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, Spruit 2013, Ries 1995, Lorig 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.