Palliative Care Series Prognosis and Palliative Care in

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Palliative Care Series: Prognosis and Palliative Care in COPD Dr. Rashad Ali Respirology Cambridge,

Palliative Care Series: Prognosis and Palliative Care in COPD Dr. Rashad Ali Respirology Cambridge, Ontario

Outline • Review a practical approach to prognostication in COPD • Discuss barriers to

Outline • Review a practical approach to prognostication in COPD • Discuss barriers to advanced care planning • General discussion of multidisciplinary care coordination in the community

End stage COPD • End-stage COPD refers to patients with very severe airflow limitation

End stage COPD • End-stage COPD refers to patients with very severe airflow limitation (GOLD stage IV) who are breathless with minimal exertion • They also have gas exchange abnormalities (hypoxemia, hypercapnia)

Quality of life in End stage COPD • Diminished mobility • Deconditioning • Poor

Quality of life in End stage COPD • Diminished mobility • Deconditioning • Poor exercise tolerance • Dependent on most ADLs • Social isolation

End stage COPD 41% of patients who died of COPD had left the house

End stage COPD 41% of patients who died of COPD had left the house less than once a month Elkington. Palliative Med. 2005

Case 1: Mrs. SB 65 yo F, lives with her son, seen May 2016

Case 1: Mrs. SB 65 yo F, lives with her son, seen May 2016 PMHx: 1. Endstage COPD on home O 2 at 5 L with 1. multiple exacerbations requiring ICU admission/Bi. PAP. 2. Quit smoking about 3 years prior 2. 3. 4. 5. 6. 7. 8. 9. Morbid Obesity Diabetes. Hypertension. GERD. Diverticulosis Anxiety. Fibromyalgia Dependent personality disorder traits

Medical history § High disease burden and difficulty attending outpatient appointments § Discharged from

Medical history § High disease burden and difficulty attending outpatient appointments § Discharged from 2 Respirology clinics previously due to lack of attendance and nonadherence § Admissions: first admission recorded at CMH for COPD was December 1999 § 2016: January , March, May , December § 2017: January, February, June, August § Started on Bi. PAP empirically in August 2017

Medications 1. Spiriva 18 mcg daily. 2. Symbicort 200 mcg 2 puffs b. i.

Medications 1. Spiriva 18 mcg daily. 2. Symbicort 200 mcg 2 puffs b. i. d. 3. Ventolin 2 puffs q. 4 h. p. r. n. 4. Ventolin nebules 2. 5 mg q. 2 h. p. r. n. 5. Metformin 1000 mg p. o. b. i. d. 6. Rivotril 0. 5 mg p. o. b. i. d. 7. Ativan sublingual 0. 5 mg t. i. d. p. r. n. 20 tabs 8. Januvia 100 mg p. o. daily. 9. Crestor 10 mg p. o. nightly. 10. Diamicron MR 90 mg p. o. daily. 11. Vitamin D 3 2000 units p. o. daily. 12. ASA 81 mg daily p. o. 13. Pantoloc 40 mg p. o. b. i. d. 12. Sulcrate suspension 1000 mg p. o. t. i. d. 13. Lasix 20 mg p. o. daily. 14. Lactulose 30 m. L p. o. b. i. d. 15. Restoralax 17 grams p. o. q. 2 days. 16. Colace 100 mg p. o. nightly. 17. Senokot 2 tabs p. o. nightly p. r. n.

Investigations FEV 1 in 2009 was 0. 6 L or 29% predicted, DLCO 44%

Investigations FEV 1 in 2009 was 0. 6 L or 29% predicted, DLCO 44% p. CO 2 usually in the low 50 s at baseline

Case 1: Mrs. SB CXR June 2017

Case 1: Mrs. SB CXR June 2017

Case 1: Mrs. SB

Case 1: Mrs. SB

Case 2: Mr. RS 72 yo M • Admitted June 2016 with progressive dyspnea,

Case 2: Mr. RS 72 yo M • Admitted June 2016 with progressive dyspnea, weakness • Has severe signs of cor-pulmonale and generalized edema • Known severe restrictive pleural fibrosis, suspected asbestos related • • Told his wife he was “going to the hospital to die”

Case 2: Mr. RS • Admitted in 2001 with severe pulmonary hypertension, with RVSP

Case 2: Mr. RS • Admitted in 2001 with severe pulmonary hypertension, with RVSP of over 90, and hypercapnic and hypoxemic respiratory failure • p. CO 2 in 2001 was in the 70 s. • Was on home Bi. PAP, on IPAP of 11 and EPAP of 7. • Overnight pulse oximetry study in hospital showed proufound hypoxemia with sats dropping into the 40 s • repeat echo essentially unchanged from 15 years ago: severe pulmonary hypertension with RVSP of 78, but normal LV AND RV systolic function

Pulmonary function testing July 2016

Pulmonary function testing July 2016

Bi. PAP therapy and Overnight pulse Oximetry July 6, 2016

Bi. PAP therapy and Overnight pulse Oximetry July 6, 2016

July 17, 2017

July 17, 2017

Advanced care planning An organized ongoing process of communication to help an individual identify,

