End stage COPD

  1. 0
    I was wondering if anyone knew much about the management of end stage COPD (Chronic Obstructive Pulmonary Disease.) I understand that it's a progressive condition with no cure - the patient I'm thinking of is 87 with severe COPD/Type II Respiratory Failure - and I've been trying to research the best ways to manage her discomfort and dyspnoea in these last months.. It's getting to the point where she can't walk to the loo (<10m) due to dyspnea (& thus won't), eating worsens her dyspnea ten fold and her sleep is significantly disturbed because she just can't seem to get comfortable.

    She has recently moved in with her family because she had a massive decline after the death of her sister. She's had two hospitalisations in about as many months for exacerbations however the medical staff have made it very clear that there are no more medical treatments worth pursuing (she's had two courses of CPAP to bring down her PCO2, however she refuses the mask and it's made little difference to her PCO2, which is sitting around 80.)

    She recently implemented home oxygen therapy with an oxygen concentrator at 2L/minute, which relives some of her dyspnea at rest however even eating or moving from sitting up to lying down wear her out. While she's been in hospital we've trialed a course of PRN Zyprexa at night to try and help her sleep (and at one point, relive her agitation when the CPAP was on.) We're hoping to continue this at home because she does not sleep (and thus keeps her family awake at night, calling out every five minutes even though she doesn't want anything.)

    Other than regular ventolin (via spacer) and seritide I'm afraid there's little else that's been suggested and I wonder if there are any particular palliative care related interventions which may make her a little more comfortable?

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  2. 24 Comments...

  3. 6
    Is she on morphine at all? It may help with discomfort and her dyspnea. Maybe a little Ordine (oral solution)?
  4. 4
    sounds like she needs medication adjustment. xanax for anxieties? if you are talking about palliative care, i've seen pts on roxanl with good effects
    rngolfer53, tewdles, pennyaline, and 1 other like this.
  5. 4
    The COPDers I've had need anxiolytics. They get terrified of being unable to breathe. Understandable.
    Altra, tewdles, pennyaline, and 1 other like this.
  6. 4
    morphine, anxiolytic...
    and hospice?
    (((gentle hugs)))

    leslie
    rngolfer53, Altra, tewdles, and 1 other like this.
  7. 2
    This woman is fairly used to being unable to breathe (as I would assume a lot of COPDers are, having lived with the condition for so many years?) I swear sometimes she doesn't even notice it, despite awful "throaty" noises that clearly sound like extreme and persistent difficulty breathing. (I don't really know how to describe it, but it's awful.)

    The medical staff weren't keen to try a benzo (I'm assuming due to respiratory depression risks) which is why they went for the Zyprexa (an anti-psychotic) instead. Effectiveness is yet to be determined.

    I was thinking about morphine but I wonder about the risks of respiratory depression. She doesn't typically have a low RR but then I don't know a lot about how this works. We're hoping for a referral to the palliative care team where they might know a bit more about this sort of stuff.
    pennyaline and leslie :-D like this.
  8. 5
    Definitely refer to palliative home care. We just got them involved in my mother's care and they have lots of tips and tricks to make people more comfortable.

    It is true that lung/COPD patients tend to be anxious, even after longstanding disease. You don't usually worry about respiratory depression in true "end stage" palliation.
    Altra, tewdles, pennyaline, and 2 others like this.
  9. 9
    morphine ... morphine ... morphine ... more morphine ... a little ativan ... more morphine ...

    It sounds like your pt is close to death and a hospice referral is in order. Unfortunately, the amount of morphine usually required to make a person with end-stage COPD completely comfortable at the very end probably constitutes malpractice outside of hospice. In hospice, we are covered by the principle of unintended effect. In this case, while it is true that morphine will depress respirations and likely shorten her life by a few hours or days, it is being given with the intent to provide comfort, which is the overriding priority in hospice.

    Even so, low doses might help take the edge off without too much risk. I find combining morphine with ativan most helpful.

