Palliative care for patients with chronic obstructive pulmonary disease

The preferences of patients with chronic obstructive pulmonary disease are to discuss palliative care plans with familiar respiratory clinicians, but to delay conversations until their condition deteriorates: A study guided by interpretative phenomenological analysis

BACKGROUND

Chronic obstructive pulmonary disease is associated with an uncertain trajectory, which challenges prognostication and means that most patients are not involved in advance care planning and do not receive palliative and end-of-life care.

AIM

To understand the preferences of patients with chronic obstructive pulmonary disease for discussions about palliative and advance care planning with clinicians.

DESIGN

Semi-structured interviews were conducted with patients with chronic obstructive pulmonary disease. Data analysis was guided by principles of interpretative phenomenological analysis, of which symbolic interactionism and interpretation principles were employed throughout.

SETTING/PARTICIPANTS

A total of 33 British patients with chronic obstructive pulmonary disease at different stages of their disease trajectory were recruited.

RESULTS

Patients preferred to discuss palliative care with clinicians they perceived had greater levels of competency and authority in care and with whom they had an established relationship, usually a specialist. Patients favoured large amounts of information about treatments and care, but reported a lack of illness-related information and problems accessing appointments with clinicians. Consequently, patients deferred discussions to the future, usually once their condition had deteriorated significantly or planned to wait for clinicians to initiate conversations. This was not rooted in patient preferences, but related to clinicians' lack of time, absence of an established relationship and belief that appointments were for managing current symptoms, exacerbations and disease factors rather than future care and preferences.

CONCLUSION

Different perceptions, competing priorities and service rationing inhibit patients from initiating early discussions with clinicians, so palliative care conversations should be initiated by respiratory-expert clinicians who know the patient well. After a sudden deterioration in the patient's condition may be a suitable time.

Noninvasive ventilation as ceiling of therapy in end-stage chronic obstructive pulmonary disease

The benefits of noninvasive ventilation (NIV) for acute hypercapnic respiratory failure caused by chronic obstructive pulmonary disease (COPD) are well recognized and consequently its use is widespread. Prognostication in advanced COPD is imperfect, limiting accurate identification of 'end-stage' COPD. Decisions regarding withholding invasive ventilation are largely dependent upon prognostication. In patients where 'invasive' ventilation is not considered to be in their best interests, NIV will be the ceiling of therapy. In this patient group, NIV is extremely valuable in reducing mortality and providing valuable symptomatic benefit. We discuss the use of NIV in the management of an acute exacerbation of 'end-stage' COPD where NIV is the ceiling of therapy, the use of advanced directives and the implications of the Mental Capacity Act 2005 on decisions regarding end-of-life care. We highlight areas where further research would be useful.