This document discusses anticipatory care approaches for patients with long-term conditions like COPD. It covers self-management strategies, responding to deterioration, the role of telehealth, and relating anticipatory care to nursing models. The key points are: 1) Self-management plans should be individualized and involve education from healthcare professionals to help patients monitor their symptoms and make lifestyle changes. 2) When patients deteriorate, care should treat physical and psychological symptoms through a multidisciplinary team using interventions like bronchodilators, opioids, and diuretics to ease distress. 3) Telehealth, mobile apps, and online resources can help patients self-manage and allow remote monitoring so clinicians can intervene early

1. Introduction:
This assignment discusses the anticipatory and alternative
approaches for long-term conditions from different aspects. It
consists of five patches explaining the importance of COPD
self-management plan, response to COPD deterioration, the role
of telehealth in managing those patients as well as philosophy
of anticipatory care relating it to nursing models.
Patch one – learning outcome one: self-management strategies.
Approximately three million people are believed to have chronic
obstructive pulmonary disease (COPD) in England, with around
30,000 lives lost as a result each year making it the fifth biggest
cause of mortality and morbidity in the UK (Stewart et al.,
2011; Wilson et al., 2015). Self-management can play a vital
part in the management of COPD and can also give the patient a
greater sense of autonomy, thereby improving their quality of
life (Robbins et al., 2013; Sallnow, Kumar, & Kellehear, 2013).
Self-management plan should be comprehensive, individualized
and tailored to suit each patient as they have varying symptoms
and needs that require individualized plan in order to achieve
optimum health outcome. For that reason, there should be a
great cooperation, education and person-centered support from
specialized health professionals who are COPD knowledgeable
and properly trained (Cornforth,2013 ). Based on that,
clinician’s goal should be directed towards working with COPD
patients collaboratively to discuss and negotiate their tolerated
healthy behaviors, the disease nature, its management and
encouragement of possible life style modifications, for instance,
more exercise, healthy eating, correct inhaler technique and
basically smoking cessation( Cornforth,2013).
Patients who have early-stage COPD may not display their
symptoms in a way that they recognise (Robbins et al., 2013;
Sallnow, Kumar, & Kellehear, 2013); but as COPD worsens
there is an increase seen in wheezing, coughing, sputum
production, and dyspnoea (Sharp, Moran, & Kuhn, 2013). In

2. some patients these symptoms may become so severe that long-
term oxygen therapy is needed (Sharp, Moran, & Kuhn, 2013).
It is important that patients are able to recognise their own
symptoms and thus any changes in them, which can be done by
keeping a daily record (Stewart et al., 2011).
It is important that patients take their medications as prescribed,
even during periods of feeling well (Robbins et al., 2013).
Continuous use of medication can help prevent exacerbations;
but it is important to check for any interactions that may occur
with medicines which are available without prescription
(Sallnow, Kumar, & Kellehear, 2013). In addition to regular
medications, it is also important that patients receive annual
vaccinations such as the flu jab and an anti-pneumococcal
vaccination which protects against serious infections caused by
pneumococcal bacteria (Sallnow, Kumar, & Kellehear, 2013).
Self-monitoring in COPD is a key tool in preventing
exacerbations (Sharp, Moran, & Kuhn, 2013). Evidence
suggests that there is an increase in COPD symptoms about 24
hours before the onset of a full exacerbation (Robbins et al.,
2013; Sallnow, Kumar, & Kellehear, 2013). If antibiotics and/or
steroids are started promptly this could prevent a hospital
admission (Sallnow, Kumar, & Kellehear, 2013). Although there
is some debate about which parameters patients should measure,
there are a number of parameters which are usually monitored,
including symptom score, peak flow/FEV1, and pulse oximetry
(Sallnow, Kumar, & Kellehear, 2013).
The most important lifestyle modification a patient with COPD
can make is to stop smoking, or reduce the amount they smoke
if they cannot stop completely (Robbins et al., 2013). Stopping
or reducing smoking can reduce symptoms of COPD, reduce the
rate of decline in lung function, and improve quality of life
(Robbins et al., 2013; Sallnow, Kumar, & Kellehear, 2013).
Patients may also benefit from a pulmonary rehabilitation
programme which is usually delivered by a team of specialists
and may include breathing exercises, a nutritional programme,
and give educational advice about the disease and strategies to

