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Table 1. Diagnostic Considerations Regarding Respiratory Failure in Mr V
Table 1. Diagnostic Considerations Regarding Respiratory Failure in Mr V
Table 2. Diagnostic Considerations Regarding Dyspnea in Mr V
Table 2. Diagnostic Considerations Regarding Dyspnea in Mr V
Table 3. Management of Dyspnea for Older Patients With COPDa
Table 3. Management of Dyspnea for Older Patients With COPDa
Table 4. Approach to Conditions Contributing to Functional Decline Among Patients With Advanced COPD
Table 4. Approach to Conditions Contributing to Functional Decline Among Patients With Advanced COPD
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Care of the Aging Patient: From Evidence to Action
Clinician's Corner
September 26, 2012

Caring for the Older Person With Chronic Obstructive Pulmonary Disease

Author Affiliations
 

Care of the Aging Patient Section Editor: Edward H. Livingston, MD, Deputy Editor, JAMA.

Author Affiliations: Department of Medicine, Yale University School of Medicine, New Haven, Connecticut (Drs Fried and Vaz Fragoso); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, Washington, DC (Drs Fried and Vaz Fragoso); and Department of Medicine, University of California, San Francisco (Dr Rabow).

JAMA. 2012;308(12):1254-1263. doi:10.1001/jama.2012.12422
Abstract

Chronic obstructive pulmonary disease (COPD), a common disease in elderly patients, is characterized by high symptom burden, health care utilization, mortality, and unmet needs of patients and caregivers. Respiratory failure and dyspnea may be exacerbated by heart failure, pulmonary embolism, and anxiety; by medication effects; and by other conditions, including deconditioning and malnutrition. Randomized controlled trials, which provide the strongest evidence for guideline recommendations, may underestimate the risk of adverse effects of interventions for older patients with COPD. The focus of guidelines on disease-modifying therapies may not address the full spectrum of patient and caregiver needs, particularly the high rates of bothersome symptoms, risk of functional and cognitive decline, and need for end-of-life care planning. Meeting the many needs of older patients with COPD and their families requires that clinicians supplement guideline-recommended care with treatment decision making that takes into account older persons' comorbid conditions, recognizes the trade-offs engendered by the increased risk of adverse events, focuses on symptom relief and function, and prepares patients and their loved ones for further declines in the patient's health and their end-of-life care. A case of COPD in an 81-year-old man hospitalized with severe dyspnea and respiratory failure highlights both the challenges in managing COPD in the elderly and the limitations in applying guidelines to geriatric patients.

THE PATIENT'S STORY

Acute exacerbation of dyspnea brought Mr V to the hospital. He is an 81-year-old with chronic obstructive pulmonary disease (COPD) complicated by hypertension, depression, posttraumatic stress disorder, heart failure, coronary artery disease, diabetes mellitus, hyperlipidemia, glaucoma, diverticulosis coli, and neck injury from a motor vehicle crash. He has a more than 50 pack-year smoking history but quit at age 50 years. COPD was diagnosed 10 years before, when spirometry showed a forced expiratory volume in the first second of expiration (FEV1) of 63% of predicted. Home oxygen administration at 2 L/min was begun 3 years later. Mr V's respiratory status was gradually deteriorating, manifested by the inability to walk more than block without the need to rest.

Mr V's medications include 3 inhalers: albuterol (90 μg, 1-2 puffs every 6 hours as needed); formoterol (12 μg twice daily); and mometasone (220 μg twice daily). Mr V also takes 11 oral medications: aspirin (81 mg daily); lisinopril (10 mg daily); metformin (500 mg twice daily); simvastatin (40 mg orally nightly); omeprazole (20 mg twice daily); cholecalciferol (1000 IU daily); buspirone (15 mg daily); sertraline (200 mg daily); mirtazapine (30 mg nightly); triazolam (0.125 mg nightly as needed); and oxycodone/acetaminophen (10 mg/650 mg every 6 hours as needed) as well as 3 eye drops: carboxymethylcellulose (1 drop 4 times daily); dorzolamide (2% solution, 1 drop twice daily); and travoprost (0.004% solution, 1 drop at bedtime).

Mr V's wife developed Alzheimer disease, moved into a nursing home, and subsequently died. Mr V moved to an assisted-living facility in anticipation of declining health. Prior to the move he was involved in several social organizations, but now most of his friends are gone. Mr V's advance directive calls for treatment of all potentially reversible conditions, with the exception of cardiopulmonary resuscitation or artificial ventilation in the case of a catastrophic event. Mr V has 2 sons; his younger son is his health care proxy.

