Controlling COPD Symptoms at the End of Life

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Controlling COPD Symptoms at the End of Life

• Helen M. Sorenson MA RRT FAARC

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Death rate per 100,000 from COPD
CDC MMWR Chronic Obstructive Pulmonary Disease
Surveillance Report, 1971 2000 August 2,
2002.
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Emphysema/COPD

• A long course of chronic disease characterized by
  exacerbations and remissions, but a clear or
  steady decline
• When the patient gets to last days, careful
  attention to symptom control can prevent,
  minimize or eliminate distress thus improve
  quality of life till time of death

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Emerging Profile of Dying COPD Patient ( Within
a Year)

• Best FEV1 lt 30 of predicted
• Declining performance in ADL
• Uninterrupted walk distance lt a few steps
• 1 urgent hospitalization in past year
• Left-heart and/or other comorbid diseases
• Older age
• Depression
• Unmarried

Hansen-Flaschen J. COPD The Last Year of Life.
Respiratory Care, 2004 49(1) 90-98.
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Signs of Impending Death(hours to days)

• Hypersomnolence ? Urine production
• Disorientation Cool extremities
• Irregular breathing Altered vital signs
• Mottled skin Hypothermia
• Retained secretions ? Interest in food
• in upper airway and/or water

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Symptom Assessment

• Subjective nature ( self-reported)
• Clinician accuracy poor
• Symptom measurement must be considered
• Symptom measurement instruments
• MSAS Memorial Symptom Assessment Scale
• RSC Rotterdam Symptom Checklist
• VAS Visual Analog Scale (0 / 10)
• Dyspnea Assessment (Ventilator check)

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Barriers to Symptom Assessment

• Advanced disease accompanied by fatigue,
  depression, delirium
• Difficult in patients with more than one
  symptom
• Caregivers not willing to share time
• Disease itself not open to
  discussion

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Severity of COPD symptoms3 days prior to death,
per family members
Lynn J,Teno, JM et al. Perceptions by family
members of the dying experience of older and
seriously ill patients. Ann of Intern Med
1997126(2) 97-106.
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Common Distressing COPD symptoms

• Dyspnea
• Anxiety
• Cough
• Confusion
• Pain
• Depression
• Anorexia/Cachexia

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Management of symptoms

• General principles of palliation
• Determine and treat underlying cause
• Relieve symptoms without adding any new problems
• Consider if treatment is worthwhile - for the
  patient and/or family
• Discuss all reasonable treatment options

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Causes of Dyspnea (COPD)

• Airway obstruction or restriction, hypoxemia,
  reduced respiratory muscle force (deconditioning)
• Cardiovascular CHF, cor pulmonale
• Anxiety/fear
• Anemia
• Fluid overload

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Control of Dyspnea

• Pharmacotherapy
• Bronchodilators (COPD)
• Diuretics (CHF)
• Opioids oral is preferred route
• Oxygen as needed and/or tolerated but not
  monitored

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Control of Dyspnea

• Benzodiazepines - anxiolytic
• Phenothiazine (Thorazine) antipsychotic which
  may be used for severe agitation
• Corticosteroids anti-inflammatory side effects
  not an issue at this point

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Nebulized Opioids (Anecdotal)

• Direct action of OPM on lung afferent nerves
• OPM may diminish response to hypoxia and
  hypercapnia at chemoreceptor level
• May alter perception of breathlessness
• May exert peripheral effect on opioid receptor in
  lungs
• Nebulized morphine may cause histamine-mediated
  bronchospasm during 1st nebulization

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Control of Dyspnea

• Non-Pharmacological
• Elevate head of bed 30? (whatever works)
• Pursed-lip breathing
• Calming presence
• Relaxation therapy
• Massage therapy
• Fans ( cool air)

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COPDers and Fans

• In end-stage COPD, primary ventilatory muscle 10
  efficient, secondary muscle 3 efficient.
• Increased WOB, increased energy expenditure,
  increased body temp, do fans provide relief ?
• Fans improve dyspnea by stimulating receptors in
  the trigeminal nerve located in the cheek and
  nasopharynx, altering the perception of
  breathlessness (Enck, Johns-Hopkins, 1994)

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Pain control

• Pain is whatever the experiencing person says it
  is, whenever the experiencing person says it
  does McCaffery Pasero, 1999
• Symptom assessment
• VAS (0/10)
• Sad face/happy face
• Establish level of pain!

