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Palliative care and COPD

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Palliative care and COPD Powered By Docstoc
					Palliative/ Supportive
Care in COPD, Key
Issues
Dawn Weston – Lead Public Health Nurse,
Respiratory Conditions

Margaret Mc Sloy – Respiratory Specialist
Nurse
Aims and Objectives
To understand the palliative care issues of
  patients with Chronic Obstructive
  Pulmonary Disease, especially in relation
  to;
 The identification of end stage disease.
 Specific symptom management
 Specific ethical considerations
 Specific palliative care challenges


A whistle stop tour!
Introduction

COPD is the UK’s fifth biggest killer
  disease, claiming more lives than
  breast, bowel or prostate cancer.
On average 15% of those admitted to
  hospital with COPD die within three
  months
50% die within two years
The Three Triggers for
Supportive/Palliative Care

1.   The Surprise question
2.   Choice/ need
3.   Clinical indicators



           Gold standards framework programme (2006)
Clinical Indicators/ General

 Multiple co-morbities
 Weight loss, 10% over 6 months
 General physical decline
 Serum Albumin < 25g/l
 Reducing performance status, < 50%
  dependence in most ADLs

           Gold standards framework programme (2006)
Specific Clinical Indicators
Disease assessed to be severe e.g. FEV1 < 30% of
   predicted
Recurrent hospital admissions >3 admissions in 12
   months
Fulfils LTOT criteria
MRC grade 4-5
Signs and symptoms of right sided heart failure
Combination of other factors e.g. anorexia previous
   ITU/NIV/resistant organism, depression

                       Gold standards framework programme (2006)
Common distressing COPD
symptoms
 Dyspnoea
 Anxiety

 Cough

 Confusion

 Depression

 Anorexia/cachexia
Specific symptom
management
   Breathlessness
            Non-pharmacological
            Pharmacological

 Cough
 Sputum

 Psychological issues
Breathlessness

Non Pharmacological
 Anxiety management
 Breathing control
 Fan
 Occupational therapy- adaptations etc
 Physiotherapy
 Complementary therapy
 Positioning
Breathlessness

Pharmacological

 Inhaled/ nebulised bronchodilators
 Nebulised sodium chloride 0.9%

 Benzodiazepines

 Opiates

 Oxygen
Benzodiazepines

Sublingual Lorazepam
500mcg- 1mg PRN max 4mg daily

Diazepam
2mg- 5mg PRN to max TDS
Opiates

Oral morphine solution (10mg/5ml)
Commence at low dose 2.5mg
  QDS+PRN as needed up to 3-4 hourly
Titrate upwards every 48 hours as
  needed and tolerated
Cough

 If difficulty expectorating – nebulised
  Sodium Chloride 0.9% (evidence
  anecdotal)
 Physiotherapy

 Symptomatic relief – Simple linctus

 Cough suppressants e.g. Codeine
  Linctus or Morphine
Sputum

Exclude infection
 Encourage fluids

 Physiotherapy

 Mucolytics e.g. Carbocisteine,
  Mecysteine
 Nebulised Sodium Chloride 0.9%
Psychological Issues

 Pharmacological - consider
  Anxiolytics, Antidepressants, NRT,
  night sedation
 Consider referral to mental health
  services
 Cognitive behaviour therapy
Specific Ethical
Considerations
 To treat or not to treat
        e.g. NIV therapy, antibiotics
 Opiates and anxiolytics

 Wariness of HCP discussing
  prognosis/ end of life issues
 Attitudes by HCP towards people who
  continue smoke?
Challenges

 Experience in primary care
 Communication

 Co-ordination of services

 Documentation issues

 Availability of resources e.g.
  psychological support
 Equitable service
One Final Thought…..


Never deprive someone of hope; it
 might be all they have.



               H. Jackson Brown Jr.
Discussion



The way forward………
The Gold Standards
Framework – 7 Key Tasks

C1 – Communication
C2 – Co-ordination
C3 – Control of symptoms
C4 – Continuity out of hours
C5 – Continued learning
C6 – Carer support
C7 – Care of the dying

				
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