jhf 2008. advanced lung disease: palliative and terminal care john hansen-flaschen professor of...
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JHF 2008
Advanced Lung Disease: Palliative and Terminal Care
John Hansen-FlaschenProfessor of MedicineUniversity of PennsylvaniaPhiladelphia, Pennsylvania
American Thoracic Society
Ischemic heart diseaseCerebrovascular diseaseLower resp infectionDiarrheal diseasePerinatal disordersCOPDTuberculosisMeaslesRoad traffic accidentsLung cancer
6th
1990
COPD Mortality WorldwideCOPD Mortality Worldwide
- & . 1997 Murray Lopez Lancet modified from GOLD2005 slide set
Ischemic heart diseaseCerebrovascular diseaseLower resp infectionDiarrheal diseasePerinatal disordersCOPDTuberculosisMeaslesRoad traffic accidentsLung cancer
Stomach CancerHIVSuicide
6th
3rd
- & . 1997 Murray Lopez Lancet 2005 modified from GOLD slide set
1990 2020
COPD Mortality WorldwideCOPD Mortality Worldwide
United States Mortality 2006Top Five Medical Causes, per 100,000United States Mortality 2006Top Five Medical Causes, per 100,000
199.4180.8
51.140.4 38.5
00
5050
100100
150150
200200
250250
300300Heart DiseaseHeart Disease
CancerCancer
StrokeStroke
ChronicLung DiseaseChronicLung Disease
AccidentsAccidents
- U.S. National Vital Statistics Report, NCHS, 2008.
United States Mortality 2006Top Five Medical Causes, per 100,000United States Mortality 2006Top Five Medical Causes, per 100,000
199.4180.8
51.140.4 38.5
00
5050
100100
150150
200200
250250
300300Heart DiseaseHeart Disease
CancerCancer
StrokeStroke
ChronicLung DiseaseChronicLung Disease
AccidentsAccidents
- U.S. National Vital Statistics Report, NCHS, 2008.
124,614
Burden of COPD in the USBurden of COPD in the US
• Between 2000 and 2005, COPD was the underlying cause of death for 718,077 persons.
• In 2005, COPD was the underlying cause of death for approximately1 person in 20.
- Morbidity Mortality Weekly Report, November 17 2008 / 57:1229.
American Thoracic Society Documents
An Official American Thoracic Society Clinical Policy Statement:
Palliative Care for Patients with Respiratory Diseases and Critical Illnesses
Paul N. Lanken, Peter B. Terry, Horace M. DeLisser, Bonnie F. Fahy,John Hansen-Flaschen, John E. Heffner, Mitchell Levy, Richard A. Mularski, Molly L. Osborne, Thomas J. Prendergast, Graeme Rocker, William J. Sibbald, Benjamin Wilfond and James R. Yankaskason behalf of the ATS End-of-Life Care Task Force
American Journal of Respiratory and Critical Care MedicineVol 177. pp. 912-927, (2008).© 2008 American Thoracic Society
Palliative care aims to prevent and relieve suffering by early identification, assessment, and treatment of pain and other types of physical, psychological, emotional, and spiritual distress.
- World Health Organization
Palliative Care
Current Concepts: Palliative CareCurrent Concepts: Palliative CareCurrent Concepts: Palliative CareCurrent Concepts: Palliative Care
- Lanken PN et al. Am J Respir Crit Care Med 177:912, 2008.
Current Concepts: Palliative CareCurrent Concepts: Palliative CareCurrent Concepts: Palliative CareCurrent Concepts: Palliative Care
- Lanken PN et al. Am J Respir Crit Care Med 177:912, 2008.
Current Concepts: Palliative CareCurrent Concepts: Palliative CareCurrent Concepts: Palliative CareCurrent Concepts: Palliative Care
- Lanken PN et al. Am J Respir Crit Care Med 177:912, 2008.
Current Concepts: Palliative CareCurrent Concepts: Palliative CareCurrent Concepts: Palliative CareCurrent Concepts: Palliative Care
- Lanken PN et al. Am J Respir Crit Care Med 177:912, 2008.
Case #1A 74-year-old woman was transferred to the medical intensive care unit for further management of respiratory failure associated with:
• Very severe chronic obstructive lung disease• Severe mitral stenosis and coronary artery disease• Diabetes
Case #1She lived alone.
