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1/18/2021 Palliative Care for Patients with Chronic Obstructive Pulmonary Disease: Current Perspectives
Palliative Care for Patients with Chronic Obstructive Pulmonary Disease: Current Perspectives
Anirban Hom Choudhuri
Abstract
Chronic obstructive pulmonary disease (COPD) is a chronic respiratory illness with a myriad of disabling symptoms and a decline in the functional
parameters that affect the quality of life. The mortality and morbidity associated with severe COPD is high and the patients are mostly housebound
and in need of continuous care and support. The uncertain nature of its prognosis makes the commencement of palliative care and discussion of end-
of-life issues difficult even in the advanced stage of the disease. This is often compounded by inadequate communication and counseling with patients
and their relatives. The areas that may improve the quality of care include the management of dyspnea, oxygen therapy, nutritional support,
antianxiety, and antidepressant treatment, and advance care planning. Hence, it is necessary to pursue a holistic care approach for palliative care
services along with disease-specific medical management in all such patients to improve the quality of life in end-stage COPD.
Keywords: Palliative care COPD, End of life issues COPD, Current perspectives COPD
INTRODUCTION
Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease affecting 6–10% of the adult population worldwide and causing
significant mortality and morbidity.[1]
The cause underlying COPD is chronic airflow limitation and destruction of lung parenchyma with raised levels of circulating inflammatory
mediators. The disease is characterized by worsening dyspnea, exercise limitation, and progressive deterioration of health. A majority of the patients
with COPD experience considerable problems arising out of breathlessness leading to immobility, dependency on others, and social isolation.[2] It can
be easily speculated that such patients have their preferences, desires, and demands to lead a better quality of life. There is an immense scope of
palliative medicine in providing good care and improved quality of life in these patients. But the data to guide physicians on how to actually
accomplish this in practice in severe or end-stage COPD are limited. This is quite evident from the updated global initiative on COPD guidelines,[3]
assembled by an expert panel under the auspices of National Heart Lung and Blood Institute and the World Health Organization which does not
include recommendations on providing quality end-of-life care for patients with COPD due to scarcity of data. Nevertheless, some researchers and
clinicians have recognized the need for palliative care and have also outlined its importance in this population.[4–6]
The keywords “Palliative care in COPD” in PUBMED revealed a total of 285 titles and 97 review articles within the search limit of 20 years between
1991 and 2011. Only articles in English were chosen.
PROBLEMS IN SELECTING THE APPROPRIATE BENEFICIARIES OF PALLIATIVE CARE IN COPD

The definition of palliative care adopted by WHO[7] identifies it as “the patient and family centered care that optimizes quality of life by anticipating,
preventing, and treating suffering.” It seeks to address the physical, intellectual, emotional, social, and spiritual needs to facilitate patient autonomy,
access to information, and choice throughout the continuum of disease. In contrast, “end of life” care focuses on caring for the patient and his or her
family only during the final stages of the life. Therefore, although the terms “palliative care” and “end of life” care may sound synonymous, the
former has a much broader meaning and involves comprehensive care more than what is just required for improving the quality of life whereas “end
of life” care focuses only on the final stage of the disease which may be days, weeks, or months before death depending on the illness. It is important
to realize this difference in the context of COPD, where it may be difficult to institute “end of life” care early but not palliative care.[8]
The disagreement among medical professionals in identifying the suitable patients for palliative care in COPD is equivocal[9,10] and this can be
explained from the concept of illness trajectories. The concept of illness trajectories describe three recognizable patterns of function and well-being in
diseases[11]: (i) diseases with a high level of function and a short period of decline, e.g., cancer; (ii) diseases with a long-term limitation of function
with intermittent serious episodes requiring emergency admissions, e.g., organ system failure; (iii) diseases with low-level functioning and a
prolonged decline with associated problems, e.g., stroke, dementia. The physical, social, and psychological needs of the patients vary considerably
according to the type of disease trajectory. COPD fits into the second class of trajectory being characterized by declining functions with acute
exacerbations. The reasons for disagreement among medical professionals in deciding suitability of COPD patients for palliative care are these
multiple “entry–reentry” trajectories in COPD. The “entry–reentry” trajectories involve episodic, acute exacerbations requiring frequent
hospitalization followed by stabilization. This often masks the steady decline of a patient's condition making referral for palliative care difficult.
Also, unlike the terminally ill cancer patients, there are no prognostic tools to aid clinicians in assessing the survival in COPD. Since there is a strong
co-relation between the end-of-life care and actual life expectancy, there is a need is to develop some reliable prognostic estimates for COPD. This can
identify the patients who are terminally ill and can be maximally benefited from end-of-life care [Table 1].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3401737/ 1/6
Table 1
Summary of some of the potential barriers of palliative care in patients with advanced chronic obstructive pulmonary disease
However, the concept of “prognostic paralysis”[12] urges the clinicians to institute patient-centered active treatment and supportive care along with
discussions on end-of-life issues when faced with illnesses with uncertain trajectories. If we consider COPD as an illness with some features of
uncertain trajectories, we can apply this concept to institute palliative care at some stages of the illness.
POOR PROGNOSTIC FACTORS IN COPD

