Management of
End-Stage COPD
Dr Patrick Fitzgerald GPwSI Palliative Care
Sr Doreen O’Hara COPD CNS
End-Stage COPD
 Identification
 Prognostication
 Holistic Assessment
 Pharmacological Management
 Non-pharmacological Management
 Advance Care Planning
IDENTIFICATION AND PROGNOSTICATION
Fig 1 Typical illness trajectories for people with progressive chronic
illness. Adapted from Lynn and Adamson, 2003.7 With permission from
RAND Corporation, Santa Monica, California, USA.
Murray, S. A et al. BMJ 2005;330:1007-1011
Copyright ©2005 BMJ Publishing Group Ltd.
Holistic Assessment
 Physical - How’s things?
 Emotional - What worries do you have?
About the future?
 Personal - How are you coping?
 Social/Spiritual - Do you need any help at home? From
chaplaincy?
 Information/Communication - GP letter/OOH/DNs
Symptom control
Common symptoms include:
 Dyspnoea
 Pain
 Anxiety/Depression
 Fear/Panic
 GI symptoms
 Cachexia and poor nutrition
Dyspnoea
Management
Adapted from: Rocker G et al. Thorax 2009;64:910-915
 Conscious experience arises from the sensory cortex
 If the sensory cortex perceives a mismatch between ventilatory demand and the body's
ability to respond
Treatment
Once all COPD treatment is optimised then 1st line is
immediate-release opiate:
“There is evidence in favour of using oral or injectable
opioid drugs for the palliative treatment of breathlessness”
Cochrane review 2001
 Low dose Oramorph to start eg. 1.25-2.5mg 4 hourly
 Remember: 30mg codeine @ = 3mg morphine
Non-pharmacological
Non-pharmacological interventions Cochrane 2008
 “…interventions can help to relieve shortness of breath:
vibration of patient's chest wall, electrical stimulation of
leg muscles, walking aids and breathing training. Further
interventions identified were counselling and support, either
alone or in combination with relaxation-breathing training,
music, relaxation, a hand-held fan directed at a patient's face,
case management and psychotherapy.
 Reassurance
 Talking though fears
Adjuncts
 Aperients: OPIOIDS ARE ALWAYS CONSTIPATING
 Anti-emetic for first week – which one?
 Benzodiazepines:
“…on the basis of seven included studies… there is no evidence for a
beneficial effect of benzodiazepines in the relief of breathlessness in adults
with advanced disease”Benzodiazepines caused more drowsiness as an
adverse effect compared to placebo, but less compared to morphine.
Cochrane Review 2009
BUT – good for panic of breathlessness?
 Lorazepam 0.5-1mg tds prn: short-acting and sub-lingual formulation
 Steroids
Harry is 82
 Called by daughter to review
 Worsening breathlessness
 Can’t get out of chair
 Frail and upset
 OOH GP visits and wants to send to A&E
 Concern this is exacerbation –
REVERSIBILITY?
Harry gives history slowly
 Chest pain on inspiration
 More breathless past weeks
 Cachectic
 RR 25, p 98, bp 148/89, sats 90% on 24% O2
 Chest - added noises noted - poor air entry
 3 recent admissions to hospital, NIV last time
 Harry wants to stay at home
 Family demand admission as they feel they can’t cope
Harry
Issues
 Harry’s prognosis – what lies ahead?
 Harry's symptoms - what can we do?
 Harry’s wishes – how can we support his choice?
 What would be your management plan?
Advance Care Planning
PPC/PPD/ADRT
 What to record
 Where to record it
 Capacity to make decisions
 Who keeps the document?
 Where do they keep it?
 Who has access?
 EPACCS
COPD Team Stockport
 New Palliative Care MDT
 Patients identified as worsening – GSF type register with plan
of care developing. Interface with EPACCS
 Holistic assessment by Pall Care Team
 Management plan devised between teams
 Aim to support PPC
 Keeping patients where they want to be longer
 Does it stop admission?
 Is it OK to die in hospital?
Key Worker Care Plan
What Care Plan might you make for your COPD patients?
 Think GSF – anticipatory care
 Think PEPSI – holistic assessment
 Think COPD/Palliative Care Teams if symptoms severe –
expert advice
 Think ACP/ADRT – patient choice in future plans
 Think OOH
 Anything else?
Your Questions
Contact me
07715518135
patrick.fitzgerald1@nhs.net
Dr Fitzgerald
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