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Case based discussions
COPD, end of life and Ceiling of Treatment
  1. D Robin Taylor
  1. Correspondence to Professor D Robin Taylor, Primary Palliative Care Research Group, Centre for Population Health Sciences, University of Edinburgh Medical School, Teviot Place, Edinburgh EH8 9AG, UK; rtaylorscot{at}gmail.com

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Case history

An elderly patient with severe COPD and at least four previous admissions with acute on chronic respiratory failure was admitted under my care. During the final admission, an end-of-life conversation took place with the patient and his family, acknowledging that the patient was terminally ill. It was agreed that treatment would be limited to oxygen, fluids, lorazepam and morphine. This was documented, but at 3:00 next morning, when nursing staff noted the patient to be more breathless, the on-call registrar commenced non-invasive ventilation (NIV). The patient died 4 h later, incommunicado. The family lodged an informal complaint.

Discussion

Death is inevitable. Death is sometimes preventable, but ultimately it is only postponed. This existential truth applies to us all. More immediately, the logic applies to patients with severe COPD just as it does to patients with disseminated malignancy. The only difference between these situations is that the trajectory towards end of life is less predictable in COPD; the distinction between preventable and inevitable death is more difficult to make. However in ‘frequent flyers’ with severe COPD, the distinction is crucial in deciding how to provide best possible care. Just because it is difficult does not mean that the challenge should be avoided. How we manage life-threatening exacerbations of COPD should be appropriate and we need to be prepared to adapt our approach as the patient nears the end of life. Such responsiveness will impact positively on the quality of care received by patients and perceived by families.

Many studies have highlighted the predictors for mortality for COPD. The underlying assumption is that by identifying these factors, we will focus our efforts on high-risk patients with a view to reducing mortality. The most reliable predictor of mortality is the frequency of exacerbations, and the most reliable predictor of exacerbations is the frequency of exacerbations …

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