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Keywords:

  • advance care planning;
  • chronic obstructive;
  • palliative care;
  • pulmonary disease

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. CURRENT STATE OF ACP IN COPD
  5. BARRIERS TO ACP
  6. GOALS OF ACP
  7. TIMING OF ACP
  8. ACCESS TO ACP AND PALLIATIVE CARE
  9. IMPROVING COMMUNICATION IN ACP
  10. PATIENT DECISION AIDS
  11. CONCLUSION
  12. REFERENCES
  13. Appendix

The review aims to discuss current concepts in advance care planning (ACP) for patients with COPD, and to provide a narrative review of recent trends in ACP and end-of-life care for patients with COPD. ACP, which involves patient–clinician communication about end-of-life care, can improve outcomes for patients and their families, and may be especially relevant for patients with COPD. Effective patient–clinician communication is needed to inform and prepare patients about their diagnosis, treatment, prognosis and what dying might be like. It is important for clinicians to understand patients' values and preferences for life-sustaining treatments as well for their site of terminal care. Unfortunately, discussions about ACP and end-of-life care in current practice are scarce, and their quality is often poor. ACP can improve outcomes for patients and their relatives. The challenge remains in the practical implementation of ACP in the clinical setting, especially for patients with COPD. ACP should be implemented alongside curative-restorative care for patients with advanced COPD. The disease course of COPD is such that there will rarely be a clear transition point predicting the timing of the need for initiation of end-of-life care. Future studies should focus on interventions that facilitate concurrent ACP and prepare patients for making in-the-moment decisions, with the goal of improving the quality of end-of-life care.


INTRODUCTION

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. CURRENT STATE OF ACP IN COPD
  5. BARRIERS TO ACP
  6. GOALS OF ACP
  7. TIMING OF ACP
  8. ACCESS TO ACP AND PALLIATIVE CARE
  9. IMPROVING COMMUNICATION IN ACP
  10. PATIENT DECISION AIDS
  11. CONCLUSION
  12. REFERENCES
  13. Appendix

COPD is a major cause of morbidity worldwide and is also one of the few leading causes of mortality that is currently rising.1,2 The escalating prevalence of COPD has imparted an increasing burden on patients and their families worldwide due to the difficulty of having to manage the often progressive and debilitating physical, psychological and social impairments over a relatively long period of time. The therapeutic goals in the treatment of COPD are generally focused on relieving dyspnoea, improving function and enhancing quality of life.3,4 Patients with COPD have a spectrum of treatment options ranging from those that reduce mortality or halt disease progression (e.g. oxygen supplementation, smoking cessation) to those that reduce morbidity and improve symptoms (e.g. bronchodilators, pulmonary rehabilitation, opioids). There is considerable overlap between these options, and unless clinicians are knowledgeable about the extensive palliative care resources available to patients with COPD, opportunities can easily be missed to provide effective relief from the refractory dyspnoea and other symptoms that can develop in advanced COPD.5

Advance care planning (ACP), which involves early patient–clinician communication about end-of-life care, is very important for patients with COPD.5 The importance of ACP is increased by the unique and uncertain disease trajectory of COPD, coupled with a high burden of chronically debilitating symptoms such as dyspnoea and anxiety. Clinicians can initiate ACP discussions by informing patients of the nature and prognosis of the disease, and by listening to their concerns, life values and wishes. These discussions allow patients to prepare to make informed choices and can help ensure that they receive end-of-life care that is consistent with their life values and goals.5 In addition to discussions about the expected course of the disease and prognosis, preferences for care at the end of life and desire for spiritual care are also important components of ACP.

A particularly important component of ACP involves educating patients about their disease and prognosis. This can be difficult to practically implement in COPD because the disease course is often unpredictable in that gradual deterioration in functional status can be interrupted by sudden and potentially life-threatening exacerbations.6 For example, patients can appear to be relatively stable after a hospitalization, yet mortality within 1 year after hospitalization for an acute exacerbation of COPD has been estimated to be as high as 23%.7 Some patients with COPD die from progressive respiratory failure, but other comorbidities, such as cardiovascular disease and cancer, can also affect survival and end-of-life care.8

Unfortunately, even the best models of 6-month survival for patients with COPD have a limited ability to predict death for individual patients; thus, unexpected deaths occur frequently.9,10 As a result, the opportunity to recognize the appropriate time for ACP may not be obvious to clinicians or patients. Therefore, early patient–clinician communication about prognosis, preferences for life-sustaining treatments and care at the end of life is essential.

