The Role of Palliative Care in COPD

Abstract

COPD is the fourth leading cause of death in the United States and is a serious respiratory illness characterized by years of progressively debilitating breathlessness, high prevalence of associated depression and anxiety, frequent hospitalizations, and diminished well-being. Despite the potential to confer significant quality-of-life benefits for patients and their care partners and to improve end-of-life (EOL) care, specialist palliative care is rarely implemented in COPD, and when initiated, it often occurs only at the very EOL. Primary palliative care delivered by frontline clinicians is a feasible model, but is not integrated routinely in COPD. In this review, we discuss the following: (1) the role of specialist and primary palliative care for patients with COPD and the case for earlier integration into routine practice; (2) the domains of the National Consensus Project Guidelines for Quality Palliative Care applied to people living with COPD and their care partners; and (3) triggers for initiating palliative care and practical ways to implement palliative care using case-based examples. This review solidifies that palliative care is much more than hospice and EOL care and demonstrates that early palliative care is appropriate at any point during the COPD trajectory. We emphasize that palliative care should be integrated long before the EOL to provide comprehensive support for patients and their care partners and to prepare them better for the EOL.

Keywords: COPD; end-of-life care; hospice care; palliative care.

Figure 1

Diagram showing early palliative care and trajectories of decline in serious illness. This figure illustrates the declining trajectories of well-being and function (y-axis) in serious illness over time (x-axis). Compare COPD and heart failure (red) with advanced cancer and idiopathic pulmonary fibrosis (blue), and visualize how hospitalizations (+) detrimentally impact well-being and function. Early palliative care (gray) starts proactively in the disease trajectory and increases in intensity over time as a patient experiences worsening symptoms, needs, and hospitalizations approaching the end of life (EOL). This approach seamlessly transitions from life-prolonging COPD therapies to a focus on comfort through hospice, EOL care, respite care, and bereavement.

Figure 2

Diagram showing the eight National Consensus Project Domains for Quality Palliative Care applied to COPD. We provide recommendations within each domain on how to integrate key aspects into routine COPD practice using interprofessional collaboration, a balance between primary and specialist palliative care, and a focus on maximizing quality of life and function. ADL = activities of daily living; BODE = Body Mass Index, Airflow Obstruction, Dyspnea, and Exercise Tolerance; IADL = instrumental activities of daily living; IMV = invasive mechanical ventilation; NIV = noninvasive ventilation.

Figure 3

Diagram showing the levers model for palliative care integration in COPD. This figure illustrates four potential triggers, or “levers,” for palliative care (primary, specialist, or both) in COPD. Each lever can be tuned up or down, and any one or more can pass a critical threshold to integrate palliative care. In this example, the patient meets referral criteria by high symptoms and severe exacerbations. Sample thresholds for each category could be as follows: (1) lung function: moderate stage COPD (GOLD grade II; FEV₁, 50%-80%); (2) symptoms and care needs: refractory breathlessness, unintentional weight loss, declining functional status, high burden of social determinants of health, or caregiver needs; (3) poor prognosis: high BODE Index; and (4) ≥ 1 severe exacerbation. BODE = Body Mass Index, Airflow Obstruction, Dyspnea, and Exercise Tolerance; CAT = COPD Assessment Test; GOLD = Global Initiative for Chronic Obstructive Pulmonary Disease; mMRC = modified Medical Research Council dyspnea scale. (Adapted by permission from Springer Nature, Palliative care in Lung Disease, Lindell KO and Danoff SY, Copyright 2021.⁸⁰)