Copd Pallative Care


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  • Copd Pallative Care

    1. 1. COPD Chronic Obstructive Pulmonary Disease By Matthew Hodson Respiratory Nurse Specialist COPD Westminster Primary Care Trust
    2. 2. Aim of Session <ul><li>Understand the epidemiology of COPD </li></ul><ul><li>Improve knowledge and understanding of COPD and its treatments </li></ul><ul><li>Increase awareness of Oxygen Therapy in COPD </li></ul><ul><li>Gain an greater insight into when COPD may be palliative and exploring options </li></ul><ul><li>Understand COPD Services in WPCT </li></ul>
    3. 3. Definition <ul><li>Chronic obstructive pulmonary disease (COPD) is characterised by airflow obstruction. The airflow obstruction is usually progressive, not fully reversible and does not change markedly over several months. 1 </li></ul><ul><li>The disease is predominantly caused by smoking. </li></ul><ul><li>1. NICE 2004 </li></ul>
    4. 4. The Umbrella Disease
    5. 5. Umbrella Disease <ul><li>COPD now preferred term for previous diagnosis of bronchitis or emphysema, chronic asthma </li></ul><ul><li>Significant airflow obstruction may be present before individual is aware of it </li></ul><ul><li>May also be related to occupational exposures e.g. asbestos </li></ul>
    6. 6. Burden <ul><li>Up to 1 in 8 emergency admissions maybe due to COPD 1 </li></ul><ul><li>Over one million bed days are contributed to COPD 1 </li></ul><ul><li>A total of 32,155 deaths in the UK where attributed to COPD in 1999 1 </li></ul><ul><li>1 BTS Consortium 2005 </li></ul>
    7. 7. Epidemiology <ul><li>COPD is the fourth leading cause of death in the USA and Europe. The leading cause of death worldwide 1 </li></ul><ul><li>Mortality in females has more than doubled over the last 20 years. 1 </li></ul><ul><li>Nearly 900,000 people in England and Wales have a diagnosis of COPD 2 </li></ul><ul><li>Morbidity data greatly underestimate the total burden of COPD because the disease is usually not diagnosed until it is clinically apparent and moderately advanced . 1 </li></ul><ul><li>COPD is a more costly disease than asthma and, depending on country, 50–75% of the costs are for services associated with exacerbations. 1 </li></ul><ul><li>1 COPD Audit Commission 2 BTS Consortium 2005 </li></ul>
    8. 8. Characteristic <ul><li>Changes characteristic of the disease include: </li></ul><ul><ul><li>smooth muscle contraction (bronchoconstriction) </li></ul></ul><ul><ul><li>mucus hypersecretion </li></ul></ul><ul><ul><li>ciliary dysfunction </li></ul></ul><ul><ul><li>pulmonary hyperinflation </li></ul></ul><ul><ul><li>gas exchange abnormalities </li></ul></ul><ul><ul><li>pulmonary hypertension </li></ul></ul><ul><ul><li>cor pulmonale </li></ul></ul><ul><li>These abnormalities contribute to the characteristic symptoms of COPD - chronic cough, sputum production and dyspnoea 1 </li></ul><ul><li>1 Pauwels et al, 2001 </li></ul>
    9. 9. Healthy Respiratory Mucosa This electron micrograph shows the respiratory mucosa in a healthy state The cells are fully ciliated The cilia beat in a co-ordinated fashion to move mucus out of the airways (mucociliary transport) Scanning electron micrograph showing a sheet of mucus being moved along by the cilia
    10. 10. Damaged Respiratory Mucosa <ul><li>Damage to the cilia and epithelium occur as a result of disease processes in COPD. This can also occur as a result of bacterial damage </li></ul><ul><li>This slide shows the result of bacterial infection stripping away the cilia from the mucosa </li></ul><ul><li>The damage to the cilia means they are less effective in removing mucus from the airways </li></ul>Scanning electron micrograph showing cilial and epithelial damage induced by bacteria
    11. 11. <ul><li>Chronic Bronchitis </li></ul><ul><li>↑ in mucus glands and goblet cells </li></ul><ul><li>Production of sputum on most days for > 3 months on 2 consecutive years </li></ul><ul><li>Small airway disease </li></ul><ul><li>(structural changes in the small airways 2-5mm) </li></ul><ul><li>> 50% of bronchioles may be effected before any SOB </li></ul><ul><ul><li>↑ airway smooth muscle </li></ul></ul><ul><ul><li>Inflammatory infiltration resulting in structural narrowing and distortion </li></ul></ul><ul><li>Collagen deposition / fibrosis / mucous plugging </li></ul>
