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Chronic obstructive pulmonary disease - Management
Basis for recommendation
Difficulty deciding when and how to initiate discussions
Acceptability and when to initiate
- In one qualitative study identified in the NICE guideline [National Clinical Guideline Centre, 2010], a descriptive questionnaire was used to assess the attitudes of 105 people on a pulmonary rehabilitation programme to end-of-life decision making. Most people wanted to learn more about advance directives, mechanical ventilation, and intubation. They said they would find discussions with physicians about these issues acceptable, but such discussions should take place when the person was in a stable condition. Although only half thought physicians should initiate such discussions, only 20 people had had such discussions, almost all of which had been initiated by the patient and not the physician.
Criteria indicating the need to discuss end-of-life issues
- In a systematic review of tools and predictor variables to help clinicians estimate survival and appropriate timing of palliative care for older adults with non-malignant life-threatening disease, low forced expiratory volume in 1 second (FEV1) was the only variable that can be measured in primary care that was found to be effective in estimating survival [Coventry et al, 2005]. A review article also considered the evidence for commonly used prognostic criteria, finding them to be unreliable [Spathis and Booth, 2008]. However, given that decisions about the timing of end-of-life discussions still need to be made, the criteria presented are based on prognostic factors each recommended in more than one review article [Seamark et al, 2007; Barnett, 2008; Curtis, 2008; Halpin et al, 2008; Spathis and Booth, 2008].
- The Prognostic Indicators Guidance paper from the Gold Standards Framework and the Royal College of General Practitioners suggests indicators for survival of 12 months or less in people with COPD [RCGP, 2008]. The paper references the full 2004 NICE guideline [National Collaborating Centre for Chronic Conditions, 2004]; however, CKS could not locate in the NICE guideline the source of these proposed indicators.
What end-of-life issues to discuss
DS1500 form for disability living allowance
- This recommendation is based on what CKS considers to be good clinical practice.
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