National Hospice and Palliative Care Organization’s Palliative Care Resource Series

1. National Hospice and Palliative Care Organization’sPalliative 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. DISEASE MANAGEMENT • Invasive Strategies • 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