Description #
This unit is designed to help health care professionals develop a better understanding of the surgical interventions used in advanced Chronic Obstructive Pulmonary Disease (COPD). End-of-life care issues will also be addressed.
Learning Objectives #
By the end of this unit, you should be able to:
1. Describe end-stage COPD
2. Explain the goals of palliative care and therapies available for symptom control
3. Explain the importance of end-of-life discussions
End-Stage COPD #
COPD is a life-limiting disease. Lung function decline is progressive, especially in patients who continue to smoke. The majority of patients with COPD will die from respiratory failure or from a comorbid condition such as lung cancer, heart failure, or pulmonary embolism. This unit addresses the clinical picture of end-stage COPD, strategies for symptom management, and other important considerations in the end-of-life care of COPD patients.
Symptoms of End-Stage COPD #
Common Symptoms of End-Stage COPD:
End-stage COPD is not easy to define. The clinical picture varies between patients. However, some of the most common symptoms experienced by patients with advanced COPD include:
Dyspnea
Cough and Phlegm
Depression and anxiety
Insomnia
Fatigue
Delirium
Pain
Anorexia and weight loss
Prognosis #
Prognosis of end-stage COPD:
In COPD patients, rate of lung function decline and presence and severity of comorbid conditions also varies between individuals. It is therefore difficult to predict life-expectancy for patients with COPD. Death might come quickly from an exacerbation, or dying can be a slower process, with a gradual increase in severity of symptoms. For patients with end-stage COPD, both prognosis and treatment plans are likely to change over time.
Despite these challenges, there are several indicators that a patient is approaching the end of life.
These include:
1. Poor functional status (Medical Research Council dyspnea scale 4 to 5)
2. Severe airflow obstruction (FEV1 less than 30% predicted)
3. Frequent or severe acute exacerbatons requiring hospitalization
4. Body mass index of less than 20 kg/m2
5. Respiratory failure (eg, chronic hypoxemia and/or chronic hypercarbia)
6. Deteriorating psychosocial/cognitive status (eg. patient is starting to wish for or talk about death)
BODE Index #
The BODE Index:
The BODE Index is a tool used to assist with the prognosis of advanced COPD. This scoring system accounts for both the respiratory and systemic manifestations of COPD, and it can be used in both inpatient and home care settings.
The BODE Index uses four different variables to predict the risk of death from COPD. These variables are:
1. Body mass index (BMI)
2. Airway Obstruction (as measured by FEV1)
3. Dyspnea (as measured by the MRC dyspnea scale)
4. Excercise tolerance (as measured by the 6-minute walk test)
BODE Index is a better predictor of COPD mortality than each variable alone. The table below shows how points are assigned based on each variable, in order to determine the BODE score. A higher BODE score is associated with a poorer prognosis (higher risk of death).
End-of-Life Care #
COPD progresses slowly over a period of years. Advanced disease is associated with multiple comorbid conditions, more frequent exacerbations, and further reductions in airflow. As the disease advances, shortness of breath severely limits the activity levels of individuals, reducing their quality of life. Premature death is common. The goals of managing COPD begin to change as the disease becomes more debilitating. Maximizing quality of life continues to be the primary focus in caring for patients with COPD. However in the final stages of the disease, there is an increased need for providing psychosocial and spiritual care to patients. When caring for COPD patients who are at an increased risk of dying in the near future, adopting a palliative care approach may be appropriate. The health care team should provide support for the family during the patient’s illness and bereavement. Some goals for end-of-life care include: Management of all symptoms (including those of co-morbid conditions)Achievement of optimal functional ability and quality of life. Discussion of end of life issues with early advanced care planning to ensure patient autonomy. Consideration of health & wellness of family members and caregivers. Consideration of consultation with specialists in respirology, palliative care or geriatric medicine. The rest of this unit focuses on controlling dyspnea and advanced care planning in management of end-stage COPD.
Managing Dyspnea #
Dyspnea occurring at rest or with minimal activity is the most common symptom experienced by patients with end-stage COPD . It is distressing for patients and families and has a great impact of quality of life. Severe dyspnea in patients who are already coping with anxiety, depression, and fear of death can lead to great suffering. Dyspnea control is a priority in the care for patients with advanced COPD.
Standard pharmacological and non-pharmacological COPD management, as described in previous units, should be optimized and continue to be optimized while treating dyspnea in advanced COPD. A stepwise approach to the comprehensive management of refractory dyspnea in patients with advanced COPD is recommended by the Canadian Thoracic society. This approach is outlined in Figure 1.
For patients who are being cared for in a hospice or hospice, palliative care or dyspnea guidelines may be utilized in the management of dyspnea that persists despite optimal conventional management.
