Hospice Management of Chronic Obstructive Pulmonary Disease (COPD)TOMMIE W. FARRELL, MD FAAHPM HMDC

PATHWAYS AND HENDRICK HOSPICE, ABILENE TX

DisclaimerGoverning Board and Exam Committee Chair of the Hospice Medical Director Certification Board

“The educational material I am presenting does not represent preparation for the HMDCB exam and this presentation is not meant to be preparation for this exam.”

What is toughest in managing COPD?

COPD diagnosing• Not going to discuss

• COPD, Emphysema, Chronic Bronchitis, Chronic Asthma

• If they have the diagnosis or any of its synonyms I admit and manage based off goals and symptom needs

COPD prognosticatingTrue or False Questions:

A Bode Score of 7 to 10 is a good marker that a person has less than 6 months of life?

Being hospitalized for an exacerbation of COPD indicates a person has less than 6 months of life?

Being intubated for an exacerbation of COPD indicates a person has less than 6 months of life?

The National Hospice and Palliative Care Organization (NHPCO) guidelines for prognosis for COPD are most accurate for indicating a prognosis of less than 6 months of life?

(Bobby)

COPD prognosticatingBODE Scoring

COPD prognosticating• Roughly 10% of patients admitted with a PaCO2 >50 mmHg will die during the index hospitalization• 33% will die within six months and 43% die within one-year

•COPD patients who require mechanical ventilation have an in-hospital mortality of ~25%• 50% will die within one-year

COPD prognosticating• NHPCO guidelines for hospice admission

• evidence of cor pulmonale• pO2 <55 mmHg while on oxygen• albumin < 2.5 gm/dl• weight loss of > 10%• progression of disease• and poor functional status

• When studied 50% of the patients were still alive at six months

So when do you start hospice?• Avoid “Prognostic Paralysis”

• Start with the “Surprise Question”• ‘would I be surprised if my patient were to die in the next 12 months?’

• Include transparency in interactions with patients / families

(Bobby)

So when do you start hospice?• Use severity of disease / disease burden / evidence of disease progression / goals of care

• Dyspnea at rest

• Hypoxia or hypoxemia at rest

• Poor response to bronchodilators

• NHPCO indicators of progression of disease• evidence of cor pulmonale• pO2 <55 mmHg while on oxygen• albumin < 2.5 gm/dl• weight loss of > 10%• progression of disease (including hospitalization, ER visits, steroid use)• and poor functional status

And when do you keep hospice?• This is a irreversible disease and most will continue to meet criteria for hospice eligibility unless new treatment interventions improve the baseline picture

• BUT YOU MUST KEEP DOCUMENTING EVERY VISIT • severity of disease / disease burden / evidence of disease progression / goals of care

• Level of dyspnea, oxygen saturation, evidence of disease progression, weight loss, and functional status should be documented every visit

• Include interventions which likely prevented hospitalization / ER visits

(Bobby)

COPD Symptom BurdenWhich of the following is highest reported symptom of those with COPD?

A. Breathlessness

B. Anorexia

C. Constipation

D. Depression/anxiety

COPD Symptom Burden• Breathlessness recorded in 94% of chronic lung disease cases

• Anorexia in 67%

• Constipation in 44%

• Anxiety or Depression 90%

• Fatigue

• Pain

• Poor sleep

•A prospective comparison between patients with end stage COPD and lung cancer indicated that patients with COPD had significantly worse activities of daily living and physical, social and emotional functioning than patients with lung cancer.

(Bobby)

COPD Overall Treatment Strategy• Buckle up for how many of the interventions have no clinical evidence or found to not be effective, SO

• Use what makes Hospice great – interdisciplinary team (Bobby)

• Total Pain / Suffering Model• Physical• Emotional• Social• Spiritual

• Physician / Nurse reminder – you can prescribe Persons or both Persons and Pills• never pills alone

COPD Dyspnea ManagementWhich of the following has the best evidence in management of dyspnea in COPD?

A. Oxygen

B. Fans

C. Morphine

D. Albuterol MDI

COPD Dyspnea Management / Hospice B-team

• Long-acting beta agonist – effectiveness at end of life and cost may limit

• Inhaled steroid – effectiveness at end of life and cost may limit

• Long acting anticholinergic – effectiveness at end of life may limit

• Theophylline may be of value in some patients, but has a narrow therapeutic index and multiple interactions which may limit its use.