    If she or her family are not ready to discuss hospice yet, ask her doc if a course of steroids might be helpful ... if she has inflammation and wheezing it can offer some temporary ease along with neb treatments, Of course, it'll probably exacerbate her anxiety and insomnia.

    I'm interested that you're using an antipsychotic for insomnia ... is she demented or psychotic as well? If not, trazadone may be more helpful ... you'll see some hangover effect but dosage can range from 25 to as much as 300 mg if needed. Most sleep fairly well on 25-100mg and you see fewer paradoxical reactions (increased agitation).

    Keep an eye, too, on her oxygen use. Many docs poo-poo the old time idea of the hypoxic drive being suppressed by a high O2 saturation, but in my experience many of these very end-stage COPD pts become highly anxious when sats get much over 93%. On my hospice inpt unit we attempt to keep sats between 88 and 92. The first thing many people do when short of breath is crank up the oxygen, so she or her family may be upping the O2 when she gets antsy regardless of the order.

    Did that help?
  10. 6
    Quote from ghillbert
    You don't usually worry about respiratory depression in true "end stage" palliation.
    you may have to write that 100 times, before anyone believes it.

    rachelgeorgina, fans are known to help with dyspnea...blowing right in their faces.
    also, masks tend to suffocate these folks.

    i would definitely stick with the benzos for anxiety, or haldol, which is used often in hospice as well.

    leslie
    Scrubby, ghillbert, SuesquatchRN, and 3 others like this.
  11. 1
    Quote from heron
    morphine ... morphine ... morphine ... more morphine ... a little ativan ... more morphine ...

    It sounds like your pt is close to death and a hospice referral is in order. Unfortunately, the amount of morphine usually required to make a person with end-stage COPD completely comfortable at the very end probably constitutes malpractice outside of hospice. In hospice, we are covered by the principle of unintended effect. In this case, while it is true that morphine will depress respirations and likely shorten her life by a few hours or days, it is being given with the intent to provide comfort, which is the overriding priority in hospice.

    Even so, low doses might help take the edge off without too much risk. I find combining morphine with ativan most helpful.

    If she or her family are not ready to discuss hospice yet, ask her doc if a course of steroids might be helpful ... if she has inflammation and wheezing it can offer some temporary ease along with neb treatments, Of course, it'll probably exacerbate her anxiety and insomnia.

    I'm interested that you're using an antipsychotic for insomnia ... is she demented or psychotic as well? If not, trazadone may be more helpful ... you'll see some hangover effect but dosage can range from 25 to as much as 300 mg if needed. Most sleep fairly well on 25-100mg and you see fewer paradoxical reactions (increased agitation).

    Keep an eye, too, on her oxygen use. Many docs poo-poo the old time idea of the hypoxic drive being suppressed by a high O2 saturation, but in my experience many of these very end-stage COPD pts become highly anxious when sats get much over 93%. On my hospice inpt unit we attempt to keep sats between 88 and 92. The first thing many people do when short of breath is crank up the oxygen, so she or her family may be upping the O2 when she gets antsy regardless of the order.

    Did that help?
    This helped so much. Thank you. To be honest, she is close to death - though whether it will be days or months nobody knows. She's a stubborn woman, I'm sure she'll hang on as long as she can.

    The family is well educated in the use of oxygen at home and have been known to freak out if she sats get to high or someone turns the oxygen up. Unfortunately because ABGs can't be monitored at home it's a tricky situation to know whether she's getting to much or how it's really effecting her.

    The anti-psychotic order came in because the doctor on call who made the order was very, very hesitant to use a benzo (respiratory depression, I assume?) The doctor suggested Hadol however the family were concerned that it was a bit "old school" (hence the side effect profile) and suggested Zyprexa instead.

    Unfortunately the hospital are sending her home today without a palliative care referral, which is appalling, seeing as the medical staff told them that she was dying and there wasn't anything else they could do. I wonder how hard it will be for the family to get themselves into the palliative care service as outpatients..? What hospice resources could I point them toward for support at home (we're in Australia so this makes it a bit hard.)
    Altra likes this.


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