Some strategies found in such guidelines are outlined below:
Bronchodilators and standard therapy: In dyspnea management, the use of maximal doses of bronchodilators is the first line of therapy. Short-acting bronchodilators should be used as needed and long-acting bronchodilators and inhaled anticholinergics should be used regularly. Theophylline may be of some value but patients should be monitored closely for side effects. Oral corticosteroids are thought also to be of some benefit.
Oral opioids: Medications such as Morphine and Fentanyl are effective in dyspnea management for palliation of many advanced diseases. These drugs are thought to reduce ventilation and reduce the sensation of dysnea. Even when opioids are initiated for palliation inend-stage COPD, non-pharmacological strategies should continue. Similar to pain medication, opioid dose is individualized and titrated until the patient is comfortable. Respiratory depression from opioids is rare and they do not hasten death if used appropriately. An example of dyspnea management guidelines using opioid therapy can be found in Table 1.
Oxygen: Supplemental oxygen may be effective in relieving dyspnea when hypoxemia is present. Oxygen should be titrated to achieve a saturation of 90%. To receive funding for supplemental oxygen at home, a patient must meet specific criteria Consult the Home Oxygen Program guidelines in your region for eligibility criteria.
Air flow: Wind through open windows and air movement with the use of a fan can be very helpful in relieving dyspnea.
Non-invasive Ventilation: Ventilatory support by nasal or full face mask is effective for relieving dyspnea in some patients with end-stage COPD. In patients who tolerate the tight fitting mask interface and respond to the therapy, non-invasive ventilation should be used for short-term relief only.
Physiotherapy: Breathing control techniques, such as pursed-lip and diaphragmatic breathing may be effective and should be reviewed with patients by knowledgeable clinicians. Chest wall vibration and neuromuscular electrical stimulation may also have some benefit.
Energy Conservation: Walking aids and other energy conservation devices and techniques can be helpful in relieving dyspnea with activity. An occupational therapy consult should be considered for in-patients experiencing difficulties performing activities of daily living.
Positioning: Elevating the head of the bed, or placing pillows behind the patient’s back may provide some relief from dyspnea. When sitting in a chair or on the edge of the bed, patients may get some relief from leaning forward over a table. Positions that compress the abdomen or chest wall should be avoided. Patients may direct their own optimal positioning.
Education: Dyspnea is a distressing symptom to experience and to witness. Providing information and education is important in helping patients and families to cope. Education should include the potential causes of dyspnea and the purpose of each medication used in dyspnea management. As well, a clear plan should be developed to help the patient and family feel confident that this symptom can be controlled.
Counseling: Psychosocial support, spiritual or emotional counseling should be offered to patients suffering from dyspnea in advanced COPD.
Advanced Care Planning #
One of the most difficult roles of health care professionals is helping patients and families to understand and cope with the dying process. For patients with advanced COPD, exacerbations and respiratory failure can occur suddenly and at any time. These patients will benefit from timely, honest and empathetic end-of life discussions.
A physician-initiated discussion about options for end-of-life care will help patients to accept that they are in the terminal stages of their disease. It will also enable patients to retain dignity in maintaining some control over what happens in this phase of their illness. Ongoing dialogue with members of the health care team about end-of-life issues is important throughout this phase of the illness, as it provides the patient with an opportunity to ask for more information and support.
The desire for interventions such as cardiopulmonary resuscitation and intubation should be discussed ahead of an emergency situation. Although these interventions can be life-saving, they can also have a detrimental impact on quality of life.
Some specific issues to address with patients with end-stage COPD include:
- Where should future exacerbations be managed: at home, in a hospice, in the hospital?
- How should future exacerbations be treated: with antibiotics or with opioids to provide comfort?
- What level of care should be provided in the event of acute respiratory deterioration: intubation with mechanical ventilation or comfort care?
- How can we ensure that family members and caregivers are adequately supported?
- Who should be made the substitute decision maker for financial and health care matters?
Making decisions about end-of-life care is highly individualized and requires continuous review and communication and the disease progresses. Once a patient has made decisions about their preferences for end-of-life care, they should be encouraged to create Advanced Directives, also known as a Living Will. This document will make their wishes known to caregivers in the event of critical illness and no ability to communicate.
References #
Celli BR, Cote CG, Marin JM, et al. The Body-Mass Index, Airflow Obstruction, Dyspnea, and Exercise Capacity Index in Chronic Obstructive Pulmonary Disease. New Engl J Med 2004;350:1005-12
Smith R. A Good Death. An important aim for health services and for us all. BMJ 2000;320:129–30
Goodridge D, Marciniuk D, Brooks D, et al. End-of-life care for persons with advanced chronic obstructive pulmonary disease: Report of a national interdisciplinary consensus meeting. Can Respir J 2009;16(5):e51-e53.
Marciniuk D, et al. Managing dyspnea in patients with advanced chronic obstructive pulmnary disease: A Canadian Thoracic Society clinical practice guideline. Can Respir J 2011, 18(2), 69-78.