SYMPTOM CONTROL FOR ADVANCED RESPIRATORY DISEASE

1. SYMPTOM CONTROL FOR ADVANCED RESPIRATORY DISEASE DR SHARON CHADWICK CONSULTANT IN PALLIATIVE MEDICINE HOSPICE OF ST FRANCIS Dr Sharon Chadwick HOSF 2012

2. WHICH DISEASES? • COPD • Pulmonary fibrosis • Bronchiectasis • Pulmonary hypertension • Cystic fibrosis Dr Sharon Chadwick HOSF 2012

3. Symptoms Dr Sharon Chadwick HOSF 2012

4. KEY CONSIDERATIONS IN COPD • Often have high anxiety levels • Frequent fliers • May have osteoporosis • Think about reduction in doses of nebulisers • Need to assess relative contribution of anxiety/pure dyspnoea Dr Sharon Chadwick HOSF 2012

5. KEY CONSIDERATIONS IN PULMONARY FIBROSIS • Rapidly progressive disease • Catastrophic dyspnoea • Cough sometimes problematic • May affect younger patients • Highly likely to require morphine/midazolam at the end of life for symptom control PLEASE CONSIDER PALLIATIVE CARE REFERRAL Dr Sharon Chadwick HOSF 2012

6. Breathlessness • Optimise medical management • Pulmonary rehabilitation • Oxygen assessment • Non-pharmacological • Breathing control/relaxation • Pacing • Hand held fan • Pharmacological • Opioids • Benzodiazepines Dr Sharon Chadwick HOSF 2012

7. Breathlessness • Is the breathlessness worrying the patient? • Is the problem primarily breathlessness or anxiety? • Are current interventions being used appropriately? Dr Sharon Chadwick HOSF 2012

8. Breathlessness • Anxiety • Explore reasons • Consider benzodiazepines (lorazepam 0.5mg od) • CBT • Breathlessness • Explore triggers • Encourage pacing • Consider morphine (2.5mg od) May need to use both in some patients START LOW, GO SLOW!! Dr Sharon Chadwick HOSF 2012

9. Psychological issues Dr Sharon Chadwick HOSF 2012

10. Psychological issues • Anxiety • Fear of the future-fear of dying, fear of being dead, worsening symptoms, loss of independence, concern for the carer, financial issues • Failure to adjust to loss of function, feeling of should be doing more • Reluctance to use oxygen out of home environment and to use wheelchair. • Reluctance to ‘give in to the illness’ Dr Sharon Chadwick HOSF 2012

11. Psychological issues • Acknowledge difficulties • Explain benefits of doing things differently • Explore ways that things might change and look different • Giving the patient control ‘A different way to fight the disease’ Dr Sharon Chadwick HOSF 2012

12. A Holistic Approach • Use of CBT techniques • Stop negative thoughts • Pleasure vs mastery • Goal setting • Life grid • Diary Dr Sharon Chadwick HOSF 2012

13. When to think palliative care • Advanced respiratory disease with complex physical, psychological, spiritual or social problems • Continued severe symptoms despite optimal medical management • Repeated hospital admissions i.e more than 3 per year • End-stage disease for whom hospital admission may not be the best option in the event of worsening dyspnoea Dr Sharon Chadwick HOSF 2012

14. Chest Consultant Palliative Care Consultant The GP Respiratory nurse specialist Palliative care nurse specialist The patient and carer Community matrons Occupational therapists District nurses Carers Physiotherapists Dr Sharon Chadwick HOSF 2012

15. In the last year of life 32% of patients dying from COPD have three or more hospital admissions Elkington H, White P,Addington-Hall J, Higgs R, Edmonds P. The Healthcare needs of chronic obstructive pulmonary disease patients in the last year of life. Palliat Med 2005; 19: 485-491 Dr Sharon Chadwick HOSF 2012

16. GSF Prognostic Indicator Guidance Three triggers for Supportive/ Palliative Care are suggested- to identify these patients we can use any combination of the following methods: • The surprise question ‘Would you be surprised if this patient were to die in the next 6-12 months’ • Choice/ Need - The patient with advanced disease makes a choice for comfort care only, not ‘curative’ treatment, or is in special need of supportive / palliative care eg refusing renal transplant 3. Clinical indicators - Specific indicators of advanced disease for each of the three main end of life patient groups - cancer, organ failure, elderly frail/ dementia Dr Sharon Chadwick HOSF 2012

17. Conclusions • Breathlessness and anxiety are the main symptoms (but check for others) • Remember non-pharmacological interventions • Consider palliative care referral for any respiratory patient struggling with physical or psychological symptoms • Consider palliative care referral for all pulmonary fibrosis patients • ADVANCE CARE PLANNING!!!!! Dr Sharon Chadwick HOSF 2012

18. Dr Sharon Chadwick HOSF 2012