Prognostication in COPD: science or fiction?
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Presentation to Respiratory Medicine Department at Whittington Hospital 2015
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Prognostication in COPD: science or fiction?
- 1. Prognostication in COPD: science or fiction? Dr Laura-Jane Smith ST5 Respiratory Medicine Wellcome Trust Clinical Research Fellow Whittington Respiratory Meeting June 2015
- 2. COPD and death Prognostication Future practice
- 4. Inhaled noxious particles (eg cigarette smoke, solid fuel fire smoke) Inflammation, white cell recruitment Bronchial wall thickening and fibrosis Mucous gland hyperplasia Alveolar destruction (neutrophil proteases) CHRONIC BRONCHITIS SMALL AIRWAYS NARROWING AND OBSTRUCTION EMPHYSEMA, BULLAE LOSS OF ELASTIC RECOIL DYNAMIC AIRWAYS COLLAPSE
- 5. Images from Eureka: Respiratory Medicine 2015. Smith, Quint, Brown
- 6. WHAT DO WE DIE OF?
- 8. Prevalence of COPD increasing globally, and projected to be the 3rd leading cause of mortality and 5th leading cause of disability by 2020 Many people die with COPD, or from a complication related to it COPD may not be cited as the primary cause of death on their death certificate - under-reported as a cause of death
- 9. HOW DO COPD PATIENTS DIE?
- 11. Trajectories of death COPD Heart failure Dementia Frailty Cancer From Spathis and Booth 2008. End of life care in chronic obstructive pulmonary disease: in search of a good death. International Journal of COPD. 2008;3(1):11–39. Adapted from Murray et al.
- 13. Functional impairment Symptom burden (breathlessness, anorexia, pain, cough, insomnia, confusion, fatigue, low mood, anxiety, panic) Social isolation Impaired HRQoL Treatment preferences Invasive interventions near the end of life Advance care planning Access to specialist palliative care services Habraken JM et al. 2009 Edmonds P et al.. 2001;15(4):287–95 Gore et al 2000 COPD Lung cancer
- 14. All of these factors suggest that a palliative care approach would be beneficial for patients with advanced COPD. National and International guidelines recommend such an approach.
- 15. WHO definition of Palliative Care Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care: • provides relief from pain and other distressing symptoms • affirms life and regards dying as a normal process • intends neither to hasten or postpone death • integrates the psychological and spiritual aspects of patient care • offers a support system to help patients live as actively as possible until death • offers a support system to help the family cope during the patients illness and in their own bereavement • uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated • will enhance quality of life, and may also positively influence the course of illness • is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications
- 16. Why don’t COPD patients access palliative care?
- 17. Enhance access to a palliative care approach Improve prognostication Move to a needs- based approach Identify transitions in the course of disease as triggers
- 18. Enhance access to a palliative care approach Improve prognostication Move to a needs- based approach Identify transitions in the course of disease as triggers
- 20. How good is human intuition?
- 21. Chow et al 2001, Christakis 2000, Wildman 2007
- 22. Can data help?
- 23. FEV1% Hypoxaemia Breathlessness Cor pulmonale Exacerbation frequency Hospitalisation Exercise tolerance Biomarkers Low BMI Older age RVSP Low serum albumin ICU admission Co-morbid CCF Functional status Use of NIV Nishimura 2002 Soler-Cataluña 2005 Knaus 1991, Almagro 2002 Ai-Ping 2005 Pinto-Plata 2004 Coxson 2013 Connors 1996 Connors 1996, Almagro 2002 Connors 1996Connors 1996 Connors 1996Dallari 1994 Anthonisen 1989 NOTT 1980 Plant 1998 Incalzi 1999
- 24. Can more data help?
- 25. BODE Celli BR, Cote CG, Marin JM, Casanova C, Montes de Oca M, Mendez RA, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. New England Journal of Medicine. 2004;350(10):1005–12.
- 26. BODE For each one-point increment in the BODE score the hazard ratio for death from any cause was 1.34 (95%CI 1.26-1.42) and the hazard ratio for death from a respiratory cause was 1.62 (95%CI 1.48-1.77).