Geriatric functional assessment revealed independence in Mr V’s activities of daily living (ADL) and instrumental activities of daily living (IADL), with the exception of household chores and shopping resulting from his lack of mobility. He requires a walker and scooter to travel long distances. Mr V recently fell when using his scooter.

Mr V had difficulty talking because of his shortness of breath when evaluated in the emergency department; he was feeling fine the night before but awoke feeling very short of breath. Physical examination revealed vital signs of temperature, 98.4°F; heart rate, 114 beats/min; blood pressure, 169/80 mm Hg; and respiratory rate, 30 breaths/min. He was observed to be experiencing moderate respiratory distress. Apart from his lungs, which showed poor air movement with bilateral expiratory wheezes, his physical examination was unremarkable. Mr V had a tachycardic regular rhythm with normal S1 and S2 sounds and no murmurs on his heart examination. He scored 9 of 15 on the Geriatric Depression Scale and 29 of 30 on the Mini-Mental State Examination.

Mr V's hemoglobin level was 11.4 g/dL; hematocrit, 33.6%; mean corpuscular volume, 81.8 ×10–15 L; and white blood cell count, 23 300 cells/μL. Levels of serum electrolytes, creatinine, and blood urea nitrogen were normal. Chest radiography showed large lung fields but no infiltrates or effusions. Blood gas analysis showed that pH was 7.19; PCO2, 66.1 mm Hg; PO2, 55.8 mm Hg; and oxygen saturation, 80.3%. Sputum was unobtainable.

A diagnoses of COPD exacerbation was made and systemic methylprednisolone sodium, ceftriaxone, and azithromycin administered. Initially, Mr V was admitted to the intensive care unit (ICU) and placed on bilevel positive airway pressure overnight. On the first hospital day, oral prednisone (40 mg daily) was started, with a plan to continue it for 5 days. Oral levofloxacin (750 mg/d) was started, as were albuterol and ipratropium nebulizations every 2 hours. Following his transfer to the general medicine floor, the albuterol nebulizations were changed to 1 to 2 puffs every 6 hours, and he was started on inhalations of formoterol (12 μg twice daily), tiotropium bromide (18 μg daily), and mometasone (220 μg twice daily). He continued his usual medications for his other comorbid conditions. Mr V's respiratory status gradually improved, and he was discharged back to his assisted care facility after 4 days in the hospital.

Perspectives

Mr V: As soon as I exert myself, I’m breathless . . . if I walk from the dining room to the mailbox, which is maybe 100 feet, I’ll have to stop twice.

Dr G: My impression . . . was [of] somebody who had very advanced lung disease.

Disease management guidelines for COPD provide a synthesis of a strong evidence base for the diagnosis and treatment of both the stable phase and acute exacerbations. However, the application of guideline-directed care has not consistently demonstrated good outcomes, and recent evidence suggests complexities not yet fully understood.1

As Mr V's experience illustrates, guidelines applied to older patients with dyspnea and respiratory failure are limited for a number of reasons. First, acute episodes of respiratory failure and chronic dyspnea are both likely to be multifactorial. Treatment paradigms will be influenced by the interaction of a variety of diseases and impairments in addition to COPD. Second, the diagnosis and staging of COPD requires special consideration. Third, guidelines may not address the full spectrum of patient needs resulting from the burdens of advanced disease, particularly the high risk of functional and cognitive decline and need for end-of-life care planning. Fourth, the grading of the evidence base for interventions presented in guidelines can underestimate the prevalence of adverse events for older patients and patients with multiple medical conditions. Fifth, although most guidelines recognize the importance of comorbid conditions, they do not always account for the potential adverse consequences of polypharmacy.

Disease management guidelines for COPD provide a comprehensive summary of many components of Mr V's care, and we refer the reader to these guidelines for details of the evidence base underlying these components.2,3 In this article, we focus on the components of care for which the clinician needs to look beyond the guidelines to address the needs of the older patient with COPD, severe dyspnea, and respiratory failure.

The Multifactorial Nature of Dyspnea and Respiratory Failure in an Older Patient With COPD

Mr V: I had woken up in the middle of the night to go to the bathroom and I couldn't breathe. I called for security and they got an ambulance for me. I woke up at the VA hospital and I was in the ICU.

