nice copd palliative care

/ January 19, 2021/ Uncategorised

The Australian and New Zealand COPD guidelines (2019) refer to palliative care, but in their key recommendations state that the evidence for palliative care is weak (as it is categorised under optimising function) . For standards and measures on palliative care, see the NICE quality standard on end of life care for adults. [2018]. It involves close attention to the emotional, spiritual and practical needs and goals of patients and of the people who are close to them, including determining their views on future care 1.2.80 Palliative Care in Advanced Lung Disease Scottish Guideline. [2004], 1.3.43 People who have had an episode of respiratory failure should have satisfactory oximetry or arterial blood gas results before discharge. Informed consent should be obtained and documented. [2010, amended 2018]. For guidance on care for people in the last days of life, see the NICE guideline on care of dying adults. Palliative care in chronic obstructive pulmonary disease (COPD) is an area that needs development. Follow-up of all people with COPD should include: highlighting the diagnosis of COPD in the case record and recording this using Read Codes on a computer database, recording the values of spirometric tests performed at diagnosis (both absolute and percent predicted), offering advice and treatment to help them stop smoking, and referral to specialist stop smoking services (see the NICE guideline on stop smoking interventions and services), recording the opportunistic measurement of spirometric parameters (a loss of 500 ml or more over 5 years will show which people have rapidly progressing disease and may need specialist referral and investigation). For people who have used 3 or more courses of oral corticosteroids and/or oral antibiotics in the last year, investigate the possible reasons for this. Biographies and registered interests for members of the Technology Appraisal Committee A. Search results. Palliative care also helps you establish goals for end-of-life care. Start prophylaxis without monitoring for people over 65. [2004], 1.2.35 Monitor people who are having long-term oral corticosteroid therapy for osteoporosis, and give them appropriate prophylaxis. [2004]. 1.2.16 For people with COPD who are taking LAMA+LABA, consider LAMA+LABA+ICS if: 1.2.17 Chronic obstructive pulmonary disease (COPD) is a growing cause of morbidity and mortality worldwide. Composite assessment tools such as the ASA scoring system are the best predictors of risk. * Or FEV1 below 50% with respiratory failure. European Respiratory Journal, 51(2), 1702645. doi: 10.1183/13993003.02645-2017. People have the right to be involved in discussions and make informed decisions about their care, as described in your care. [2004, amended 2018], 1.2.101 For guidance on diagnosing and managing depression, see the NICE guideline on depression in adults with a chronic physical health problem. It describes high-quality care in priority areas for improvement. [2004], Degree of breathlessness related to activities, Not troubled by breathlessness except on strenuous exercise, Short of breath when hurrying or walking up a slight hill, Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace, Stops for breath after walking about 100 metres or after a few minutes on level ground, Too breathless to leave the house, or breathless when dressing or undressing. Most hospice services in the UK accept patients with non-malignant illness and this openness should increase with the recent publication of NICE guidelines, which encourages a palliative care approach for patients with severe COPD. [2004], 1.2.96 continue to have 1 or more of the following, particularly if they have significant daily sputum production: frequent (typically 4 or more per year) exacerbations with sputum production, prolonged exacerbations with sputum production, exacerbations resulting in hospitalisation. [2018], 1.2.122 Be aware of the obligation to provide accessible information as detailed in the NHS Accessible Information Standard. [2004, amended 2018], 1.2.138 Review people with COPD at least once per year and more frequently if indicated, and cover the issues listed in table 6. Offer LAMA+LABA[2] to people who: do not have asthmatic features/features suggesting steroid responsiveness and. Although chronic obstructive pulmonary disease (COPD) is recognized as being a life-limiting condition with palliative care needs, palliative care provision is seldom implemented. [2004], 1.3.39 Use intermittent arterial blood gas measurements to monitor the recovery of people with respiratory failure who are hypercapnic or acidotic, until they are stable. This taxonomy involves different levels of care provision and integrated care is the last step of this dynamic process. [2004], 1.2.106 When appropriate, use opioids to relieve breathlessness in people with end-stage COPD that is unresponsive to other medical therapy. 