COPD as a Life-Limiting Illness

The Burden of COPD

In spite of the fact that chronic circulatory and respiratory conditions engender a significant amount of suffering^[1] and cause more deaths among older adults in developed countries than cancer,^[2,3] we know very little about the end-of-life care needs of people with advanced, progressive chronic illnesses such as chronic obstructive pulmonary disease (COPD).^[4] As COPD progresses, individuals experience significant decreases in functional capacity, quality of life, communication abilities, and psychosocial well-being, impairments that equal or surpass those of persons with cancer.^[5] Advanced practice nurses (APNs), particularly those in primary, respiratory, and palliative care, have critical roles to play in identifying and addressing the needs of people with this life-limiting illness.

The purpose of this article is to review the literature relating to end-of-life care for persons with COPD. Two electronic databases — the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Medline — were searched for articles published from March 1986 to March 2006, using key words. The search strategy used was "chronic obstructive lung disease" OR "chronic obstructive pulmonary disease" AND "end of life care" OR "palliative care" OR "terminal care." In addition, a manual search yielded related publications, including the updated Global Initiative for COPD 2006 guidelines published in November 2006. This article reviews the current state of knowledge regarding the burden of COPD, and the state of end-of-life health services for individuals with COPD.

COPD is currently the fourth leading cause of death in the world, and is projected to become the third most common cause of death by 2015.^[6] The economic burden of COPD is immense. In 2003, US healthcare costs related to COPD rose to $31.4 billion, with total costs over the next 20 years estimated to reach about $832.9 billion.^[7]

The 5-year mortality rate for people with COPD typically ranges from 40% to 70%, depending on disease severity,^[8] while the 2-year mortality rate for people with severe COPD is about 50%.^[9,10] Survival rates for people with severe COPD are, in fact, worse than those for people with many common cancers.^[11]

The trend in COPD-related mortality differs markedly from that of other chronic diseases. While mortality rates for heart disease and stroke have fallen significantly over the last 30 years (59% to 64% decrease), death rates from COPD have more than doubled, mostly as a result of past smoking history.^[12,13]

COPD has also become a significant health concern for women in particular. While the death rate among males has gradually declined, overall COPD mortality rates for females between 1988 and 1999 rose by 53% and continue to escalate.^[12] Several factors may account for this increase. Historically, fewer women than men smoked, but that gender gap narrowed gradually until the mid-1980s, when it became fairly constant. Employment in workplaces with occupational exposure to noxious agents, as well as increased exposure to second-hand smoke outside of work, are other factors contributing to this alarming trend.^[14] In fact, women with COPD may experience poorer perceptions of health and higher functional limitations than do men,^[15,16] although further research is needed in this area.

Cite this: COPD as a Life-Limiting Illness: Implications for Advanced Practice Nurses - Medscape - Dec 31, 2006.

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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