The established factors for poor prognosis in COPD patients include reduced pulmonary function (FEV1 <30%), arterial blood gas measures, and cor
pulmonale with pulmonary hypertension. However, several other factors like dyspnea, muscle mass, health status, and exercise capacity are also
believed to be of prognostic value. The MRC dyspnea scale[13] which is actually used for respiratory trauma has been found to be more
discriminatory than FEV1 in the assessment of disease severity and survival in COPD [Table 2].[14]
Table 2
MRC dyspnea scale[13]
Hence, the level of dyspnea can be a useful adjunct to FEV1 in assessing the need for palliative care in COPD patients. Some studies have shown that
the systemic measures of change in health status and exercise capacity may be important functional parameters for the multifactor evaluation of COPD
patients.[15] The information collected on the causes of death in COPD patients has shown that about 30% deaths are due to acute chronic respiratory
failure, 15% due to heart failure, and the remaining due to pulmonary infection, pulmonary embolism, cardiac arrhythmia, and lung cancer.[16] The
mortality rate is particularly high for older patients who have frequent exacerbations of COPD and chronic respiratory failure with maximum
symptom burden in the last 6 months of life.[17] The 6-year mortality of patients with acute exacerbation of COPD is very high (at 6 years roughly
15% remain alive) and is influenced by the pre-ICU admission quality of life.[18] The early institution of palliative care can no doubt improve the
quality of life in patients with poor prognosis.
ELEMENTS OF EFFECTIVE PALLIATIVE CARE

The aim of palliative care in COPD patients is to reduce symptoms, improve quality of life, and increase participation in day-to-day activities. This
can be achieved in the following ways:
a. Management of dyspnea
b. Oxygen therapy
c. Nutritional support
d. Antianxiety and antidepressants
e. Advance care planning
Management of dyspnea
In majority of patients with end-stage COPD, the dyspnea becomes refractory to medications. However, a combination of long-acting beta agonist, an
inhaled steroid and a long-acting anticholinergic may be useful in them. It is believed that long-acting bronchodilators are more effective and
convenient than short-acting bronchodilators though they are a bit more expensive [Table 3].[19]
Table 3
Various drugs and their combinations available for the use of chronic obstructive pulmonary disease patients
The principal bronchodilators of the benefit for such patients are the beta-2 antagonists, methylxanthines and anticholinergics. But although the
methylxanthines are useful for reducing exacerbations of COPD, their therapeutic index is low and they cannot be administered in aerosol form. The
aerosol administration of bronchodilators is most effective for decreasing the airway resistance, work of breathing, and alleviating breathlessness.
Hence, a combination of beta-2 antagonist and anticholinergic or beta-2 antagonist with a glucocorticoid is the preferred choice in COPD.
Oxygen therapy
Although conclusive evidence is lacking on several issues, supplemental oxygen therapy allows COPD patients to tolerate higher levels of exercise
activity with fewer exertional symptoms and an overall improvement in the quality of life. Metouska et al.[20] and Tarpy et al.[21] had found that
long-term oxygen therapy when administered to hypoxemic COPD patients for more than 15 h/day increases the survival [Table 4].
Table 4
Several studies where some benefits were seen and some studies where no benefit was seen with oxygen therapy in end-stage chronic
obstructive pulmonary disease patients
It is apparent from the studies that there are enough evidences supporting long-term oxygen therapy in hypoxemic COPD patients for improving their
exercise capacity but the benefits of short-burst oxygen therapy are limited.
Nutritional support
The resting energy expenditure (REE) is raised in COPD patients in comparison to the healthy subjects due to increased work of breathing and the
frequent hospitalizations associated with episodes of acute exacerbations produce a state of negative energy balance. This makes nutritional support an
important aspect of palliative care in these patients. It has been seen that weight loss and skeletal muscle mass are strong predictors of mortality risk in
COPD, independent of the severity of airflow limitation.[27] In a study[28] which investigated the dietary problems in patients with severe COPD, it
was found that anorexia, dyspeptic symptoms other than diarrhea, and fear of gaining weight were quite frequent in these patients [Table 5].
Table 5
Some factors which can precipitate nutritional deficiencies in patients with chronic obstructive pulmonary disease
The administration of nutritional supplements containing high carbohydrate, protein, and less fat resulted in a significant improvement in body weight,
handgrip strength, decreased airflow limitation and quality of life.[29] Many studies have highlighted the benefits of the supplementation of anabolic
steroids, growth hormone, and testosterone for such patients but many others have shown disappointing results.[30,31]
Antianxiety and antidepressants