3. manage it (Robbins et al., 2013).
Patch two – learning outcome two: care providers response to a
deterioration in COPD patients.
Patients with COPD who have deteriorated or are reaching the
end of their life often have an increase in symptoms,
particularly coughing, dyspnoea, and anxiety and/or depression
(Townsend, 2014). In order to provide effective care for these
patients the interventions and responses should be aimed at
easing symptoms such as breathlessness and pain and
psychological symptoms such as anxiety and depression
(Townsend, 2014). Palliative care should be thought of as a
series of actions, interventions, and responses to treat the whole
patient, including psychological factors, not just physical
manifestations of the disease (Badger et al., 2012;Liaw, 2016).
The goal of palliative care should be to prevent and relieve
suffering and to reach the best possible quality of life for the
patient (Badger et al., 2012; Liaw, 2016). In order to be able to
meet this goal, care will be provided by a multidisciplinary
team including, but not limited to, doctors, nurses,
physiotherapists, and nutritionists (Elliott, 2011; Baker et al.,
2012).
Bronchodilators are often used to relieve bronchospasm and
non-invasive ventilation (NIV) can be particularly helpful to
alleviate signs and symptoms of respiratory distress (Elliott,
2011; Baker et al., 2012). Multi-centre randomised control trials
have shown NIV to reduce dyspnoea and respiratory rate faster
than the control group, and these patients also required less
morphine (Badger et al.,2012; Liaw, 2016). Mechanical
ventilation can also be used; but the failure to wean patients
from mechanical ventilation before death occurs is well
documented and the primary goal of easing respiratory distress
should be to avoid endotracheal intubation where possible
without causing unnecessary discomfort (Badger et al.,2012;
Liaw, 2016). The decision to begin mechanical ventilation
should be made in conjunction with the patient, and it is also
clear that one of the key parts of patient education should be

4. about disease progression and what treatment options are
available and may be considered at each stage in order to
facilitate advanced care planning (Townsend, 2014).
Patients with end-stage COPD often also require significant
pain management. Opioids are the only class of drugs which
have a proven effect on dyspnoea by inhibiting the respiratory
drive (Baker et al., 2012; Diaz-Lobato, Smyth, & Curtis, 2015).
The Global Initiative for Chronic Lung Disease (GOLD)
guidelines state that opioids are contraindicated in the
management of COPD because of the potential for inhibition of
the respiratory drive and thereby increasing hypercapnia;
however the American Thoracic Society clinical policy
statement on palliative care states that the use of opioids to
relieve suffering is adequate justification for their use (Lanken
et al., 2008). The dose of opioid should be titrated for each
patient and reviewed regularly for its effect on relieving
dyspnoea (Lanken et al., 2008; Diaz-Lobato, Smyth, & Curtis,
2015). Patients with end-stage COPD often also develop
congestive heart failure and the use of diuretics can be
particularly helpful in removing excess fluid which in turn
reduces breathlessness (Diaz-Lobato, Smyth, & Curtis, 2015).
Patch three – learning outcome three: The role of telehealth in
supporting COPD patients.
Digital Health is an emerging industry arising from the
intersection of healthcare services, information technology and
mobile technology (Monitor Deloitte, 2015), providing patients
and their families with remote access to accurate information in
order to make effective choices about their care (National
Information Board, 2014). Consequently, digital health services
have the power to improve health, give patients more control
over their health and wellbeing, empower carers, and reduce the
administrative burden for care professionals (National
Information Board, 2014). Current provision of digital health
services in the U.K. can be categorised as tele-healthcare

5. (including both remote care and support using ICT and the
exchange of clinical data between patient and clinician),
mobile-health (mhealth) apps related to health and well-being,
and patient centric educational/assisted decision making
websites.
Telehealth has been used to deliver multi-faceted support to
patients with COPD, including web-based self-management and
exercise programs, automated feedback on patients' daily
exercise levels, and tele-consultation via a web portal (Tabak et
al., 2014). Additional benefits of tele-health to patients with
COPD include early recognition of worsening symptoms
through real-time monitoring, quick feedback, and access to
information and support (Nguyen et al., 2013). However, a case
manager is required to interpret monitoring data or determine
patient feedback and this could slow the care process (Tabak et
al., 2014).
The proportion of mobile phone users who use their phones to
look up health information increased significantly from 17% in
2010 to 31% in 2012 (Monitor Deloitte, 2015), however only
7% of consumers aged 55-64 reported using mHealth apps
(Monitor Deloitte, 2015). A survey of mhealth engagement
reported that 10% of UK responders had downloaded an app to
track their health, 17% had used an app to monitor and manage
fitness and health improvement goals, 15% had used an app to
manage health issues, 8% had used mobile technology to receive
medically related alerts or reminders, and 5% had used mobile
technology to send or receive a picture related to a health
problem. For patients with COPD, apps can be utilised to report
respiratory measures (including peak expiratory flow) that are
flagged as at-risk by an algorithm should they deviate over a
threshold from a baseline measure. Such measures can be
reviewed by health care practitioners and same day treatment
provided (Cordova et al., 2016).
Internet based resources can play an important role in
supporting patients, and their carers, living with a chronic
condition. Patients utilise the internet to conduct searches for

