Date of Award

8-15-2009

Degree Type

Capstone Project

Degree Name

Master of Science in Physician Assistant Studies

First Advisor

Rob Rosenow PharmD, OD

Second Advisor

Annjanette Sommers MS, PA-C

Abstract

Background: Chronic Obstructive Pulmonary Disease (COPD) is a progressive terminal illness that can hospitalize those with the affliction multiple times during its evolution. COPD often also requires care in the Intensive Care Unit (ICU) and mechanical ventilation with or without intubation. The care provided to COPD patients at the end of their life is invasive and shows a high mortality rate despite full medical treatment. Some patients in the terminal stages of COPD may be aggressively treated with full medical care when their discomfort may be better assuaged by palliative care. There is a great need to identify those patients in the terminal stages of COPD so that the medical community can assist them in dying.

Question: Is there an objective set of criteria that could be used to identify COPD patients who would be best served by treatment with palliative care as opposed to intensive care?

Study Design: Exhaustive search of available medical literature.

Methods: The goal was to find studies relevant to terminal care and critical care of a COPD in the ICU. Ovid, CINAHL, Google Scholar, and Pubmed were all searched for the terms Intensive Care Unit, Chronic Obstructive Pulmonary Disease, and Palliative Care or Terminal Care. Due to the limited number of clinical trials, cohort studies were identified as the best source of information on the dying process of COPD patients. Editorials and reviews were excluded but examined. Studies older than ten years were excluded in order to show the most current state of treatment.

Results: Six studies were identified using the above methods. Five cohort studies using different ICUs and one mixed method study. Age, elevated PACO2 at admission, long-term oral steroid use, a worse exacerbation, worse disease at baseline, any abnormality on Arterial Blood Gas (ABG) analysis, complications during the ICU stay, prior intubations, high serum albumin levels at admission, higher APACHE II score, and duration of hospital stay were all associated with increased mortality, or decreased survival to discharge.

Conclusion: Chronic Obstructive Pulmonary Disease has a high rate of in-hospital mortality; it is the fifth leading cause of death in the United States. The dying process of a COPD patient is painful and not well managed under current treatment regimes. The death of a COPD patient ranks lower on evaluations than other deaths, and there is room for improvement. There is a discrepancy in the care of terminal patients with lung cancer versus terminal care of a COPD patient. This difference may be from the medical providers not identifying those COPD patients within the last 6 months of life or to a higher level of acceptance of hospice care for those patients with lung cancer. Although there is good information about the terminal care of COPD patients in the ICU, further study needs to focus on how to identify terminal patients so that future treatment can be tailored to the individual. There is not an accepted set of criteria that can be used to identify terminal COPD patients who would be best served by palliative care as opposed to intensive care. Table 1 in this study is an objective set of criteria that could be used to help identify those COPD patients in the terminal stages of their disease.

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