- 27. Kaplan-Meier Survival curves for the 4 quartiles of the BODE index and the 3 stages of severity of COPD based on FEV1% as defined by the ATS. Quartile 1 = 0-2 Quartile 2 = 3-4 Quartile 3 = 5-6 Quartile 4 = 7-10 Stage 1 = FEV1 >50% predicted Stage 2 = FEV1 36-50% predicted Stage 3 = FEV1 <36% predicted
- 28. Puhan MA, Hansel NN, Sobradillo P, Enright P, Lange P, Hickson D, et al. Large-scale international validation of the ADO index in subjects with COPD: an individual subject data analysis of 10 cohorts. BMJ Open. 2012 Jan 1;2(6):e002152. BODE v2
- 29. ADO
- 30. Making models count Wyatt JC, Altman DG. Commentary: Prognostic models: clinically useful or quickly forgotten? BMJ. 1995 Dec 9;311(7019):1539–41. Clinical credibility • Patient data required for model is easily and reliably accessible • Avoid arbitrary thresholds for continuous variables • Simple to calculate at point-of-care Evidence of accuracy • At least as accurate as clinician prediction • Error rates tested in large data set not used to generate model Evidence of generality • Model testing in other populations, in time and space • Each item of data clearly defined to ensure easy use in different settings/languages • Prospective validation in well-defined populations Evidence of clinical effectiveness • Measure effects on practice and outcomes of using model • Similar to phase III study in drug trials
- 31. FEV1% Specific co- morbidities Multi-morbidity Breathlessness Functional status Previous need for NIV/ventilation HRQL QoL Socioeconomic group Healthcare utilisation Weight loss/cachexia/BMI <21 Sarcopenia Exercise capacity Social isolation Use of long term steroids Contact with comm resp/pall care team
- 33. COPD model of care Does this capture what patients and physicians want? What needs to happen to achieve this?
- 36. YouGov poll 2014
- 38. QUESTIONS?
- 39. Conclusions • Many patients with COPD have a high symptom burden and poor quality of life, yet fail to access a palliative care approach • Patients, carers, physicians, and policy makers would welcome greater prognostic certainty • Current prognostic markers and scores are limited in their ability to accurately predict prognosis in individual patients • There are great opportunities to improve the lives of patients with COPD and their carers, which requires research and investment
- 40. References • Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. The Lancet. 1997 May 24;349(9064):1498–504. • Goodridge D, Lawson J, Duggleby W, Marciniuk D, Rennie D, Stang M. Health care utilization of patients with chronic obstructive pulmonary disease and lung cancer in the last 12 months of life. Respir Med. 2008 Jun;102(6):885–91. • Zielinski J, MacNee W, Wedzicha JA, Ambrosino N, Braghiroli A, Dolensky J, et al. Causes of death in patients with COPD and chronic respiratory failure. Monaldi Arch Chest Dis Arch Monaldi Mal Torace Fondazione Clin Lav Irccs Ist Clin Tisiol E Mal Appar Respir Univ Napoli Secondo Ateneo. 1997 Feb;52(1):43–7. • Vilkman S, Keistinen T, Tuuponen T, Kivelä S-L. Survival and Cause of Death among Elderly Chronic Obstructive Pulmonary Disease Patients after First Admission to Hospital. Respiration. 1997;64(4):281–4. • McGarvey LP, John M, Anderson JA, Zvarich M, Wise RA. Ascertainment of cause-specific mortality in COPD: operations of the TORCH Clinical Endpoint Committee. Thorax. 2007 May 1;62(5):411–5. • Jensen HH, Godtfredsen NS, Lange P, Vestbo J. Potential misclassification of causes of death from COPD. Eur Respir J. 2006 Oct 1;28(4):781–5. • Habraken JM, ter Riet G, Gore JM, Greenstone MA, Weersink EJM, Bindels PJE, et al. Health-Related Quality of Life in End-Stage COPD and Lung Cancer Patients. J Pain Symptom Manage. 2009 Jun;37(6):973–81.