Mr V presented with acute-on-chronic respiratory failure manifested by severe dyspnea. His long-standing oxygen dependency indicates chronic hypoxemic respiratory failure, and his respiratory acidosis is a manifestation of acute hypercapneic respiratory failure. Rather than being considered solely as a manifestation of COPD, Mr V's dyspnea and respiratory failure necessitate consideration of multiple domains. One domain contributing to both dyspnea and respiratory failure is a reduction in ventilatory capacity. Before being hospitalized, Mr V had manifestations of severely reduced ventilatory capacity resulting from advanced COPD. His prehospital pulmonary function tests showed irreversible airflow limitation (ratio of FEV1 to forced vital capacity reduced to 0.42) associated with hyperinflation (total lung capacity, 164% of predicted) and abnormal gas exchange (reduced diffusion capacity for carbon monoxide, 54% of predicted). Based on these features—especially in the setting of prior tobacco use—airways obstruction resulting from COPD is a major contributor to his decreased ventilatory capacity.2,4 Mr V's COPD is classified as moderate, based on criteria from the Global Initiative for Obstructive Lung Disease, because his most recent FEV1 was 68% of predicted.2 Respiratory failure and disabling dyspnea are not usually complicating features of moderate COPD. An alternative staging strategy that rigorously accounts for age-related changes in pulmonary function and variability in spirometric performance, the lambda-mu-sigma method, demonstrates that 28.1% of severe COPD is classified as moderate by the Global Initiative for Obstructive Lung Disease.5 Accurate classification of COPD severity is essential for the appropriate attribution of symptoms and use of COPD-directed therapies.

Table 1 summarizes causes of reduced ventilatory capacity. Mr V's presentation suggests pathophysiology other than COPD, such as heart failure.10,11 Acute pulmonary thromboembolism must be considered because Mr V's dyspnea had increased abruptly on admission. Postmortem studies of patients hospitalized for what was initially thought to be an exacerbation of COPD (n = 43; median age, 70 years) revealed that heart failure was present in 16 patients (37%) and pulmonary thromboembolism in 9 (21%).7 Mr V may have respiratory muscle weakness from fatigue related to increased work of breathing because of his COPD.Quiz Ref IDRespiratory muscle weakness can also be caused by sarcopenia attributable to COPD, heart failure, diabetes, and advanced age. He also might have sustained a phrenic nerve injury related to a neck injury in his prior motor vehicle crash.8 Mr V is taking medications that reduce ventilatory capacity: concurrent use of opiates and benzodiazepines decreases ventilatory control and increases risk of recurrent aspiration, and statins and systemic corticosteroids may cause myopathy of respiratory muscles. Corticosteroids also may cause osteoporosis-related kyphoscoliosis.911 The interaction between these medication effects and age-related reductions in ventilatory control, respiratory mechanics, respiratory muscle strength, and gas exchange12 potentially contribute to the occurrence of pneumonia (28%) and respiratory failure (14%) as established causes of death among older persons hospitalized for exacerbation of COPD.7

A second domain contributing to dyspnea is increased ventilatory demand. Increased oxygen demands of muscle during periods of exercise increase ventilatory requirements.13,14 If the exercising muscle has a reduced aerobic capacity, the ventilatory demand increases further because of the carbon dioxide load resulting from anaerobic metabolism.13,14 As occurred in Mr V, increases in ventilatory demand accompanying exercise results in severe dyspnea, including during ADL.Quiz Ref IDOlder persons are especially burdened by a multiplicity of impairments that reduce aerobic capacity. For Mr V, these may include low cardiac output from heart failure, COPD with cor pulmonale, and pulmonary hypertension caused by chronic pulmonary thromboembolism. Aerobic capacity also might be compromised by anemia that reduces arterial oxygen content. Similarly, muscular sarcopenia in the muscles of ambulation caused by COPD, heart failure, diabetes, malnutrition, advanced age, and deconditioning can reduce aerobic capacity, as can medication-related adverse effects such as postural hypotension associated with use of lisinopril, sertraline, and mirtazapine; loss of balance with use of oxycodone, triazolam, buspirone, albuterol, formoterol, and omeprazole; and myopathy with use of simvastatin, methylprednisolone, and prednisone.

