COPD as a Life-Limiting Illness

Advance Care Planning

Patients with severe COPD and their families often must decide whether they want to undergo life-supportive care, such as admission to the intensive care unit or mechanical ventilation, during acute medical crises such as sudden, life-threatening exacerbations of COPD or episodes of acute respiratory failure.^[48] COPD patients are more likely than lung cancer patients to die receiving aggressive, technological care directed at preservation of life, despite having expressed a preference for comfort care alone.^[49]

Understanding the nature and implications of treatment options is a critical component of advance care planning for persons with advanced COPD. A study in Oregon found that patients did not understand their treatment options at the end of life, such as refusal or withdrawal of life support, physician-assisted suicide, active euthanasia, and the principle of double effect.^[50] The principle of double effect governs interventions that seek a good effect (such as relief of pain), but which may have a bad result (such as death from respiratory depression).

Unfortunately, there is substantial evidence that only a small portion of people with COPD have the opportunity to discuss their wishes for care before the onset of a medical emergency.^{[38,51,52,53,54]} In 1 study, few patients with moderate to severe COPD had discussed end-of-life care issues with their physicians, and less than 15% of them believed that their physicians understood their preferences for treatment at the end of life.^[52] Another study noted that patient-physician communication about end-of-life care occurred very late in the COPD trajectory and usually took place in the intensive care unit, with most physicians waiting to initiate the discussion until dyspnea was severe.^[55]

Many people with COPD want to have such discussions,^[44,56,57] yet the majority of participants in 1 study reported that their physicians never discussed prognosis, the experience of dying, or patients' spirituality.^[53] Of interest, most general practitioners believe that discussions of prognosis are necessary or even essential in severe COPD, yet less than half "often or always" engage in such discussions themselves.^[38] Those who "never or rarely" discussed prognosis with severe COPD patients said they felt ill-prepared to talk about it. Knowing the patient as an individual was considered a necessary prequel to initiating end-of-life care discussions, and physicians also recognized the importance of their framing of the issues on patients' treatment choices.^[58]

This "deadlock" in end-of-life communication was described by Heffner and colleagues.^[52] While most physicians wait for their patients to ask for information, most COPD patients wait for their physicians to bring up the topic.

Thus, APNs can play a significant role in initiating and continuing discussions about outcomes values and treatment preferences. The APN should recognize that some patients may, however, prefer not to talk about dying and end-of-life care,^[54,59,60] thus creating an additional barrier to advance care planning. For example, Willems and colleagues^[61] noted in a study of advanced heart failure patients that none were very concerned about the end-of-life decision-making process, and most said they did not think about death at all, or only during exacerbations. Because these individuals had experienced long periods of health stability, which is a characteristic of many chronic illness trajectories, and also had successfully recovered from previous acute exacerbations, the authors speculated that the patients may not have fully understood the advanced and life-threatening nature of their disease. APNs need to be sensitive to the choices patients make about participating in end-of-life discussions.

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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