- 41. • Skilbeck J, Mott L, Page H, Smith D, Hjelmeland-Ahmedzai S, Clark D. Palliative care in chronic obstructive airways disease: a needs assessment. Palliat Med. 1998 Apr 1;12(4):245–54. • Gore JM, Brophy CJ, Greenstone MA. How well do we care for patients with end stage chronic obstructive pulmonary disease (COPD)? A comparison of palliative care and quality of life in COPD and lung cancer. Thorax. 2000;55(12):1000–6. • Mt C, J L, Z Z, Na D, Rs P, Aw W, et al. Dying with lung cancer or chronic obstructive pulmonary disease: insights from SUPPORT. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. J Am Geriatr Soc. 2000 May;48(5 Suppl):S146–53. • Connors AF, Dawson NV, Thomas C, Harrell FE, Desbiens N, Fulkerson WJ, et al. Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). Am J Respir Crit Care Med. 1996 Oct 1;154(4):959–67. • Gavazzi A, De Maria R, Manzoli L, Bocconcelli P, Di Leonardo A, Frigerio M, et al. Palliative needs for heart failure or chronic obstructive pulmonary disease: Results of a multicenter observational registry. Int J Cardiol. 2015 Apr;184:552–8. • Janssen DJA, Engelberg RA, Wouters EFM, Curtis JR. Advance care planning for patients with COPD: Past, present and future. Patient Educ Couns. 2012 Jan 1;86(1):19–24. • Seamark DA, Blake SD, Seamark CJ, Halpin DM. Living with severe chronic obstructive pulmonary disease (COPD): perceptions of patients and their carers An interpretative phenomenological analysis. Palliat Med. 2004;18(7):619–25. • Booth S, SilvesterS, Todd C. Breathlessness in cancer and chronic obstructive pulmonary disease: using a qualitative approach to describe the experience of patients and carers. Palliat Support Care. 2003;1(04):337–44. • Burge F, Lawson B, Mitchell G. How to move to a palliative approach to care for people with multimorbidity. BMJ. 2012 Sep 21;345(sep21 1):e6324–e6324. • Stahl E, Lindberg A, Jansson S-A, Ronmark E, Svensson K, Andersson F, et al. Health-related quality of life is related to COPD disease severity. Heal Qual Life Outcomes. 2005;3(1):56.
- 42. • Edmonds P, Karlsen S, Khan S, Addington-Hall J. A comparison of the palliative care needs of patients dying from chronic respiratory diseases and lung cancer. Palliat Med. 2001;15(4):287–95. • National Gold Standards Framework for End of Life Care [Internet]. Available from: http://www.goldstandardsframework.org.uk/ • Chronic obstructive pulmonary disease | Guidance and guidelines | NICE [Internet]. [cited 2015 Mar 30]. Available from: https://www.nice.org.uk/guidance/cg101 • Celli BR, MacNee W, Agusti A, Anzueto A, Berg B, Buist AS, et al. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004 Jun 1;23(6):932–46. • GOLD. Global Initative for Chronic Obstructive Pulmonary Disease (GOLD) Report 2015. • Neuberger J. More care, less pathway - a review of the Liverpool Care Pathway. London: Department of Health; 2013. • Harding R, Simms V, Calanzani N, Higginson IJ, Hall S, Gysels M, et al. If you had less than a year to live, would you want to know? A seven-country European population survey of public preferences for disclosure of poor prognosis: European citizens’ preference to be told of poor prognosis. Psychooncology. 2013 • Steinhauser KE, Christakis NA, Clipp EC, McNeilly M, McIntyre L, Tulsky JA. Factors Considered Important at the End of Life by Patients, Family, Physicians, and Other Care Providers. 2000;284(19):2476–82. • Chow E, Harth T, Hruby G, Finkelstein J, Wu J, Danjoux C. How Accurate are Physicians’ Clinical Predictions of Survival and the Available Prognostic Tools in Estimating Survival Times in Terminally Ill Cancer Patients? A Systematic Review. Clin Oncol. 2001;13:209–18. • Christakis NA, Lamont EB, Smith JL, Parkes CM. Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort studyCommentary: Why do doctors overestimate? Commentary: Prognoses should be based on proved indices not intuition. Bmj. 2000;320(7233):469–73. • Wildman MJ, Sanderson C, Groves J, Reeves BC, Ayres J, Harrison D, et al. Implications of prognostic pessimism in patients with chronic obstructive pulmonary disease (COPD) or asthma admitted to intensive care in the UK within the COPD and asthma outcome study (CAOS): multicentre observational cohort study. BMJ. 2007 Nov 29;335(7630):1132.
