D5. Treat anxiety and depression
The strong relationship between
anxiety and COPD has long been
established.93 Anxiety symptoms
lead to repeated presentations for
hospital admission for many
patients, at a significant financial
cost. 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.99
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.
D6. 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.93
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. Although no direct
evaluation of support groups has
been published, the likely benefits
are summarised in Box
12.
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Box 12: Patient support groups
Typical support group activities
-
Regular meetings
-
Expert guest speakers on COPD topics
-
Telephone calls, hospital and home visits
-
Receive and distribute lung health education
information
-
Special seminars and patient programs
-
Social outings
-
Rehabilitation assistance and maintenance of
exercise
-
Social enjoyment
Benefits of support groups
-
Reinforce and clarify information learnt
from health professionals
-
Provide access to new information on lung
health
-
Share experiences in a caring environment
-
Empower patients to be more actively
involved in their healthcare through self-management
techniques
-
Participate in social activities and
exercise programs
-
Encourage patients to think more positively
about their lung disease
-
Help carers understand lung disease
COPD = chronic obstructive pulmonary disease. |
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D7. 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.152,227
[evidence level II]