As shown in Table 2, Quiz Ref IDpsychosocial and environmental factors unrelated to cardiopulmonary physiology can contribute to dyspnea.1518 Mr V has psychosocial burdens, including depression, posttraumatic stress disorder, chronic back pain, and social isolation. Moreover, Mr V also may face environmental barriers, such as the distance he needs to walk to get to his meals, that worsen his dyspnea. Because these psychological and environmental factors are independently associated with dyspnea, physiologic measures such as FEV1 and ejection fraction, although important in establishing disease and predicting adverse outcomes, cannot by themselves fully explain the experience of dyspnea.16,17,19,20

A Comprehensive Approach to the Diagnosis and Treatment of Respiratory Failure and Dyspnea in the Older Patient With COPD

Dr G: I usually try to prioritize people's health problems in my mind. So, I wrote in my notes that his main issue was COPD and he was oxygen dependent. That was driving the treatment plan. . . . The plan was to mainly optimize his function with lung disease, try to prevent decline, and optimize and streamline his treatments for his other chronic conditions . . . and also a significant psychiatric constellation which included [posttraumatic stress disorder] and depression.

In the acute setting, especially during an ICU admission, the focus is on cardiopulmonary physiology, because reduced ventilatory capacity and cardiac output are likely to be the predominant underlying mechanisms for respiratory failure.2 Acute clinical management is guided primarily by assessments of COPD and heart failure exacerbations, pulmonary thromboembolism, and medication-related adverse effects (Table 1). Evidence-based guidelines are available for treatment of heart failure and pulmonary thromobembolism.21,22 Once a patient leaves the ICU, clinical management should include consideration of additional determinants of increased ventilatory demand and dyspnea, including psychosocial and environmental factors (Table 2).

Guidelines for management of COPD summarize the evidence supporting the use of inhaled β-agonist and anticholinergic agents and, for patients with severe COPD, inhaled corticosteroids and phosphodiesterase-4 inhibitors.2,3 However, among older patients with comorbid conditions, greater caution and more vigilant monitoring for adverse effects of these agents above and beyond what is in the guidelines is necessary. For example, guidelines present inhaled bronchodilators as having few adverse effects.2 This may not be the case for elderly patients like Mr V. Information regarding adverse events is obtained from the same randomized controlled trials (RCTs) that provide information regarding medication efficacy. Quiz Ref IDIncreasingly, however, it is recognized that RCTs underestimate the likelihood of adverse events,23,24 This is in part because the generally relatively small sample sizes for these studies, although sufficient to establish efficacy, may not be sufficient to demonstrate complications. The studies also have relatively short follow-up and incomplete ascertainment of adverse events. Even more important is the exclusion from RCTs of patients who have risk factors for adverse effects. Although a pooled analysis of several trials has reported increased risks for cardiovascular events and mortality with use of inhaled anticholinergics,25 1 large RCT that did not demonstrate this association excluded patients with previous myocardial infarction, heart failure, or preexisting arrhythmias.26,27 Although there are no studies among patients with COPD examining the representativeness of patients in clinical trials, it has been shown that patients in RCTs of coronary interventions are younger and healthier than patients in clinical practice.28

Observational studies may help to clarify the spectrum of medication adverse effects.6 Studies of inhaled β-adrenergics showed increases in urinary retention associated with inhaled anticholinergics29 and greater risk for mortality and exacerbation of heart failure among patients with COPD and heart failure.30 Taken together, these studies demonstrate a need for caution when prescribing medications to patients with risk factors for conditions that may be exacerbated by these therapies. Older patients with multiple comorbid conditions should be monitored closely for improvement in target symptoms and for adverse events from prescribed medications.

Evidence also suggests that provision of COPD guideline–directed therapies is not sufficient to relieve dyspnea with advancing illness. Although they have not reported on the proportion of patients who were receiving maximal guideline-directed care, studies have demonstrated that breathlessness is a nearly universal symptom in advanced COPD, occurring in 90% to 95% of individuals.31 Other common symptoms include pain (34%-77%), fatigue (68%-80%), insomnia (55%-65%), and anorexia (35%-67%).31 Patients with advanced lung disease require symptom-directed, palliative care coordinated with their COPD-directed treatment. Patients with advanced COPD have a similar or worse symptom burden and quality of life than those with advanced lung cancer but are given less palliative care.3234 The American Thoracic Society adopted a position in 2008 regarding patients with respiratory disease, stating that treating symptoms “without effecting a cure” must become an integral component of standard care.35

The evidence base regarding treatment of symptoms is limited relative to that for COPD-directed pharmacologic treatments.36 Several treatment approaches for symptom control, including opioids for refractory dyspnea, are generally safe, adequately researched, and increasingly accepted and recommended for use among patients with COPD.35,37,38 Biases and fears persist among clinicians about use of opioids, precluding their most effective use.39Table 3 outlines evidence-based suggestions for palliative treatments of dyspnea.

