Planning for the future - when does the future start?
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Presentation at PLAN Network event, on advance care planning in chronic respiratory disease. NB last few slides are resources for the group task, and references. Let me know i I missed any!
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Planning for the future - when does the future start?
- 1. Planning for the future – when does the future start? Dr Laura-Jane E Smith Wellcome Clinical Research Fellow, Imperial College Respiratory SpR, NorthEast London @drlaurajane November 2015
- 3. The Challenge of Palliative Care. Smith, LJE and Quint JK, in: Controversies in COPD, Publisher: European Respiratory Society. Editors: Antonio Anzueto, Yvonne Heijdra, John R Hurst, Chapter: 20 pp.297-322
- 5. Advance care planning Advance statement Advance decision to refuse treatment Lasting Power of Attorney Mental Capacity Act 2005
- 7. Why do ACP? How can we identify people nearing the end of life? How can we put this into practice?
- 8. WHY DO ACP IN COPD?
- 10. 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 Gore JM et al 2000 COPD Lung cancer
- 11. Mutual understanding Enhancing openness Enabling discussion of concerns Enhancing hope Relieving fear Strengthening family ties Debunking myths Providing practical advice/support Enhancing autonomy
- 12. HOW CAN WE IDENTIFY PEOPLE NEARING THE END OF LIFE?
- 14. Group task
- 15. 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
- 16. Declining functional status Complications eg LTOT, cor pulmonale High use of healthcare Symptom burden Patient choice Triggers eg hospitalisation, bereavement
- 17. HOW CAN WE PUT THIS INTO PRACTICE?
- 25. • Age: whilst advancing age is an independent predictor of mortality (eg Celli 2005, Soler-Cataluna 2005), it is not very practically helpful in discriminating within COPD population • FEV1%: traditionally way we determined severity, and prognosis (Anthonisen 1989). Helpful at extremes, but alone a poor predictor. Large variations in prognosis within GOLD stages • MRC: breathlessness a better predictor of 5year survival than FEV1 (Nishimura 2002) • BODE: Includes FEV1% predicted, 6MWT, mMRC, BMI . 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). Score of 2 = 80% survival, score of 7 = 18% survival at 4years (Celli 2004)
- 26. • BMI: Independent prognostic factor (Landbo 1999). Falling BMI may be due to chronic systemic inflammation. Nutritional interventions not helpful. Marker, not causal. Part of BODE index. • SGRQ: In a prospective study of patients with COPD after hospitalisation, SGRQ (total score and subscales of activity, impact and symptoms) was related to higher mortality (Gudmundsson 2006) • Surprise question: Said to be able to identify people who would benefit from palliative care input (Murray 2011), but others think unhelpful in COPD (Small 2010). No studies testing accuracy? Depends on clinician assessment. • Clinician prediction: Clinician’s estimates of prognosis for malignant (Parkes 1972)and non-malignant disease are inaccurate (Christakis 2000). Often overly- optimistic, and vast inter-rater variability.
- 27. • LTOT: Those on LTOT have more severe disease. Often low FEV1%, and cor pulmonale, both assoc with poorer survival. • Depression: Those with clinical diagnosis of depression had higher mortality when adjusted for FEV1% (Stage 2004). What about milder depression? Less clear… • Albumin: In the SUPPORT study, albumin was one of the independent predictors of mortality found, in a group of >1000 patients with COPD admitted to hospital with an exacerbation (Connors 1996). • Co-morbidities: A number of comorbidities are associated with higher mortality (eg diabetes Gudmunnson 2006). A high Charlson index is also associated.