In contrast to patients with lung cancer, there are several differences in end-of-life care for patients with COPD.5 The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments showed that patients with COPD were much more likely than patients with lung cancer to receive invasive mechanical ventilation, cardiopulmonary resuscitation or tube feeding before dying, even though both groups were equally likely to prefer care that was focused on comfort rather than extending life.11 There may be many reasons for these differences in care received by patients with COPD, including difficulty in prognostication and decreased communication about end-of-life care, leading patients and families to choose more aggressive care. This seems consistent with the finding that family caregivers of patients with COPD report feeling a higher burden with decisions regarding life-sustaining treatments, whereas caregivers of patients with cancer mostly report that decisions arise from patients who have already accepted that there are no further life-sustaining options available.12 These studies highlight the need for timely discussions, allowing patients with COPD to participate actively in the decision-making process early on.

ACP also provides an opportunity to introduce the concept of palliative care.13 When compared with terminal lung cancer, patients with advanced COPD have important palliative care needs during their last 6 months of life, including significantly worse activities of daily living, and lower physical, social and emotional functioning; yet despite this need, they receive less palliative care.3,14 While approximately 35% of patients with cancer and 23% of patients with heart failure die at home, only 16% of patients with COPD receive end-of-life care at home.3 This was despite the fact that one study demonstrated that as many as 51% of clinically stable outpatients with advanced COPD prefer to die in their home environment.15 During acute exacerbations when the symptom burden is high, patients with COPD infrequently receive palliative care, and whatever services they do receive are usually poorly integrated with hospital care.16

CURRENT STATE OF ACP IN COPD

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. CURRENT STATE OF ACP IN COPD
  5. BARRIERS TO ACP
  6. GOALS OF ACP
  7. TIMING OF ACP
  8. ACCESS TO ACP AND PALLIATIVE CARE
  9. IMPROVING COMMUNICATION IN ACP
  10. PATIENT DECISION AIDS
  11. CONCLUSION
  12. REFERENCES
  13. Appendix

Currently, ACP is rarely implemented for patients with COPD. Only a minority of patients with advanced COPD have discussed their end-of-life care preferences with their clinicians, received information about their prognosis or discussed palliative care options available to manage refractory dyspnoea.17–19 Even at the stage when COPD severity necessitates home oxygen therapy, many patients remain unaware of the fact that they suffer from a life-limiting disease and cannot provide a correct name for their condition.20,21 One study demonstrated that only 63% of housebound patients with end-stage COPD, refractory symptoms and a recent hospital admission knew that they were likely to die from COPD.22 If clinicians do not discuss end-of-life care with patients with COPD, it is not surprising that patients will rarely have advance care plans or receive any palliative care.

Even when ACP discussions do occur, clinician-directed communication typically occurs in the intensive care unit rather than in ambulatory offices during stable phases of the disease.23 Evidence for poor outpatient communication is demonstrated by studies showing that only 19% of patients entering pulmonary rehabilitation reported having discussed advance care plans with their clinician, and only 14% thought that their clinician understood their wishes for end-of-life care.17 Nevertheless, 94% of these patients had opinions about intubation, and 99% wanted to discuss advance care plans with their clinician. Similarly, in a study of oxygen-dependent patients with COPD, only a third of patients reported having discussed with a clinician the care they would want if they were too sick to speak for themselves.24 Although patients with severe COPD rated their clinicians' general communication skills highly (e.g. listening, answering questions), they rated their clinicians' skills at discussing end-of-life topics as poor, and reported that many topics were not discussed at all (e.g. prognosis, what dying might be like, spiritual issues).25

To corroborate this, clinicians have reported frequent failure in discussing end-of-life care with their patients with advanced COPD.26 It does not appear that this is due to lack of awareness because clinicians acknowledge that the appropriate timing for these discussions is when patients are well enough to participate in decision-making.26 The fact that discussions are often initiated when patients are too ill to make decisions about care is probably exacerbated by inadequate outpatient reimbursement for ACP as well as insufficient time scheduled for outpatient visits.