05 December 2018 1.2.54 Starting strong opioids—titrating the dose. [2018], 1.2.20 Offer pneumococcal vaccination and an annual flu vaccination to all people with COPD, as recommended by the Chief Medical Officer. Advance care plans should be reviewed whenever there is a clinical event, deterioration, or change in social circumstances (for example a move into supported care). [2018], 1.2.68 To set a common goal, effective and empathetic communication with patients and families is important. Assess the need for oxygen therapy in people with: very severe airflow obstruction (FEV1 below 30% predicted), oxygen saturations of 92% or less breathing air.Also consider assessment for people with severe airflow obstruction (FEV1 30–49% predicted). As part of the risk assessment, cover the risks for both the person with COPD and the people who live with them, including: the risks of falls from tripping over the equipment, the risks of burns and fires, and the increased risk of these for people who live in homes where someone smokes (including e‑cigarettes).Base the decision on whether long-term oxygen therapy is suitable on the results of the structured risk assessment. Palliative care is not the same as hospice. To find out why the committee made the 2018 recommendations on long-term oxygen therapy and how they might affect practice, see rationale and impact. Inhaled combination therapy refers to combinations of long-acting muscarinic antagonists (LAMA), long-acting beta2 agonists (LABA), and inhaled corticosteroids (ICS). [2004], 1.1.10 Spirometry services should be supported by quality control processes. [2004]. To find out why the committee made the 2018 and 2019 recommendations on inhaled combination therapy and how they might affect practice, see rationale and impact. Before starting LAMA+LABA+ICS, conduct a clinical review to ensure that: the person's non-pharmacological COPD management is optimised and they have used or been offered treatment for tobacco dependence if they smoke, acute episodes of worsening symptoms are caused by COPD exacerbations and not by another physical or mental health condition, the person's day-to-day symptoms that are adversely impacting their quality of life are caused by COPD and not by another physical or mental health condition. In the absence of significant contraindications, use oral corticosteroids, in conjunction with other therapies, in all people admitted to hospital with a COPD exacerbation. If they do, consider including a cognitive behavioural component in their self-management plan to help them manage anxiety and cope with breathlessness. To find out why the committee made the 2018 recommendation on risk factors for exacerbations and how it might affect practice see rationale and impact. Type 2 respiratory failure occurs. Do not offer long-term oxygen therapy to people who continue to smoke despite being offered smoking cessation advice and treatment, and referral to specialist stop smoking services. [2004], 1.3.16 This summary is in the process of being updated. If the person is not a current smoker, their spirometry is normal and they have no symptoms or signs of respiratory disease: ask them if they have a personal or family history of lung or liver disease and consider alternative diagnoses, such as alpha‑1 antitrypsin deficiency, reassure them that their emphysema or chronic airways disease is unlikely to get worse. For people at risk of hospitalisation, explain to them and their family members or carers (as appropriate) what to expect if this happens (including non-invasive ventilation and discussions on future treatment preferences, ceilings of care and resuscitation). [2010], 1.2.43 Treatment with alpha-tocopherol and beta-carotene supplements, alone or in combination, is not recommended. For people who are using long-acting bronchodilators outside of recommendations 1.2.11 and 1.2.12 and whose symptoms are under control, explain to them that they can continue with their current treatment until both they and their NHS healthcare professional agree it is appropriate to change. 1.2.12 • Divergent meanings and goals of palliative care in COPD lead to confusion about whether such services are the responsibility of home care, primary care, specialty care, or even critical care. severe exacerbation, the person experiences a rapid deterioration in respiratory status that requires hospitalisation. 2018 Feb;15(1):36-40. doi: 10.1177/1479972317721562. Palliative care can, and should, be a standard offered to the patient and family. COPD do not receive palliative care. [2004, amended 2018], Night time waking with breathlessness and/or wheeze, Significant diurnal or day-to-day variability of symptoms, 1.1.20 In addition to the features in table 3, use longitudinal observation of people (with spirometry, peak flow or symptoms) to help differentiate COPD from asthma. • Palliative end-of-life care may not be anticipated prior to referral for such care. For people who are taking prophylactic azithromycin and are still at risk of exacerbations, provide a non-macrolide antibiotic to keep at home as part of their exacerbation action plan (see recommendation 1.2.126). (4), NICE guidelines [2018]. 