    12. 12. <ul><li>Emphysema </li></ul><ul><li>Dilation of alveolar wall </li></ul><ul><li>↓ alveolar capillary network, loss of guy rope effect </li></ul><ul><li>↓ lung tissue elasticity </li></ul><ul><li>Caused by smoking » irritation » inflammation » neutrophils and macrophages » release neutrophil elastase (type of proteases) </li></ul>Emphysema Normal Lung
    13. 14. The COPD Patient <ul><li>Generally over 40 years 1 </li></ul><ul><li>A smoker or ex-smoker </li></ul><ul><li>Presentation with: </li></ul><ul><ul><li>cough </li></ul></ul><ul><ul><li>excessive sputum production </li></ul></ul><ul><ul><li>shortness of breath </li></ul></ul><ul><li>Dyspnoea is the reason most patients seek medical attention 3 </li></ul>1 . BTS, 1997; 3. GOLD, 2003
    14. 15. Diagnosis <ul><li>>35 years </li></ul><ul><li>Smoker or ex-smoker </li></ul><ul><li>Spirometry (obstructive pattern) </li></ul><ul><li>Any symptoms : </li></ul><ul><ul><ul><ul><ul><li>Exertional breathlessness </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Chronic cough </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Regular sputum production </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Frequent “winter bronchitis” </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Wheeze </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>+ no clinical features of asthma </li></ul></ul></ul></ul></ul>
    15. 16. Clinical features of Asthma vs. COPD
    16. 17. Assessment of Severity of COPD 1 NICE Guidelines 2004 GOLD state that spirometry is the gold standard for diagnosing COPD, severity is measured by FEV1. <30% Severe 30-49% Moderate 50-80% Mild FEV1 % predicted 1 Severity of airflow obstruction
    17. 18. Impact of Chronic Disease <ul><li>Impairment </li></ul><ul><li>Disability </li></ul><ul><li>Handicap </li></ul>
    18. 19. Management of COPD (Stable) <ul><li>Use short acting bronchodilator PRN (beta2-agonist or anti-cholinergic) </li></ul><ul><li>If still symptomatic try combined therapy with a short acting beta2 agonist and a short acting anti-cholinergic. </li></ul><ul><li>If still symptomatic use a long acting bronch-dilator (beta2 agonist or anti-cholinergic) </li></ul>
    19. 20. Management In moderate or severe COPD <ul><li>If still symptomatic consider a trial of a combination of a long acting beta2 agonist and inhaled corticosteroid. ( Discontinue if no benefit after 4 – 6 weeks) </li></ul><ul><li>If still symptomatic consider adding theophylline. </li></ul><ul><li>Offer pulmonary rehab to all patients who consider themselves functionally disabled (usually MRC 3 and above) </li></ul><ul><li>Consider referral for surgery. </li></ul><ul><li>End of Life Care ( need to start these conversations ,what the future will hold, discuss issues, worries and concerns with patients at an earlier stage. Palliative care being part of end of life care) </li></ul>
    20. 21. Acute exacerbation of COPD <ul><li>Sustained worsening of patients symptoms from their usual stable state, which is beyond normal day-to-day variations and is acute in onset. 1 </li></ul><ul><li>Symptoms : </li></ul><ul><ul><ul><ul><ul><li>Increased shortness of breath </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Increased sputum production and/or change in colour </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Increased cough </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Increased wheeze/tightness </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Decreased exercise tolerance </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Increased fatigue </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Confusion </li></ul></ul></ul></ul></ul><ul><li>1 NICE Guidelines 2004 </li></ul>