BARRIERS TO ACP

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. CURRENT STATE OF ACP IN COPD
  5. BARRIERS TO ACP
  6. GOALS OF ACP
  7. TIMING OF ACP
  8. ACCESS TO ACP AND PALLIATIVE CARE
  9. IMPROVING COMMUNICATION IN ACP
  10. PATIENT DECISION AIDS
  11. CONCLUSION
  12. REFERENCES
  13. Appendix

The unpredictable disease trajectory of COPD itself represents an important barrier in the timing of ACP. This can falsely reassure clinicians into thinking that ACP can wait until a future date.20 In contrast, the trajectory of advanced cancers often demonstrates more obvious transitions towards end-of-life care, more clearly signalling the need for ACP.

The following table (Table 1) lists the multiple potential clinician and patient-related barriers to ACP identified through studies of patients with COPD and their clinicians.24 A recent randomized trial suggests that clinician awareness of these patient-specific barriers can improve communication about end-of-life care.27

Table 1.  Potential aetiologies for clinician and patient-related barriers to advance care planning (ACP)
Barriers to advance care planning
Clinician-related barriersUnique disease trajectory with unclear prediction for prognosis and obscure transitions towards the end of life
Poor recognition that ACP should begin early in the course of COPD
False belief that patients with advanced COPD would not want treatment limitations
Concern that early ACP will lead to unnecessary anxiety and depression
Concern that early ACP will take away patients' hope
Inpatient or intensive care unit end-of-life discussions provide poor environments for ACP
Limited outpatient contact time and reimbursement to discuss treatment options, life values and preferences
Inadequate clinician training in ACP or end-of-life care communication
Delayed diagnosis of chronic respiratory failure
Multiple comorbidities that distract from COPD care
Patient-related barriersAssumptions that clinicians will initiate ACP discussions when they are needed
Lack of education regarding COPD, and its course and prognosis
Avoidance of ACP discussions out of fear of abandonment
Assuming that insidious deterioration is a normal part of ageing rather than disease deterioration
Poor medical literacy
Feeling guilty about their smoking-related disease

GOALS OF ACP

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. CURRENT STATE OF ACP IN COPD
  5. BARRIERS TO ACP
  6. GOALS OF ACP
  7. TIMING OF ACP
  8. ACCESS TO ACP AND PALLIATIVE CARE
  9. IMPROVING COMMUNICATION IN ACP
  10. PATIENT DECISION AIDS
  11. CONCLUSION
  12. REFERENCES
  13. Appendix

Effective communication is the cornerstone of end-of-life care for patients with COPD. This includes regular information about their diagnosis, and expected disease process, treatment and prognosis, as well as what dying might be like—all components of ACP. Traditionally, the ACP model has relied on effective patient education, providing a means for patients to extrapolate their disease course into one or more hypothetical scenarios and to document wishes for future care. Due to the inherent challenges of prognostication, as well as the difficulty of predicting the individual patient's circumstances of end-of-life care, experts have emphasized that the objective of ACP should be to prepare patients and surrogates to participate with clinicians in making the best possible in-the-moment decisions (Fig. 1).28 Preparing patients for such decisions focuses less on trying to make treatment decisions based on incomplete or hypothetical information. This ensures that complex health-care decisions are based on a more comprehensive set of considerations, including the precise clinical context, shifting and evolving goals, and patients' and surrogates' needs.28

image

Figure 1. A newly proposed model in the medical management of COPD involves initiating advance care planning (ACP) early, such as when prompted by an acute exacerbation. Further ACP discussions occur in the context of making in-the-moment decisions for acute care interventions. All of this occurs in the context of chronic disease management, which in itself can incorporate palliative care (figure obtained from Professor D. Robin Taylor and adapted for publication with permission).

