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.

A study by Janssen et al (Janssen 2012) in a group of 265 patients with stable severe or very severe COPD, heart failure or chronic renal failure, found that more than a third of patients changed their preferences regarding life supporting measures at least once over a period of twelve months, reinforcing the importance of regular re-evaluation of advanced care planning and advanced directives.

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 (Jennings 2002, Abernethy 2003) [evidence level II].