1. PALLIATIVE CARE FOR COPD PATIENTS:
National Hospice and Palliative Care Organization’s Palliative Care Resource Series
PALLIATIVE CARE FOR COPD PATIENTS:
PRACTICAL TIPS FOR HOME BASED PROGRAMS
Parag Bharadwaj, MD, AAHPM
Jakrin Kewcharoen, MD
Kenneth Unger, MD, FACP, FCCP, FAAHPM

2. INTRODUCTION
Chronic obstructive pulmonary disease (COPD) is the third leading cause of death and morbidity worldwide. In the United States, it affects 12 to 16 million people
Patients experience deterioration in symptoms and quality of life on a scope similar to those with advanced malignancy
Palliative care intervention provides comfort and optimization of treatment plan and goals

3. OVERVIEW COPD Definition Pathophysiology Clinical Features
Disease Management
Palliative Care in COPD Patients at Home

4. DEFINITION OF HEART FAILURE
COPD is an irreversible chronic progressive disease. It is characterized by persistent airflow limitation associated with an enhanced chronic inflammatory response
The chronic airflow limitation is caused by a mixture of small airways disease (obstructive bronchiolitis) and parenchymal destruction (emphysema)

5. RELEVANT PATHOPHYSIOLOGY
Destruction of the lung parenchyma, also by inflammatory processes, leads to the loss of alveolar attachments to the small airways and decreases lung elastic recoil
Other features of COPD include
Gas trapping during expiration
Gas exchange abnormalities
Mucus hypersecretion
Pulmonary hypertension

6. CLINICAL FEATURES Predominant Symptoms Shortness of Breath
Chronic cough with sputum production
Episodes of acute exacerbation
Pain around the chest and other parts of the body is under diagnosed

7. CLINICAL FEATURES Other Common Signs and Symptoms: Fatigue
Muscle wasting and Cachexia
Sexual Dysfunction
Sleep disturbance

8. DISEASE MANAGEMENT Non-Pharmacological Interventions Smoking Cessation
Regular exercise and physical activities
Pulmonary rehabilitation
Influenza and pneumococcal vaccination

9. DISEASE MANAGEMENT Pharmacological Interventions Bronchodilators
Steroids
Opioids
Benzodiazepines
Mucolytics
Cough suppressants

10. Invasive Strategies DISEASE MANAGEMENT Supplement oxygen BiPAP
Lung volume reduction surgery (LVRS)

11. PALLIATIVE CARE FOR COPD PATIENTS AT HOME
Palliative care aims to increase quality of life of patients and should be a standard offered to patient and family
Delivery of this type of care requires intense planning and care coordination between all involved medical specialties, as well as family, caregivers, and psychosocial support

12. CLINICAL: AREAS OF FOCUS
Symptoms
Assess and address any change in symptoms, such as cough, sputum production, breathlessness, pain and sleep disturbances, since the last visit.
Evaluate exacerbation history
Physical Exam
Vital Signs, especially pulse oximetry

13. CLINICAL: AREAS OF FOCUS
Smoking status
Co-morbidity
Medication
The current therapeutic regimen should be discussed at each visit. Avoid polypharmacy.
Teach and evaluate the proper use of MDIs.

14. ADDITIONAL NEEDS ASSESSMENT: AREAS OF FOCUS
Emotional and Financial Support Screening
Request social worker follow-up, if needed, in addition to routine social worker visits
Spiritual Needs Screening
Request chaplain visit, if needed, in addition to routine chaplain visits
Caregiver Screening
Ensure social worker and chaplain support to caregiver(s)
Monitor for burnout

15. PATIENT GOALS: AREAS OF FOCUS
Care plan and patient goals should be reviewed frequently with the patient and caregiver to ensure the appropriate care is being delivered
Every patient should have an advance directive completed, preferably a POLST (Physician Orders for Life Sustaining Treatment)
Any changes should be promptly reflected in the document
Documents should be readily available to patient, caregiver and paramedics (if called)

16. PATIENT GOALS: AREAS OF FOCUS
Depending on the patient’s clinical status, options and goals should be readdressed on a regular basis
Informing the patient and the caregiver of options, including hospice, is necessary

17. REVIEW AND EDUCATION: AREAS OF FOCUS
Any change in the treatment plan should be carefully discussed with the patient and family. Everything that was discussed at the meeting should be reviewed before the palliative care team leaves the patient’s residence
Ensure that patient and family can contact medical team at all time if needed
Develop an individualized Action Plan to help patients recognize the early symptoms of an exacerbation and to support the patient with an AE until the care team can be reached

18. SUMMARY: LESSONS LEARNED AND BEST PRACTICES
A Plan of Care should be based on the patient’s individualized needs and goals of care.
24/7 access to medical support and advice
Medical providers skilled in medical and psychosocial assessment and in advanced care planning is essential. Including access to respiratory and palliative care medicine expertise

19. SUMMARY: LESSONS LEARNED AND BEST PRACTICES
Patient and caregiver education is extremely important
Regular home visits, with physician assessment when needed
Support for a home environment that is comfortable and safe
An Individualized Action Plan, to support the patient/caregivers, in event of an AE

20. SUMMARY: LESSONS LEARNED AND BEST PRACTICES
Direct hospital admission, bypassing the emergency department, when indicated
Availability of Hospice Care