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Feature Article

Advanced COPD: symptom management and advance care planning

Karen M Detering, David C Currow

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Abstract

Patients with advanced chronic obstructive pulmonary disease (COPD) experience chronic breathlessness, have progressively limited function and often have unmet needs. Access to advance care planning and palliative care are often limited. Worsening of chronic breathlessness is closely associated with prognosis.

Key Points

  • Advanced COPD becomes a disease with systemic manifestations. More frequent hospitalisations are a signal to consider advance care planning.
  • Advance care planning (ACP) is a co-ordinated communication process between a person, their family and healthcare providers clarifying the person’s values, treatment preferences and goals.
  • Patients with COPD want information about their diagnosis and expected disease trajectory, treatment, prognosis, what dying might be like and advance care planning.
  • Two questions likely to elicit the impact of chronic breathlessness are: ‘What do you have to do in order to become breathless?’ and ‘What have you given up in order to avoid breathlessness?’
  • The Canadian Thoracic Society has proposed a three-step ‘ladder’ for the treatment of chronic breathlessness: optimise management of the reversible causes; use nonpharmacological supports; and introduce regular low-dose (10 mg/24 hours) extended-release morphine (and regular laxatives) if breathlessness persists and titrate weekly up to 30 mg/24hours.
  • A recent meta-analysis of trials of morphine in steady state compared to placebo among people with COPD showed a consistent small to moderate effect, with all trials having a point estimate of reduced chronic breathlessness in favour of morphine over placebo.

    Picture credit: © Silvia Jansen/iStockphoto. Model used for illustrative purposes only.

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