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

Donna M. Goodridge, RN, PhD

Disclosures

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

In This Article

Promoting Excellent Care for People With Severe COPD

There is increasing recognition that active treatment and palliative treatment may need to run concurrently throughout the course of any chronic illness.[62] Excellent care, whether acute or palliative, is always patient-centered and focuses on ensuring the highest degree of wellness possible at that point in the patient's illness. Because people with advanced COPD may be unwilling to express their needs,[63] adequate understanding of the potential problems will help direct the nurse's assessment.

APNs must support and educate patients with severe COPD to take an active role in self-management of their illness. Pulmonary rehabilitation programs, long-term oxygen, and even noninvasive ventilation may help enhance the patient's health status.[64] In order to optimize patient self-management, nurses should engage in ongoing dialogue about the progression of the disease, its evolving management, the relative benefit of treatments at different times, and the plans for physical and emotional support throughout the course of the illness.[65]

Integrated care pathways for people dying with chronic illnesses incorporate best practice guidelines and provide tools for nurses at various levels of expertise and in different practice settings.[66] Clinical pathways can focus providers on appropriate care goals for the last few days of life, and can result in significant improvements in care.[66]

Interdisciplinary, community-based teams (including respiratory nurse specialists with expertise in palliative care) have been developed in a number of areas to coordinate care and services, and to address both physical and psychosocial needs of people with advanced COPD in an integrated and holistic manner.[30,33,43,67] Strategic planning between primary and secondary care providers might result in stronger and more viable partnerships between different care settings.[68] Psychosocial needs assessment, counseling, and intervention should be seen as integral components of routine services for people with advanced COPD, just as they are for palliative cancer patients.[43]

Formal hospice services can be important in the care of people with advanced COPD, although the disease's unpredictable trajectory can complicate the hospice eligibility process.[67] Some authors have advocated using the following signs of poor prognosis as hospice admission criteria: peak flow less than 150 mL/min, long-term oxygen use, low BMI, and a low serum total protein.[69,70]

The American Thoracic Society/European Respiratory Society COPD Standards are less specific, suggesting that evidence of a high likelihood of death, constituted by repeated exacerbations and very poor measures of pulmonary function, are appropriate circumstances in which to consider hospice admission.[71] These same guidelines, however, also note that one cannot wait to consider using hospice services until death is nearly certain, and that neglect in offering appropriate resources for supportive end-of-life care results in unnecessary admissions to acute care hospitals for worsening respiratory symptoms.

In conclusion, people with advanced COPD and their caregivers face significant physical and psychosocial challenges, and they are inadequately supported by the present configuration of healthcare services. APNs have many opportunities to make an enormous difference in these patients' quality of life by offering education, symptom management, and advance care planning.

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