Both anxiety and depression are commonly seen in COPD patients.[32,33] It has also been noticed that depressive symptoms are associated with
increased risk for 3-year mortality[34] and longer stay, persistent smoking, increased symptom burden, and poorer physical and social functioning.[35]
In patients with moderate to severe symptoms of depression and anxiety, cognitive behavioral therapy (CBT) and COPD education have been found to
achieve significant improvement in the quality of life,[36] which emphasizes the need for integrating mental health care into the overall treatment
regime for COPD.
The success of pharmacological treatment for anxiety and depression in COPD has been very little. It is important to distinguish true anxiety disorders
in COPD from anxiety and panic states associated with the side effects of beta-2 agonists and high dose of corticosteroids before starting any
medication.
The patient acceptance of fluoxetine for depression in COPD is poor and often leads to chronicity.[37]
Since the benzodiazepines can precipitate severe hypercapnea, their use should be restricted in these patients. One study[38] had found a significant
decrease in anxiety and dyspnea in COPD patients treated with buspirone but the time to achieve peak therapeutic effect was high (4–6 weeks).
Similar beneficial effects have been also observed with sertraline.[39]
However, no studies have so far elucidated the long-term effects of anxiety treatment on the quality of life in COPD patients. More studies are
required to understand the effective treatments of anxiety and depression in COPD patients.
Advance care planning

The integration of palliative care early in the disease along with disease-specific therapy for COPD falls within the ambit of advance care planning.
This not only provides a platform for coordinating integrated services but also improves patient satisfaction and functional capacities. In one study[40]
which sought to find out the barriers and facilitators of advance care planning in COPD patients, only 32% patients reported having a discussion about
end-of-life care with their physician. The two most common barriers that patients faced were what care they would need and what kind of doctors
would cater to those needs. However, further researches are expected to elaborate on which specific areas of communication can be more effectively
targeted through advance care planning.[40,41]
CONCLUSION
COPD has a long, chronic course with a high level of symptom burden with a considerable psychosocial impact on the patient and his family
members. The disease management should be shared between the primary physician and the palliative care physician from an early stage to facilitate
smooth transition from active treatment stage to palliative care stage. The progressive deterioration of health and respiratory functions with frequent
exacerbations requiring hospitalization and the need for long-term oxygen therapy suggest the arrival of the stage of palliative care. It is important to
reach out to the patient and his family members at an early stage through proper communication and understand their concerns and wishes about
future care.[41]
All these can make the management of this life-threatening, noncancer illness much easier and pave the way for an improvement in the end-of-life
care.
Footnotes
Source of Support: Nil.
Con ict of Interest: None declared.
Article information
Indian J Palliat Care. 2012 Jan-Apr; 18(1): 6–11.
doi: 10.4103/0973-1075.97342
PMCID: PMC3401737
PMID: 22837604
Anirban Hom Choudhuri
Department of Anesthesiology and Intensive Care, GB Pant Hospital, New Delhi, India
Address for correspondence: Dr. Anirban Hom Choudhuri; E-mail: anirbanhc@redi mail.com
Copyright : © Indian Journal of Palliative Care