- 43. • Anthonisen NR. Prognosis in Chronic Obstructive Pulmonary Disease: Results from Multicenter Clinical Trials. Am Rev Respir Dis. 1989 Sep 1;140(3_pt_2):S95–S99. • Nishimura K, Izumi T, Tsukino M, Oga T. Dyspnea is a better predictor of 5-year survival than airway obstruction in patients with COPD. Chest J. 2002;121(5):1434–40. • Soler-Cataluña JJ, Martínez-García MÁ, Sánchez PR, Salcedo E, Navarro M, Ochando R. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease. Thorax. 2005 Nov 1;60(11):925–31. • Almagro P, Calbo E, Ochoa de Echagüen A, Barreiro B, Quintana S, Heredia JL, et al. Mortality after hospitalization for copd*. Chest. 2002 May 1;121(5):1441–8. • Ai-Ping C, Lee K-H, Lim T-K. In-hospital and 5-year mortality of patients treated in the icu for acute exacerbation of copd*: A retrospective study. Chest. 2005 Aug 1;128(2):518–24. • Pinto-Plata VM, Cote C, Cabral H, Taylor J, Celli BR. The 6-min walk distance: change over time and value as a predictor of survival in severe COPD. Eur Respir J. 2004 Jan 1;23(1):28–33. • Coxson HO, Dirksen A, Edwards LD, Yates JC, Agusti A, Bakke P, et al. The presence and progression of emphysema in COPD as determined by CT scanning and biomarker expression: a prospective analysis from the ECLIPSE study. Lancet Respir Med. 2013 Apr;1(2):129–36. • Dallari. Predictors of survival in subjects with Chronic Obstructive Pulmonary Disease Treated with Long-Term Oxygen Therapy. Respiration. 1994;61:8–13. • Knaus WA, Wagner DP, Draper EA, Zimmerman JE, Bergner M, Bastos PG, et al. THe apache iii prognostic system. risk prediction of hospital mortality for critically ill hospitalized adults. Chest. 1991 Dec 1;100(6):1619–36. • Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive pulmonary disease: a clinical trial. Ann Intern Med 1980; 93:391-8. • Plant, P. K., and M. W. Elliott. "Non-invasive ventilation in acute exacerbations of COPD." QJm 91.10 (1998): 657-660. • Incalzi, R. A., Fuso, L., De Rosa, M., Di Napoli, A., Basso, S., Pagliari, G., & Pistelli, R. (1999). Electrocardiographic Signs of Chronic Cor Pulmonale A Negative Prognostic Finding in Chronic Obstructive Pulmonary Disease. Circulation, 99(12), 1600-1605. • Puhan MA, Hansel NN, Sobradillo P, Enright P, Lange P, Hickson D, et al. Large-scale international validation of the ADO index in subjects with COPD: an individual subject data analysis of 10 cohorts. Bmj Open. 2012 Jan 1;2(6):e002152.
- 44. @drlaurajane
Notas del editor
- Definition of COPD: a cluster of heterogenous disorders, characterised by expiratory flow limitation that is not completely reversible, and is progressive. A multi-factorial disorder caused by chronic environmental insults in individuals with predispositions due to variations in one or multiple genes. COPD is caused primarily by smoking in UK (biofuels also worldwide). But remember that smoking encompasses cigarettes, pipes, shisha. Also inhaling crack and heroin cause very severe form of COPD at younger age. Debate about impact of marijuana. If smoked with tobacco appears to have synergistic effect, therefore greater lung damage. Inconsistent but suggestive evidence from population studies that marijuana smoking alone leads to modest airflow obstruction and hyperinflation, but not COPD itself. Definitely leads to emphysema. Pipe – Magritte painting called “The Treachery of Images”.
