Dhr. S.
End-stage COPD:
nog naar de IC?
Wat wil de patiënt?
•  78 jaar, weduwnaar
•  COPD GOLD III D, restrictieve component,
ernstige diffusiestoornis
•  Roken 20 jaar geleden gestaakt
•  Pseudomonaskolonisatie
•  OZT 3L continu, 5L bij inspanning, forse
desaturatie bij inspanning
Daisy J.A. Janssen, MD PhD
Dhr. S.
•  Obesitas: BMI 31
•  Osteoporose en 5 wervelinzakkingsfracturen,
chronische rugpijn
•  Myocardinfarct
•  Cardioversie voor atriumflutter
•  mMRC 4
•  CAT-score 34 punten
•  6MWD 170m.
Dhr. S.
•  Woont alleen in woning met aanpassingen,
waaronder traplift
•  Dagelijks thuiszorg
•  Recidiverende ZH-opnames vanwege COPD
•  Nooit beademend, nooit IC
•  Geen beleidsafspraken over reanimatie of
beademing
Advance care planning
Dhr. S. komt morgen voor reguliere
controle.
Wie van u gaat met Dhr. S. spreken over
zijn prognose en behandelvoorkeuren?
% patients with ACP
25
According to physician
According to physician and patient
20
20%
15
16%
10
5
6%
0
COPD
4%
CHF
Janssen et al. Chest 2011
1
Advance care planning
Planning for and about preference-sensitive
decisions often arising at the end of life and
implemented usually by means of effective
patient–provider communication and education.
•
•
•
•
•
goals of care
resuscitation and life support
palliative care
surrogate decision making
living wills and medical directives
Benefits ACP interventions
•  Increased completion of advance directives
•  Increased occurrence of end-of-life care
discussions
•  Improved concordance between preferences
for care and delivered care
•  May improve quality of communication
Patel et al. Respirology 2011
Houben et al. JAMDA 2014
Dhr. S.
•  De volgende ochtend blijkt dhr. S. opgenomen
met exacerbatie en toegenomen respiratoire
insufficiëntie.
•  Arts-assistent heeft op SEH beleidsafspraken
gemaakt: dhr. wenst volledig actief beleid
Vindt u dat een wijs besluit?
Welke informatie zou u meneer geven die
hem kunnen helpen bij zijn
besluitvorming?
Preferences for mechanical
ventilation
Preferences for CPR
4%
2%
26%
28%
yes
yes
70%
no
70%
don't know
n=105
Janssen et al. Chest. 2011
n=105
no
don't know
Janssen et al. Chest. 2011
2
Treatment preferences
1 week hospital
Recovery
95%
1 month hospital
Recovery
83%
1 week hospital
1 week hospital
Bedbound
29%
Memory loss
7%
proportion choosing treatment (%)
Treatment preferences
100
Low-burden, death
80
High-burden, death
60
Low-burden, functional
impairment
Low-burden, cognitive impairment
40
20
0
0
10 20 30 40 50 60 70 80 90 100
Likelihood of adverse outcome (%)
Janssen et al. Chest 2011
Expectation patient survival inhospital CPR
Janssen et al. Chest 2011
COPD patients discharged ICU
n=126 COPD
46% first ICU admission
Nava et al. Int J COPD 2008
12 months outcome ICU COPD
23% died in
hospital
Dhr. S.
•  Dhr. herstelt en wordt weer naar huis
ontslagen
4791 patients
LTOT
45% died in
subsequent 12
months
Schmidt et al. Crit Care Med 2014
67%
readmitted
within 12
months
40% of 3177
pts nursing
home within
12 months
•  Tijdens een polibezoek wilt u nogmaals met
meneer zijn behandelvoorkeuren bespreken, in
aanwezigheid van zijn zoon.
Hajizadeh et al. Thorax 2014
3
Patients’ wishes for ACP
•
•
•
•
Little previous discussion with HCP about COPD.
All aware of progressive and fatal nature.
Consultations with HCP focused on the present.
Most participants wanted more information about
how their disease would progress, and more
discussion about the future.
•  Difficult to raise these discussions themselves,
despite wanting to.
Hoe begint u dit gesprek?
MacPherson et al. Palliat Med 2013
Understanding of Illness
Advance care planning
What do you think will happen
Think about the last time your COPD got so bad that
to you as a result of your COPD
you had trouble breathing.
in the future?
If you were in this situation again, what would you
hope for? What would you be most worried about?
What are your biggest hopes?
What are your greatest fears?
Fried et al. JAMA 2012
Advance care planning
Some patients say that if they became so sick that
they could not recognize or talk to their loved ones,
they would still want all possible treatments to
prolong their life. Other patients say they would
rather have care focused on comfort.
Fried et al. JAMA 2012
Dhr. S.
•  Er wordt een NRNB-beleid afgesproken, wel
bipap.
•  Meneer is een tijd stabiel
•  Wel achteruitgang mobiliteit
•  6 maanden later polibezoek
Which kind of person are you?
Fried et al. JAMA 2012
4
Stability of preferences for CPR
13%
Bespreekt u opnieuw
behandelvoorkeuren?
11%
no change
decreased willingness
62%
14%
increased willingness
variable preference
Janssen et al. Chest 2012
Dhr. S.
Δ
Δ
Δ
Δ
Δ
Health status
Depression
Anxiety
Marital status
Mobility
•  Enkele maanden later wordt meneer opnieuw
opgenomen
•  Respiratoir insufficiënt
•  SEH, verlaagd bewustzijn, gesprek niet
mogelijk
•  Zoon is erbij aanwezig
Patients’ wishes for ACP
Komt u met de zoon nog terug op de
gemaakte beleidsafspraken?
•  Participants wanted to be involved in decisions
about their treatment and to discuss treatment
options.
•  Participants did not want HCP to make decisions
based on previously stated preferences without
reviewing those preferences with them and their
family in the immediate circumstance those
decisions apply to.
MacPherson et al. Palliat Med 2013
5
ACP objective
Take home messages
To have patients make treatment decisions in
advance so that clinicians can attempt to provide
care consistent with their goals.
•  Advance care planning improves outcomes for
The preparation of patients and surrogates to
participate with clinicians in making the best
possible in-the-moment medical decisions.
patients and loved ones
•  Complexity of decision-making
•  Changes in preferences
Sudore et al. Ann Intern Med 2010
6