Advance Care Planning in Chronic Obstructive Pulmonary Disease: Barriers and Opportunities

Barriers and Opportunities

John E. Heffner

Disclosures

Curr Opin Pulm Med. 2011;17(2):103-109. 

In This Article

Opportunities for Improving Advance Care Planning for Patients with Chronic Obstructive Pulmonary Disease

International awareness is growing that patients with COPD need greater access to palliative care services. In the United Kingdom, a national service framework for COPD is being developed to improve the quality of care for patients with COPD, and a recently published EOL care strategy for England emphasizes the importance of appropriate care for patients with advanced nonmalignant conditions.[14•] The UK National Council for Palliative Care has formed a chronic respiratory disease policy group.[23] Pulmonary professional societies have published guidelines on palliative care for patients with chronic respiratory diseases[27,46] and leaders in pulmonary rehabilitation have recognized that the goals of pulmonary rehabilitation and palliative care overlap, with both services addressing symptom management to promote patient independence and sense of well-being.[10••,34,37,47•] The incorporation of palliative care into pulmonary rehabilitation provides an effective model for promoting ACP for patients with COPD by facilitating better communication between patient, family, and physician.[10••,47•] Although patients prefer doctors to discuss ACP, they accept other healthcare professionals as sources of advance planning information.[13••,21]

Physicians, however, represent the primary communicators for ACP and, as such, need to access available resources to diagnose COPD at an earlier stage[48] and gain a better understanding of palliative care resources and how to discuss ACP with patients.[1] Investigators are studying methods to help physicians frame conversations in the context of 'hoping for the best and planning for the worst',[49] assessing whether patients welcome such conversations by using an 'ask–tell–ask' format,[50] and introducing preprinted forms and other decision support tools to determine patients' EOL preferences.[51] But an urgent need exists to identify additional strategies to enhance patient–physician communication to realize the objectives of ACP.

Most importantly, new models of continuous palliative care specifically tailored for patients with COPD require validation. These models start palliative care at the time of COPD diagnosis and integrate palliative services with disease-directed treatments as needed with patient-centered goals during the progression of the disease.[1] Palliative care in this model represents a life-long, essential component of healthcare, starting at a low base and rising eventually to become the predominant theme.[1,13••] Specific to COPD, palliative care can increase in response to acute exacerbations and decrease as allowed with recovery of patients toward baseline function. Observations that patients with COPD enrolled in palliative care programs are eight times more likely to die at home as compared with patients managed by usual care underscore the value of this model.[1]

Timing of ACP discussions, however, remains a challenge for many physicians at least partly because cessation of curative treatment is too often considered a distinct event forcing patients to arbitrarily choose between disease-directed care and palliative care. Various sources have recommended specific thresholds for targeting patients with COPD for prompting ACP discussions in this dichotomous model:[1,23,52,53]

  1. Canadian Thoracic Society guidelines:[52]

    1. Any one of the following:

      1. FEV1 less than 40%.

      2. Medical Research Council Dyspnea Scale score of 4 or 5.

      3. Recurrent severe acute exacerbations requiring hospitalization.

      4. Poor nutritional status with a BMI less than 19 kg/m2.

  2. Curtis et al.:[53]

    1. Two or more of the following:

      1. FEV1 less than 30% predicted.

      2. Oxygen dependence.

      3. One or more hospital admissions in prior year for exacerbation, left heart failure or other comorbidities.

      4. Weight loss or cachexia.

      5. Decreased functional status

      6. Increasing dependence on others.

      7. Age more than 70 years.

  3. Partridge et al.:[23]

    1. The treating physician would not be surprised if the patient died within the next 12 months.

  4. Hardin et al.:[1]

    1. Global initiative for chronic obstructive lung disease (GOLD) stages II through IV.

    2. At least two admissions per year for exacerbations.

    3. BODE index score greater than 5.

    4. ICU admission for respiratory failure.

    5. Home noninvasive positive pressure ventilation.

    6. Supplemental oxygen requirement.

    7. Patients with more than 10% decrease in body weight in 6 months or BMI less than 21 kg/m2.

    8. Concomitant congestive heart failure.

    9. Patients with transplant or lung volume reduction surgery – before or after.

    10. Lack of home support system.

    11. Presence of anxiety or depression.

    12. Patients expressing poor symptom control.

    13. Patients who are unable to meet their activities of daily living.

But these signposts are often poorly recognized by either patients or clinicians, seldom serve as effective triggers, and derive from physicians' perspectives. Transitions of care should also be examined from the patient and family members' perspectives, which allows clinicians to target ACP discussions based on patient's self-perceived needs.[28] Different patients perceive different transitions that span a range of issues including changes in therapeutic options but also changes in symptoms, quality of life, and functional status.[28] Interventions that utilize an individualized approach to understanding and addressing transitions of care may result in increased patient and family satisfaction with care, decreased fear and anxiety, and overall improved healthcare experience.[28]

In regard to timing ACP discussions, recent guidelines recommend that patients with chronic respiratory disease should have palliative care available throughout the course of their disease with greater emphasis on palliative measures as symptoms increase.[1,27] The Consensus Project for Quality Palliative Care emphasizes that palliative care should begin in the primary care setting in the course of routine care.[1] Considering the uncertainty of predicting the course of COPD, it seems reasonable to offer palliative care services at the time of diagnosis while simultaneously treating and preventing the underlying disease and associated comorbid conditions.[10••]

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