1.2.27 1.1.25 [2004, amended 2018], 1.3.4 Hospital-at-home and assisted-discharge schemes are safe and effective and should be used as an alternative way of caring for people with exacerbations of COPD who would otherwise need to be admitted or stay in hospital. In this guideline 'cor pulmonale' is defined as a clinical condition that is identified and managed on the basis of clinical features. Ensure the person has an advance care plan (if they wish) and discuss end-of-life issues (where appropriate) including advance decisions. after 3 months, conduct a clinical review to establish whether or not LAMA+LABA+ICS has improved their symptoms: if symptoms have not improved, stop LAMA+LABA+ICS and switch back to LAMA+LABA, if symptoms have improved, continue with LAMA+LABA+ICS. It also includes recommendations about managing medicines for these patients, and protecting staff from infection. The provision of early palliative care can improve survival (Higginson 2014, Temel 2010). Existing palliative care models for cancer and chronic diseases such as heart failure do not seem to fit well with problems encountered by patients with COPD. [2004], 1.1.11 [2004]. Objective: To describe an outpatient palliative medicine program for patients with COPD. 1 Celli BR, MacNee W (2004) Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Do not offer the following treatments solely to manage pulmonary hypertension caused by COPD, except as part of a randomised controlled trial: 1.2.78 Palliative care is specialized medical care for people living with a serious illness. To assess cardiac status if cardiac disease or pulmonary hypertension are suspected because of: • a history of cardiovascular disease, hypertension or hypoxia or, • clinical signs such as tachycardia, oedema, cyanosis or features of cor pulmonale, To assess cardiac status if cardiac disease or pulmonary hypertension are suspected, To investigate symptoms that seem disproportionate to the spirometric impairment, To investigate signs that may suggest another lung diagnosis (such as fibrosis or bronchiectasis), To investigate abnormalities seen on a chest X-ray, To assess suitability for lung volume reduction procedures, To assess for alpha-1 antitrypsin deficiency if early onset, minimal smoking history or family history, Transfer factor for carbon monoxide (TLCO). Palliative care in COPD: an unmet area for quality improvement Julia H Vermylen,1 Eytan Szmuilowicz,2 Ravi Kalhan3 1Department of Medicine, 2Section of Palliative Medicine, Department of Medicine, 3Asthma and COPD Program, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Abstract: COPD is a leading cause of morbidity and mortality worldwide. It is appropriate for all people living with COPD regardless of stage or prognosis. Formally endorses resources produced by external organisations that support the implementation of NICE guidance and the use of quality standards. A formal activities of daily living assessment may be helpful when there is still doubt. Be alert for anxiety and depression in people with COPD. Advise people with queries to seek specialist advice. 2. [2018], 1.2.50 Review prophylactic azithromycin after the first 3 months, and then at least every 6 months. Perform additional investigations when needed, as detailed in table 2. [2018], 1.2.62 Relevance Chronic obstructive pulmonary disease Cystic fibrosis ... Opioids for pain relief in palliative care Maternity services. [2004]. [2004], 1.3.10 Change people to hand-held inhalers as soon as their condition has stabilised, because this may allow them to be discharged from hospital earlier. Do not offer routine telehealth monitoring of physiological status as part of management for stable COPD. Palliative care for adults: strong opioids for pain relief. Indeed, an Irish study showed that key barriers towards the delivery of palliative care for COPD patients included the reluctance to negotiate end-of-life decisions and a perceived lack of understanding among patients and carers regarding the illness trajectory. [2004]. Referral may be appropriate at all stages of the disease and not solely in the most severely disabled people (see table 5). 1.2.121 [2019], 1.3.17 For guidance on stopping oral corticosteroid therapy it is recommended that clinicians refer to the BNF. [2004], 1.2.113 Consider referring people for assessment by social services if they have disabilities caused by COPD. For people with end-stage COPD, the focus is on palliative care to relieve symptoms and improve quality of life. [2004], 1.3.12 The driving gas for nebulised therapy should always be specified in the prescription. PCRS-UK Algorithm for Assessing and Palliative Care Requirements for patients with COPD. [2004], 1.2.8 Do not use oral corticosteroid reversibility tests to identify which people should be prescribed inhaled corticosteroids, because they do not predict response to inhaled corticosteroid therapy. 