Quiz Ref IDPulmonary rehabilitation should be a critical component of Mr V's management because it addresses many of the contributors to dyspnea.2,16 Pulmonary rehabilitation includes lower and upper extremity exercise training, physiotherapy techniques, education, and psychosocial support. Evidence-based guidelines conclude that pulmonary rehabilitation improves dyspnea, health-related quality of life, and psychosocial outcomes.14,16,17 Two small observational studies of pulmonary rehabilitation demonstrated equivalent outcomes for older and younger patients.40,41 One study has shown that participants with the greatest physiologic impairments achieve the greatest improvement in exercise capacity.42

Functional and Cognitive Disability Among Persons With Advanced COPD

Mr V: What prompted me to move was that I was getting on in years and getting too decrepit to maintain the property and the house.

Dr G: The . . . thing that is very common in older folks is that there is less reserve in physical function than in a younger person. So an 80-year-old with advanced lung disease, and also several other chronic diseases and pain, his actual physical functioning may be more limited than in somebody with COPD in a younger age and without some of the other chronic conditions.

Dyspnea is strongly associated with functional disability among persons with COPD,43 and the approach to maximizing functional capacity overlaps with the approach to treating dyspnea. Both aging44 and COPD45,46 contribute to an increased risk of physical and cognitive impairments, which in turn are risk factors for the development of functional disability or the inability to complete tasks associated with daily living. Although effective therapies to reverse cognitive impairment and functional disability are limited, it is nonetheless important for the clinician to recognize their presence. Functional disability among older persons is a predictor of multiple outcomes, including mortality47,48 and nursing home placement.49 In addition, disability determines care needs, and the clinician must evaluate whether the patient has sufficient support to carry out tasks of daily living. For Mr V, recognition of his risk for worsening function led to his decision to move to an assisted living facility. Cognitive deficits can interfere with a patient's ability to adhere to complex medical regimens and use inhalation devices accurately.50,51

Older patients with COPD are at risk for other conditions that contribute to functional disability. COPD is associated with both osteoporosis and fall risk factors, which greatly increase the risk of hip fractures, a major cause of disability among the elderly. A systematic review found that the prevalence of osteoporosis in COPD varies from 9% to 69%, depending on the population studied, with an overall prevalence of 35%.52 Although there have been no large studies evaluating the prevalence of falls among persons with COPD, 1 small study demonstrated a high rate of falls among persons with COPD recruited from pulmonary rehabilitation.53 Patients with COPD have a high prevalence of fall risk factors, including gait and balance impairments, muscle weakness, and nutritional deficits.54

Table 4 provides recommendations for evaluation and management of functional decline. Formal evaluation of the patient's functional status includes ADL and IADL. The former consist of basic self-care tasks, such as bathing, dressing, toileting, continence, grooming, feeding, and transferring, whereas IADL are higher-order tasks necessary to live independently in the community, including shopping, cooking, driving or using public transportation, using the telephone, housework, laundry, taking medications, and handling finances. Assessment of these activities must be accompanied by an evaluation of available social support to determine needs for higher levels of care.55 For patients with functional disability, a comprehensive home evaluation can determine needs for modifications in the home environment to reduce dyspnea and improve function. Examples of home modifications include alternatives to stairs (such as a chair glide) or creating living spaces on a single floor. Social isolation must be avoided by addressing transportation needs and identifying resources for social engagement, such as senior centers.

Screening for cognitive impairment can be performed using one of several brief validated instruments. The Mini-Cog provides an assessment of both short-term memory and executive function.56 Hypoxemia has been shown to be a risk factor for cognitive impairment in some studies.57 In 1 large cohort study, use of supplemental oxygen was associated with a lower risk of cognitive impairment,46 and, in 1 RCT, continuous oxygen therapy was associated with modest improvements in some, but not all, tests of cognitive function after 6 months of therapy.58 An increasing body of evidence suggests that exercise may be associated with improved cognitive performance.57,59 Together with the evidence for improvements in dyspnea and physical functioning, this provides additional support for the utility of pulmonary rehabilitation in addressing a wide variety of health outcomes in patients with COPD.