    21. 22. Annual Review – Primary Care <ul><li>Smoking cessation </li></ul><ul><li>Spirometry </li></ul><ul><li>Need for Oxygen Assessment </li></ul><ul><li>Pharmacological Therapy - inhaler technique </li></ul><ul><li>Pulmonary Rehabilitation </li></ul><ul><li>LVRS / Transplantation </li></ul><ul><li>BMI – Need for Dietician Input </li></ul><ul><li>Referral to other Services </li></ul><ul><li>MRC Scale </li></ul><ul><li>Need for Specialist Referral </li></ul><ul><li>Chronic NIV </li></ul><ul><li>End of Life Care </li></ul>
    22. 23. Severe COPD <ul><li>Smoking cessation </li></ul><ul><li>Oxygen </li></ul><ul><li>Pharmacological Therapy </li></ul><ul><li>Pulmonary Rehabilitation </li></ul><ul><li>Dyspnoea Clinic </li></ul><ul><li>LVRS / Transplantation </li></ul><ul><li>Chronic NIV </li></ul><ul><li>End of Life Care - Palliation </li></ul>
    23. 24. Natural History
    24. 25. Look magazine ad from 1951
    25. 26. Oxygen Therapy <ul><li>Long Term Oxygen Therapy (LTOT) </li></ul><ul><li>Short Burst Oxygen Therapy </li></ul><ul><li>Ambulatory Oxygen Therapy </li></ul>
    26. 27. Benefits of LTOT <ul><li>Improved survival </li></ul><ul><li>Prevention of deterioration of pulmonary haemodynamics </li></ul><ul><li>Reduction in secondary polycythaemia </li></ul><ul><li>Neuropsychological benefit </li></ul><ul><li>improved sleep quality </li></ul><ul><li>Increased renal blood flow </li></ul><ul><li>reduction in cardiac arrhythmias </li></ul><ul><li>Reduction in dyspnoea, improved exercise tolerance </li></ul><ul><li>Should be worn for 15 hrs or more a day to gain these benefits </li></ul>
    27. 28. Short Burst Oxygen Therapy <ul><li>Further research is required </li></ul><ul><li>Episodic dyspnoea not relieved by other treatments </li></ul><ul><li>Palliative therapy or in emergency situations </li></ul><ul><li>If improvement in dyspnoea or exercise tolerance can be documented </li></ul>
    28. 29. Ambulatory Oxygen Therapy <ul><li>Improved exercise tolerance </li></ul><ul><li>Reduced dyspnoea </li></ul><ul><li>Improved quality of life </li></ul>
    29. 30. Medicines Management <ul><li>Flu and Pneumonia vaccination </li></ul><ul><li>Bronchodilators </li></ul><ul><li>Coticosteroids </li></ul><ul><li>Mucolytics </li></ul><ul><li>Pharmacotherapy does not modify long-term decline, but is used to </li></ul><ul><ul><li>prevent and control symptoms / improve exercise tolerance </li></ul></ul><ul><ul><li>reduce the frequency and severity of exacerbations </li></ul></ul><ul><ul><li>improve health status </li></ul></ul>
    30. 31. Long – Acting Inhaled bronchodilators e.g. Salmeterol / Tiotropium <ul><li>Significant improvement in lung function 1-3 </li></ul><ul><ul><li>better sustained improvement in lung function over 12 hours than ipratropium bromide 1 </li></ul></ul><ul><li>Improve shortness of breath day and night 1,3 </li></ul><ul><li>Reduce risk of exacerbations vs. placebo 1 </li></ul><ul><li>Clinically significant improvements in quality of life 4,5 </li></ul><ul><ul><li>unlike ipratropium bromide, Salmeterol significantly increased the percentage of patients showing a clinically relevant improvement in health status compared with placebo 5 </li></ul></ul>1. Mahler et al, 1999, 2. Mahler et al, 2001, 3. Boyd et al, 1997, 4. Jones et al, 1997, 5. Cox et al , 2000
    31. 32. Xanthines - e.g. theophylline <ul><li>Less commonly used than other bronchodilators </li></ul><ul><li>Only modest bronchodilators </li></ul><ul><li>Side effects within therapeutic range </li></ul><ul><li>Many drug interactions </li></ul><ul><li>Smoking can affect the metabolism of theophylline </li></ul>
    32. 33. Inhaled Corticosteroids <ul><li>Inhaled steroids now limited to moderate symptomatic disease with  2 exacerbations per year to reduce admission rates 1 </li></ul><ul><li>Emerging evidence of enhanced effect of xanthines when combined with corticosteroid </li></ul><ul><li>1 NICE (2004) </li></ul>
    33. 34. Mycolytics <ul><li>Carbocisteine </li></ul><ul><li>Reduces sputum viscosity to aid expectoration </li></ul><ul><li>Reduces exacerbations of COPD in those with chronic productive cough </li></ul><ul><li>(caution in peptic ulceration / can cause gastrointestinal irritation) </li></ul><ul><li>Erdotin - Short course during acute exacerbation </li></ul><ul><li>GOLD guidelines (2007) suggest there is not enough evidence to support there use. However, there are a group of patients in which it works well in </li></ul>