Advanced care planning An organized ongoing process of communication to help an individual identify, reflect upon, discuss, and articulate her or his values, beliefs, goals, and priorities to guide personal care decision making including end-of-life care

Barriers to Advanced care planning (ACP) Physician-related 1. disease trajectory with unclear prediction for

Barriers to Advanced care planning (ACP) Physician-related 1. disease trajectory with unclear prediction for prognosis and obscure transitions towards the end of life 2. Poor recognition that ACP should begin early in the course of COPD 3. False belief that patients with advanced COPD would not want treatment limitations 4. Concern that early ACP will take away patients’ hope

Barriers to Advanced care planning (ACP) Physician-related 5. Limited outpatient contact time and reimbursement

Barriers to Advanced care planning (ACP) Physician-related 5. Limited outpatient contact time and reimbursement to discuss treatment options, life value and preferences 6. Inadequate clinician training in ACP or end-of-life care communication 7. Multiple comorbidities that distract from COPD care

Barriers to Advanced care planning Patient-related: 1. desire to focus on the present rather

Barriers to Advanced care planning Patient-related: 1. desire to focus on the present rather than the future and dying 2. concern about potential negative effects on loved ones 3. Fear of abandonment 4. Lack of education regarding COPD and its course and prognosis 5. Feeling guilty about their smoking-related disease

Barriers to Advanced care planning • 75% of patients in one study reported “I

Barriers to Advanced care planning • 75% of patients in one study reported “I would rather concentrate on staying alive than talk about death” • only 23% of the patients with severe COPD reported “my doctor is very good at talking about end-of-life care” Advance care planning in COPD. Patel K, Janssen DJ, Curtis JR. Respirology. 2012 Jan; 17(1): 72 -8.

Advance care planning in COPD. Patel K, Janssen DJ, Curtis JR. Respirology. 2012 Jan;

Advance care planning in COPD. Patel K, Janssen DJ, Curtis JR. Respirology. 2012 Jan; 17(1): 72 -8.

Do we know when to Initiate Palliative Care in COPD?

Do we know when to Initiate Palliative Care in COPD?

Prognostication in COPD

Prognostication in COPD

Palliative care and prognosis in COPD: a systematic review with a validation cohort Pere

Palliative care and prognosis in COPD: a systematic review with a validation cohort Pere Almagro, 1 Sergi Yun, 1 Ana Sangil, 1 Mónica Rodríguez-Carballeira, 1 Meritxell Marine, 1 Pedro Landete, 2 Juan José Soler-Cataluña, 3 Joan B Soriano, 4 and Marc Miravitlles 5 Int J Chron Obstruct Pulmon Dis. 2017; 12: 1721– 1729. Published online 2017 Jun 9

Rationale • One of the main barriers for initiating PC in COPD is the

Rationale • One of the main barriers for initiating PC in COPD is the unpredictability of vital prognosis in an individual patient. • Many variables have demonstrated a close relationship with impaired survival in COPD, but their utility for evaluating survival in an individual patient in the short or medium term is debatable • Several studies have shown that mortality in COPD is highly concentrated in the days or weeks following an exacerbation and frequently related with comorbidities, and therefore hardly predictable

When to Initiate Palliative Care in COPD Pere Almagro et al: Palliative care and

When to Initiate Palliative Care in COPD Pere Almagro et al: Palliative care and prognosis in COPD: a systematic review with a validation cohort International Journal of Chronic Obstructive Pulmonary Disease. 2017; 12()1721

Variables related with 1 -year mortality in the systematic review

Variables related with 1 -year mortality in the systematic review

Prognostic variables and number of studies

Prognostic variables and number of studies

Prognosis in COPD: BODE INDEX Celli et al. NEJM 2004 B: BMI O: Obstruction

Prognosis in COPD: BODE INDEX Celli et al. NEJM 2004 B: BMI O: Obstruction D: Dyspnea E: Exercise Capacity

BODE Index: Is it precise? BODE score from 7 to 10, proposed as a

BODE Index: Is it precise? BODE score from 7 to 10, proposed as a criterion for considering PC in COPD patients in several publications, carries a yearly mortality ranging from 7% in the original cohort, based on ambulatory patients without comorbidity, to >20% in patients hospitalized for COPD exacerbation A longitudinal study of serial BODE indices in predicting mortality and readmissions for COPD. Ko FW et al. Respir Med. 2011 Feb; 105(2): 266 -73. Pseudomonas aeruginosa and mortality after hospital admission for chronic obstructive pulmonary disease. Almagro P et al. Respiration. 2012; 84(1): 36 -43.