6. condition related information, register to receive updates about
their condition, and read/share experiences with other people
with the same condition via blogs (Mahler et al., 2015).
Additionally, patients can access tailored information within
online patient education programs (Farmer et al., 2014; Hewitt
et al., 2015) and any online support groups (Kuijpers et al.,
2013). Jones et al (2014) reported that 85% of patients with a
chronic condition had either direct or indirect (family member
or carer) access to the internet. In the U.K., patients have
access to a number of large national health websites that are
delivered using a mass media format and generalizable across a
diverse population despite evidence that more effective e-
communications are tailored to specific patient populations
(Jones et al, 2014).
Patch four - learning outcome four (a and b): philosophy of
anticipatory care in relation to nursing models.
With an increasing elderly population and an increase in the
number of people living with long-term health conditions such
as COPD, there must be a change in the models of care which
are used to support these patients (Sharp, Moran, & Kuhn,
2013). To this extent, anticipatory care planning seeks to
establish shared decision making through a collaborative
process to support a self-management approach to personal
health. This process should encourage individuals with long
term chronic conditions to be aware of potential changes in
their health status and to prioritise their desired future
healthcare, including planning of dignity and care in practice
(Steel,2015; Stewart et al., 2011; Sharp, Moran, & Kuhn, 2013).
This process should allow effective communication of personal
choice, practical need and sharing of key information to those
who provide care (Steel, 2015; Stewart et al., 2011; Sharp,
Moran, & Kuhn, 2013).
Anticipatory care is essentially patient-centered, patient-
focused, and patient-led (Steel, 2015) as demonstrated in Patch
1 through exploration of self-management strategies, symptom

7. recognition, self-monitoring, and lifestyle modifications. This
discussion showed that self-management can play a vital part in
the management of COPD, including prevention or reducing
exacerbations (Paradis et al., 2011; Wilson et al., 2015), and
can also give the patient a greater sense of autonomy, thereby
improving their quality of life (Paradis et al., 2011; Wilson et
al., 2015).
Anticipatory care planning was also evident within Patch 2 that
discussed the actions, interventions, and responses that should
be made when patients with COPD have a deterioration in their
illness or reach end of life care. This discussion explored the
use of non-invasive ventilation, mechanical ventilation, and
medications such as opioids. This discussion is important
because anticipatory care will allow patients to consider and
discuss options about their care in advance of any deterioration
(Badger et al.,2012; Liaw, 2016). The discussion also
highlighted the need for thorough holistic assessment of
patients, as palliative care should be thought of as a series of
actions, interventions, and responses to treat the whole patient,
including psychological factors, not just physical manifestations
of the disease (Badger et al.,2012; Liaw, 2016). The goal of
palliative care should be to prevent and relieve suffering and to
reach the best possible quality of life for the patient (Badger et
al.,2012; Liaw, 2016).
The role and extent of digital health, including tele-healthcare,
mobile apps, and internet resources for individuals with chronic
conditions is key to both self-management and timely care
intervention in the event of a deterioration in patient health.
This was discussed in Patch 3 and is fundamental to the patient-
led philosophy of anticipatory care. The utilisation of digital
resources can allow patients with chronic conditions to remain
autonomous within their own home, and yet receive time
appropriate treatment through real-time monitoring by remote
heath care practitioners.
Anticipatory care is fundamentally located within a humanistic
philosophy that acknowledges the needs of the 'whole person'.

8. This underlying principle has given rise to several models of
nursing that identify the individual as a biopsychosocial being
within an ever changing environment. A nursing model has
been defined as
set of concepts which are formulated efficiently , inter-related
in a logical manner and based on science that describe the main
elements of nursing practice along with the theoretical basis
behind those concepts as well as the required values for their
practice by the health care provider (McCrae et al., 2012). An
example of such a model is Roy's Adaptation model that
challenges nursing to support both the individual's biological
needs and self-perception as they adapt to a changing
environment. Similarly, Rogers theory encouraged nursing to
deal with patients as a whole unit in both care design and
provision. Therefore, it could be argued that nursing
differentiates itself from a medical model by seeing a person's
health as more than their biological status or presence of
disease. Consequently, the nursing process needs to be multi-
dimensional in order to address the biological, psychological,
sexual, and spiritual needs of patients. Roper, Logan &
Tierney's model of nursing is widely used in the U.K. and
promotes maximum independence through complete assessment
of activities of living that further support independence. Such a
framework supports nurses to fulfill their duties bestowed upon
them by the Nursing and Midwifery Council (2015) that
registered nurses are expected to be able to make holistic and
systematic assessments of their patients, which includes
physical, emotional, psychological, and other needs.
Roper's holistic model of nursing sought to assess the
biological, psychological, sociocultural, environmental, and
politic economic aspects of care and how they influenced an
individual's independence. In Patch 1, the psychological
element of Roper's model is demonstrated by increasing patient
independence through self-management strategies. Patch 2
referred to healthcare interventions required as a result of
deterioration in health and can be referenced to the biological

9. assessment noted in Roper's model. Patch 3 identified the role
of digital health services to support patients and families and is
closely associated with both biological and psychological
elements of Roper's model of nursing. It could be argued that a
lack of literacy, including IT skills, may inhibit patients from
accessing the full benefits of digital health services, and
additional interventions (or adaptations) to address
independence may need to be considered.