    34. 35. Lung Reduction In Emphysema <ul><li>Remove hyperinflated areas of lung : </li></ul><ul><ul><li>Improve V/Q matching </li></ul></ul><ul><ul><li>Reduce resting length of respiratory muscles </li></ul></ul><ul><ul><li>Reduce Dynamic Hyperinflation </li></ul></ul>           
    35. 36. Pulmonary Rehabilitation <ul><li>The goal of PR are to reduce the symptoms, disability and handicap to improve functional independence in COPD 5 </li></ul><ul><li>Programme incorporates a programme of physical training, disease education, nutritional, psychological, social and behaviour intervention 5 </li></ul><ul><li>Provided by a inter professional team, with attention to individual goals and needs. </li></ul><ul><li>Improves exercise tolerance and function / reduces dyspnoea / improves QOL 1,2 </li></ul><ul><li>Empowerment for patients to manage their own condition recognition of exacerbations. </li></ul><ul><li>1 Ries et al. 1995, 2 De Paepe et al. 2000 3, Griffiths at al.2000, 4, Troosters et al, 2000 5 BTS 2001 </li></ul>
    36. 37. Pulmonary Rehabilitation <ul><li>Introduction </li></ul><ul><li>Benefits of exercising </li></ul><ul><li>Anatomy, Physiology and Pathology </li></ul><ul><li>Medication </li></ul><ul><li>Chest Clearance techniques </li></ul><ul><li>Dyspnoea management </li></ul><ul><li>OT pacing/aids </li></ul><ul><li>Age Concern Benefits system </li></ul><ul><li>Exacerbation </li></ul><ul><li>Nutrition </li></ul><ul><li>Psychosocial factors - Coping/Anxiety/Panic </li></ul><ul><li>Breath easy </li></ul><ul><li>Expert patient </li></ul><ul><li>What next? – Health improvement team </li></ul>
    37. 38. Chronic Non-Invasive Ventilation <ul><li>Domiciliary NIV for a highly selected group of COPD patients with recurrent admissions requiring assisted ventilation is effective at reducing admissions and minimizes costs from the perspective of the acute hospital 1 </li></ul><ul><li>1 Tuggey JM, Plant PK, Elliott MW. Thorax. 2003 </li></ul>
    38. 39. When does COPD become Palliative? (1 of 2) <ul><li>Primary clinical indicators </li></ul><ul><li>FEV1 < 30% pred </li></ul><ul><li>History of >2 acute exacerbations in last 12 months </li></ul><ul><li>Frequent admissions to hospital </li></ul><ul><li>Progressive shortening of of the intervals between admissions </li></ul><ul><li>Limited improvement following admission 1 </li></ul>
    39. 40. When does COPD become Palliative? (2 of 2) <ul><li>Supporting clinical Indicators </li></ul><ul><li>On maximum therapy- no other intervention is likely to alter the conditions progression </li></ul><ul><li>Dependence on oxygen therapy </li></ul><ul><li>Severe unremitting dyspnoea (MRC Dyspnoea Scale grade 5) </li></ul><ul><li>Severe co morbidities e.g. heart failure, diabetes </li></ul><ul><li>Housebound – unable to carry out normal ADL </li></ul>
    41. 42. Consider… <ul><li>Mortality in severe COPD is between 36% and 50% at 2 years 1 </li></ul><ul><li>In the last year of life 2 </li></ul><ul><ul><li>40% had unrelieved breathlessness </li></ul></ul><ul><ul><li>68% had low mood unrelieved </li></ul></ul><ul><ul><li>51% had unrelieved pain </li></ul></ul><ul><ul><li>20% did not know they might die </li></ul></ul><ul><ul><li>70% died in hospital (for 25% of whom it was not the best place to die) </li></ul></ul><ul><li>It has been shown that NIV in acute exacerbations of COPD reduces mortality and need for ICU 3,4 </li></ul>1 Connors et al AJRCCM 1996; 2 Elkington et al Palliat Med 2005 3 Brochard et al N Engl J Med 1995 4 Plant et al Lancet 2000
    42. 43. Dyspnoea - Symptomatic Treatment <ul><li>Opioids </li></ul><ul><ul><li>Mechanism unclear </li></ul></ul><ul><ul><ul><li> respiratory drive,  sensation of respiratory muscle fatigue, cognitive changes, central effect, cough suppressant 2 </li></ul></ul></ul><ul><li>Oral morphine 2.5 4 hourly (dose maybe escalated if well tolerated) 1 </li></ul>No evidence to support nebulised morphine 1 Watson et al 2006 2 Jenner 1991