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Articles from Indian Journal of Palliative Care are provided here courtesy of Wolters Kluwer -- Medknow Publications
REFERENCES
1. Mannino DM, Buist S. Global burden of COPD: Risk factors, prevalence, and future trends. Lancet. 2007;370:765–73. [PubMed] [Google Scholar]
2. Elkington H, White P, Addington-Hall J, Higgs R, Pettinari C. The last year of life of COPD: A qualitative study of symptoms and services. Respir Med.
2004;98:439–45. [PubMed] [Google Scholar]
3. Gold PM. The 2007 Gold Guidelines: A comprehensive care framework. Respir Care. 2009;54:1040–49. [PubMed] [Google Scholar]
4. Murray SA, Pinnock H, Sheikh A. Palliative Care for people with COPD: We need to meet the challenge. Prim Care Resp J. 2006;15:362–4.
[PMC free article] [PubMed] [Google Scholar]
5. O’Kelly N, Smith J. Palliative care for patients with end-stage COPD (letter) Prim Care Resp J. 2007;16:57–8. [PMC free article] [PubMed] [Google Scholar]
6. Goodridge D. People with chronic obstructive lung disease at the end-of-life: A review of literature. Int J Palliat Nurs. 2006;12:390–6. [PubMed]
[Google Scholar]
7. National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for quality palliative care, executive summary. J Palliat Med.
8. Curtis JR. Palliative and end-of-life care for patients with severe COPD. Eur Respir J. 2008;32:796–803. [PubMed] [Google Scholar]
9. Farquhar M, Grande G, Todd C, Barclay S. Defining patients as palliative: Hospital doctors’ versus general practitioners’ perceptions. Palliative Med.
10. Christakis NA, Lamont EB. Extent and determinants of error in doctors’ prognosis in terminally ill patients: Prospective cohort study. BMJ. 2000;320:469–
72. [PMC free article] [PubMed] [Google Scholar]
11. Lynn J. Perspectives on care at the close of life. Serving patients who may die soon and their families: The role of hospice and other services. JAMA.
12. Stewart S, McMurray JJ. Palliative care for heart failure. BMJ. 2002;325:915–6. [PMC free article] [PubMed] [Google Scholar]
13. Stenton C. The MRC Breathlessness Scale. Occup Med (Lond) 2008;58:226–7. [PubMed] [Google Scholar]
14. Glare P, Christakis N. Predicting survival in patients with advanced disease. In: Doyle D, Hanks G, Cherny N, Calman K, editors. Oxford Textbook of
Palliative Medicine. 3rd ed. Oxford: Oxford University Press; 2004. pp. 29–42. [Google Scholar]
15. Oga T, Nishimura K, Tsukino M, Sato S, Hajro T. Analysis of the factors related to mortality in chronic obstructive pulmonary disease. Role of exercise
capacity and health status. Am J Respir Crit Care Med. 2003;167:544–9. [PubMed] [Google Scholar]
16. Frostad A, Soyseth V, Haldorsen T, Andersen A, Gulsvik A. Respiratory symptoms and 30 year mortality from obstructive lung disease and pneumonia.
Thorax. 2006;61:951–6. [PMC free article] [PubMed] [Google Scholar]
17. Groenewegen KH, Schols AM, Wouters EF. Mortality and mortality-related factors after hospitalization for acute exacerbation of COPD. Chest.
18. Rivera-Fernandez R, Navarrete-Navarro P, Fernandez-Mondejar E, Rodriguez-Elvira M, Guerrero-Lopez F, Vazquez-Mata G. Project for the
epidemiological analysis of the critical care patients (PAEEC) group. Six-year mortality and quality of life in critically ill patients with chronic obstructive
pulmonary disease. Crit Care Med. 2006;34:2317–24. [PubMed] [Google Scholar]
19. Vincken W, van Noord JA, Greefhorst AP. Improved health outcomes in patients with COPD during 1 years treatment with tiotropium. Eur Respir J.
20. Mitrouska I, Tzanakis N, Siafakas NM. Siafakas NM, editor. Oxygen therapy in chronic obstructive pulmonary disease. Management of chronic obstructive
pulmonary disease. Eur Respir Mon. 2006;38:302–12. [Google Scholar]
21. Tarpy SP, Celli BR. Long term oxygen therapy. N Engl J Med. 1995;333:710–4. [PubMed] [Google Scholar]
22. Emtner M, Porszasz J, Burns M, Somfay A, Casaburi R. Benefits of supplemental oxygen in exercise training in non hypoxemic chronic obstructive
pulmonary disease patients. Am J Respir Crit Care Med. 2003;168:1034–42. [PubMed] [Google Scholar]
23. van Helvoort HA, Heijdra YF, Heunks LM, Meijer PL, Ruitenbeek W, Thijs HM, et al. Supplemental oxygen prevents exercise-induced oxidative stress in
muscle-wasted patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2006;173:1122–9. [PubMed] [Google Scholar]
24. Nonoyama M, Brooks D, Lacasse Y, Guyatt G, Goldstein R. Oxygen therapy during exercise training in chronic obstructive pulmonary disease. Cochrane
