing the experiences of patients and their caregivers in integrated care revealed that fewer than half of the patients visited a palliative care physician at the integrated clinic [4]. This underscores the importance of training and empowering respiratory physicians to equip them with the necessary skills and knowledge to deliver palliative care to their patients effectively. Such empowerment would facilitate the delivery of comprehensive care for individuals who prefer not to consult palliative care specialists. Moreover, the absence of palliative care in respiratory care clinics throughout India poses a challenge to integration. In this regard, trained respiratory physicians can consider referring only those patients who require specialized palliative care consultation to the nearest palliative care facility. This approach would help alleviate the sense of abandonment reported by respiratory physicians in the current study. Previous research has demonstrated that a majority of individuals with advanced COPD and breathlessness necessitated emergency hospitalization [5]. Empowering respiratory physicians would minimize ambiguity in treatment decisions during such emergencies, as they would be able to identify whether patients require palliative care or intensive respiratory care. These factors underscore the importance of empowering respiratory physicians to ensure the timely provision of palliative care, as acknowledged by the respiratory physicians themselves.

Empowering respiratory physicians through training is crucial and will greatly enhance their ability to provide comprehensive care to patients. The survey highlighted that lack of time and inadequate training were major barriers preventing physicians from initiating discussions on palliative care. This aligns with the findings of a study conducted in a South Indian hospital, which revealed that patients with advanced COPD had limited opportunities to discuss palliative care during their hospitalization [5,6]. Additionally, the same study indicated that participants wished for their physicians to initiate discussions on endof- life care. This finding should be taken into account when designing training programs for respiratory physicians. The survey revealed that a significant proportion (70.35%) of respiratory physicians emphasized the importance of training in pain and symptom management, with communication skills and end-of-life care also being identified as areas of need. However, they did not specifically identify the need to address psycho-spiritual issues. It is important to note that a previous study conducted in India with participants suffering from advanced COPD demonstrated significant psychological and spiritual distress [7,8]. Therefore, training programs for respiratory physicians should also include the identification and management of psycho-spiritual issues [9,10]. The findings of this study shed light on the importance of integrating palliative care into non-malignant diseases in India. The choice between integration and empowerment in the Indian context requires thoughtful consideration, taking into account the factors discussed here. Specifically, further exploration of integration should involve a more diverse sample, encompassing various healthcare sectors and types of service provision, to gain a comprehensive understanding of the topic.

1. Atreya S, Jeba J, Patil CR, Iyer R, Christopher DJ, et al. (2022) Indian J Palliat Care 28:314-20.

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2. Payne S, Eastham R, Hughes S, Varey S, Hasselaar J, et al. (2017) BMC Palliat Care 16:64.

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3. Maddocks M, Lovell N, Booth S, Man WD, Higginson IJ (2017) Lancet 390:988-1002.

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4. Smallwood N, Moran T, Thompson M, Eastman P, Le B, et al. (2019) BMC Palliat Care 18:7.

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5. Bakthavatsalu B, Walshe C, Simpson J (2022) Chronic Illn.

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6. Lupu D, Quigley L, Mehfoud N, Salsberg ES (2018) J Pain Symptom Manag 55:1216-1223.

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7. Shah H, Vandermeer L, MacDonald F, Larocque G, Nelson S, et al. (2022) Support Care Cancer 30:9079-9091.

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8. Valenti V, Rossi R, Scarpi E, Ricci M, Pallotti MC, et al. J Clin Nurs 1-8.

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9. Dionne-Odom JN, Williams GR, Warren PP, Tims S, Huang CHS, et al. (2021) J Palliat Med 24:347-353.

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10. Rummans TA, Clark MM, Sloan JA, Frost MH, Bostwick JM, et al. (2006) J Clin Oncol 24:635-642.

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