O10. Palliation and end of life issues
The World Health Organisation defines palliative care as an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
The goals of palliation are the elimination or attenuation of symptoms where the underlying cause remains irreversible or resistant to therapy. The risks and benefits of each treatment must be reviewed for individual patients so as to maximise comfort and function. One of the most concise and comprehensive resources for symptom control is the therapeutic guidelines for palliative care www.tg.com.au/index.php?sectionid=47.
Despite appropriate treatment, the trajectory of COPD is one of increasing disability and morbidity with time. As the severity of the disease increases quality of life is reduced, more frequent complications require treatment and increasing dependency impacts on carers. Unlike the cancer trajectory, the intermittent and potentially reversible exacerbations of COPD make palliative referral and discussion about end of life care difficult to initiate (Dean 2008). Palliative care services have evolved into integrated systems of multidisciplinary care focussing on symptom control and support in hospital, community or hospice.
Compared to cancer patients:
- COPD patients were more likely to have poor symptom control (Claessens 2000)
- COPD patients were more likely to die in hospital (Gore 2000)
- COPD patients were less likely to receive palliative support (Gore 2000)
The Gold standards framework suggests three triggers for supportive or palliative care (Gold Standards Framework Programme 2005):
- Would you be surprised if this patient were to die in the next 6-12 months?
- Has the patient made a choice for comfort care only, treatment limitations (maintenance therapy) or do they have a special need for supportive or palliative care?
- Specific clinical indicators of severe COPD