Page 26 - Hospital Authority Convention 2017

Masterclasses Masterclasses
HOSPITAL AUTHORITY CONVENTION 2017

M10.1 Palliative and/or End-of-life Care for Patients with Advanced 09:00 Room 428
Chronic Obstructive Pulmonary Disease

Overall Perspective and Scientific Basis of Palliative Care in Patients with Advanced Chronic Obstructive
Pulmonary Disease
Lau KS
Integrated Medical Service, Ruttonjee and Tang Shiu Kin Hospitals, Hong Kong

Chronic lower respiratory diseases were the sixth leading cause of death in Hong Kong in recent years. Patients with
advanced chronic obstructive pulmonary disease (COPD) suffer from significant symptoms and impaired quality of life (QOL).
An early study showed that patients with advanced COPD had worse QOL than patients with advanced lung cancer (Gore,
2000); and similar findings were reported in recent study (Javadzadeh, 2015).

A holistic approach is required for care of patients with advanced COPD so as to address disease management; minimise
physical, psychosocial and spiritual distress; maximise QOL via rehabilitation and palliation; and care for their end-of-life
journey. Recent international guidelines on COPD have included palliation and care at the end-of-life, which is an integral
component of care for patients with advanced COPD (GOLD guideline, 2017). Inclusion criteria for palliative care in patients
with advanced COPD are reported by various respiratory and palliative care professional bodies.
Canadian guideline on dyspnoea in patients with advanced COPD (CTS 2011) and experts (Mularski and Rocker, 2015)
recently recommended a triple approach on dyspnea in advanced COPD: (1) disease management; (2) non-pharmacological
management of dyspnoea; and (3) pharmacological management of dyspnea by using opioids.

On the aspect of disease management, patients with advanced COPD are classified to the Group D of GOLD guideline. An
updated GOLD guideline 2017 recommends the use of triple inhaled therapy (LAMA + LABA + ICS), plus options of roflumilast
and macrolide in Group D patients.

Non-pharmacological managements on dyspnoea were reviewed by Cochrane review (2011). The positive result of the
combination of non-pharmacological treatments was reported by a random control trial (RCT) on an integrated palliative
and respiratory care service of Breathlessness Support Service (BSS) for patients with advanced disease and refractory
breathlessness (Higginson, 2014). Cost-effectiveness of a Breathlessness Intervention Service (BIS) was supported by an
RCT (Farquhar, 2016).
Pharmacological treatment of opioids on dyspnea was recently reviewed by Ekstrom (2015) and Cochrane (2016). The main
findings are that opioids reduced breathlessness in COPD with the strongest evidence for systemic therapy, whereas there
were no effects on exercise capacity. No serious adverse effects related to opioids were reported in any study, including no
reports of hospitalisations, respiratory depression, or carbon dioxide retention (Ekstrom, 2015).

Advance care planning (ACP) is an important component of care for patient with advanced COPD in addressing patient’s
preferences on future life-sustaining treatments. A recent RCT showed that a nurse-led facilitated ACP has increased the
uptake of ACP (Sinclair, 2017).

Wednesday, 17 May

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