D4. Treat anxiety and depression

The strong relationship between anxiety and COPD has long been established.¹⁰⁴ Anxiety symptoms lead to repeated presentations for hospital admission for many patients, at a significant financial cost.^231,232 Anxiety and mood disturbances can often be exacerbated by respiratory drugs (eg, theophylline and steroids, respectively).

Identifying individuals at risk for clinical anxiety and developing effective interventions for treating, or, ideally, preventing panic disorder in COPD should be priorities. There are many outcome trials showing the effectiveness of cognitive behavioural therapy in treating panic disorder when no respiratory disease is present. Cognitive behavioural therapy should also be an effective intervention for treating patients with COPD-related panic disorder.

Depression is common in patients with chronic illness, and COPD is no exception.¹⁰⁶ This comorbidity has an important role in worsening health related quality of, life for this patient group, and also contributes to difficulty with smoking cessation. Pharmacological treatment of depression in COPD may be hampered by poor tolerance of side effects such as sedation, which may cause respiratory depression and aggravate sleep disturbances.

In addition to usual clinical assessment, the presence and impact of anxiety and depression may be reliably predicted with several validated questionnaires.

D5. Referral to a support group

Patients who receive education and psychosocial support show greater improvements in more aspects of health-related quality of life than those who receive education with no ongoing support.¹⁰⁴ One way to provide such education and support is through patient support groups. Support groups aim to empower patients with COPD to take a more active role in the management of their healthcare, and thus reduce the psychosocial impact of their disease. One pathway to support groups is through pulmonary rehabilitation programs. Although no direct evaluation of support groups has been published, the likely benefits are summarised in Box 10.

 

D6. End-of-life issues

Terminally ill patients with COPD are usually elderly and have already experienced one or more decades of increasingly frustrating functional restriction. Their course is likely to have been punctuated by hospital admissions. They often have several comorbidities and are frequently dependent on the care of others.

Determining prognosis in end-stage COPD is difficult, although guides to shortened survival include an FEV₁ < 25% predicted, weight loss (body mass index below 18), respiratory failure (PaCO₂ > 50mmHg, or 6.7 kPa), and right heart failure.

The major ethical issues are deciding whether to offer invasive or non-invasive ventilatory support, or, alternatively, to withhold, limit or withdraw such support. These decisions are often complex, but, as in other areas of medicine, they are ultimately constrained by the standard ethical principles of respect for patient autonomy, and ensuring that good and not harm is achieved. Most patients with end-stage COPD wish to participate in end-of-life management decisions and would prefer to do so in a non-acute setting.

In some states the patient's wishes can be given legal force through the use of an enduring power of attorney or advance health directive. Although difficult for the health professional and potentially distressing for the patient, a frank discussion about these often unspoken issues can be beneficial.

Opioids and many anxiolytics depress ventilatory drive and are contraindicated in most patients with COPD. When palliation is warranted, however, their use for the short term relief of dyspnoea could be considered.^164,165 [evidence level II]

D6.1 Palliative care services

Palliative care services provide symptom control and support for patients facing life threatening illness in hospice, hospital and community. Palliative care is not synonymous with terminal care as many patients have uncontrolled symptoms well before their terminal phase. Palliative care is concerned about how patients are living their lives facing terminal illness:

• Symptom control
• Maintenance of independence, physical function and activity
• Support with psychosocial problems
• Support for carers
• Inter-professional communication

The unit of care includes the family or carers and continues into bereavement. Most services operate on a consultancy basis in hospitals and in the community with direct care in a specialised palliative care unit or hospice. The service is available on consultation to support clinicians, carers and patients receiving a palliative approach. Specialist palliative care may be needed to augment or takeover care in complex situations.