Over the past 6 years, her exercise tolerance had declined until she was unable to move beyond her bed and a nearby chair and had frequent experiences of dyspnea at rest.
In the past year, she was hospitalized repeatedly for fluid overload or respiratory distress.
Case #1In the ICU, she became continuously dependent on mechanical ventilation, vasopressors and hemodialysis. Her mental status waxed and waned.
Two of 8 children visited regularly and insisted that “everything be done” to prolong her life. They repeatedly objected to the use of pain and sedating medications.
The woman survived in the ICU for 9 months until she died of septic shock despite maximal life-supporting therapy.
• Alleviation of Distress
• Counseling and Coordination of Care
Palliative CareAdvanced Lung Disease
• Alleviation of Distress
• Counseling and Coordination of Care
Palliative CareAdvanced Lung Disease
• Dyspnea• Cough• Psychological Distress
Anxiety/Panic Depression Cognitive Impairment Delirium
Distress inAdvanced Lung disease
• Dyspnea• Cough• Psychological Distress
o Anxiety/Panico Depressiono Cognitive Impairmento Delirium
Distress inAdvanced Lung disease
The subjective sensation ofbreathing discomfort.
- American Thoracic Society Statement on Dyspnea,1998.
Dyspnea
The subjective sensation ofbreathing discomfort.
- American Thoracic Society Statement on Dyspnea,1998.
Dyspnea
- Shumway NM et al. Respir Med 102:27, 2008.
Physician vs PatientPerception of Dyspnea in
Severely Ill Hospitalized Patients
Dyspnea
• Increased Work or Effort
• Chest Tightness• Air Hunger
at least three types
Dyspnea
• Increased Work or Effort
• Chest Tightness• Air Hunger
at least three types
The conscious perception of the urge to breathe. The frightening or threatening sensation of not getting enough air.
Air Hunger
Dyspnea
• Dyspnea on Exertion• Paroxysmal Dyspnea• Sustained Dyspnea at Rest
at least three situations
Dyspnea
• Dyspnea on Exertion• Paroxysmal Dyspnea• Sustained Dyspnea at Rest
at least three situations
Dyspnea
• Dyspnea on Exertion• Paroxysmal Dyspnea• Sustained Dyspnea at Rest
at least three situations
Strong evidence supports treatmentof dyspnea on exertion with:
b-agonists opioids oxygen pulmonary rehabilitation
Treatment forDyspnea on Exertion in COPD
Conclusions of a systematic reviewAmerican College of Physicians
Clinical Efficacy Assessment Subcommittee
- Lorenz KA et al. Ann Intern Med. 148:147, 2008.
Strong evidence supports treatmentof dyspnea on exertion with:
o -agonistso opioidso oxygeno pulmonary rehabilitation
Treatment forDyspnea on Exertion in COPD
Conclusions of a systematic reviewAmerican College of Physicians
Clinical Efficacy Assessment Subcommittee
- Lorenz KA et al. Ann Intern Med. 148:147, 2008.
Opioids for DyspneaOpioids for Dyspnea
- Jennings A-L, et al. Thorax; 57:939, 2002.
Strong evidence supports treatmentof dyspnea on exertion with:
b-agonists opioids oxygen pulmonary rehabilitation
Treatment forDyspnea on Exertion in COPD
Conclusions of a systematic reviewAmerican College of Physicians
Clinical Efficacy Assessment Subcommittee
- Lorenz KA et al. Ann Intern Med. 148:147, 2008.
Oxygen forExertional Dyspnea
For desaturators, distance walked in6 min increased 22%and Borg scale dyspnea decreased 36% with supplemental oxygen,
For non desaturators, Borg scale dyspnea decreased 47%, but distance walkeddid not improve.
- Jolly EC et al. Chest. 20:437, 2001.
Oxygen forExertional Dyspnea
For desaturators, distance walked in6 min increased 22%and Borg scale dyspnea decreased 36% with supplemental oxygen,
For non desaturators, Borg scale dyspnea decreased 47%, but distance walkeddid not improve.
- Jolly EC et al. Chest. 20:437, 2001.
