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By: Laura Mantine, MD
Chronic lung disease is the 4th most common cause of death among older adults in the United States. More than 3 million people worldwide died of COPD in 2015, representing 6% of all deaths that year. People dying from COPD frequently experience difficult and uncomfortable symptoms that lead to distress and panic. They commonly have disabling respiratory symptoms including severe breathlessness, limited tolerance for activity, and intractable coughing. They are also usually oxygen dependent, often experience anorexia with weight loss, cachexia, and ultimately become dependent on others for their activities of daily living.
Despite the symptomatic needs of individuals dying from end-stage COPD, only 30% of individuals receive hospice care before death. It is not clear why the rate of hospice use for patients with COPD is so low, but several explanations have been offered. The most important may be that few patients with severe COPD have discussed end-of-life planning with their clinician. Furthermore, many patients and clinicians do not view COPD as a terminal illness and feel it is more chronic in nature. Also, there may be a lack of awareness that patients enrolled in hospice can continue to receive treatments for COPD. Due to the fluctuating course of COPD, it is often difficult to accurately estimate a patient’s life expectancy which may contribute to low hospice utilization rates.
While end-of-life-care is an appropriate topic to discuss with all patients, several factors have been suggested that should prompt a discussion with patients who have severe COPD. One factor is simply that a clinician would not be surprised if a patient with COPD were to die within the next 6-12 months. A clinician should consider hospice referral in a patient with COPD if they are dyspneic at rest or with minimal exertion, have progressed to the point where they spend most of their days at home, have experienced repeated ED visits (one or more each quarter) due to infection or episodes of respiratory failure, have endured repeated hospitalizations (one or more each quarter) and no longer wish to be admitted and the patient no longer wishes to be intubated.
While these laboratory studies may be helpful to the clinician when considering patient appropriateness for hospice services, they are not required for patient admission.
COPD is a significant health issue around the world. It is ultimately a fatal disease and patients are under-referred to hospice care. Hospice, with its strong interdisciplinary approach, has been shown to improve quality of life for patients with end-stage respiratory disorders like COPD.
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Referral to palliative care in COPD and other chronic diseases: A population-based study. Kim Beernaert; Joachim Cohen; Luc Deliens; Dirk Devroey; Katrien Vanthomme; Koen Pardon; Lieve Van den Block. Respiratory Medicine. Volume 107. Issue 11, P1731-1739. November 1, 2013.