- 28. • 6MWT: Independent predictor, after accounting for age, BMI, FEV1 and comorbidities. (Pinto-Plata 2004). Part of BODE index. • Previous NIV use: Hypercapnoea, and need for NIV during an exacerbation identified in a number of studies as assoc with poorer survival (eg Connors 1996, Soler-Cataluna 2005) • Exacerbation freq: Exacerbation frequency is associated with lung function decline (Donaldson 2002) (Soler-Cataluna 2005 • Hospitalisation: Severe acute exacerbations have an independent negative effect on prognosis, particularly if they require hospital admission (Soler-Cataluna 2005)
- 29. 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
- 30. • Anthonisen, Nicholas R. “Prognosis in Chronic Obstructive Pulmonary Disease: Results from Multicenter Clinical Trials.” American Review of Respiratory Disease 140, no. 3_pt_2 (September 1, 1989): S95–S99. • Christakis, Nicholas A., Elizabeth B. Lamont, Julia L. Smith, and Colin Murray Parkes. “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 320, no. 7233 (2000): 469–473. • Connors, A F, N V Dawson, C Thomas, F E Harrell, N Desbiens, W J Fulkerson, P Kussin, P Bellamy, L Goldman, and W A Knaus. “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).” American Journal of Respiratory and Critical Care Medicine 154, no. 4 (October 1, 1996): 959–967. • Donaldson, G. C., T. a. R. Seemungal, A. Bhowmik, and J. A. Wedzicha. “Relationship Between Exacerbation Frequency and Lung Function Decline in Chronic Obstructive Pulmonary Disease.” Thorax 57, no. 10 (October 1, 2002): 847–852. • Edmonds, Polly, Saffron Karlsen, Saba Khan, and Julia Addington-Hall. “A Comparison of the Palliative Care Needs of Patients Dying from Chronic Respiratory Diseases and Lung Cancer.” Palliative Medicine 15, no. 4 (2001): 287– 295. • Gore, J. M., C. J. Brophy, and M. A. Greenstone. “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 55, no. 12 (2000): 1000–1006. • Habraken, Jolanda M., Gerben ter Riet, Justin M. Gore, Michael A. Greenstone, Els J.M. Weersink, Patrick J.E. Bindels, and Dick L. Willems. “Health-Related Quality of Life in End-Stage COPD and Lung Cancer Patients.” Journal of Pain and Symptom Management 37, no. 6 (June 2009): 973–981. • Landbo, Charlotte, Eva Prescott, Peter Lange, Jørgen Vestbo, and Thomas P. Almdal. “Prognostic Value of Nutritional Status in Chronic Obstructive Pulmonary Disease.” American Journal of Respiratory and Critical Care Medicine 160, no. 6 (December 1, 1999): 1856–1861. • Murray, S. A., and K. Boyd. “Using the ‘surprise Question’ Can Identify People with Advanced Heart Failure and COPD Who Would Benefit from a Palliative Care Approach.” Palliative Medicine 25, no. 4 (June 1, 2011): 382–382. • Parkes, C. Murray. “Accuracy of Predictions of Survival in Later Stages of Cancer.” British Medical Journal 2, no. 5804 (April 1, 1972): 29–31. • Small, N., C. Gardiner, S. Barnes, M. Gott, S. Payne, D. Seamark, and D. Halpin. “Using a Prediction of Death in the Next 12 Months as a Prompt for Referral to Palliative Care Acts to the Detriment of Patients with Heart Failure and Chronic Obstructive Pulmonary Disease.” Palliative Medicine 24, no. 7 (October 1, 2010): 740–741. • Smith, LJE and Quint JK. The Challenge of Palliative Care in: Controversies in COPD, Publisher: European Respiratory Society. Editors: Antonio Anzueto, Yvonne Heijdra, John R Hurst, Chapter: 20 pp.297-322 • Stage, K. B., T. Middelboe, and C. Pisinger. “Depression and Chronic Obstructive Pulmonary Disease (COPD). Impact on Survival.” Acta Psychiatrica Scandinavica 111, no. 4 (April 1, 2005): 320–323.
Notas del editor
- Welcome Who am I? Why am I interested in this area? It’s nice to see some friendly faces. I have already been recognised from Twitter!
- This is an area with many questions and few answers. I am here to share my thoughts and hear yours. Needs more research - opportunities for us all. PeolsP - who, what, why, where, when? Image from: http://bit.ly/1P4TYJO
- Much of this talk is covered more thoroughly in this chapter in the latest ERS monograph, published earlier this year. Unfortunately it is not open access, but you may be able to access through Athens, or ask your department to buy a copy – the book is entirely focused on COPD, with other chapters including: screening and case finding; COPD co-existing with other conditions such as asthma and bronchiectasis; the importance of physical activity; how to assess the benefits of PR… etc
- Need to start by being clear on what we are talking about when we talk about ACP. Advance statement: written records or oral expressions of future preferences for care and treatment, often a general reflection of a person’s hopes, beliefs, values and wishes for care. Used to help inform decision-making and an individual’s best interests when the person has lost capacity. Not legally binding in the same way as advance decisions. Advance decision to refuse treatment: relates to a specific refusal of medical treatment and specific circumstances. Can be made by someone >18yrs who has mental capacity. Relates to refusal of a specific treatment in specific circumstances, usually including the statement ‘even if life is at risk’, signed and witnessed. Comes into effect if the individual loses capacity. LPA: A statutory form of power of attorney created by the Mental Capacity Act (2005). Anyone who has capacity can choose a person (an ‘attorney’ to take decisions on their behalf, regarding their health and welfare, if they subsequently lose capacity.