- UK recorded causes of death on death certificates 2011. WHO stats: More than 3 million people died of COPD in 2012, which is equal to 6% of all deaths globally that year. More than 90% of COPD deaths occur in low- and middle-income countries. The primary cause of COPD is tobacco smoke (through tobacco use or second-hand smoke). The disease now affects men and women almost equally, due in part to increased tobacco use among women in high-income countries
- The prevalence of COPD is increasing globally, and is projected to be the 3rd leading cause of mortality and 5th leading cause of disability by 2020 (Murray 1997, Goodridge 2008) Many people die with COPD, or from a complication related to it (4–6) But COPD may not be cited as the primary cause of death on their death certificate making it under-reported as a cause of death (Jensen 2006). 1. Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. The Lancet. 1997 May 24;349(9064):1498–504. Goodridge D, Lawson J, Duggleby W, Marciniuk D, Rennie D, Stang M. Health care utilization of patients with chronic obstructive pulmonary disease and lung cancer in the last 12 months of life. Respir Med. 2008 Jun;102(6):885–91. 4. Zielinski J, MacNee W, Wedzicha JA, Ambrosino N, Braghiroli A, Dolensky J, et al. Causes of death in patients with COPD and chronic respiratory failure. Monaldi Arch Chest Dis Arch Monaldi Mal Torace Fondazione Clin Lav Irccs Ist Clin Tisiol E Mal Appar Respir Univ Napoli Secondo Ateneo. 1997 Feb;52(1):43–7. 5. Vilkman S, Keistinen T, Tuuponen T, Kivelä S-L. Survival and Cause of Death among Elderly Chronic Obstructive Pulmonary Disease Patients after First Admission to Hospital. Respiration. 1997;64(4):281–4. 6. McGarvey LP, John M, Anderson JA, Zvarich M, Wise RA. Ascertainment of cause-specific mortality in COPD: operations of the TORCH Clinical Endpoint Committee. Thorax. 2007 May 1;62(5):411–5. 7. Jensen HH, Godtfredsen NS, Lange P, Vestbo J. Potential misclassification of causes of death from COPD. Eur Respir J. 2006 Oct 1;28(4):781–5.
- Pin the stats on the data visualisation!
- The natural history of COPD follows the organ failure trajectory(8), with a gradual decline in function punctuated by acute exacerbations, making outcome and prognostic assessment challenging in individual patients. 8. Murray S, McLoughlin P. Illness Trajectories and Palliative Care. International Perspectives on Public Health and Palliative Care. Routledge; 2013.
- The natural history of COPD follows the organ failure trajectory(8), with a gradual decline in function punctuated by acute exacerbations, making outcome and prognostic assessment challenging in individual patients. 8. Murray S, McLoughlin P. Illness Trajectories and Palliative Care. International Perspectives on Public Health and Palliative Care. Routledge; 2013.
- Figures from BODE validation cohort
- According to bereaved informal caregivers, COPD patients in the last year of life experience breathlessness (94%) anorexia (67%), pain (77%), cough (59%), insomnia (65%), confusion (33%), and low mood (71%) Other studies have found a significant symptom burden, particularly breathlessness, fatigue, and limitation of daily activities often leading to social isolation. Anxiety, panic and depression are also prominent and under-treated. Unsurprisingly, quality of life is impaired even in those with mild disease, and continues to deteriorate in those with severe disease. However, individual trajectories vary widely, along with quality of life and health-related quality of life .
- 20
- Although a palliative care approach should not be reserved for those in the last weeks and months of life, traditionally prognosis has been the way patients have been identified for such care and services. Guidelines which advocate increased advance care planning suggest identifying patients with a likely prognosis of less than six months to a year in whom to start such conversations. Stewart and McMurray (2002) have described ‘prognostic paralysis’ in which clinicians faced with uncertain disease trajectories (particularly in COPD, cardiac failure and dementia) hesitate and delay considering end-of-life-issues, leading to failure to offer patients a palliative care approach that could in fact enhance quality of life.
- A number of options are available to try to address current shortcomings in care. Importantly, there remain growing calls from patients, their relatives, healthcare professionals and policy makers for better tools for prognostication.
- This is the area I am particularly interested in.
