Palliative care for patients with chronic obstructive pulmonary disease: Current perspectives
Chronic obstructive pulmonary disease (COPD) is a chronic respiratory illness with a myriad of disabling symptoms and a decline in the functional parameters that affect the quality of life. The mortality and morbidity associated with severe COPD is high and the patients are mostly housebound and in need of continuous care and support. The uncertain nature of its prognosis makes the commencement of palliative care and discussion of end-of-life issues difficult even in the advanced stage of the disease. This is often compounded by inadequate communication and counseling with patients and their relatives. The areas that may improve the quality of care include the management of dyspnea, oxygen therapy, nutritional support, antianxiety, and antidepressant treatment, and advance care planning. Hence, it is necessary to pursue a holistic care approach for palliative care services along with disease-specific medical management in all such patients to improve the quality of life in end-stage COPD.
Keywords: Palliative care COPD, End of life issues COPD, Current perspectives COPD
Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease affecting 6-10% of the adult population worldwide and causing significant mortality and morbidity. 
The cause underlying COPD is chronic airflow limitation and destruction of lung parenchyma with raised levels of circulating inflammatory mediators. The disease is characterized by worsening dyspnea, exercise limitation, and progressive deterioration of health. A majority of the patients with COPD experience considerable problems arising out of breathlessness leading to immobility, dependency on others, and social isolation.  It can be easily speculated that such patients have their preferences, desires, and demands to lead a better quality of life. There is an immense scope of palliative medicine in providing good care and improved quality of life in these patients. But the data to guide physicians on how to actually accomplish this in practice in severe or end-stage COPD are limited. This is quite evident from the updated global initiative on COPD guidelines,  assembled by an expert panel under the auspices of National Heart Lung and Blood Institute and the World Health Organization which does not include recommendations on providing quality end-of-life care for patients with COPD due to scarcity of data. Nevertheless, some researchers and clinicians have recognized the need for palliative care and have also outlined its importance in this population. ,,
The keywords "Palliative care in COPD" in PUBMED revealed a total of 285 titles and 97 review articles within the search limit of 20 years between 1991 and 2011. Only articles in English were chosen.
The definition of palliative care adopted by WHO  identifies it as "the patient and family centered care that optimizes quality of life by anticipating, preventing, and treating suffering." It seeks to address the physical, intellectual, emotional, social, and spiritual needs to facilitate patient autonomy, access to information, and choice throughout the continuum of disease. In contrast, "end of life" care focuses on caring for the patient and his or her family only during the final stages of the life. Therefore, although the terms "palliative care" and "end of life" care may sound synonymous, the former has a much broader meaning and involves comprehensive care more than what is just required for improving the quality of life whereas "end of life" care focuses only on the final stage of the disease which may be days, weeks, or months before death depending on the illness. It is important to realize this difference in the context of COPD, where it may be difficult to institute "end of life" care early but not palliative care. 
The disagreement among medical professionals in identifying the suitable patients for palliative care in COPD is equivocal , and this can be explained from the concept of illness trajectories. The concept of illness trajectories describe three recognizable patterns of function and well-being in diseases  : (i) diseases with a high level of function and a short period of decline, e.g., cancer; (ii) diseases with a long-term limitation of function with intermittent serious episodes requiring emergency admissions, e.g., organ system failure; (iii) diseases with low-level functioning and a prolonged decline with associated problems, e.g., stroke, dementia. The physical, social, and psychological needs of the patients vary considerably according to the type of disease trajectory. COPD fits into the second class of trajectory being characterized by declining functions with acute exacerbations. The reasons for disagreement among medical professionals in deciding suitability of COPD patients for palliative care are these multiple "entry-reentry" trajectories in COPD. The "entry-reentry" trajectories involve episodic, acute exacerbations requiring frequent hospitalization followed by stabilization. This often masks the steady decline of a patient's condition making referral for palliative care difficult.
Also, unlike the terminally ill cancer patients, there are no prognostic tools to aid clinicians in assessing the survival in COPD. Since there is a strong co-relation between the end-of-life care and actual life expectancy, there is a need is to develop some reliable prognostic estimates for COPD. This can identify the patients who are terminally ill and can be maximally benefited from end-of-life care [Table 1].
However, the concept of "prognostic paralysis"  urges the clinicians to institute patient-centered active treatment and supportive care along with discussions on end-of-life issues when faced with illnesses with uncertain trajectories. If we consider COPD as an illness with some features of uncertain trajectories, we can apply this concept to institute palliative care at some stages of the illness.
Poor Prognostic Factors in COPD
The established factors for poor prognosis in COPD patients include reduced pulmonary function (FEV 1 <30%), arterial blood gas measures, and cor pulmonale with pulmonary hypertension. However, several other factors like dyspnea, muscle mass, health status, and exercise capacity are also believed to be of prognostic value. The MRC dyspnea scale  which is actually used for respiratory trauma has been found to be more discriminatory than FEV 1 in the assessment of disease severity and survival in COPD [Table 2]. 
