D6. End-of-life issues

Terminally ill patients with COPD are usually elderly and have already experienced one or more decades of increasingly frustrating functional restriction. Their course is likely to have been punctuated by hospital admissions. They often have several comorbidities and are frequently dependent on the care of others.

Determining prognosis in end-stage COPD is difficult, although guides to shortened survival include an FEV₁ < 25% predicted, weight loss (body mass index below 18), respiratory failure (Paco₂ > 50mmHg, or 6.7 kPa), and right heart failure.

The major ethical issues are deciding whether to offer invasive or non-invasive ventilatory support, or, alterna­tively, to withhold, limit or withdraw such support. These decisions are often complex, but, as in other areas of medicine, they are ultimately constrained by the standard ethical principles of respect for patient autonomy, and ensuring that good and not harm is achieved. Most patients with end-stage COPD wish to participate in end-of-life management decisions and would prefer to do so in a non- acute setting.

In some states the patient’s wishes can be given legal force through the use of an enduring power of attorney or advance health directive. Although difficult for the health professional and potentially distressing for the patient, a frank discussion about these often unspoken issues can be beneficial.

Opioids and many anxiolytics depress ventilatory drive and are contraindicated in most patients with COPD. When palliation is warranted, however, their use for the short term relief of dyspnoea could be considered. [evidence level II] (Jennings et al., 2002),(Abernethy et al., 2003)