Palliative care for COPD patients: practical tips for home based programs

1. National Hospice and Palliative Care Organization’s Palliative Care Resource Series

National Hospice and Palliative Care Organization’s
Palliative Care Resource Series
PALLIATIVE CARE FOR COPD PATIENTS:
PRACTICAL TIPS FOR HOME BASED PROGRAMS
Parag Bharadwaj, MD, AAHPM
Jakrin Kewcharoen, MD
Kenneth Unger, MD, FACP, FCCP, FAAHPM

2. INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is the
third leading cause of death and morbidity worldwide. In
the United States, it affects 12 to 16 million people
Patients experience deterioration in symptoms and
quality of life on a scope similar to those with advanced
malignancy
Palliative care intervention provides comfort and
optimization of treatment plan and goals

3. OVERVIEW

COPD
Definition
Pathophysiology
Clinical Features
Disease Management
Palliative Care in COPD Patients at Home

4. DEFINITION OF HEART FAILURE

COPD is an irreversible chronic progressive disease. It is
characterized by persistent airflow limitation associated
with an enhanced chronic inflammatory response
The chronic airflow limitation is caused by a mixture of
small airways disease (obstructive bronchiolitis) and
parenchymal destruction (emphysema)

5. RELEVANT PATHOPHYSIOLOGY

Destruction of the lung parenchyma, also by
inflammatory processes, leads to the loss of alveolar
attachments to the small airways and decreases lung
elastic recoil
Other features of COPD include
Gas trapping during expiration
Gas exchange abnormalities
Mucus hypersecretion
Pulmonary hypertension

6. CLINICAL FEATURES

Predominant Symptoms
Shortness of Breath
Chronic cough with sputum production
Episodes of acute exacerbation
Pain around the chest and other parts of the body is under
diagnosed

7. CLINICAL FEATURES

Other Common Signs and Symptoms:
Fatigue
Muscle wasting and Cachexia
Sexual Dysfunction
Sleep disturbance

8. DISEASE MANAGEMENT

Non-Pharmacological Interventions
Smoking Cessation
Regular exercise and physical activities
Pulmonary rehabilitation
Influenza and pneumococcal vaccination

9. DISEASE MANAGEMENT

Pharmacological Interventions
Bronchodilators
Steroids
Opioids
Benzodiazepines
Mucolytics
Cough suppressants

10. DISEASE MANAGEMENT

Invasive Strategies
Supplement oxygen
BiPAP
Lung volume reduction surgery (LVRS)

11. PALLIATIVE CARE FOR COPD PATIENTS AT HOME

Palliative care aims to increase quality of life of patients
and should be a standard offered to patient and family
Delivery of this type of care requires intense planning
and care coordination between all involved medical
specialties, as well as family, caregivers, and
psychosocial support

12. CLINICAL: AREAS OF FOCUS

Symptoms
Assess and address any change in symptoms, such as
cough, sputum production, breathlessness, pain and sleep
disturbances, since the last visit.
Evaluate exacerbation history
Physical Exam
Vital Signs, especially pulse oximetry

13. CLINICAL: AREAS OF FOCUS

Smoking status
Co-morbidity
Medication
The current therapeutic regimen should be discussed at
each visit. Avoid polypharmacy.
Teach and evaluate the proper use of MDIs.

14. ADDITIONAL NEEDS ASSESSMENT: AREAS OF FOCUS

Emotional and Financial Support Screening
Request social worker follow-up, if needed, in addition to
routine social worker visits
Spiritual Needs Screening
Request chaplain visit, if needed, in addition to routine
chaplain visits
Caregiver Screening
Ensure social worker and chaplain support to caregiver(s)
Monitor for burnout

15. PATIENT GOALS: AREAS OF FOCUS

Care plan and patient goals should be reviewed frequently
with the patient and caregiver to ensure the appropriate
care is being delivered
Every patient should have an advance directive completed,
preferably a POLST (Physician Orders for Life Sustaining
Treatment)
Any changes should be promptly reflected in the document
Documents should be readily available to patient, caregiver
and paramedics (if called)

16. PATIENT GOALS: AREAS OF FOCUS

Depending on the patient’s clinical status, options and
goals should be readdressed on a regular basis
Informing the patient and the caregiver of options,
including hospice, is necessary

17. REVIEW AND EDUCATION: AREAS OF FOCUS

Any change in the treatment plan should be carefully
discussed with the patient and family. Everything that
was discussed at the meeting should be reviewed before
the palliative care team leaves the patient’s residence
Ensure that patient and family can contact medical team
at all time if needed
Develop an individualized Action Plan to help patients
recognize the early symptoms of an exacerbation and to
support the patient with an AE until the care team can be
reached

18. SUMMARY: LESSONS LEARNED AND BEST PRACTICES

A Plan of Care should be based on the patient’s
individualized needs and goals of care.
24/7 access to medical support and advice
Medical providers skilled in medical and psychosocial
assessment and in advanced care planning is essential.
Including access to respiratory and palliative care
medicine expertise

19. SUMMARY: LESSONS LEARNED AND BEST PRACTICES

Patient and caregiver education is extremely important
Regular home visits, with physician assessment when
needed
Support for a home environment that is comfortable and
safe
An Individualized Action Plan, to support the
patient/caregivers, in event of an AE

20. SUMMARY: LESSONS LEARNED AND BEST PRACTICES

Direct hospital admission, bypassing the emergency
department, when indicated
Availability of Hospice Care