Prognosis, palliative care and advance care planning for COPD

Lung function impairment is a strong predictor of mortality; however, using lung function alone to classify disease severity does not capture the multidimensional nature of chronic obstructive pulmonary disease (COPD). Severe dyspnoea, cough, fatigue, social isolation, anxiety and depression are all features of late-stage COPD. As the disease progresses, a palliative approach to care may be appropriate.

The course of COPD is typically punctuated by recurrent exacerbations, which may require hospitalisation and consideration of assisted ventilation. Hospitalisation for an exacerbation increases subsequent mortality risk, and is a sentinel event that should prompt consideration of advance care planning.

Determining prognosis in end-stage COPD is difficult; however, features that should trigger discussions about a palliative approach to care, advance care planning, and end-of-life issues include:

  • forced expiratory volume in 1 second (FEV1) less than 25% of predicted
  • oxygen dependence
  • respiratory failure or hypercapnia
  • heart failure or other comorbidities
  • weight loss or cachexia
  • decreased functional status
  • increasing dependence on others
  • advanced age.

Ideally, end-of-life discussions (eg resuscitation and intubation wishes, advance care planning) should occur in an outpatient setting when the patient’s condition is relatively stable. These discussions should include consideration of the appointment of a substitute decision-maker.

Patients with severe COPD and their caregivers should be made aware of palliative care services, including carer respite and admission to hospice. See Advance care planning for further detail. The Advance Care Planning Australia website also provides useful information.

Patients with severe COPD may benefit from low-dose opioids, which reduce the sensation of breathlessness without significantly depressing respiration. See also Chronic breathlessness in palliative care. Principles of palliative care for patients with chronic respiratory disease gives further information on end-of-life considerations.