Strong evidence supports treatmentof dyspnea on exertion with:
b-agonists opioids oxygen pulmonary rehabilitation
Treatment forDyspnea on Exertion in COPD
Conclusions of a systematic reviewAmerican College of Physicians
Clinical Efficacy Assessment Subcommittee
- Lorenz KA et al. Ann Intern Med. 148:147, 2008.
Dyspnea
• Dyspnea on Exertion• Paroxysmal Dyspnea• Sustained Dyspnea at Rest
at least three situations
Dyspnea
• Dyspnea on Exertion• Paroxysmal Dyspnea• Sustained Dyspnea at Rest
at least three situations
• supplemental oxygen• opioids and
benzodiazepines• non-invasive mechanical
ventilation• intubation for deep
sedation
Palliation ofSustained Dyspnea at Rest
• supplemental oxygen• opioids and
benzodiazepines• non-invasive mechanical
ventilation• intubation for deep
sedation
Palliation ofSustained Dyspnea at Rest
• supplemental oxygen• opioids and
benzodiazepines• non-invasive mechanical
ventilation• intubation for deep
sedation
Palliation ofSustained Dyspnea at Rest
Morphine and MidazolamMorphine and Midazolamfor Dyspneafor Dyspnea
Morphine and MidazolamMorphine and Midazolamfor Dyspneafor Dyspnea
- Navigante A, et al. J Pain Symptom Management 57:939, 2002.
Mo MorphineMi MidazolamMM Morphine and Midazolam
Terminally ill cancer patients at 24 hours
Percent experiencing pain relief
• supplemental oxygen• opioids and
benzodiazepines• non-invasive mechanical
ventilation• intubation for deep
sedation
Palliation ofSustained Dyspnea at Rest
NoninvasiveVentilatory Support for Dyspnea at Rest
NoninvasiveVentilatory Support for Dyspnea at Rest
Exacerbation of COPDExacerbation of COPDNon-invasive Mechanical VentilationNon-invasive Mechanical Ventilation
for Relief of Dyspnea at Restfor Relief of Dyspnea at Rest
Exacerbation of COPDExacerbation of COPDNon-invasive Mechanical VentilationNon-invasive Mechanical Ventilation
for Relief of Dyspnea at Restfor Relief of Dyspnea at Rest
- Keenan SP, et al. Resp Care 50:610, 2005.
only 12 of 25randomized tointermittent NIMV(BiPAP)completed 3 days of treatment
• supplemental oxygen• opioids and
benzodiazepines• non-invasive mechanical
ventilation• intubation for deep
sedation
Palliation ofSustained Dyspnea at Rest
Mechanically Ventilated Patients
Shortness of Breath 11%
Mild 8%
Moderate 2%
Severe 1%
No Shortness of Breath 89%
- Karampela I, et al. Respiratory Care 47:1158, 2002.
Are you short of breath right now?
• Dyspnea• Cough• Psychological Distress
Anxiety/Panic Depression Cognitive impairment Delirium
Distress inAdvanced Lung disease
Steroids for Cough inSteroids for Cough inIdiopathic Pulmonary FibrosisIdiopathic Pulmonary Fibrosis
Steroids for Cough inSteroids for Cough inIdiopathic Pulmonary FibrosisIdiopathic Pulmonary Fibrosis
- Hope-Gill BDM, et al. AJRCCM 168:996, 2003.
• Dyspnea• Cough• Psychological Distress
o Anxiety/Panico Depressiono Cognitive Impairmento Delirium
Distress inAdvanced Lung disease
Prevalence of anxiety & depressionPrevalence of anxiety & depressionin chronic breathing disordersin chronic breathing disorders
Prevalence of anxiety & depressionPrevalence of anxiety & depressionin chronic breathing disordersin chronic breathing disorders
204 outpatients at the Houston VA 204 outpatients at the Houston VA
- Kunik ME, et al. Chest 127:1205, 2005.
anxiety 51%
depression 39%
both 26%
either of both 65%
COPD in Patients withSerious Mental IllnessesCOPD in Patients with
Serious Mental Illnesses
National Health & Nutrition Examination Study III National Health & Nutrition Examination Study III
Mental Illness Control
Chronic Bronchitis
19.5% 6.1%
Emphysema 7.9% 1.5%
- Himelhoch S, et al. Am J Psychiat 161:2317, 2004
PRIME-MD ScreenPRIME-MD Screenfor Anxiety and Depressionfor Anxiety and Depression
PRIME-MD ScreenPRIME-MD Screenfor Anxiety and Depressionfor Anxiety and Depression
DepressionIn the past month have you been bothered a
lot by:1. little interest or pleasure in doing things?2. feeling down, depressed or hopeless?
