COPD AND PALLIATIVE CARE JEAN WATERS FNP-BC SENTARA RMH PALLIATIVE CARE JANUARY 13, 2018

Transcription

1 COPD AND PALLIATIVE CARE JEAN WATERS FNP-BC SENTARA RMH PALLIATIVE CARE JANUARY 13, 2018

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3 THOUGHTS TO CONSIDER What is Palliative Care? COPD and impact on Quality of Life. Prognosis and impact of co-morbidities Ideas for Symptoms management. Progression/trajectory and transition to comfort Eligibility for Hospice

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5 PALLIATIVE CARE Specialized medical care for people living with severe illness. Focus is on relief of symptoms/stress/burden of medical interventions. Goal to improve quality of life.

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7 MORE ON PALLIATIVE CARE Complex chronic illness Intensive family meetings Coordination of care Benefit of early intervention

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9 COPD AND RESPIRATORY FAILURE Expected to be the 3 rd leading cause of morbidity by 2020 Presently 6 th leading cause of mortality Estimated 24 M <65 $$$$$ Expenses increase with complications and hospitalizations BOLD study (Burden of obstructive lung diseases) GOLD initiative

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15 GOLD DEFINITION OF COPD PROGRESSION Exacerbation- reported medical visit for an episode of breathing problems that interfered with usual daily activities

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20 COPD SYMPTOMS EARLY Chronic cough Sputum (usually worse in AM) Persistent dyspnea Sleep apnea with desats. Weight loss, muscle wasting Frequent/severe URI Anxiety LATE Anemia (normochromic, normocytic) O2 desats. with exertion Cyanosis of mucus membranes Barrel shaped chest Hyperinflation, diminished BS Resting RR 20+, tachycardia Prolonged expiration, accessory muscle use Continued weight loss, temporal thinning

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23 WHAT DO PATIENTS WITH COPD WANT? Quality of life (barriers) Symptom management

24 COPD EFFECTS ON QUALITY OF LIFE Stopping work Unable to plan for future Drop in income Decline in social activities Cough symptoms/dyspnea in public Increased dependence

25 SYMPTOM BURDEN 94% breathlessness 67% anorexia 44% constipation Additional issues included anxiety, depression, insomnia

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27 TREATMENTS The usual- bronchodilators/beta2 agonists/anticholinergics Tiotropium Corticosteroids Antibiotics Smoking cessation, Oxygen therapy, avoiding irritants

28 TREATMENTS BEYOND THE USUAL Diet/nutrition/hydration Vaccines Breathing exercises (diaphragmic/pursed lip/cough/posture) Relaxation techniques Music/aromatherapy Cool humidified air Circulating fan

29 PALLIATIVE CARE RECOMMENDATIONS Low dose morphine (scheduling and prn flexibility) Aggressive treatments of other symptoms (antidepressants, anxiety, insomnia, anorexia, constipation Early conversations- not waiting until severe exacerbation Advanced care plan Open discussions about mechanical ventilation, intubation, palliative care strategies, hospice services

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31 THE LAST YEAR OF LIFE 32% of severe COPD patients reported discussions about end of life care. Estimated 250,000 Americans die each year with COPD Many die after prolonged functional decline-accompanied by much suffering Outlined criteria to support the idea of terminal care Anticipation opens the door for planning and preparation for terminal care. Hope for the best but plan for the worse- not necessarily the ideal approach

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33 COPD TRAJECTORY Sudden death less common COPD has a steady progression and usually a terminal phase COPD typically follows similar path of Heart Failure with many similar symptoms. Frequent admissions, exacerbations, intensive treatments Each exacerbation may result in death, uncertainty in timing of death Co-morbidities and declining reserves

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36 WHAT DO END STAGE COPD PATIENTS WANT AT END OF LIFE? Die at home Hospice services Community support Symptom control 6-12 month question

37 HOSPICE TRANSITION Poor prognostic indicators (50% were still alive at 6 months) Cor pulmonale po2 <55 on Oxygen Albumin <2.5

38 PRACTICAL PLANNING FOR A GOOD DEATH Death at home Unfinished business Place of care Empowering with knowledge Most welcome discussions- some will cope by denial One size fit all? Not likely Early referral, early symptom management, improved QOL, higher chance for peaceful EOL experience

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40 LIVE EACH DAY AS IF IT IS YOUR LAST ONE DAY YOU LL BE RIGHT. John Rosenberg

41 DO NOT COUNT THE DAYS MAKE THE DAYS COUNT Muhammad Ali

42 CONCLUSION Palliative care sees the person beyond the disease COPD is a serious, progressive disease with complex issues in delivery of care Early referral to palliative care can be helpful in symptom management and potentially enhance quality of life Development of caring relationship can support patient going forward with difficult decisions

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