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Pain control

• Most pain can be alleviated
• Dosing of pain medications should be on a regular
  round-the clock basis
• Analgesics wear offdelay in administration
  exacerbation of pain
• anxiety /fright
• family dissatisfaction

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Cough control

• Cough is a normal protective mechanism but can
  also be induced by
• Infection
• Airway disease
• Drug induced (ACE inhibitor)
• Reflux
• Aspiration of saliva

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Cough control

• Establish level of distress (0/10)
• Educate family
• Warm humidified air
• Expectorants and/or mucolytics of little value
• Codeine 15-30 mg oral Q4
• Morphine 2.5 mg oral Q4
• Nebulized lidocaine 2 mls (1, 2 or 4) Q6
• (wait 30 minutes post before eating aspiration
  risk)

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Death Rattle - Last 24 to 48 hours

• Caused by airflow through retained secretions at
  back of throat
• Patients lethargic, comatose unaware
• Family members find noise distressing need to
  be educated
• Oropharyngeal suction may be done, but if it
  causes gagging or coughing, it is not palliative
• Lateral recumbent position with head elevated
  slightly may reduce pooling of secretions

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Death Rattle - Last 24 to 48 hours

• Anticholinergic use needs to start early will
  not dry up secretions already present

Rousseau P. Nonpain Symptom Management in the
Dying Patient Hospital Physician, February 2002.
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Bronchorrhea

• Defined as the profuse production of sputum of gt
  100mL/day
• Has been observed in patients with end-stage
  bronchioalveolar carcinoma
• Has been successfully treated with inhaled
  Indomethacin, probably by causing down regulation
  of cyclo-oxygenase
• 2 RCT (1985,1992) case studies (1999) and In-vivo
  study(1995) all indicate efficacy

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Anorexia/Cachexia

• lt 3 days, 55 unable to eat
• Common in dying patients
• Check for treatable conditions
• Oral candidiasis, poorly fitting dentures, mouth
  sores, pain, nausea

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Anorexia/Cachexia

• Family education ?benefit from force feeding
• Any food is acceptable ?worry about nutritional
  value
• Enteral maybe, TPN not recommended
• Starvation/dehydration analgesic effect
• Xerostomia associated with dehydration does cause
  discomfort good oral care, mouth swabs, ice
  chips recommended

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Confusion

• Mental changes can accompany
• terminal stage of illness
• Causes drugs, hypoxia, metabolic imbalance,
  urinary retention, sleep deprivation, poor pain
  control
• Treatment If cause can be determined
• Simple treatment may improve communication

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Confusion /Depression

• Non-specific therapy
• Handholding, frequent reminders of place and
  person
• Unfinished business
• Addressing religious/spiritual needs
• Environment is going home an option
• Music therapy
• Meditation

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Palliative Respiratory Therapy

• Palliative care is comfort care! What will be
  comfortable for your patients?
• Nebulized bronchodilators?
• Oxygen therapy device and liter flow?
• Continuous pulse oximetry?
• Chest physiotherapy?
• CPAP/IPPB?
• ABGs?
• NT suctioning?
• Patient positioning?

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What do Families Need?

• Caring for dying patients necessitates caring for
  their families
• Adequate communication
• Feeling supported
• Giving good care to loved ones

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Palliative Care

• Broadening medical care to integrate palliative
  and life-prolonging interventions is a major
  challenge for health care in our country
• Allied Health care professionals should be
  prepared to render comfort care at the bedside to
  our patients

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Palliative Care

• All patients with a terminal condition should be
  provided
• Access to palliative care delivered by
  knowledgeable practitioners
• Treatment that looks to quality of life as well
  as quality of care
• Information regarding the close collaboration
  between hospice and palliative care

Clinical Practice Guidelines for Quality
Palliative Care National Consensus Project.
www.nationalconsensusproject.org
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Integration of Palliative Care

• Pain, symptom control, psychosocial distress,
  spiritual issues and practical needs are
  addressed
• Patients receive necessary information in a
  timely and understanding manner
• Care of the patient is truly coordinated among
  disciplines
• Both the patient and the family are prepared for
  the dying process

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Palliative Care Means
To cure, sometimes To relieve, often To comfort,
always