AnxietyIn the past month, have you been bothered a lot
by:3. “nerves” or feeling anxious or on edge?4. worrying about a lot of different things?5. During the last month have you had an
anxiety attack?
1 positive response: highly sensitiveall positive responses: highly specific
- Kunik ME et al. Psychosomatics 48:1. 2007.
Treatment of Anxiety and DepressionTreatment of Anxiety and Depressionin Severe COPDin Severe COPD
Treatment of Anxiety and DepressionTreatment of Anxiety and Depressionin Severe COPDin Severe COPD
• Few small studies have reported conflicting results for the treatment of anxiety with buspirone and depression with antidepressants.
• Similarly mixed results for treatment of anxiety with cognitive behavioral therapy.
• Several studies have reported benefits of pulmonary rehabilitation with education sessions for treatment of anxiety and depression.
• Few small studies have reported conflicting results for the treatment of anxiety with buspirone and depression with antidepressants.
• Similarly mixed results for treatment of anxiety with cognitive behavioral therapy.
• Several studies have reported benefits of pulmonary rehabilitation with education sessions for treatment of anxiety and depression.
- Hill, K, et al. E Respir J.; 31:667, 2008.
Evidence Basis
Treatment ofTreatment ofAnxiety and DepressionAnxiety and Depression
in Severe COPDin Severe COPD
Treatment ofTreatment ofAnxiety and DepressionAnxiety and Depression
in Severe COPDin Severe COPD
• patient education
• antidepressants: sertraline, bupropion, fluoxetine
• buspirone or a benzodiazepine in moderate doses
• cognitive and behavioral therapy
• patient education
• antidepressants: sertraline, bupropion, fluoxetine
• buspirone or a benzodiazepine in moderate doses
• cognitive and behavioral therapy
- Brenes, GA. Psychosomatic Med 65:963, 2003.
• Alleviation of Distress
• Counseling and Coordination of Care
Palliative CareAdvanced Lung Disease
• Alleviation of Distress
• Counseling and Coordination of Care …
…near the end of life
Palliative CareAdvanced Lung Disease
Barriers to DiscussingBarriers to DiscussingEnd-of-Life CareEnd-of-Life Care
Barriers to DiscussingBarriers to DiscussingEnd-of-Life CareEnd-of-Life Care
• I’d rather concentrate on staying alive than talk about death.
• I’m not sure which physician will be taking care of me if I get very sick.
• I’d rather concentrate on staying alive than talk about death.
• I’m not sure which physician will be taking care of me if I get very sick.
commonly endorsed by patients
- Knauft E, et al. Chest 127:2188, 2005.
Barriers to DiscussingBarriers to DiscussingEnd-of-Life CareEnd-of-Life Care
Barriers to DiscussingBarriers to DiscussingEnd-of-Life CareEnd-of-Life Care
• There is too little time during our appointments to discuss everything we should (57%).
• I worry that discussing end-of-life care will take away hope(20%).
• There is too little time during our appointments to discuss everything we should (57%).
• I worry that discussing end-of-life care will take away hope(20%).
- Knauft E, et al. Chest 127:2188, 2005.
commonly endorsed by patients
Advanced PlanningAdvanced Planningfor End of Life Carefor End of Life CareAdvanced PlanningAdvanced Planningfor End of Life Carefor End of Life Care
• Offer an honest prognosis
• Promote, document and coordinate advanced planning for health care
• Offer an honest prognosis
• Promote, document and coordinate advanced planning for health care
Advanced Planningfor End of Life CareAdvanced Planningfor End of Life Care
• Offer an honest prognosis
• Promote, document and coordinate advanced planning for health care
• Offer an honest prognosis
• Promote, document and coordinate advanced planning for health care
COPD: Staging by FEVCOPD: Staging by FEV11COPD: Staging by FEVCOPD: Staging by FEV11
- Nishimura K, et al. Chest; 212:1434, 2002.
