COPD as a Life-Limiting Illness: Implications for Advanced Practice Nurses

Donna M. Goodridge, RN, PhD

Topics in Advanced Practice Nursing eJournal. 2006;6(4)

Abstract

Chronic obstructive pulmonary disease (COPD) is a progressive and ultimately fatal chronic illness that is the fourth leading cause of death in the world. People with advanced COPD experience severely compromised functional capacity, quality of life, communication abilities, and psychosocial well-being. Although these impairments equal or surpass those of persons with cancer, the end-of-life care needs for COPD patients are only now being examined and addressed. Advanced practice nurses can make significant contributions to the care of this underserved population through appropriate, evidence-based assessments and interventions. Symptom management (including dyspnea, fatigue, and cachexia), support of self-management, patient and family education, and advance care planning are key focus areas for advanced practice nurses.

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Table 1. GOLD Spirometric Classification of COPD Severity
Stage	Severity	Spirometry
Stage I	Mild	FEV₁/FVC < 0.70
Stage I	Mild	FEV₁ ≥ 80% predicted
Stage II	Moderate	FEV₁/FVC < 0.70
Stage II	Moderate	50% ≤ FEV1 < 80% predicted
Stage III	Severe	FEV₁/FVC < 0.70
Stage III	Severe	30% ≤ FEV₁ < 50% predicted
Stage IV	Very severe	FEV₁/FVC < 0.70
Stage IV	Very severe	FEV₁ < 30% predicted or FEV₁ < 50% predicted plus chronic respiratory failure

COPD = chronic obstructive pulmonary disease; FEV₁ = forced expiratory volume in 1 second; FVC = forced vital capacity
Used with permission from the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Global Initiative for Chronic Obstructive Lung Disease, 2006. Available at www.goldcopd.org.

Table 2. The BODE Index
Variable	Points	On	BODE	Index
	0	1	2	3
FEV₁ (% of predicted)	≥ 65	50-64	36-49	≤ 35
Distance walked in 6 minutes (m)	≥ 350	250-349	150-249	≤ 149
MMRC dyspnea scale	0-1	2	3	4
Body mass index	> 21	< 21

FEV₁ = forced expiratory volume in 1 second; MMRC = Modified Medical Research Council.
Celli BR, Cote CG, Marin JM et al. (2004) The body-mass index, airflow obstruction, dyspnea and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med. 2004;350:1005-1012. Copyright 2004 Massachusetts Medical Society. All rights reserved.

Table 3. Profile of COPD Patients at Risk for Death From Acute Respiratory Failure
Severe airflow obstruction (FEV₁, 40% predicted) Poor functional status (MRC dyspnea scale 4-5) Poor nutritional status (BMI < 19 kg/m²) Older age Recurrent acute exacerbations of COPD (especially requiring hospitalization and mechanical ventilation) Chronic comorbidities (depression, congestive heart failure)

BMI = body mass index; COPD = chronic obstructive pulmonary disease; FEV₁ = forced expiratory volume in 1 second; MRC = Medical Research Council.

Table 4. Components of Palliative and End-of-Life Care for Patients With Cardiopulmonary Disease
Component	Interventions and Activities
Support for patient and family	Advance care planning
	Maintaining and supporting the patient's dignity, including cultural and spiritual needs
	Emotional support for the family, including bereavement services
Care of the patient	Relief of distressing symptoms
	Management of the dying process, including withdrawal of life-sustaining treatment
	Referral to appropriate hospital and community resources
	Quality palliative and end-of-life care in all treatment settings, including institution and home
Responsibility of the professional caregiver	Assurance of professional education and competence in quality palliative and end-of-life care
	Support and counseling to address professional caregiver grieving
	Development of institutional, professional, and regulatory policies to ensure quality palliative and end-of-life care

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