• Other non-pharmacological interventions • Relaxation techniques• Humidification of air • Unobstructed view

• Remember none of these alter mortality rates and effectiveness / delivery may wane

COPD Dyspnea Management /Hospice A-team

• Opioids – many controlled, randomized trial show this as superior to most other modalities• Oral long-acting and short-acting or subcutaneous all have good clinical evidence• Not nebulized• Respiratory depression not seen in standard dosing and titrating practices

COPD Dyspnea Management /Hospice A-team

• Oxygen – tailor to patient need, goals and safety• Clinical evidence for mortality benefit in hypoxic patients, but not in symptom benefit of

dyspnea• Concentrator versus Cylinder versus Liquid Oxygen – truly no superiority seen in repeated

clinical trials• Concentrator generally used if > 15 hours of long duration oxygen therapy• Cylinder or conservator generally used for burst oxygen therapy• Liquid oxygen generally used for people who like large shiny things• Consider no oxygen in active smokers (concentrator has slight risk reduction)

COPD Dyspnea Management /Hospice A-team

• Fans / Air flow

• Nebulized bronchodilators – effectiveness may wane at end of life

• Oral steroids (side effects may limit use)

• Benzodiazepines

COPD Weight loss and muscle wasting• Poorly understood process, but I teach the “work out” analogy which eases some patients / families on the “why is this happening”

• Calorie and protein supplementation with limited success, unless coupled with exercise (limited to some hospice patients)

• Dietician if available can be a good team member for support even if not for weight gain

• So since paucity of options – educate, normalize, support and if needed give them something to do or someone to talk to• Do what makes hospice great

COPD Anxiety Management• No clinical trials for the safety or efficacy of any particular therapy in COPD

• SO…. Support with clinical team

• Benzodiazepines as needed

• Long acting anxiolytics just as lacking in evidence as the short acting, so pick your poison• My personal preference is lorazepam / midazolam over the others

(VistaCare QAPI)

COPD Depression Management• Consider actively seeking this diagnosis for those with potentially extended prognosis.

• The symptoms are disabling and distressing, and patients often become socially isolated and have to give up activities that they enjoy. The psychosocial effects of the disease may be reinforced by the depressed mood.

• “The National Institute for Clinical Excellence (NICE) guideline on COPD recommends that patients who are found to be depressed or anxious should be treated with conventional pharmacotherapy, but for antidepressant treatment to be successful, it needs to be supplemented by spending time with the patient explaining why depression needs to be treated alongside the physical disorder.” Or in other words,• Prescribe People with Pills, not pills alone (and if person not ready to talk I find pills alone

ineffective)• Consider life expectancy and Age in considering antidepressant therapy

COPD Acute Exacerbation management• Treat like typical acute exacerbation with some special considerations

• Increase use of bronchodilators – if effective• Nebulizer v. Inhaler discussion

• Steroids – consider if indicated• Antibiotics – consider if indicated• Think and discuss and plan ahead on

• Will in-patient be available and used?• Will iv interventions be available and used?• Have frank discussion on location of death and “trade off” decision on location versus

treatment(Bobby)

COPD Non-Invasive Ventilation (BiPAP)General considerations:

• NPPV is noisy and can be uncomfortable and frightening.

• It may interfere with sleep and family intimacy and could confuse care goals if not discussed carefully.

• Not offered by all hospices in the home setting.

• Some experts have published concerned that NPPV may complicate end of life decision-making for the bereaved and by consequence increase the risk of associated anxiety

COPD Non-invasive Ventilation (BiPAP)Used in three circumstances:

1. Patients who desire full, life-prolonging interventions, regardless of prognosis. If the patient’s respiratory status deteriorates, intubation and ventilation are initiated.

• In several trials NPPV has been shown to reduce mortality, intubation rates, and hospital length of stay in patients with COPD

• Probably need to discuss goals of care in this patient on hospice

2. Patients who want life-prolonging therapy but with limitations of no desire for intubation or resuscitation.

• No high-quality trials, some observational studies suggest that NPPV can reverse acute respiratory failure and decrease hospital mortality in patients with COPD or CHF who have ‘Do Not Intubate’ orders.

• So, still needs good conversation on goals of care, but may be useful

COPD Non-invasive Ventilation (BiPAP)3. Dying patients with respiratory failure or dyspnea for palliative purposes.

The intention to reduce the work of breathing, to ease dyspnea, and to help maintain wakefulness by reducing the amount of opioids a patient needs to be comfortable.

NPPV can also be used to prolong life for a short period to meet a patient’s goals while otherwise providing a comfortable death (e.g., to allow time for family to visit).

• Endorsed in a survey of pulmonologists. • In multiple controlled studies of hospitalized cancer patients with acute respiratory failure

and life expectancy less than 6 months, NPPV was shown to improve dyspnea much faster and have an opioid sparing effect in the first 48 hours compared with passive oxygen therapy.

• So, remember opioids are first line therapy for dyspnea at end of life, but can discuss this option if sedation predominant

• For dying patients who wish to forestall death briefly for a specific goal, it is reasonable to start a trial of NPPV. Before initiating NPPV, it is important to discuss withdrawal of NPPV after the above goal has been achieved, and to caution the patient/family that NPPV might not be able to forestall death long enough as hoped

COPD Alternative medicine• There is limited evidence for the use of complementary and alternative medicine in the management of dyspnea.

• Individual patients with severe COPD may benefit from the use of acupuncture, acupressure and muscle relaxation with breathing retraining to relieve dyspnea, and aroma therapy.