Download figure to PowerPoint

Another important goal of ACP is to facilitate communication between patients with COPD and their families about the future course of their disease, as well as the process of dying. Family caregivers of patients with COPD have reported that they receive little information regarding the diagnosis, prognosis and aspects concerning end-of-life care. In one study, 44% of bereaved relatives of patients with COPD were not aware that their loved one might die from COPD, and 78% of these caregivers would have preferred to know.29 For family caregivers, information on how to care for the patient becomes a priority as the disease progresses. Family caregivers should be given information about the expected course of the disease, physical and psychological care, as well as information about medical aids and other resources such as hospice care and how to deal with an emergency.30

Finally, an often-neglected goal in ACP is to determine preferences for the site of terminal care (e.g. home, hospice, hospital, nursing home, etc.). One study showed that as many as 91% of older patients recently hospitalized for either COPD, congestive heart failure or pneumonia had specific preferences for their site of terminal care.31 Patients with COPD enrolled in palliative care programs are eight times more likely to die at home as compared with patients with COPD managed by usual care, suggesting the value of incorporating palliative care.3

TIMING OF ACP

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. CURRENT STATE OF ACP IN COPD
  5. BARRIERS TO ACP
  6. GOALS OF ACP
  7. TIMING OF ACP
  8. ACCESS TO ACP AND PALLIATIVE CARE
  9. IMPROVING COMMUNICATION IN ACP
  10. PATIENT DECISION AIDS
  11. CONCLUSION
  12. REFERENCES
  13. Appendix

The timing of ACP discussions remains challenging partly because patients and clinicians may incorrectly perceive that its initiation automatically represents a transition to cessation of life-prolonging treatments.20 One approach to overcome this is to routinely discuss ACP shortly after the time of COPD diagnosis or first exacerbation, integrating it with disease-modifying treatments throughout the course of COPD (Fig. 1). The uncertainty in predicting the course of COPD increases the need for the early introduction of palliative care alongside disease-modifying care.3 Another approach is to address ACP at certain thresholds during the COPD disease course. An example of disease-specific triggers that should prompt ACP discussions are:28,32

  • • 
    FEV1 less than 30% predicted
  • • 
    Oxygen dependence
  • • 
    One or more hospital admissions in prior year for COPD exacerbation
  • • 
    Weight loss or cachexia
  • • 
    Decreased functional status
  • • 
    Increasing dependence on others
  • • 
    Age greater than 70 years
  • • 
    Lack of additional treatment options

Unfortunately, these signposts are often poorly recognized by both patients and clinicians, and thus seldom serve as effective triggers. Events or perceptions that patients with COPD, their family members and their clinicians view as transitional milestones in the course of their disease can be used to trigger these discussions. Such events or perceptions include those listed earlier. Identifying these transitions may help in providing a patient-centred approach towards communication about ACP and end-of-life care.32

Several studies have supported the assertion that palliative care services should be introduced at the time of diagnosis of COPD, while simultaneously treating and preventing the underlying disease and its associated comorbid conditions.33 A recent study among patients with lung cancer has shown that early introduction of palliative care not only improves quality of life and mood status but also leads to less aggressive treatment and longer survival.34 Furthermore, one group recently advocated that identifying a specific time point in transitioning to palliative care generally has little significance for people with COPD or their clinicians, and is counter-productive if it distracts from early-phased introduction of palliative care.32

ACCESS TO ACP AND PALLIATIVE CARE

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. CURRENT STATE OF ACP IN COPD
  5. BARRIERS TO ACP
  6. GOALS OF ACP
  7. TIMING OF ACP
  8. ACCESS TO ACP AND PALLIATIVE CARE
  9. IMPROVING COMMUNICATION IN ACP
  10. PATIENT DECISION AIDS
  11. CONCLUSION
  12. REFERENCES
  13. Appendix

The awareness that patients with COPD need greater access to palliative care services is growing internationally. In the UK, a national service framework for COPD is being developed to improve the quality of care for patients with COPD. In addition, a recently published end-of-life care strategy in England emphasizes the importance of appropriate access for patients with advanced non-malignant conditions.14 To this effect, the UK National Council for Palliative Care has formed a chronic respiratory disease policy group. In addition, national and international pulmonary professional societies have published guidelines on incorporating palliative care for patients with chronic respiratory diseases.33 However, a recent study suggests that there may be important international differences in communication about end-of-life care for patients with COPD, with lower quality communication in the Netherlands than in the USA.35

Leaders in pulmonary rehabilitation have also recognized that the goals of pulmonary rehabilitation and palliative care overlap, with both services addressing symptom management to promote patient independence and a sense of well-being. The incorporation of palliative care into pulmonary rehabilitation provides an effective model for promoting ACP for patients with COPD by facilitating better communication among patient, family and clinician.13,36

