COPD: Disease Trajectory and Hospice Eligibility Terri L. Maxwell PhD, APRN VP, Strategic Initiatives Weatherbee Resources Hospice Education Network Course Handouts & Disclosure To download presentation handouts, click on the attachment icon Presenter discloses no financial relationships with a commercial entity producing healthcare-related products and/or services. Conflict of interest disclosure and resolution statement is on file with HEN. This presentation is for educational and informational purposes only. It is not intended to provide legal, technical or other professional services or advice. Learning Objectives List the stages and clinical course of COPD State symptoms experienced by patients with COPD Identify secondary and co-morbid conditions commonly associated with COPD Explain end-of-life issues experienced by COPD patients and their caregivers Describe the basic management and treatment of COPD Name the clinical data points necessary to substantiate hospice eligibility for patients with COPD 1
Chronic Obstructive Pulmonary Disease (COPD) Respiratory disorder characterized by chronic airway obstruction and lung hyperinflation 12 million diagnosed with COPD 4 th leading cause of death in the US Death rate for COPD has doubled over past 30 yrs, largely due to exposure to tobacco smoke and is expected to climb to 3 rd by 2020 Jemal, Ward, Hao, Thun. JAMA. 2006, 295(4): 393-394. Key Attributes of COPD 1. Airway obstruction 2. Not fully reversible 3. Progressive disease that generally worsens over time, even with treatment 4. Abnormal inflammatory response Celli BR et al. Eur Respir J. 2004;23:932-946. Pathophysiology of COPD Small airway disease Airway inflammation Airway remodeling Parenchymal destruction Loss of alveolar attachments Decrease of elastic recoil 2
Factors Determining COPD Severity Degree of symptoms Frequency and severity of exacerbations Presence of co-morbidities that can lead to complications General health status Number of medications needed to manage disease Severity of spirometric abnormality/airflow limitation Severity of airflow obstruction COPD Severity Mild 50-80% Moderate 30-40% Severe <30% FEV1 % Predicted Spirometry is the gold standard for diagnosing COPD; severity is measured by FEV 1 Note: FEV= Forced Expiratory Volume Spirometry: Normal vs COPD 3
Stages of COPD Stage I: Mild COPD: FEV 1 /FVC < 0.70; FEV 1 80% predicted. Patient unaware lung function is abnormal Stage II: Moderate COPD: FEV 1 /FVC < 0.70; 50% FEV 1 < 80% predicted. Patient typically seeks medical attention because of pulmonary symptoms Adapted from GOLD Guidelines, 2007 Stages of COPD (cont d) Stage III: Severe COPD: FEV 1 /FVC < 0.70; 30% FEV 1 < 50% predicted. Greater shortness of breath, reduced exercise tolerance, decreased quality of life Stage IV: Very Severe COPD: FEV 1 /FVC < 0.70; 30% FEV 1 < 50% predicted plus the presence of chronic respiratory failure. May have signs of cor pulmonale and usually oxygen dependent. Adapted from GOLD Guidelines, 2007 2 Natural History of COPD FEV 1 <70- dyspnea with exercise FEV 1 <45- Exacerbations/ hospitalizations/dsypnea with ADLs FEV 1 <30- Systemic effects/dyspnea at rest/respiratory failure 4
COPD and Co-morbid Conditions Common co-morbids: Cardiovascular disease Lung cancer Osteoporosis Musculoskeletal disorders Depression/anxiety Obesity/type II diabetes Systemic Effects of COPD Peptic ulceration Lung infections/lung cancer Weight loss/muscle wasting and weakness Osteoporosis Depression NOTE: If caused by the COPD, these could be considered secondary (RELATED) conditions. COPD Signs & Symptoms Dyspnea Wheezing Cough Hypoxemia and rising CO2 levels Pulmonary hypertension that may progress to right ventricular hypertrophy and cor pulmonale (right-sided heart failure) 5
Acute COPD Exacerbation Definition: Sustained worsening of symptoms from patient s usual condition; acute in onset Symptoms Increased shortness of breath Increased sputum production and/or increase in purulence Increase cough Increased wheeze/chest tightness Decreased exercise tolerance Increased fatigue Altered mental status NICE GUIDELINES 2004 Therapy at Each Stage of COPD I: Mild II: Moderate III: Severe IV: Very Severe FEV 1 /FVC < 70% FEV 1 > 80% predicted FEV 1 /FVC < 70% 50% < FEV 1 < 80% predicted FEV 1 /FVC < 70% 30% < FEV 1 < 50% predicted FEV 1 /FVC < 70% FEV 1 < 30% predicted or FEV 1 < 50% predicted plus chronic respiratory failure Active reduction of risk factor(s); influenza vaccination Add short-acting bronchodilator (when needed) Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations Adapted from GOLD Guidelines. http://www.goldcopd.com/guidelineitem.asp? l1=2&l2=1&intid=989 Add long term oxygen if chronic respiratory failure. Consider surgical treatments Management of COPD Stage IV: Very Severe COPD Characteristics Treatment FEV 1 /FVC < 70% FEV 1 < 30% predicted or FEV 1 < 50% predicted plus chronic respiratory failure Adapted from GOLD Guidelines, 2007 Recommended Short-acting bronchodilator as needed Regular treatment with one or more LA bronchodilators Inhaled glucocorticosteroids if repeated exacerbations Treat complications Rehabilitation Long-term O2 therapy if respiratory failure Consider surgical options 6