1.2.100 [2004], 1.2.41 Only continue mucolytic therapy if there is symptomatic improvement (for example, reduction in frequency of cough and sputum production). (4), News Despite the high morbidity and mortality associated with severe COPD, many patients receive inadequate palliative care. cussed palliative care issues with their patients (16). NICE (2010) guidelines define palliative care as active holistic care of patients with advanced progressive illness. Recommendation 20. [2004], 1.2.23 Only prescribe inhalers after people have been trained to use them and can demonstrate satisfactory technique. For guidance on managing anxiety, see the NICE guideline on generalised anxiety disorder and panic disorder in adults. This care approach aligns well with COPD treatment, … Patients with end-stage chronic obstructive pulmonary disease (COPD) have poor quality of life, with limited activity, breathlessness, dependence on others, and recurrent needs for medical evaluation and treatment. [2018] This study obtained qualitative data about living and dying with COPD from serial interviews with 21 patients with end-stage … [2004], 1.3.40 Do not routinely perform daily monitoring of peak expiratory flow (PEF) or FEV1 to monitor recovery from an exacerbation, because the magnitude of changes is small compared with the variability of the measurement. For people with mild airflow obstruction, only diagnose COPD if they have one or more of the symptoms in recommendation 1.1.1. 1.2.77 Offer a respiratory review to assess whether a lung volume reduction procedure is a possibility for people with COPD when they complete pulmonary rehabilitation and at other subsequent reviews, if all of the following apply: they have severe COPD, with FEV1 less than 50% and breathlessness that affects their quality of life despite optimal medical treatment (see recommendations 1.2.11 to 1.2.17), they can complete a 6‑minute walk distance of at least 140 m (if limited by breathlessness). Thorax 57(4): 289–304. [2004], 1.1.23 Reconsider the diagnosis of COPD for people who report a marked improvement in symptoms in response to inhaled therapy. 1.10 Palliative care. IMPRESS - Effective Care, Effective Communication - Living and Dying with COPD . [2018]. Date. [2018], 1.2.2 Document an up-to-date smoking history, including pack years smoked (number of cigarettes smoked per day, divided by 20, multiplied by the number of years smoked) for everyone with COPD. Advise people who are having long-term oxygen therapy that they should breathe supplemental oxygen for a minimum of 15 hours per day. If people have excessive sputum, they should be taught: how to use positive expiratory pressure devices, active cycle of breathing techniques. The goal of palliative care is to help you, and your family, achieve the best possible quality of life. [2018], 1.2.64 To ensure everyone eligible for long-term oxygen therapy is identified, pulse oximetry should be available in all healthcare settings. Palliative care has much to offer for people living with advanced COPD, but it includes more than just terminal care or symptom control and is not only relevant for people dying with COPD but has much to offer to patients at earlier stages of the disease with poorly controlled symptoms such as breathlessness, fatigue, and anxiety. European Respiratory Journal 23(6): 932–46. Attention COPD care should be delivered by a multidisciplinary team. practice in end of life care (EOLC) was identified across the local health and care sector in Shropshire. [2017]) is: mild exacerbation, the person has an increased need for medication, which they can manage in their own normal environment, moderate exacerbation, the person has a sustained worsening of respiratory status that requires treatment with systemic corticosteroids and/or antibiotics. Palliative care can, and should, be a standard offered to the patient and family. Some people with advanced COPD may need long-term oral corticosteroids when these cannot be withdrawn following an exacerbation. The diagnosis is suspected on the basis of symptoms and signs and is supported by spirometry. This review should include pulse oximetry. [2004], 1.2.140 When people with very severe COPD are reviewed in primary care they should be seen at least twice per year, and specific attention should be paid to the issues listed in table 6. [2018], 1.2.60 For people who smoke or live with people who smoke, but who meet the other criteria for long-term oxygen therapy, ensure the person who smokes is offered smoking cessation advice and treatment, and referral to specialist stop smoking services (see the NICE guidelines on stop smoking interventions and services and medicines optimisation). On generalised anxiety disorder and panic disorder in adults for recommendations on serum! 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