Palliative care in chronic obstructive pulmonary disease

Abstract

Chronic obstructive pulmonary disease (COPD) is the only major worldwide cause of mortality that is currently increasing in prevalence. Furthermore, COPD is incurable, and the only therapy that has been shown to increase survival is oxygen therapy in selected patients. Compared to patients with cancer, patients with COPD experience similar levels of pain, breathlessness, fatigue, depression, and anxiety and have a worse quality of life but have comparatively little access to palliative care. When these patients do receive palliative care, they tend to be referred later than patients with cancer. Many disease, patient-, and provider-related factors contribute to this phenomenon, including COPD's unpredictable course, misperceptions of palliative care among patients and physicians, and lack of advance care planning discussions outside of crisis situations. A new paradigm for palliative care would introduce palliative treatments alongside, rather than at the exclusion of disease-modifying interventions. This integrated approach would circumvent the issue of difficult prognostication in COPD, as any patient would receive individualized palliative interventions from the time of diagnosis. These points will be covered in this review, which discusses the challenges in providing palliative care to COPD patients, the strategies to mitigate the challenges, management of common symptoms, and the evidence for integrated palliative care models as well as some suggestions for future development.

Introduction

Chronic obstructive pulmonary disease (COPD) is a significant cause of mortality and disability worldwide. In fact, COPD is the only disease whose age-adjusted mortality continues to increase. In fact, the global burden of COPD is estimated to increase to 30% by 2030 [1], [2], [3]. Unfortunately, diagnosis is often delayed because patients do not experience significant dyspnea until at least 40% of their lung function is lost [3].

With the exception of oxygen therapy, no standard treatment for COPD has been shown to have a mortality benefit, with benefits limited to only modest symptom control in many patients. The burden of symptoms in COPD leads to markedly impaired function and thus a low quality of life [2], [4], [5]. Symptom burden in end-stage COPD is often equivalent to or worse than, in cancer, as well as the end stages of other chronic disease such as dementia, congestive heart failure, renal failure, and liver failure [6]. Although dyspnea is often the most prominent and debilitating symptom, patients with COPD also experience fatigue, depression, anxiety, pain, weight loss, insomnia, constipation, and incontinence [2]. In patients with this complex array of symptoms, palliative care is ideally suited to address physical, functional, social, and spiritual needs but is less commonly accessed compared to patients with oncologic disease, despite a comparable symptom burden and impact on quality of life [7]. The reasons for this disparity will be explored in the subsequent sections, and suggestions for improvement will be offered based on previously developed models.