Advanced COPD Management Long-acting and short-acting bronchodilators (albuterol) Anticholinergics (ipatropium bromide or tiotropium) Methylxanthines (theophylline) Combination inhaled therapies (formoterol/budesonide) Inhaled corticosteroids- note: long term oral steroids are not recommended; however, 7-10 day course of prednisone may be helpful for exacerbations Adapted from GOLD Standards, 2007 Management of Advanced COPD (cont d) Antibiotics reserved to treat infections; do not use prophylactically Opioids oral and parenteral (not nebulized) to treat dyspnea Anxiolytics helpful in managing anxiety associated with dyspnea Oxygen therapy should be worn 15 hrs or > per day for greatest benefit End of Life Issues Prognosis is difficult to predict Palliative care should be based upon patient symptoms and functional status Frequent exacerbations requiring trips to the ED and/or hospitalizations Patients and family members frequently do not comprehend the terminal nature of the illness Lack of communication and advanced care planning Isolation/depression/anxiety 7
Signs that Patient Requires Palliative Care FEV1 < 30% predicted History of 2 or more exacerbations in past year Frequent hospitalizations Progressive shortening of intervals between admissions Limited improvement after hospitalization Supporting Indicators Declining functional status/homebound Presence of co-morbidities such as heart failure or diabetes On maximum therapy and dependence on oxygen LCD Guidelines for Hospice Eligibility and Recertification for COPD NGS LCD Number L25678 CGS LCD Number L32015 NHIC LCD Number L29881 8
Non-disease Specific Guidelines Both A & B must be met: A. Impaired functional status- KPS <70 or PPS <70 B. Dependence on assistance for 2 or > ADLs C. Presence of co-morbidities that contribute to disease burden HF Diabetes Dementia, etc. Disease Specific Guideline: Pulmonary Disease 1. Severe chronic lung disease as documented by both a and b: a. Disabling dyspnea at rest, poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity, e.g., bed-to-chair existence, fatigue, and cough. (Documentation of FEV1, after bronchodilator, less than 30% of predicted is objective evidence for disabling dyspnea, but is not necessary to obtain.) Pulmonary, Cont d. b. Progression of end stage pulmonary disease, as evidenced by: increasing visits to the emergency department or hospitalizations for pulmonary infections and/or respiratory failure or increasing physician home visits prior to initial certification. (Documentation of serial decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain.) 9
Pulmonary, Cont d. 2. Hypoxemia at rest on room air as evidenced by: po2 less than or equal to 55 mmhg; or oxygen saturation less than or equal to 88%; or hypercapnia as evidenced by pco2 greater than or equal to 50mmHg. (These values may be obtained from recent [within 3 months] hospital records.) Pulmonary (supportive) 3. Cor pulmonale (right heart failure) secondary to pulmonary disease (e.g., not secondary to left heart disease or valve disease) 4. Unintentional progressive weight loss of greater than 10% of body weight over the preceding 6 months 5. Resting tachycardia >100/min Establishing, Evaluating, and Explaining Eligibility Based upon Burden of Illness in COPD 10
Assessing and Documenting Disease Burden in COPD Sustained tachypnea (RR>30 breaths/min) Sustained tachycardia (RR>100 beats/min) O2 saturation <88% on room air or patient s usual supplemental oxygen Hypotension <100mm Hg or 20% lower than patient s usual Severe impairment of ADLs ADL Documentation Describe: How much caregiver support? None Minimal Moderate Total Time-to-completion of tasks Assessing and Documenting Disease Burden in COPD Inability to speak in full sentences Sustained use of accessory muscles of respiration at rest Decreased ability to eat or sleep due to respiratory distress Repeated lung infections/courses of antibiotic therapy Hemoptysis/increased sputum production/cough 11
Assessing and Documenting Disease Burden in COPD Sustained increase in patient s usual degree of dyspnea Medication changesaddition or titration of opioids, anxiolytics, etc. Altered mental statuslethargy, confusion Increased caregiver stress/burden Documentation example Patient is now completely bed-bound and is having new episodes of urinary incontinence. Caregiver providing maximal assist with all ADLs. Pt now severely dyspneic with minimal activity, including trying to speak. Sleeping on avg 18/24 hrs per day. Po intake reduced due to coughing/choking episodes. Using MSO4 q 4 ATC with moderate relief. Conclusion COPD is the 4 th leading non-cancer diagnosis in hospice Although irreversible and progressive, COPD prognosis is difficult to predict Hospice eligibility based on pulmonary function (FEV 1 ), degree of hypoxemia, dyspnea unresponsive to therapy, functional status, recent ED/hospitalization/physician visits for recurrent infections, or respiratory failure Initial and ongoing comprehensive patient assessment with documentation is necessary for enrollment and recertification 12
References 1. Jemal, Ward, Hao, Thun. Trends in the leading causes of death in the United States, 1970-2002. JAMA. 2006, 295(4): 393-394. 2. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2007). www.goldcopd.com 3. Poole, PJ, Veale, AG, Black, PN. The effect of sustained-release morphine on breathlessness and quality of life in severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998: 157: 1877-80. Course Evaluation & Post Test Thank you for viewing this course on the Hospice Education Network The course evaluation and post test are available from your course catalog page Thank You! Terri Maxwell PhD, APRN VP, Strategic Initiatives Weatherbee Resources Inc. & Hospice Education Network tmaxwell@weatherbeeresources.com 13