D1. Support team

Enhancing quality of life and reducing handicap requires a support team. (American Thoracic Society, 1995)

Patients and their family/friends should be actively involved in a therapeutic partnership with a range of health professionals (Celli, 1995),(American Thoracic Society, 1999),(Ries et al., 1995, Lorig et al., 1999) [evidence level II]

In advanced disease, the many comorbidities, social isola­tion and disability mean that a multidisciplinary approach to coordinated care may be appropriate. The general practitioner plays a key role in the delivery and coordination of care for people with chronic disease including COPD and can access a range of Medicare items to support the delivery of multi-disciplinary care. The multidisciplinary team, depending on local resources, may include the mem­bers listed below. The role of respiratory specialists is outlined in section C.