O: Optimise function

O: Optimise function

Evidence level

Strength of recommendation*

Assessment is the first step to optimising function.III-2Strong
Non-pharmacological strategies (such as pulmonary rehabilitation and regular exercise) should be provided to all patients with COPD.IStrong
Optimise pharmacotherapy using a stepwise approach.IStrong
Adherence and inhaler technique need to be checked on a regular basis.IStrong
Comorbid conditions are common in patients with COPD.III-2Strong
Referral to specialist respiratory services may be required.III-2Strong

The principal goals of therapy are to stop smoking, to optimise function through symptom relief with medica­tions and pulmonary rehabilitation, and to prevent or treat aggravating factors and complications. Adherence to inhaled medications regimes is associated with reduced risk of death and admissions to hospital due to exacerbations in COPD (Vestbo 2009) [evidence level II].

Confirm Goals of Care

Addressing the goals of care is one of the most complex clinical issues in the management of COPD.

  • Active therapy: In the early stages of the disease the goals of care must be to delay the progress of the disease by aggressive treatment of exacerbations in order that patient function is optimised and their health is maintained. In this setting management of disease may provide the best symptom control. Should the goal of health maintenance not result in adequate symptom control then a palliative approach may also be required to augment active therapy. During this period of the patient’s disease trajectory any change in therapy should be seen as an opportunity to review the goals of care in general terms with the patient. Optimal management of any individual patient with COPD must include careful management of comorbidities and anticipation of increased risks associated with those comorbidities in the presence of COPD.
  • Active therapy with treatment limitations: The transition phase of health maintenance to functional deterioration despite maximal therapy is difficult to define. The burden of disease and care fluctuates and it may be appropriate to encourage discussion about long term goals prognosis and attitudes to future treatment and care plans can be encouraged. The initiation of long term oxygen therapy and functional deterioration have been found to be an important point at which patient’s may be receptive to reviewing the goals of care, end of life care and treatment limitations.
  • Palliative and supportive care: Functional deterioration in the presence of optimum treatment requires a reappraisal of the goals of care. Each exacerbation may be reversible until there is a suboptimal or no response to treatment. At this point the patient may enter their terminal phase and the goals of care may change rapidly to palliation with treatment limitations or palliation alone with withdrawal of active therapy. In this setting (unstable, deterioration or terminal care) the goals of care need to shift from active therapy to one of palliation. Should the patient recover despite a palliative approach then the goals of care may continue to be active management in preparation for the next crisis. A review of symptom management, end of life care issues, and advanced directives should take place to prepare for the next crisis.
  • Terminal care: Terminal care plans may be appropriate for patients who elect to avoid active management. These plans need to be communicated to all services involved in the care of the patient so that there is a continuity of care. In this situation the goals of care should be clearly communicated and the advanced directive, terminal care plan and the location of care documented. Patients may elect to be treated palliatively in their terminal phase by their respiratory physician owing to their long-standing relationship with the clinician. Terminal care does not always require specialist palliative care unless there are problems with symptom control or other complex needs. Hospice or specialist consultations should be available to patients should they be required.

Terminal Phase is characterised by the following criteria:

  1. Profound weakness
  2. Essentially bedbound (ECOG 4)
  3. Drowsy for extended periods
  4. Disorientated to time with poor attention span
  5. Disinterested in food or fluids
  6. Difficulty swallowing medications