District nurse role in end-stage COPD: a review

Management of stable chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a common condition. There are an estimated 3 million cases in the UK. Of these, 2 million have not got a formal diagnosis. Community nurses meet patients with COPD frequently, although COPD may not be the primary reason for the encounter, or the COPD may be present but undiagnosed. The number of patients with COPD is believed to be increasing and, with increased awareness of the condition and an emphasis on improving diagnosis, the number of cases is expected to rise. Community nurses are well placed to raise concerns that a patient in their care may have undiagnosed COPD; if the condition is subsequently diagnosed and appropriate treatment is given, outcomes will improve for that individual. Community nurses can also support patients and their families to manage the condition through all stages of the disease trajectory, from diagnosis to the end-of-life phase.

Can early introduction of specialized palliative care limit intensive care, emergency and hospital admissions in patients with severe and very severe COPD? a randomized study

BACKGROUND

COPD is a progressive lung disorder with rates of mortality between 36-50%, within 2 years after admission for an acute exacerbation. While treatment with inhaled bronchodilators and steroids may partially relieve symptoms and oxygen therapy may prolong life, for many patients the course of the disease is one of inexorable decline. Very few palliative care intervention studies are available for this population. This trial seeks to determine the effectiveness of the introduction of specialized palliative care on hospital, intensive care unit and emergency admissions of patients with severe and very severe COPD.

METHODS/DESIGN

The study is a three year single centre, randomized controlled trial using a 2 arms parallel groups design conducted in a tertiary center (University Hospitals; Geneva). For the intervention group, an early palliative care consultation is added to standard care; the control group benefits from standard care only. Patients with COPD defined according to GOLD criteria with a stage III or IV disease and/or long term treatment with domiciliary oxygen and/or home mechanical ventilation and/or one or more hospital admissions in the previous year for an acute exacerbation are eligible to participate. Allocation concealment is achieved using randomisation by sealed envelopes. Our sample size of 90 patients/group gives the study a 80% power to detect a 20% decrease in intensive care unit and emergency admissions--the primary endpoint. All data regarding participants will be analysed by a researcher blinded to treatment allocation, according to the "Intention to treat" principle.

DISCUSSION

Given the trends toward aggressive and costly care near end-of-life among patients with COPD, a timely introduction of palliative care may limit unnecessary and burdensome personal and societal costs, and invasive approaches. The results of this study may provide directions for future palliative care interventions in this particular population.

TRIAL REGISTRATION

This trial has been registered at clinicaltrials.gov under NCT02223780.

Exploring the concept of quality care for the person who is dying

The concept of good quality care for the patient who is dying is diverse and complex. Many of the actions that are being taken to increase the quality of care of the dying patient are based around outcome, uniformity of service and standardization of process. There are two main areas that are referred to when dealing with care of the dying patient; end-of-life care and palliative care. High quality end-of-life care is increasingly recognized as an ethical obligation of health-care providers, clinicians and organizations, and yet there appears little evidence from the patients' perspective. There are many national and local initiatives taking place to improve the quality of care people receive towards the end of their life. This being said initiatives alone will not achieve good quality care and deliver good patient experiences. Only clinicians working at the front line can truly influence the way in which quality is improved and good experiences delivered.