Patients should also be screened for comorbid conditions associated with an increased risk of disability. Although there is limited evidence regarding depression and anxiety screening in patients with COPD, the 3-question anxiety and 2-question depression items from the Primary Care Evaluation of Mental Disorders60 have demonstrated utility as an easily administered screening tool with good positive predictive value.61,62 Only 1 small, randomized controlled trial of patients with COPD has examined the efficacy of pharmacologic therapy for treatment of depression. This study showed the superiority of nortriptyline over placebo for treatment of depression, anxiety, and panic attacks in patients with COPD.63 There is preliminary evidence that cognitive behavioral therapy may improve depression and anxiety.64,65 Additionally, several studies have demonstrated the utility of pulmonary rehabilitation in improving symptoms of depression and anxiety.66

In the absence of COPD-specific data, it has been recommended that patients who have low body mass index, are being treated with corticosteroids, or both should be screened for osteoporosis by dual-energy x-ray absorptiometry scanning and measurement of serum 25-hydroxy vitamin D levels. Patients with osteoporosis or with osteopenia and either a prior fracture or use of systemic steroids should be treated with calcium, vitamin D, and an antiresorptive agent.52,67 In the absence of data specific to COPD, algorithms developed for use in the general geriatric population for screening, evaluating, and treating risk factors for falls can be used in patients with COPD.68

Decision Making in the Face of Trade-offs

Mr V: [Physicians should] [l]isten thoroughly to what the problems are and not just give you the quick touch.

Dr G: As with other diseases in older adults . . . , the risk of treatment causing a side effect or harm is greater. . . . Mr V has a very long list of medications. He has side effects . . . medication optimization is a constant thing I’m always thinking about.

In addition to the potential risks associated with individual medications, older patients with COPD face the potential of adverse effects from the combined treatment of multiple diseases and risk factors. Advancing age is associated with an increased burden of comorbid conditions.69 Guideline-directed care of Mr V's COPD, together with treatments necessary for his diabetes, hypertension, coronary artery disease, heart failure, and depression, resulted in a complicated treatment plan involving multiple medications (polypharmacy).70 Polypharmacy increases the likelihood of nonadherence,71 adverse drug events,72 falls,68 and weight loss.73 Prioritizing the treatment goals of older persons can help to tailor their treatment regimens. This requires a process of shared decision making wherein patients identify the health outcome(s) of greatest importance to them. Older persons do have the ability to prioritize among the outcomes of extending length of life, maintaining function, and improving symptoms.74 For the majority of patients who value maintaining function over life extension, medications with the greatest effect on promoting current function should be prioritized over those aimed at reducing mortality or those that provide distant benefits, such as medications for primary or secondary prevention. Moreover, medications that are not recommended by guidelines because of an unfavorable benefit-to-harm ratio for the “average” patient may be reasonable treatment choices for patients whose treatment goals lead to a different weighting of benefits and harms. An example of one such medication is oral corticosteroids. For the patient whose most important treatment goal is relief of symptoms and whose symptoms respond to oral steroids, this benefit can outweigh the medication's short- and long-term adverse effects.

Communication, Prognostication, and Advance Care Planning

Dr G: I think he recognizes that his condition is incurable and advanced. . . . The tricky thing about COPD is that it does get worse and then gets better. . . . 

Older persons with advanced COPD are at high risk for mortality. In a 5-center US study of persons defined as having advanced COPD on the basis of hypercapnia at the time of hospital admission, the in-hospital mortality rate was 11%, with a 1-year mortality rate of 43%.75 A review of palliative and end-of-life care for patients with COPD summarizes several studies demonstrating that only a minority of patients with COPD have discussed their treatment preferences and end-of-life care issues with their physicians.76 Patients with COPD vary in the amount and type of prognostic information they wish to receive76,77; therefore, this communication needs to be tailored to the information preferences of individual patients. Advance care planning can occur regardless of patients' desire for prognostic information by framing the conversation in terms of “preparing for the worst but hoping for the best.”76 Guidance exists in the literature regarding how to approach end-of-life discussions.78,79 Advance care planning includes early identification by patients of surrogate decision makers and discussions between patients and their surrogates about patient goals, values, and preferences (Box).

