Abstract
Background
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Alternatives to Commercial Flying
Commercial air travel can be physically demanding and complex. Consider alternatives. Could family visit the patient instead? Would another transportation option such as a train or car be more accessible and comfortable? Is there a closer destination that could be a surrogate “home” or meeting place? 1 Commercial airlines may not be the only option for air travel. Numerous charitable pilot organizations provide free flights for patients and their families via Air Care Alliance. 2
Coordination with Airlines
Airports are often crowded, noisy, and fast-paced. This environment may increase stress and infection risk for frail patients. Good coordination with airlines may reduce distress; some airports even provide therapy animals for passengers. 3 Passengers who provide notice of a medical disability that can be accommodated by the airlines should be accommodated per the Air Carrier Access Act. 4 Guidelines for wheelchair use, early boarding, seats with extra leg room, and device use are available. Medical clearance forms may be required before airport arrival. Of note, the Federal Aviation Administration does not allow for personal oxygen tanks, only portable oxygen concentrators.
Flight Preparation
Patients may want to have the following items easily accessible in carryon luggage:
• A doctor's letter summarizing medical conditions, clinical status, and medications. • All medications, including controlled substances, can be brought onto domestic U.S. flights if they are in their original prescription bottle with a current prescription date and placed in a separate bag for security checks.
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For foreign travel, check with the individual country. • Advance directive documents.
Hospice Eligibility
The Medicare Modernization Act of 2003 enables hospice providers to contract with a destination provider if a patient travels longer than 14 days. 6 However, it is not a legal requirement that hospice agencies maintain hospice coverage in the destination. Some hospice providers may discharge a patient, whereas others may arrange admission to a different hospice agency where the patient will be staying. Consequently, pretravel coordination with the hospice providers is essential.
Physiologic Changes in Flight
Commercial flights generally maintain a cabin air pressure that is equivalent to 5000–8000 feet above sea level. Healthy individuals usually tolerate the physiologic changes associated with these altitudes, whereas patients near the end of life may not. In case of medical events, emergency medical kits should be available on commercial airplanes >7500 lbs with the following palliative-based therapies: opioids, diuretics, corticosteroids, and benzodiazepines.
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Other important in-flight physiologic factors include:
• Cardiopulmonary: Lower barometric pressure increases hyperventilation, tidal volume, and pulmonary vasoconstriction, lowers the partial pressure of oxygen. Hypoxia, dyspnea, anxiety, and pulmonary edema may result. Patients with a hemoglobin <8.5 g/dL, congestive heart failure, or pulmonary disorders may benefit from the prophylactic use of supplemental oxygen during air travel. Those on oxygen should continue it.8–10
• Gastrointestinal: Gases within body cavities can expand 30% from the lower barometric pressure. Patients who have recently undergone surgery should confer with their surgeon before air travel. • Vascular: Low humidity and increased immobility can increase the risk of venous thromboembolism and peripheral edema. In-flight compression stockings may reduce this risk.9,10 • Neurological: Lower barometric pressure and other stressors increase the risk of delirium.
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Do-Not-Resuscitate Status
Despite the most careful planning, patients may die in flight. It makes sense to ask the patient, “Is this trip important enough to die trying?” Commercial pilots may decide to divert the flight and land at the nearest airport if they are notified of a death in route. 7 Travel companions, therefore, may opt against notifying flight attendants of an expected death. Although state-issued advance directives, do-not-resuscitate bracelets, or Orders for Life Sustaining Treatment (e.g., POLST, POST, MOLST) can be helpful in communicating the patient's wishes on an airplane, airline crewmembers are not mandated by law to follow these directives across state lines. Hence, patients and surrogates should know that cardiopulmonary resusciatation (CPR) may be initiated if airline personnel are notified of a patient's death, depending on an airline's policy. Travel companions should advocate for the patient's treatment preferences in real time if they are known.7,11,12
Contraindications to Air Travel
For many acute medical events or procedures, there are suggested waiting periods before flying; a 10-day waiting period after an uncomplicated myocardial infarction is a relatively common example. Few diagnoses strictly prohibit a patient from commercial flying. Some of those conditions are listed next.8,9,11,13
• Pneumothorax with persistent air leak.
• Baseline oxygen requirement >4 L/minutes.
• Unstable angina.
• Severe symptomatic valvular heart disease.
• Gastrointestinal obstruction without a venting gastrostomy tube.