Palliative Supportive Care in COPD, Key Issues

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Palliative/ Supportive Care in COPD, Key Issues

• Dawn Weston Lead Public Health Nurse,
  Respiratory Conditions
• Margaret Mc Sloy Respiratory Specialist Nurse

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Aims and Objectives

• To understand the palliative care issues of
  patients with Chronic Obstructive Pulmonary
  Disease, especially in relation to
• The identification of end stage disease.
• Specific symptom management
• Specific ethical considerations
• Specific palliative care challenges
• A whistle stop tour!

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Introduction

• COPD is the UKs fifth biggest killer disease,
  claiming more lives than breast, bowel or
  prostate cancer.
• On average 15 of those admitted to hospital with
  COPD die within three months
• 50 die within two years

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The Three Triggers for Supportive/Palliative Care

• The Surprise question
• Choice/ need
• Clinical indicators
• Gold standards framework
  programme (2006)

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Clinical Indicators/ General

• Multiple co-morbities
• Weight loss, 10 over 6 months
• General physical decline
• Serum Albumin lt 25g/l
• Reducing performance status, lt 50 dependence in
  most ADLs
• Gold standards framework
  programme (2006)

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Specific Clinical Indicators

• Disease assessed to be severe e.g. FEV1 lt 30 of
  predicted
• Recurrent hospital admissions gt3 admissions in 12
  months
• Fulfils LTOT criteria
• MRC grade 4-5
• Signs and symptoms of right sided heart failure
• Combination of other factors e.g. anorexia
  previous ITU/NIV/resistant organism, depression
• Gold
  standards framework programme (2006)

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Common distressing COPD symptoms

• Dyspnoea
• Anxiety
• Cough
• Confusion
• Depression
• Anorexia/cachexia

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Specific symptom management

• Breathlessness
• Non-pharmacological
• Pharmacological
• Cough
• Sputum
• Psychological issues

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Breathlessness

• Non Pharmacological
• Anxiety management
• Breathing control
• Fan
• Occupational therapy- adaptations etc
• Physiotherapy
• Complementary therapy
• Positioning

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Breathlessness

• Pharmacological
• Inhaled/ nebulised bronchodilators
• Nebulised sodium chloride 0.9
• Benzodiazepines
• Opiates
• Oxygen

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Benzodiazepines

• Sublingual Lorazepam
• 500mcg- 1mg PRN max 4mg daily
• Diazepam
• 2mg- 5mg PRN to max TDS

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Opiates

• Oral morphine solution (10mg/5ml)
• Commence at low dose 2.5mg QDSPRN as needed up
  to 3-4 hourly
• Titrate upwards every 48 hours as needed and
  tolerated

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Cough

• If difficulty expectorating nebulised Sodium
  Chloride 0.9 (evidence anecdotal)
• Physiotherapy
• Symptomatic relief Simple linctus
• Cough suppressants e.g. Codeine Linctus or
  Morphine

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Sputum

• Exclude infection
• Encourage fluids
• Physiotherapy
• Mucolytics e.g. Carbocisteine, Mecysteine
• Nebulised Sodium Chloride 0.9

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Psychological Issues

• Pharmacological - consider Anxiolytics,
  Antidepressants, NRT, night sedation
• Consider referral to mental health services
• Cognitive behaviour therapy

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Specific Ethical Considerations

• To treat or not to treat
• e.g. NIV therapy, antibiotics
• Opiates and anxiolytics
• Wariness of HCP discussing prognosis/ end of life
  issues
• Attitudes by HCP towards people who continue
  smoke?

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Challenges

• Experience in primary care
• Communication
• Co-ordination of services
• Documentation issues
• Availability of resources e.g. psychological
  support
• Equitable service

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One Final Thought..

• Never deprive someone of hope it might be all
  they have.
• H. Jackson Brown Jr.

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Discussion

• The way forward

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The Gold Standards Framework 7 Key Tasks

• C1 Communication
• C2 Co-ordination
• C3 Control of symptoms
• C4 Continuity out of hours
• C5 Continued learning
• C6 Carer support
• C7 Care of the dying