Although patients often prefer doctors to discuss ACP, they also accept other health-care professionals as sources of advance planning information.20 Indeed, a recent randomized trial has shown that formal ACP by a trained nurse or allied health-care professional, in coordination with the patient's physician, improves end-of-life care, and patient and family satisfaction in elderly patients admitted to the hospital.37

IMPROVING COMMUNICATION IN ACP

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. CURRENT STATE OF ACP IN COPD
  5. BARRIERS TO ACP
  6. GOALS OF ACP
  7. TIMING OF ACP
  8. ACCESS TO ACP AND PALLIATIVE CARE
  9. IMPROVING COMMUNICATION IN ACP
  10. PATIENT DECISION AIDS
  11. CONCLUSION
  12. REFERENCES
  13. Appendix

Studies have specifically sought to identify ways to improve patient–clinician communication in end-of-life care for patients with COPD. Not surprisingly, 75% of patients reported that they ‘would rather concentrate on staying alive rather than talk about death’.24 Despite the need for conversations about end-of-life care, most patients will not initiate discussions and assume that their clinician will identify the need when it arises.17 Clinicians, therefore, need to develop skills in initiating difficult topics such as end of life. The American Thoracic Society Clinical Policy Statement: ‘Palliative Care for Patients with Respiratory Diseases and Critical Illnesses’ has recommended that communication and ACP should be one of the core competencies for pulmonary clinicians.33

The first step in ACP involves preparation for a discussion, which consists of choosing the appropriate time and venue as well as deciding who should be present. This includes determining which clinicians should be involved in ACP. In fact, in one study, 64% of oxygen-dependent COPD patients reported that a common communication barrier in ACP was concern over which doctor would be treating them if they got sick.20 Coordinated efforts by an interdisciplinary health-care team can help ensure that patients and their families receive consistent messages from all members of the health-care team.38

Balancing empathy and honesty when discussing prognosis is a central component of ACP.39 However, because patients differ in the extent to which they want to receive information regarding their prognosis, the challenge is to incorporate patients' preferences into the discussion of prognosis. A systematic review concerning end-of-life care communication in patients with life-limiting illnesses has identified factors associated with wanting a high level of information: younger age, a higher level of education and patient's expectation of a worse prognosis of survival.30 Because preferences for prognostic information is complex, direct questioning at one point in time about how much information patients and families desire helps but may not fully elucidate their informational needs. Furthermore, patients and their families may differ in the extent to which they prefer to receive information, and family members will often appreciate the opportunity to talk directly to clinicians.40 Checking the patient's and family members' understanding and preferences for information should be an ongoing process during the course of the disease and will facilitate the process of ACP.30

Finally, affirming non-abandonment of patients and families is important to include in conversations about end-of-life care. These kinds of reassurances have been shown to be associated with increased family satisfaction.41

The style in which ACP is delivered is also critical. Not only do clinicians need to communicate in an honest and straightforward way using language that is culturally appropriate, but it is also important to explore emotional reactions and encourage patients to ask questions. Active listening is an essential component of ACP.30 In studies of family conferences, an increased proportion of time spent listening rather than talking was significantly associated with increased family satisfaction with clinician communication.42 Acknowledging that the patient is an individual and adapting the discussion to the patient's social and cultural situation also help personalize care.

One study used interviews with patients and families to develop an approach in providing prognostic information while supporting patients' individual needs for hope about the future.40 Although some patients and family members report preferring to hear direct and explicit information about the patient's prognosis, others prefer a more indirect approach that describes prognosis in general for other patients with COPD. Understanding patients and their families' perspective on prognostic information will help clinicians match their approach to the preferences and needs of individual patients and their families.30,40

There are also a number of communication topics about end-of-life care that are important for family members of patients with COPD. Such topics include available support, medical aids and resources, and how to deal with an emergency. In addition, surrogate decision-making is an important topic to discuss with family members and patients. Indeed, agreement between patients and their surrogate decision-makers about the acceptability of health states may be poor, and surrogate decisions based on considerations of treatment outcomes may not effectively represent patients' preferences. Communication with patients and their family about these topics can improve agreement.30

