End-of-life care is a poorly understood and often neglected aspect of the management of patients with chronic obstructive pulmonary disease (COPD). Knowing what to say to patients and when to say it allows physicians to help patients and their families cope with COPD. Younger patients with mild or preclinical COPD Lung Disease should be counseled to stop smoking. For them, diseases other than COPD pose the greatest risk. Older patients with more severe COPD Lung Disease are more likely to die of a COPD-related illness, and need counseling more specific to COPD Lung Disease. Almost all COPD patients who require some form of mechanical ventilation can be successfully weaned from ventilation, but most have a poor post-ICU prognosis.
However, half do survive for longer than 1 year after ventilation is introduced. All patients with COPD Lung Disease require reassurance that they will receive competent and compassionate care throughout their illness.Patients with chronic obstructive pulmonary disease (COPD) face many hurdles during their illness. Having the diagnosis made in the first place can be a challenge because access to spirometry may be difficult. Once diagnosed, access to medication, rehabilitation, and community support is often limited.The day-to-day struggle of coping with advanced COPD makes planning for end-of-life care a low priority.
Physicians and caregivers can help patients with COPD Lung Disease who are approaching the end of life by knowing the answers to a number of questions, including: What do patients of COPD die of? At what stage should physicians and other caregivers start the end-of-life discussion? Is it possible to place patients in prognostic categories that predict a high risk of death? Which patients should be offered mechanical ventilation for acute exacerbations of COPD Lung Disease? What specific measures can be taken to palliate the symptoms associated with near-death COPD Lung Disease?
Causes of death
Studies show the causes of death in COPD Lung Disease patients vary with disease severity and length of follow-up. The Lung Health Study followed smokers with airflow limitation who “did not consider themselves ill” after a smoking cessation intervention. These patients had mild to moderate COPD Lung Disease and were followed for 14.5 years. Of 5887 patients, 731 died. The most frequent causes of death were lung cancer (33%), cardiovascular disease (22%), and cancer in organs other than the lung (21%). Only 57 patients (7.8%) died of respiratory disease other than lung cancer.Incidentally, and importantly, the study showed a mortality benefit from smoking cessation.
These data suggest that detailed end-of-life discussions with newly diagnosed COPD Lung Disease patients would be premature and irrelevant, but a stop-smoking intervention at this early stage of COPD Lung Disease would save lives.Respiratory failure is the most likely cause of death among patients with more advanced COPD. The BODE index combines four easily obtained patient variables (body mass index, airflow obstruction, dyspnea, and exercise tolerance) and has been validated as a prognostic tool in COPD Lung Disease.A trial of the index followed 625 patients over a 5-year period during which 162 (26%) died. Survivors averaged an FEV1 of 43% of predicted and nonsurvivors averaged 28% of predicted.
(Normal values would be above 80% of predicted.) The leading cause of death was respiratory failure (61%), with myocardial infarction (14%) and lung cancer (12%) causing a minority of deaths.These COPD Lung Disease patients are more representative of those seen by caregivers in clinics and hospitals. End-of-life discussions would be highly relevant for these patients with their more advanced airflow limitation.As ill as members of the BODE cohort were, only 26% died during the 5-year trial. Most patients survived for several years. However, the trial still validated the prognostic value of the BODE index by identifying a group of patients with COPD at very high risk of death. Patients with the highest BODE index scores had a 5-year mortality of 80%, with about half of these patients surviving less than 44 months. It is clear that this is the cohort of COPD patients most appropriate for an end-of-life discussion.
Other high-risk groups of COPD Lung Disease patients include those who survive acute exacerbations of COPD (AECOPD) and survivors of invasive mechanical ventilation (IMV). In-hospital mortality from AECOPD can be as high as 11%, and 1-year mortality is in the range of 50%.With the advent of noninvasive mechanical ventilation (NIMV) for primary treatment of AECOPD and for bridging from IMV, the in-hospital mortality rates for COPD patients can be surprisingly low. One retrospective study looked at a highly selected cohort of tracheostomized COPD Lung Diseasepatients who were referred to a regional weaning unit after having been acutely ventilated for respiratory failure.
The study reported a 95.5% successful weaning rate and a 92.5% survival to discharge. Long-term survival for those weaned from IMV approximated the poor survival expected of the worst BODE index cohort. One conclusion from these data is that patients with COPD Lung Disease who require mechanical ventilation may have a prognosis similar to patients who do not require mechanical ventilation. That is, the long-term prognosis in COPD is determined by the severity of the underlying disease rather than the need for ventilation.Thus, patients need not “get stuck” on the ventilator, as our weaning techniques continue to improve. However, the long-term prognosis for these patients is poor, and end-of-life discussions would be appropriate for all survivors of mechanical ventilation for COPD Lung Disease.