Results in the study cohort of 697 COPD Patients : • Of the 18

Results in the study cohort of 697 COPD Patients : • Of the 18 variables analyzed in their cohort, only age ≥ 70 years, depression, health-related quality of life (SGRQ ≥ 60 points) and dyspnea 3– 4 in the m. MRC scale had a concomitant sensitivity and specificity ≥ 50%. • Age ≥ 70 years had the greatest sensitivity (0. 71) with a specificity of 0. 41; in contrast, the greatest specificity was associated with severe functional dependence (0. 92) but at the expense of a very low sensitivity (0. 11).

CODEX index Comorbidities and short-term prognosis in patients hospitalized for acute exacerbation of COPD:

CODEX index Comorbidities and short-term prognosis in patients hospitalized for acute exacerbation of COPD: the EPOC en Servicios de medicina interna (ESMI) study. Almagro P, Cabrera FJ, Diez J, Boixeda R, Alonso Ortiz MB, Murio C, Soriano JB, Working Group on, COPD, Spanish Society of Internal Medicine. Chest. 2012 Nov; 142(5): 1126 -1133.

CODEX index calculator

CODEX index calculator

Carlson comorbidity index

Carlson comorbidity index

Conclusions from study None of the suggested criteria for initiating palliative care based on

Conclusions from study None of the suggested criteria for initiating palliative care based on an expected poor prognosis in COPD patients in the short or medium term offers sufficient reliability, and consequently, they should be avoided as exclusive criteria for considering PC or at least critically appraised

My experience…. Good Prognostic Factors 1. 2. 3. 4. 5. Normal LV systolic function.

My experience…. Good Prognostic Factors 1. 2. 3. 4. 5. Normal LV systolic function. Reasonable renal function Lack of RV failure (reduced systolic function or Dilation) Lack of hypotension Lack of severe structural lung disease ( distortion and fibrosis)

My experience… The bad ones Progressive functional decline despite maximal therapy Cachexia

My experience… The bad ones Progressive functional decline despite maximal therapy Cachexia

Thank you

Thank you

Opioids in COPD The candidate treatment with best evidence to date is regular, low-dose,

Opioids in COPD The candidate treatment with best evidence to date is regular, low-dose, non-nebulised (systemic) morphine 2 The efficacy of low-dose systemic opioids was supported by a Cochrane review by Jennings et al, 3 , 4 an adequately powered crossover trial in 2003, 5 and the meta-analysis in people with severe COPD by Ekström et al. Jennings AL, Davies AN, Higgins JP, et al. Opioids for the palliation of breathlessness in terminal illness. Cochrane Database Syst Rev 2001 Ekström MP, Abernethy AP, Currow DC. The management of chronic breathlessness in patients with advanced and terminal illness. BMJ 2015 Abernethy AP, Currow DC, Frith P, et al. Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ 2003 Ekström M, Nilsson F, Abernethy AA, et al. Effects of opioids on breathlessness and exercise capacity in chronic obstructive pulmonary disease: a systematic review. Ann Am Thorac Soc 2015

Cochrane Database Syst Rev. 2012 Jul 11; (7): CD 002066. doi: 10. 1002/14651858. CD

Cochrane Database Syst Rev. 2012 Jul 11; (7): CD 002066. doi: 10. 1002/14651858. CD 002066. pub 2. WITHDRAWN: Opioids for the palliation of breathlessness in advanced disease and terminal illness. Jennings AL 1, Davies AN, Higgins JP, Anzures-Cabrera J, Broadley KE. Author information Department of Palliative Medicine, Royal Marsden NHS Trust, London, UK. annelouise. jennings@rmh. nhs. uk.

The meta-analysis of Barnes et al 7 re-analysed using random effects model and accounting

The meta-analysis of Barnes et al 7 re-analysed using random effects model and accounting for matched data of crossover trials. In the pooled analysis compared with placebo, systemic opioids reduced breathlessness by a mean 0. 32 (95% CI 0. 18 to 0. 47; p<0. 001) SDs.

Proposal • Is the patient is on maximum or maximally tolerated optimal medical therapy

Proposal • Is the patient is on maximum or maximally tolerated optimal medical therapy • Is there progressive functional decline, recurrent hospitalization, or distress about symptoms despite maximal therapy

The Cochrane Library Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma

The Cochrane Library Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma Christopher J Cates, Emma J Welsh, Brian H Rowe First published: 13 September 2013 Nebuliser delivery produced outcomes that were not significantly better than metered-dose inhalers delivered by spacer in adults or children, in trials where treatments were repeated and titrated to the response of the participant. Spacers may have some advantages compared to nebulisers for children with acute asthma. The studies excluded people with life-threatening asthma; therefore, the results of this meta-analysis should not be extrapolated to this patient population.

Holding chambers (spacers) versus nebulisers for beta‐agonist treatment of acute asthma Cochrane Database of

Holding chambers (spacers) versus nebulisers for beta‐agonist treatment of acute asthma Cochrane Database of Systematic Reviews 13 SEP 2013 DOI: 10. 1002/14651858. CD 000052. pub 3 http: //onlinelibrary. wiley. com/doi/10. 1002/14651858. CD 000052. pub 3/full#CD 000052 -fig-00409