PATIENT DECISION AIDS

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. CURRENT STATE OF ACP IN COPD
  5. BARRIERS TO ACP
  6. GOALS OF ACP
  7. TIMING OF ACP
  8. ACCESS TO ACP AND PALLIATIVE CARE
  9. IMPROVING COMMUNICATION IN ACP
  10. PATIENT DECISION AIDS
  11. CONCLUSION
  12. REFERENCES
  13. Appendix

In recent years, a novel strategy has emerged aiming to facilitate the interaction between patients and clinicians regarding preference-sensitive care decisions. These so-called patient decision aids function to assist in patient–clinician communication and can be in the form of informational brochures, audio or video material, as well as interactive web-based formats.43

Unfortunately, little research has been conducted testing the efficacy of these patient decision aids on meaningful outcomes for patients with COPD in a real-life setting. Preliminary research suggests that these decision aids provide feasible approaches that have the potential to enhance patient–clinician communication in end-of-life care and ACP.44

CONCLUSION

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. CURRENT STATE OF ACP IN COPD
  5. BARRIERS TO ACP
  6. GOALS OF ACP
  7. TIMING OF ACP
  8. ACCESS TO ACP AND PALLIATIVE CARE
  9. IMPROVING COMMUNICATION IN ACP
  10. PATIENT DECISION AIDS
  11. CONCLUSION
  12. REFERENCES
  13. Appendix

ACP, which involves communication about values and preferences regarding end-of-life care, is of major importance for patients with COPD and their loved ones. Due to the uncertain prognosis and the frequent occurrence of unexpected declines in health status in COPD, ACP must be an important part of regular care for patients with advanced COPD. Unfortunately, ACP occurs infrequently, and the quality of patient–clinician communication about end-of-life care is poor for patients with COPD. Studies have shown that ACP improves outcomes for patients and their relatives, and supports the use of advance directives. The challenge remains in the practical implementation of this in the clinical setting. Greater understanding of the appropriate timing of ACP and the increasing development of tools and decision aids should help this come to fruition. Newer models of ACP have emphasized focusing on preparation for in-the-moment decision-making rather than fixing future preferences based upon a hypothetical outcome. Future studies should focus on the effectiveness of interventions that facilitate ACP in patients with COPD, with the goal of improving the overall quality of end-of-life care. With increasing clinician recognition of the importance of ACP and improving patient–clinician communication, ACP will be an effective way to improve the quality of end-of-life care for patients with COPD and their loved ones.

REFERENCES

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. CURRENT STATE OF ACP IN COPD
  5. BARRIERS TO ACP
  6. GOALS OF ACP
  7. TIMING OF ACP
  8. ACCESS TO ACP AND PALLIATIVE CARE
  9. IMPROVING COMMUNICATION IN ACP
  10. PATIENT DECISION AIDS
  11. CONCLUSION
  12. REFERENCES
  13. Appendix
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    Parker SM, Clayton JM, Tattersall MH et al. A systematic review of prognostic/end-of-life communication with adults in the advanced stages of a life-limiting illness: patient/caregiver preferences for the content, style, and timing of information. J. Pain Symptom Manage. 2007; 34: 8193.
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    Janssen DJ, Curtis JR, Au DH et al. Patient-clinician communication about end-of-life care for Dutch and US patients with COPD. Eur. Respir. J. 2011; 38: 26870.
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Appendix

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. CURRENT STATE OF ACP IN COPD
  5. BARRIERS TO ACP
  6. GOALS OF ACP
  7. TIMING OF ACP
  8. ACCESS TO ACP AND PALLIATIVE CARE
  9. IMPROVING COMMUNICATION IN ACP
  10. PATIENT DECISION AIDS
  11. CONCLUSION
  12. REFERENCES
  13. Appendix

APPENDIX I

Definitions
Palliative careCare that focuses on improving the quality of life of patients and their families facing the problem associated with life-threatening illness through the prevention and relief of suffering by means of early identification and assessment, and treatment of pain and other problems, physical, psychosocial and spiritual
End-of-life careCare occurring in the last part of a patient's life, typically in the last few months depending on the underlying diagnosis and clinical course
Terminal careCare occurring imminently before death (generally the final days to weeks)
Advance care planningPlanning for and about preference-sensitive decisions often arising at the end of life and implemented usually by means of effective patient–provider communication and education. This may involve discussions regarding goals of care, resuscitation and life support, palliative care options, surrogate decision making, as well as living wills and medical directives.