• As these interventions are low risk it would seem reasonable to employ these therapies on an individual basis if they are requested by the patient.

COPD miscellaneous• Smoking?

• Evidence that there is mortality and morbidity benefit of quitting even in hospice setting

• Flu and pneumonia shots?• Yes, of course

ReferencesCelli BR, Cote CG, Marin JM, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Eng J Med. 2004; 350(10):1005-12.

Connors AF Jr, Dawson NV, Thomas C, et al. Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). Am J Respir Crit Care Med. 1996; 154:959-967.

Patil SP, Kirshnan JA, et al. In-hospital mortality following acute exacerbations of chronic obstructive pulmonary disease. Arch Intern Med. 2003; 163:1180-1186.

Nevins ML, Epstein SK. Predictors of outcome for patients with COPD requiring invasive mechanical ventilation. Chest. 2001; 119:1840-9

Fox E, Landrum-McNiff K, Zhong Z, Dawson NV, Wu AW, Lynn J. Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. JAMA. 1999; 282(17):1638-45.

ReferencesStewart S, McMurray JJ. Palliative care for heart failure. BMJ 2002. ;325:915 -6

Edmonds P, Karlsen S, Khan S, Addington-Hall J. A comparison of the palliative care needs of patients dying from chronic respiratory diseases and lung cancer. Palliat Med 2001. ;15:287 -95

Gore JM, Brophy CJ, Greenstone MA. How well do we care for patients with end stage chronic obstructive pulmonary disease (COPD)? A comparison of palliative care and quality of life in COPD and lung cancer.

Aronson JK, Hardman M, Reynolds DJ. ABC of monitoring drug therapy. Theophylline. BMJ 1992. ;305:1355 -8

Schwartzstein RM, Lahive K, Pope A, Weinberger SE, Weiss JW. Cold facial stimulation reduces breathlessness induced in normal subjects

Jennings AL, Davies AN, Higgins JP, Gibbs JS, Broadley KE. A systematic review of the use of opioids in the management of dyspnoea. Thorax 2002. ;57:939 -944

ReferencesBruera E, et al. Nebulized versus subcutaneous morphine for patients with cancer dyspnea: a preliminary study. J Pain Symptom Manage. 2005 Jun; 29(6):613-8.

Abernethy AP, et al. Effect of palliativeoxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial. Lancet. 2010 Sep 4;376(9743):784-93.

Evans TW, Waterhouse JC, Carter A, Nicholl JF, Howard P. Short burst oxygen treatment for breathlessness in chronic obstructive airways disease. Thorax 1986. ;41:611 -5

Eaton T, Fergusson W, Kolbe J, Lewis CA, West T. Short-burst oxygen therapy for COPD patients: a 6-month randomised, controlled study. Eur Respir J 2006. ;27:697 -704

Creutzberg EC, Wouters EF, Mostert R, Weling-Scheepers CA, Schols AM. Efficacy of nutritional aupplementation therapy in depleted patients with chronic obstructive pulmonary disease. Nutrition 2003. ;19:120 -7

ReferencesNational Institute for Clinical Excellence (NICE). Chronic obstructive pulmonary disease. National clinical guideline for management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax 2004. ;59(Suppl 1):1 -232

Pan CX, Morrison RS, Ness J, Fugh-Berman A, Leipzig RM. Complementary and alternative medicine in the management of pain, dyspnea, and nausea and vomiting near the end of life. A systematic review. J Pain Symptom Manage 2000. ;20:374 -87

Corner J, Plant H, A'Hern R, Bailey C. Non-pharmacological intervention for breathlessness in lung cancer. Palliat Med 1996;10:299 -305

Peter JV, Moran JL. Noninvasive ventilation in exacerbations of chronic obstructive pulmonary disease: implications of different meta-analytic strategies. Ann Intern Med. 2004; 141(5):W78-9.

Keenan SP, Sinuff T, Cook DJ, Hill NS. Does noninvasive positive pressure ventilation improve outcome in acute hypoxemic respiratory failure? A systematic review. Crit Care Med. 2004; 32(12):2516-23.

ReferencesSchettino G, Altobelli N, Kacmarek RM. Noninvasive positive pressure ventilation reverses acute respiratory failure in select "do-not-intubate" patients. Crit Care Med. 2005; 33(9):1976-82.

Levy M, Tanios MA, Nelson D, et al. Outcomes of patients with do-not-intubate orders treated with noninvasive ventilation. Crit Care Med. 2004; 32(10):2002-7.

Nava S, et al. Multicenter, randomized study of the use of non-invasive ventilation (NIV) vs oxygen therapy (O2) in reducing respiratory distress in end-stage cancer patients (Abstract). Am J Respir Crit Care Med. 2008; 177:A767.

Nava S, Ferrer M, et al. Palliative use of non-invasive ventilation in end of life patients with solid tumours: a randomized feasibility trial. Lancet Oncol 2013; 14:219-227