    43. 44. Dyspnoea related to Anxiety <ul><li>Benzodiazepines </li></ul><ul><li>Examples include </li></ul><ul><li>- Diazepam 2 – 5mgs BD and PRN </li></ul><ul><li>- Lorazepam 1 – 2 mgs p.r.n 1 </li></ul><ul><li>1 Watson et al 2006 </li></ul>
    44. 45. Oxygen Therapy <ul><ul><li>Some patients do derive good benefit if not already on LTOT </li></ul></ul><ul><ul><li>But: Beware the CO2 retainers </li></ul></ul><ul><ul><li>Also: </li></ul></ul><ul><ul><ul><li>Risk of psychological dependence </li></ul></ul></ul><ul><ul><ul><li>Paradoxical restriction to activity </li></ul></ul></ul><ul><ul><ul><li>Dry mouth / nose </li></ul></ul></ul><ul><ul><ul><li>Isolation and communication problems </li></ul></ul></ul><ul><ul><ul><li>Consider open window, fan, cool flannel, heliox </li></ul></ul></ul>
    45. 46. Intractable Cough <ul><li>Steam inhalation </li></ul><ul><li>Nebulisation - (0.9% sodium chloride. Consider nebulised bronchodilation and steroid) </li></ul><ul><li>Oral morphine 2.5 - 5mg, 4 hourly 1 </li></ul><ul><li>1 Watson et al 2006 </li></ul>
    46. 47. Excessive Respiratory Secretions – Pharmacological Management <ul><li>Hyoscine Hydrobromide – Patches or sub cut. </li></ul><ul><li>Glycopyrronium </li></ul><ul><li>Care must be taken to prevent dry mouth </li></ul>
    47. 48. Terminal Breathlessness <ul><ul><li>Non-pharmacological management </li></ul></ul><ul><ul><ul><ul><li>Touch </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Relaxation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Environment </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Modelling of behaviour </li></ul></ul></ul></ul><ul><ul><li>Subcutaneous Route may be necessary </li></ul></ul><ul><ul><li> </li></ul></ul>
    48. 49. COPD CNS - Current Role (1 of 2) <ul><li>To provide expert treatment for all COPD patients Westminster, in line with the NICE guidelines </li></ul><ul><li>To provide expert advice and education to patients and carers </li></ul><ul><li>To educate and advise other health care professionals on the management of COPD patients in both primary and secondary care settings </li></ul><ul><li>To reduce hospital admissions, length of stay and improved use of primary care resources </li></ul>
    49. 50. COPD CNS - Current Role (2 of 2) <ul><li>To support GPs and non-respiratory consultants in diagnosis and management of COPD patients </li></ul><ul><li>To continue to develop services for COPD patients in both primary and secondary care. </li></ul><ul><li>Work with Community Matrons and other community staff i.e. rapid response nurses in the management of exacerbations of COPD </li></ul><ul><li>Support COPD patients on Long Term Oxygen therapy </li></ul><ul><li>Proactive Health Screening for COPD </li></ul>
    50. 51. Community COPD Service <ul><li>Home Visits – COPD Nurse Specialist </li></ul><ul><ul><li>Education and advice – Proactive Management </li></ul></ul><ul><ul><li>Smoking cessation </li></ul></ul><ul><ul><li>Review of medication and Inhaler technique </li></ul></ul><ul><ul><li>Assess Home Situation </li></ul></ul><ul><ul><li>Long Term Oxygen Assessment / Review </li></ul></ul><ul><ul><li>Supported discharge from Hospital </li></ul></ul><ul><ul><li>Exacerbation recognition/management plans </li></ul></ul><ul><ul><li>Ongoing support and advice – Telephone </li></ul></ul>
    51. 52. Community COPD Service <ul><li>Community Clinic – COPD Nurse Specialist </li></ul><ul><ul><li>Education and advice – Proactive Management </li></ul></ul><ul><ul><li>Smoking cessation </li></ul></ul><ul><ul><li>Review of medication and Inhaler technique </li></ul></ul><ul><ul><li>Long Term Oxygen Assessment / Review </li></ul></ul><ul><ul><li>Exacerbation recognition/management plans </li></ul></ul><ul><ul><li>Advice and Support </li></ul></ul><ul><ul><li>Identification & Referral to other agencies </li></ul></ul>
    52. 53. And I haven’t touched on… <ul><li>The Management of an COPD Exacerbation </li></ul><ul><li>Inhaler Technique / Nebulisers </li></ul><ul><li>Diet & Nutrition </li></ul><ul><li>Anxiety and Depression </li></ul><ul><li>We will leave that for another day…! </li></ul>
    53. 55. Thank – You Any Questions ?
