Controlling COPD Symptoms at the End of Life

1. Controlling COPD Symptoms at the End of Life Helen M. Sorenson MA RRT FAARC

2. Death rate per 100,000 from COPD CDC MMWR Chronic Obstructive Pulmonary Disease Surveillance Report, 1971 – 2000; August 2, 2002.

3. Emphysema/COPD • A long course of chronic disease characterized by exacerbations and remissions, but a clear or steady decline • When the patient gets to “last days”, careful attention to symptom control can prevent, minimize or eliminate distress – thus improve quality of life till time of death

4. Emerging Profile of Dying COPD Patient ( Within a Year) • Best FEV1 < 30% of predicted • Declining performance in ADL • Uninterrupted walk distance < a few steps • 1 urgent hospitalization in past year • Left-heart and/or other comorbid diseases • Older age • Depression • Unmarried Hansen-Flaschen J. COPD: The Last Year of Life. Respiratory Care, 2004; 49(1): 90-98.

5. Signs of Impending Death(hours to days) Hypersomnolence  Urine production Disorientation Cool extremities Irregular breathing Altered vital signs Mottled skin Hypothermia Retained secretions  Interest in food in upper airway and/or water

6. Symptom Assessment • Subjective nature ( self-reported) • Clinician accuracy poor • Symptom measurement must be considered • Symptom measurement instruments • MSAS – Memorial Symptom Assessment Scale • RSC – Rotterdam Symptom Checklist • VAS – Visual Analog Scale (0 / 10) • Dyspnea Assessment (Ventilator check)

7. Barriers to Symptom Assessment Advanced disease accompanied by fatigue, depression, delirium Difficult in patients with more than one symptom Caregivers not willing to share time Disease itself not open to discussion

8. Severity of COPD symptoms3 days prior to death, per family members Lynn J,Teno, JM et al. Perceptions by family members of the dying experience of older and seriously ill patients. Ann of Intern Med 1997;126(2): 97-106.

9. Common Distressing COPD symptoms Dyspnea Anxiety Cough Confusion Pain Depression Anorexia/Cachexia

10. Management of symptoms General principles of palliation Determine and treat underlying cause Relieve symptoms without adding any new problems Consider if treatment is worthwhile - for the patient and/or family Discuss all reasonable treatment options

11. Causes of Dyspnea (COPD) • Airway obstruction or restriction, hypoxemia, reduced respiratory muscle force (deconditioning) • Cardiovascular – CHF, cor pulmonale • Anxiety/fear • Anemia • Fluid overload

12. Control of Dyspnea • Pharmacotherapy • Bronchodilators (COPD) • Diuretics (CHF) • Opioids – oral is preferred route • Oxygen –as needed and/or tolerated but not monitored

13. Control of Dyspnea • Benzodiazepines - anxiolytic • Phenothiazine (Thorazine) – antipsychotic which may be used for severe agitation • Corticosteroids – anti-inflammatory side effects not an issue at this point

14. Nebulized Opioids (Anecdotal) Direct action of OPM on lung afferent nerves • OPM may diminish response to hypoxia and hypercapnia at chemoreceptor level • May alter perception of breathlessness • May exert peripheral effect on opioid receptor in lungs • [Nebulized morphine may cause histamine-mediated bronchospasm during 1st nebulization]

15. Control of Dyspnea • Non-Pharmacological • Elevate head of bed 30 (whatever works) • Pursed-lip breathing • Calming presence • Relaxation therapy • Massage therapy • Fans ( cool air)

16. COPDers and Fans In end-stage COPD, primary ventilatory muscle 10% efficient, secondary muscle 3% efficient. Increased WOB, increased energy expenditure, increased body temp, do fans provide relief ? Fans improve dyspnea by stimulating receptors in the trigeminal nerve located in the cheek and nasopharynx, altering the perception of breathlessness (Enck, Johns-Hopkins, 1994)

17. Pain control “Pain is whatever the experiencing person says it is, whenever the experiencing person says it does” McCaffery & Pasero, 1999 Symptom assessment VAS (0/10) Sad face/happy face Establish level of pain!