- There is limited value to doing ACP if the conversation is not captured and shared with other health care professionals. One way to do this is through an EPaCCs, of which co-ordinate my care is one example, used in London. You may have used this yourself.
- Great reason to celebrate. However, care is patchy. Postcode lottery. Not equal access or quality across diagnoses. Is this the story of our COPD patients? Evidence suggests they get a bad deal. We need to identify patients who may benefit in order to direct care/services – including advance care planning. ACP is one part of palliative care.
- 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. However, individual trajectories vary widely, along with quality of life and health-related quality of life . Patients with advanced COPD have similar treatment preferences to patients with lung cancer but are more likely to undergo invasive interventions near the end of life and less likely to complete advanced care planning or access specialist palliative care services. Informal carers take on a significant burden of emotional and practical support and have high rates of post-bereavement depression. 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. 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 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.
- I could have also put extending life on this list. 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. eg NEJM Temel early palliative care in lung cancer study, and Higginson (Cambridge) Breathlessness clinic (incl ACP) including COPD patients. Many clinicians fear removing hope, and we know that hope is vitally important to many patients. Reassuringly, a study in patients with end stage renal disease explored this and found it not to be the case. Davidson & Simpson (2006) found in their qualitative study that patients’ hopes were highly individualized and were shaped by personal values. Participants identified hope as central to the process of advance care planning. More information earlier in the course of the illness focusing on the impact on daily life, along with empowerment of the patient and enhancing professional and personal relationships, were key factors in sustaining patients’ ability to hope. The reliance on health professionals to initiate end of life discussions (since this did not happen early or often enough) and the daily focus of clinical care were seen as potential barriers to hope. “Current practices concerning disclosure of prognosis are ethically and psychologically inadequate in that they do not meet the needs of patients.” Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010;363(8):733–42. Higginson IJ, Bausewein C, Reilly CC, Gao W, Gysels M, Dzingina M, et al. An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomised controlled trial. Lancet Respir Med [Internet]. 2014 Oct Davison, S. N, and C. Simpson. “Hope and Advance Care Planning in Patients with End Stage Renal Disease: Qualitative Interview Study.” BMJ 333, no. 7574 (October 28, 2006): 886–0.
- We have seen that there are many reasons to think that ACP would be beneficial for patients with COPD. ACP can happen at any time and anyone should have the opportunity to discuss issues relating to prognosis and end of life planning at any point in their disease. However, we know patients wait for healthcare professionals to bring it up, and many HCPs want to start these discussions ‘when the time is right’. At diagnosis may be too early, and not of immediate relevance to the patient. But end-of-life is too late, as plans cannot be enacted and choices are limited. So why is it difficult to identify patients with COPD who are nearing the end of life?
- The natural history of COPD follows the organ failure trajectory, with a gradual decline in function punctuated by acute exacerbations, making outcome and prognostic assessment challenging in individual patients. 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. Stewart S, McMurray JJV. Palliative care for heart failure. BMJ. 2002 Oct 26;325(7370):915–6.
- Get into groups and discuss the 16 prognostic markers in front of you. Pick your top three, and nominate someone to feedback to the whole group the highlights of your discussion, and your rationale for choosing those three. Discuss the prognostic markers groups picked. Bring out: Clinician prediction (and how poor this is, particularly in non-malignant disease) Multivariate scores such as BODE Patient reported measures eg breathlessness, QoL – as good if not better than ‘objective’ measures A limitation of many existing studies is that they have been conducted in specific populations. The findings are therefore not applicable to the large population of patients with moderate to severe COPD in the community. The analysis of data from electronic health record databases of routinely captured data offers an opportunity to create and validate models which could potentially identify patients in the last year of life. Let’s hope so for the sake of my PhD viva!
- The limitations of data: Specific populations Markers not available in community Heterogenous disease What is missing on this list?
- For now, these would be good concepts to use when thinking about who to start ACP with.
- A challenge is to differentiate end-of-life care, focused on the last weeks and days of life, from palliative care, a much longer term approach to care that can begin at any point in the trajectory of a life-limiting illness and can co-exist with other ‘active’ or disease-orientated treatments. It is particularly important to make a distinction between these two terms in the context of COPD, as the time-frame over which a patient may benefit from a palliative care approach may be several years. We must put ACP within this model, maintaining hope for our patients and helping them make choices that make sense for them.
- 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.