Database Syst Rev. 2007;2:CD005372. [PubMed] [Google Scholar]
25. Croxton TL, Bailey WC for the NHLBI Working Group on Long Term Oxygen Treatment in COPD. Long-term oxygen treatment in chronic obstructive
pulmonary disease: Recommendations for future research. An NHLBI Workshop Report. Am J Respir Crit Care Med. 2006;174:373–8. [PMC free article]
[PubMed] [Google Scholar]
26. Bradley JM, Lasserson T, Elborn S, MacMohan J, O’Neill B. A systematic review of randomized controlled trials examining the short-term benefit of
ambulatory oxygen in COPD. Chest. 2007;131:278–85. [PubMed] [Google Scholar]
27. Marquis K, Debigare R, Lacasse Y, LeBlanc P, Jobin J, Carrier G, et al. Midthigh muscle cross-sectional area is a better predictor of mortality than body
mass index in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2002;166:809–13. [PubMed] [Google Scholar]
28. Gronberg AM, Slinde F, Engstrom CP, Hulthen L, Larsson S. Dietary problems in patients with severe chronic obstructive pulmonary disease. J Hum Nutr
Diet. 2005;18:445–52. [PubMed] [Google Scholar]
29. Planas M, Alvarez J, Garcia-Peres PA, de la Cuerda C, de Lucas P, Castellà M, et al. Nutritional support and quality of life in stable chronic obstructive
pulmonary disease (COPD) patients. Clin Nutr. 2005;24:433–41. [PubMed] [Google Scholar]
30. Schools AM, Soeters PB, Mostert R, Pluymers RJ, Wouters EF. Physiologic effects of nutritional support and anabolic steroids in patients with chronic
obstructive pulmonary disease. Am J respire Crit Care Med. 1995;152:1268–74. [PubMed] [Google Scholar]
31. Burdet L, de Muralt B, Schutz Y, Pichard C, Fitting JW. Administration of growth hormone to underweight patients with chronic obstructive pulmonary
disease. A prospective, randomized controlled study. Am J Respir Crit Care Med. 1997;156:1800–6. [PubMed] [Google Scholar]
32. Peveler R, Carson A, Rodin G. Depression in medical patients. BMJ. 2002;325:149–52. [PMC free article] [PubMed] [Google Scholar]
33. Wagena EJ, Arrindell WA, Wouters EF, van Schaysck CP. Are patients with COPD psychologically distressed? Eur Respir J. 2005;26:242–8. [PubMed]
[Google Scholar]
34. Fan VS, Ramsey SD, Giardino ND, Make BJ, Emery CF, Diaz PT, et al. Sex, depression and risk of hospitalization and mortality in chronic obstructive
pulmonary disease. Arch Intern Med. 2007;167:2345–53. [PubMed] [Google Scholar]
35. Ng TP, Niti M, Tan WC, Cao Z, Ong KC, Eng P. Depressive symptoms and chronic obstructive pulmonary disease: Effect on mortality, hospital
readmission, symptom burden, functional status and quality of life. Arch Intern Med. 2007;167:60–7. [PubMed] [Google Scholar]
36. Kunik ME, Veazey C, Cully JA, Souchek J, Graham DP, Hopko D, et al. COPD education and cognitive behavioral therapy for clinically significant
symptoms of depression and anxiety in COPD patients: A randomized controlled trial. Psychol Med. 2008;38:385–96. [PubMed] [Google Scholar]
37. Yohannes AM, Connolly MJ, Baldwin RC. A feasibility of antidepressant drug therapy in depressed elderly patients with chronic obstructive pulmonary
disease. Int J Geriatr Psychiatry. 2001;16:451–4. [PubMed] [Google Scholar]
38. Argyropoulou P, Patakas D, Koukou A, Vasiliadis P, Georgopoulos D. Buspirone effect on breathlessness and exercise performance in patients with chronic
obstructive pulmonary disease. Respiration. 1993;60:216–20. [PubMed] [Google Scholar]
39. Smoller JW, Pollack MH, Systrom D, Kradin RL. Sertraline effects on dyspnea in patients with obstructive airways disease. Psychosomatics. 1998;39:24–9.
[PubMed] [Google Scholar]
40. Knauft E, Nielsen EL, Engelberg RA, Patrick DL, Curtis JR. Barriers and Facilitators to end-of-life care communication for patients with COPD. Chest.
41. Curtis JR, Engelberg RA, Wenrich MD, Au DH. Communication about palliative care for patients with chronic obstructive pulmonary disease. J Palliat
Care. 2005;21:157–64. [PubMed] [Google Scholar]

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1/18/2021 Palliative Care for Patients with Chronic Obstructive Pulmonary Disease: Current Perspectives

PROBLEMS IN SELECTING THE APPROPRIATE BENEFICIARIES OF PALLIATIVE CARE IN COPD

POOR PROGNOSTIC FACTORS IN COPD

ELEMENTS OF EFFECTIVE PALLIATIVE CARE

d. Antianxiety and antidepressants

e. Advance care planning

Antianxiety and antidepressants

Advance care planning

Con ict of Interest: None declared.

Anirban Hom Choudhuri

Copyright : © Indian Journal of Palliative Care

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