Box. Words to Say When Communicating With Patients With Advanced COPD About Prognosis, Goals, and Advance Care Planning

Understanding of Illness

  • What do you think will happen to you as a result of your COPD in the future?

  • What are your biggest hopes?

  • What are your greatest fears?

Symptoms and Goals of Care

  • What are the most distressing symptoms you are having?

  • Treatments to make one thing feel better can have side effects that make other things worse. When thinking about your breathing, mobility, energy, clarity of thinking, and mood, which is most important to you and why?

Desire for Prognostic Information

  • How much do you want to know about your prognosis?80

Advance Care Planning

  • Do you have someone you trust to make medical decisions for you if you cannot make them for yourself?

  • Think about the last time your COPD got so bad that you had trouble breathing. If you were in this situation again, what would you hope for? What would you be most worried about?

  • Did this situation make you think of ways of being that would be so unacceptable that you would consider them worse than death?

  • Some patients say that if they became so sick that they could not recognize or talk to their loved ones (for example, if they had dementia or were in a coma), they would still want all possible treatments to prolong their life. Other patients say they would rather have care focused on comfort. Which kind of person are you?

  • When you have your next COPD flare, if it is very severe and you needed to be hospitalized or intubated again to get through it, would you want that? Would you agree to be hospitalized again? To be intubated again?

Abbreviation: COPD, chronic obstructive pulmonary disease.

Advance care planning is particularly challenging in COPD because of its prognostic uncertainty. Using models with good overall calibration and discrimination in a multicenter study of adults hospitalized with serious illness, patients with lung cancer had 6-month survival estimates approaching 0% on the day before death. In contrast, patients with COPD had median 6-month survival estimates of 40% or greater on 5 of the last 7 days of life. Whereas only 38% of patients with lung cancer who received mechanical ventilation survived to hospital discharge, the rate was 76% of patients with COPD.34 Because of this uncertainty, making definitive treatment decisions in advance of illness exacerbations may not be a realistic goal for advance care planning. Although some patients, like Mr V, will be ready to make decisions such as forgoing cardiopulmonary resuscitation, others may not. For these patients, the goal should be preparing patients (if they are able), their surrogates, or both to make the best possible real-time decisions based on the details of the patient's clinical scenario.81 The use of the “therapeutic trial” may be particularly useful in the face of prognostic certainty.82 Because patients' preferences are strongly determined by the functional and cognitive outcomes of care,83 it is important for clinicians to understand patients' attitudes toward these outcomes or, in other words, their goals of care. This allows a process of reevaluating therapy as prognosis becomes more certain over time, with a plan to withdraw life-sustaining treatment if it will not meet patients' goals. These goals should be reassessed if patients survive, in the context of patients' experiences of interventions.84 Among older persons with COPD who were hospitalized in 1 study within the prior 2 years, 16% would not want to be readmitted for a similarly severe exacerbation in the future.85

CONCLUSIONS

Mr V recovered from his COPD exacerbation after treatment of his underlying respiratory pathology. However, he is returning to a fundamentally compromised state of health. His physical functioning will require reevaluation. Mr V's history of multiple COPD exacerbations predict further declines in his health, although his precise prognosis is not known. He will need ongoing, clear, and explicit communication with his clinicians to prioritize his current and future care goals and to plan for his future medical care despite medical uncertainty.

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Article Information

Corresponding Author: Terri R. Fried, MD, Clinical Epidemiology Research Center 151B, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516 (terri.fried@yale.edu).

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: Dr Fried is the recipient of a mid-career development award from the National Institute on Aging (K24AG028443). Dr Vaz Fragoso is a recipient of a Career Development Award from the Department of Veterans Affairs and an R03 award from the National Institute on Aging (R03AG037051). The Care of the Aging Patient series is made possible by funding from The SCAN Foundation.

Role of the Sponsors: The sponsors had no role in the preparation, review, or approval of the manuscript.

Call for Patient Stories: The Care of the Aging Patient editorial team invites physicians to contribute a patient story to inspire a future article. Information and submission instructions are available at http://geriatrics.medicine.ucsf.edu/agingpatient/.

Care of the Aging Patient: From Evidence to Action is produced and edited at the University of California, San Francisco, by Seth Landefeld, MD, Louise Walter, MD, Louise Aronson, MD, MFA, and Anna Chang, MD; Amy J. Markowitz, JD, is managing editor.

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