COPD: Staging by FEVCOPD: Staging by FEV11COPD: Staging by FEVCOPD: Staging by FEV11
- Nishimura K, et al. Chest; 212:1434, 2002.
- Celli, BR et al. N Engl J Med 2004;350:1005.
COPD BODE Survival IndexCOPD BODE Survival Index
Body Mass IndexAirflow ObstructionDyspneaExercise Capacity
COPDCOPDEmerging Profile of PatientsEmerging Profile of Patients
in the Last Year of Lifein the Last Year of Life
COPDCOPDEmerging Profile of PatientsEmerging Profile of Patients
in the Last Year of Lifein the Last Year of Life severely reduced FEV1
severely reduced and declining performance status
multiple recent exacerbations Prior ICU admissions co-morbidities low body weight depressed lives alone
COPDCOPDEmerging Profile of PatientsEmerging Profile of Patients
in the Last Year of Lifein the Last Year of Life
COPDCOPDEmerging Profile of PatientsEmerging Profile of Patients
in the Last Year of Lifein the Last Year of Life severely reduced FEV1
severely reduced and declining performance status
multiple recent hospitalizations Prior ICU admissions co-morbidities low body weight depressed lives alone
“Have you been thinking about how or when you might die?”
“Have you been thinking about how or when you might die?”
- Quill TE.JAMA; 284:2502 2000.
“Some people in your current condition live 1 or 2 years or longer.
But your lung reserve is so reduced now that you might die at any time from a complication of your disease.”
“Some people in your current condition live 1 or 2 years or longer.
But your lung reserve is so reduced now that you might die at any time from a complication of your disease.”
“Some people in your current condition live 1 or 2 years or longer.
But your lung reserve is so reduced now that you might die at any time from a complication of your disease.”
“Some people in your current condition live 1 or 2 years or longer.
But your lung reserve is so reduced now that you might die at any time from a complication of your disease.”
“Hope and expect for the
best.
Prepare for the worst.”
“Hope and expect for the
best.
Prepare for the worst.”
-Back AL et al.Ann Intern Med 138:439, 2003
Preparing aMedical Advance Directive
Preparing aMedical Advance Directive
• Based upon a structured discussion between patient, designated proxy and physician.
• A written Medical Advance Directive summarizes the discussion and is signed by all 3 participants.
• Based upon a structured discussion between patient, designated proxy and physician.
• A written Medical Advance Directive summarizes the discussion and is signed by all 3 participants.
Preparing aMedical Advance Directive
Preparing aMedical Advance Directive
• Based upon a structured discussion between patient, designated proxy and physician.
• A written Medical Advance Directive summarizes the discussion and is signed by all 3 participants.
• Based upon a structured discussion between patient, designated proxy and physician.
• A written Medical Advance Directive summarizes the discussion and is signed by all 3 participants.
Preparing aPreparing aMedicalMedical Advance Directive Advance Directive
Preparing aPreparing aMedicalMedical Advance Directive Advance Directive
• Preferences for initiating and continuinglife support.
• Dying at home or in a hospital.
• Preferred facilities for medical care.
• Plan for the “what ifs.”
• Preferences for initiating and continuinglife support.
• Dying at home or in a hospital.
• Preferred facilities for medical care.
• Plan for the “what ifs.”
Penn Hospice at Rittenhouse
Case #2A 58-year-old school teacher was found to have idiopathic pulmonary fibrosis. He declined consideration for lung transplantation.
Over 4 years, his disease progressed until he required high-flow supplemental oxygen.
Case #2The pulmonologist met with the man and his wife to discuss advanced medical planning.
The wife wrote a letter summarizing the conversation. All three participants signed the letter.
As symptoms progressed, treatment was initiated with sertraline and lorezepam for anxiety and depression and low-dose prednisone for cough.
Case #2Three months later, the man was hospitalized and emergently intubated for respiratory failure accompanied by air hunger at rest.
Three days later, in accordance with his medical advanced directive, he was extubated under palliative sedation with his wife at the bedside.
Palliative care aims to prevent and relieve suffering by early identification, assessment, and treatment of pain and other types of physical, psychological, emotional, and spiritual distress.
- World Health Organization
Palliative Care