Palliative care in COPD: an unmet area for quality improvement

Figures & data

Figure 1 Structure and goals of outpatient palliative care services.

Table 1 Triggers to begin or intensify proactive palliative resources for patients with COPD

Age ≥75^Citation35,Citation54–Citation56,Citation61

Comorbiditiesa,^Citation35,Citation54,Citation55,Citation61–Citation66

Change 6-minute walk by 50 m^Citation53

Functional dependence and patient reported minimal physicalb activity^Citation35,Citation53,Citation65,Citation67

Poor health-related quality of lifec,^Citation35,Citation57,Citation65,Citation68

FEV1 <30%^Citation9,Citation54,Citation66

BMI <20%^Citation61,Citation69

≥1 hospitalization within last year^Citation55,Citation65

Notes

a Comorbidities include diabetes, cardiovascular disease (ischemic heart disease, congestive heart failure), end-stage chronic renal disease.

b Patient reported minimal physical activity defined as spending more time in a recliner chair or bed than not during the day.

c Methods to assess health-related quality of life include the St George’s Respiratory Questionnaire, Chronic Respiratory Disease Questionnaire, and the Breathing Problems Questionnaire.

Abbreviations: FEV₁, forced expiratory volume in 1 second; BMI, body mass index.

Table 2 Primary palliative care

Step 1: build a team, share the load
Nurses	Medical triage and support
Social workers	Psychosocial support, connecting patients to needed community resources
Respiratory and physical therapists	Exercise training and non-pharmacologic approaches to dyspnea relief
Chaplains/pastoral care palliative care clinicians	Spiritual support, legacy work complex symptom management, and additional support
Step 2: screen for and address unmet needs
Symptom management	Consider opioids for refractory dyspnea and train patients/caregivers to use non-pharmacologic techniques to help decrease breathlessness (eg, positioning and use of personal fans)
Depression and anxiety	Routine screen given high prevalence Consider pharmacotherapy
Early and regular discussions about future care and concerns	“Given how things are going, what is most important to you?” “What are you most concerned about?” “Would it help to talk about what to expect or what to prepare for as your illness worsens?” “Hope for the best, but prepare for the worst”
Advance care planning: identifying decision-makers and clarifying limits around potential interventions	“Who would speak for you and share your wishes with regards to medical decisions if you were not able to speak for yourself?” “Are there treatments or interventions that you would not want as you approached the end of life?”

Figure 2 Proactive palliative care in COPD.

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