Hence, the level of dyspnea can be a useful adjunct to FEV 1 in assessing the need for palliative care in COPD patients. Some studies have shown that the systemic measures of change in health status and exercise capacity may be important functional parameters for the multifactor evaluation of COPD patients.  The information collected on the causes of death in COPD patients has shown that about 30% deaths are due to acute chronic respiratory failure, 15% due to heart failure, and the remaining due to pulmonary infection, pulmonary embolism, cardiac arrhythmia, and lung cancer.  The mortality rate is particularly high for older patients who have frequent exacerbations of COPD and chronic respiratory failure with maximum symptom burden in the last 6 months of life.  The 6-year mortality of patients with acute exacerbation of COPD is very high (at 6 years roughly 15% remain alive) and is influenced by the pre-ICU admission quality of life.  The early institution of palliative care can no doubt improve the quality of life in patients with poor prognosis.
The aim of palliative care in COPD patients is to reduce symptoms, improve quality of life, and increase participation in day-to-day activities. This can be achieved in the following ways:
In majority of patients with end-stage COPD, the dyspnea becomes refractory to medications. However, a combination of long-acting beta agonist, an inhaled steroid and a long-acting anticholinergic may be useful in them. It is believed that long-acting bronchodilators are more effective and convenient than short-acting bronchodilators though they are a bit more expensive [Table 3]. 
The principal bronchodilators of the benefit for such patients are the beta-2 antagonists, methylxanthines and anticholinergics. But although the methylxanthines are useful for reducing exacerbations of COPD, their therapeutic index is low and they cannot be administered in aerosol form. The aerosol administration of bronchodilators is most effective for decreasing the airway resistance, work of breathing, and alleviating breathlessness. Hence, a combination of beta-2 antagonist and anticholinergic or beta-2 antagonist with a glucocorticoid is the preferred choice in COPD.
Although conclusive evidence is lacking on several issues, supplemental oxygen therapy allows COPD patients to tolerate higher levels of exercise activity with fewer exertional symptoms and an overall improvement in the quality of life. Metouska et al.  and Tarpy et al.  had found that long-term oxygen therapy when administered to hypoxemic COPD patients for more than 15 h/day increases the survival [Table 4].
It is apparent from the studies that there are enough evidences supporting long-term oxygen therapy in hypoxemic COPD patients for improving their exercise capacity but the benefits of short-burst oxygen therapy are limited.
The resting energy expenditure (REE) is raised in COPD patients in comparison to the healthy subjects due to increased work of breathing and the frequent hospitalizations associated with episodes of acute exacerbations produce a state of negative energy balance. This makes nutritional support an important aspect of palliative care in these patients. It has been seen that weight loss and skeletal muscle mass are strong predictors of mortality risk in COPD, independent of the severity of airflow limitation.  In a study  which investigated the dietary problems in patients with severe COPD, it was found that anorexia, dyspeptic symptoms other than diarrhea, and fear of gaining weight were quite frequent in these patients [Table 5].
The administration of nutritional supplements containing high carbohydrate, protein, and less fat resulted in a significant improvement in body weight, handgrip strength, decreased airflow limitation and quality of life.  Many studies have highlighted the benefits of the supplementation of anabolic steroids, growth hormone, and testosterone for such patients but many others have shown disappointing results. ,
Antianxiety and antidepressants
Both anxiety and depression are commonly seen in COPD patients. , It has also been noticed that depressive symptoms are associated with increased risk for 3-year mortality  and longer stay, persistent smoking, increased symptom burden, and poorer physical and social functioning.  In patients with moderate to severe symptoms of depression and anxiety, cognitive behavioral therapy (CBT) and COPD education have been found to achieve significant improvement in the quality of life,  which emphasizes the need for integrating mental health care into the overall treatment regime for COPD.
The success of pharmacological treatment for anxiety and depression in COPD has been very little. It is important to distinguish true anxiety disorders in COPD from anxiety and panic states associated with the side effects of beta-2 agonists and high dose of corticosteroids before starting any medication.
The patient acceptance of fluoxetine for depression in COPD is poor and often leads to chronicity. 
Since the benzodiazepines can precipitate severe hypercapnea, their use should be restricted in these patients. One study  had found a significant decrease in anxiety and dyspnea in COPD patients treated with buspirone but the time to achieve peak therapeutic effect was high (4-6 weeks). Similar beneficial effects have been also observed with sertraline. 
However, no studies have so far elucidated the long-term effects of anxiety treatment on the quality of life in COPD patients. More studies are required to understand the effective treatments of anxiety and depression in COPD patients.
Advance care planning
The integration of palliative care early in the disease along with disease-specific therapy for COPD falls within the ambit of advance care planning. This not only provides a platform for coordinating integrated services but also improves patient satisfaction and functional capacities. In one study  which sought to find out the barriers and facilitators of advance care planning in COPD patients, only 32% patients reported having a discussion about end-of-life care with their physician. The two most common barriers that patients faced were what care they would need and what kind of doctors would cater to those needs. However, further researches are expected to elaborate on which specific areas of communication can be more effectively targeted through advance care planning. ,
COPD has a long, chronic course with a high level of symptom burden with a considerable psychosocial impact on the patient and his family members. The disease management should be shared between the primary physician and the palliative care physician from an early stage to facilitate smooth transition from active treatment stage to palliative care stage. The progressive deterioration of health and respiratory functions with frequent exacerbations requiring hospitalization and the need for long-term oxygen therapy suggest the arrival of the stage of palliative care. It is important to reach out to the patient and his family members at an early stage through proper communication and understand their concerns and wishes about future care. 
All these can make the management of this life-threatening, noncancer illness much easier and pave the way for an improvement in the end-of-life care.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]