- It is well documented that clinician estimates of prognosis in both malignant and non-malignant life-limiting disease are inaccurate, even if the clinicians are highly experienced. Most often predictions are overly optimistic, and there is vast inter-rater variability(46). Estimates of survival vary amongst physicians in patients with COPD, perhaps partly because of differential weighting of physiological and social factors. The CAOS study, which considered people with asthma and COPD (Wildman 2007) found that clinician predictions were generally pessimistic for patients being considered for admission to an intensive care unit, as compared to actual survival. Clinicians seem more comfortable with, and accurate at predicting mortality in patients with cancer compared to non-malignant disease. There is therefore a need to stop relying on intuition and to develop instruments which could aid more reliable clinical predictions.
- The limitations of data Specific populations Markers not available in community Heterogenous disease
- Prognostic models: Attempts have been made to more rigorously assess the validity of clusters of patient characteristics by using statistical and epidemiological techniques to create models. Such models exist for populations such as the hospitalized elderly (Walter 2001), and the critically ill (APACHE).
- Jan 97 – June 2002 859 outpatients with a wide range of severity of COPD recruited from clinics in the USA, Spain and Venezuela COPD = smoking >20 pack years, and FEV1/FVC <0.7 20mins after albutarol. Exclusion criteria: illness other than COPD likely to cause death in <3yrs; asthma; inability to do lung function tests and 6MWT; MI in last 3 months; unstable angina; heart failure NYHA III-IV. Factors that were recorded: age; sex; pack-years of smoking; FVC; FEV1; the best of two six minute– walk tests performed at least 30 minutes apart; the degree of dyspnea, measured with the use of the modified Medical Research Council (MMRC) dyspnea scale; the body-mass index; the functional residual capacity and inspiratory capacity the hematocrit; and the albumin level. The validated Charlson index was used to determine the degree of comorbidity. Each of these possible explanatory variables was independently evaluated to determine its association with one-year mortality in a stepwise forward logistic-regression analysis.
- Limitations: Relatively few women recruited Unlike widely used risk scores such as the Framingham risk score and the APACHE (acute physiology and chronic health evaluation) scores, the BODE index does not provide absolute risks of mortality and its calibration has never been assessed. As a consequence, the BODE index seems not yet ready for use as a prognostic instrument in patients with COPD.
- Could aid individualised COPD management according to risk profile. Allows identification of patients at moderate or high risk of mortality, for which more comprehensive management with, for example respiratory rehab, might be appropriate to reduce their risk. At what thresholds a more or less intensive treatment should be proposed to have an acceptable risk–benefit ratio is unclear. But examples from cardiovascular medicine show that a consensus can be reached on how to treat patients at different risk for mortality.
- Pin the stats on the data visualisation!
- What needs to happen to achieve this? Increasing awareness of wider aspects of care within the respiratory community, accessing education and training on how to assess these needs, and constructing models of close working with specialist palliative care teams to offer appropriate support, are essential in moving forward to provide high quality palliative care for patients with COPD. The initiation of palliative care must not be seen as an end to treatment, or as an inevitable start of the end of life phase. In fact a palliative care approach can not only enhance quality of life but may extend duration of life. Currently, patients with COPD are most likely to be cared for in a reactive crisis model at the time of deterioration, with management focused exclusively on prolongation of life. New models are needed to better support chronic disease management.
- A number of new models of care have been proposed and some have been piloted. They follow the model of mixed management and simultaneous care, such that respiratory and palliative care services work in parallel, and ‘active’ or ‘disease-focused’ treatments are provided alongside a palliative care approach. Although we are aware of innovative practice in individual institutions, not all of these have been formally evaluated, and therefore the available literature is limited.
- At a time of increased political commitment to high quality palliative care regardless of diagnosis, further investment in research is needed in this field. http://www.lse.ac.uk/newsAndMedia/news/archives/2015/04/PalliativeCare.aspx
- Pin the stats on the data visualisation!
- Patients with advanced COPD have a high burden of symptoms and significant physical, emotional and psychological needs. These are not being met by current models of care, leaving patients with impaired quality of life and a lack of advance care planning. More accurate prognostication, would be welcomed by healthcare professionals, patients and carers. In addition, investment in research into interventions for breathlessness and other symptoms such as pain, fatigue, anxiety and depression is essential. There are great opportunities to improve the lives of patients with advanced COPD, which can be achieved if Respiratory and Palliative care specialists work in parallel to conduct research and to support patients and their carers.