    54. 56. Case Study 1 <ul><li>Mrs Jones – Age 63 </li></ul><ul><li>Retired Care Worker </li></ul><ul><li>Heavy smoker, still smoking 2 -3 day </li></ul><ul><li>Diagnosed with COPD 2 years ago, after spilling a bottle of bleach </li></ul><ul><li>‘ Smokers cough’ / winter chest infections for years </li></ul><ul><li>Housebound – Lives Ground Floor Flat </li></ul><ul><li>On maximum inhaled therapy including nebuliser </li></ul><ul><li>Long Term Oxygen </li></ul><ul><li>Nocte BiPAP </li></ul><ul><li>Problems </li></ul><ul><ul><li>- Unable to accept diagnosis of long term condition </li></ul></ul><ul><ul><li> - Depressed and socially isolated </li></ul></ul><ul><ul><li>- Breathless on minimal exertion </li></ul></ul><ul><ul><li>- Continues to smoke </li></ul></ul>
    55. 57. COPD Chronic Obstructive Pulmonary Disease COPD Project Nurse – End of Life Care By Matthew Hodson Respiratory Nurse Specialist COPD Westminster Primary Care Trust
    56. 58. Definition <ul><li>Chronic obstructive pulmonary disease (COPD) is characterised by airflow obstruction. The airflow obstruction is usually progressive, not fully reversible and does not change markedly over several months. 1 </li></ul><ul><li>The disease is predominantly caused by smoking. </li></ul><ul><li>1. NICE 2004 </li></ul>
    57. 59. The Umbrella Disease
    58. 60. Background <ul><li>Mortality in Severe COPD is between 36 – 50% at 2 years </li></ul><ul><li>- High Number of Hospital Admissions </li></ul><ul><li>– Exacerbations </li></ul><ul><li>Type 2 respiratory failure </li></ul><ul><li>Non – Invasive Ventilation </li></ul><ul><li>Access to specialist palliative care variable </li></ul><ul><li>Traditionally on malignant disease into SPC </li></ul><ul><li>Improving care and patient journey </li></ul><ul><li>Patient Pathways – acute / suspected / stable – EOL missing </li></ul>
    59. 61. The Role <ul><li>Project Nurse COPD – End of Life </li></ul><ul><li>6 Month Role </li></ul><ul><li>2 days a week </li></ul>
    60. 62. Scope of Role <ul><li>To understand the current provision of general palliative care by GPs, Practice Nurses, DNs and Community Matrons to COPD patients and their knowledge of this area of care. </li></ul><ul><li>To assess the current local provision of palliative care needs for COPD patients in Westminster </li></ul><ul><li>To understand the potential benefits of specialist palliative care to COPD patients. </li></ul>
    61. 63. Scope of Role <ul><li>To provide and develop an education opportunity for general providers regarding recognising palliative needs in COPD patients. </li></ul><ul><li>To produce a guideline and pathway for recognising and managing COPD patients at the end of their life, linking in with the overall EOL care pathways. </li></ul>
    62. 64. Outcome Measures <ul><li>Baseline Audit Completed </li></ul><ul><li>Improved rate’s of referral to SPC </li></ul><ul><li>Care pathway for COPD into SPC </li></ul><ul><li>Guidelines on criteria for referral </li></ul><ul><li>Education for Primary Care Staff </li></ul><ul><li>Evaluation and recommendations for the future </li></ul>
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