18. Pain control Most pain can be alleviated Dosing of pain medications should be on a regular round-the clock basis Analgesics wear off…delay in administration = exacerbation of pain = anxiety /fright = family dissatisfaction

19. Cough control Cough is a normal protective mechanism but can also be induced by; Infection Airway disease Drug induced (ACE inhibitor) Reflux Aspiration of saliva

20. Cough control Establish level of distress (0/10) Educate family Warm humidified air Expectorants and/or mucolytics of little value Codeine 15-30 mg oral Q4 Morphine 2.5 mg oral Q4 Nebulized lidocaine 2 mls (1%, 2% or 4%) Q6 (wait 30 minutes post before eating – aspiration risk)

21. Death Rattle - Last 24 to 48 hours • Caused by airflow through retained secretions at back of throat • Patients lethargic, comatose – unaware • Family members find noise distressing – need to be educated • Oropharyngeal suction may be done, but if it causes gagging or coughing, it is not palliative • Lateral recumbent position with head elevated slightly may reduce pooling of secretions

22. Death Rattle - Last 24 to 48 hours Anticholinergic use needs to start early – will not dry up secretions already present Rousseau P. Nonpain Symptom Management in the Dying Patient Hospital Physician, February 2002.

23. Bronchorrhea • Defined as the profuse production of sputum of > 100mL/day • Has been observed in patients with end-stage bronchioalveolar carcinoma • Has been successfully treated with inhaled Indomethacin, probably by causing down regulation of cyclo-oxygenase • 2 RCT (1985,1992) case studies (1999) and In-vivo study(1995) all indicate efficacy

24. Anorexia/Cachexia < 3 days, 55% unable to eat Common in dying patients Check for treatable conditions Oral candidiasis, poorly fitting dentures, mouth sores, pain, nausea

25. Anorexia/Cachexia Family education benefit from force feeding Any food is acceptable worry about nutritional value Enteral – maybe, TPN not recommended Starvation/dehydration – analgesic effect Xerostomia associated with dehydration does cause discomfort – good oral care, mouth swabs, ice chips recommended

26. Confusion Mental changes can accompany terminal stage of illness Causes: drugs, hypoxia, metabolic imbalance, urinary retention, sleep deprivation, poor pain control Treatment: If cause can be determined Simple treatment may improve communication

27. Confusion /Depression Non-specific therapy Handholding, frequent reminders of place and person Unfinished business Addressing religious/spiritual needs Environment – is going home an option Music therapy Meditation

28. Palliative Respiratory Therapy Palliative care is comfort care! What will be comfortable for your patients? • Nebulized bronchodilators? • Oxygen therapy – device and liter flow? • Continuous pulse oximetry? • Chest physiotherapy? • CPAP/IPPB? • ABGs? • NT suctioning? • Patient positioning?

29. What do Families Need? Caring for dying patients necessitates caring for their families Adequate communication Feeling supported Giving good care to loved ones

30. Palliative Care • Broadening medical care to integrate palliative and life-prolonging interventions is a major challenge for health care in our country • Allied Health care professionals should be prepared to render comfort care at the bedside to our patients

31. Palliative Care All patients with a terminal condition should be provided; • Access to palliative care delivered by knowledgeable practitioners • Treatment that looks to quality of life as well as quality of care • Information regarding the close collaboration between hospice and palliative care Clinical Practice Guidelines for Quality Palliative Care; National Consensus Project. www.nationalconsensusproject.org

32. Integration of Palliative Care • Pain, symptom control, psychosocial distress, spiritual issues and practical needs are addressed • Patients receive necessary information in a timely and understanding manner • Care of the patient is truly coordinated among disciplines • Both the patient and the family are prepared for the dying process

33. Palliative Care Means To cure, sometimes To relieve, often To comfort, always