L20 COPD 2

Question 1

Pulmonary Rehabilitation general

Answer 1

Important and growing area
-can make a big difference in the disability of COPD (dabilitating and isolating)
Counties Manukau

Question 2

Pulmonary rehabilitation aims

Answer 2

Pulmonary Rehabilitation is a program for patients with chronic lung disease which aims to:
1. improve adherence to treatment (people dont take prescribed medication. Not always their fault (dont understand which/when/current new ones and which old to replace))
-decrease frequency and severity of symptoms (pace in daily activities to reduce shortness of breath) (signs and symptoms of deterioration/exacerbation)
-improve mood and motivation (isolating to be stuck at home)
-improve quality of life
-decrease dependency (on family members and hospital resources)
… through exercise and education

Question 3

Exercise Intolerance

Answer 3

Exercise intolerance is one of the main factors limiting participation in activities of daily living in people with chronic lung disease

Question 4

Exercise Intolerance Symptoms and Cause

Answer 4

Symptoms: which limit exercise tolerance the most:
-dyspnoea
-fatigue
Cause: of reduced exercise tolerance is often complex and multifactorial
-reduction in exercise capacity which limits their participation in daily activities (cycle of inactivity, exercise capacity reduces and become more short of breath)
-dyspnoea (difficult to shower, make bed, get dressed etc)

Question 5

Three main reasons for dyspnoea/shortness of breath?

Answer 5

Cause: of reduced exercise tolerance is often complex and multifactorial
-Permanent lung changes
-Exercise tolerance
-Breathing pattern (become chronically hyperinflated, changes in breathing pattern, impacts shortness of breath)
Pulmonary rehab tries to reduce this shortness of breath

Question 6

Cycle of inactivity

Answer 6

1. Short of breath. Difficulty with day-to-day activities (scary)
2. Poor confidence. Less Physical activity (avoid activities which make them short of breath.)
3. Muscles lose strength. Heart function decreases. (family member compensate as dont want to see them distressed)
4. Fitness declines. Social isolation. (dont go to supermarket/shops)
5. Worsening shortness of breath. Anxiety and/or depression (home alone constantly and more problems develop)
6. Loss of independence. Symptom worsen.

Question 7

Key goal of Pulmonary Rehab

Answer 7

Reverse the cycle of inactivity

• increase exercise tolerance
• work on good breathing patterns
• get confidence up to start re-doing the activities that they enjoy

Question 8

Programme Structure

Answer 8

Class Programme- Exercise and Education

• 6-8 weeks duration (not to cure as is chronic condition. but to give tools to better manage their longterm condition as know it isnt going away)
• 2 classes/per week; one-two home sessions recommended
• sit through an informal interactive education session. different speakers come to talk about managing health (dietitian- eating plan. occupational therapest- energy conservation. pharmacist- what medication does) (stress management, breathing techniques, introduce advanced care planning) (consultant- what is happening in their lungs)
• hospital or community venue

Question 9

Hospital vs Community venues

Answer 9

Community more accessable to patient. “wellness” model. easier to access
Hospitals: congested. difficult parking. “Illness” model

Question 10

Case study problem list

Answer 10

Patients coming to Pulmonary Rehab dont have COPD alone. often have multiple conditions all of which need to be managed (e.g. Sleep apnoea)

• CPAP machine overnight + medications
• FEV1 mild but MRC (Medical Research Scale- used to quantify someone’s breathlessness) 1-5. 5= breathless when getting dressed.
• -spirometry results werent that bad. but was significantly dabilitated by symptoms associated with his condition
• Submaximal exercise Test (6 min walk test. Arthur-255m)
• normal oxygen saturation

Question 11

Goals

Answer 11

important as makes the programme more meaningful to the patient

• and hence increase the likelihood that they’re going to adhere to the rehab plan
• initially came to rehab because doctor had sent him. took a little while for him to engage fully in the programme.

Question 12

Beginning an End differences after the 8 week programme

Answer 12

no changes in spirometry results (no change in lung function)-expected
improvement in exercise capacity
MRC dyspnoea score 5–>3
Submaximal exercise test 6 mins: able to walk over 357m
HR and Oxygen saturation good

Question 13

Lacking areas of Rehab programme

Answer 13

• engaging with participants. Arthur is a volunteer.
• welcomes and orientates people
• offers support and encouragement for other members

Question 14

Definition of Advanced Care planning

Answer 14

ACP is a process of thinking about, talking about and planning for future health care and end-of-life

Question 15

Reasons for Advanced Care planning

Answer 15

ACP gives people the opportunity to develop and express their preferences for future care based on:
-their values, beliefs, concerns, hopes and goals
-a better understanding of their current & likely future health
-the treatment and care options available
(can talk to gp and family members)

Question 16

Benefits of ACP

Answer 16

For the person: should help lessen anxiety about what lies ahead (put plan aside and go on living life)
For the person’s loved ones: they know what choices the person would likely have made if they were capable (passing away, grieving child can accept parent’s plan) (daughter can stand up for dad’s choices)
For healthcare workers: members of health care team will feel more comfortable providing care that is in accordance with the person’s wishes (makes conversation easier for family)

Question 17

It is a fact

Answer 17

80% of people say that if seriously ill, they would want to talk to their doctor about end-of-life care
7% report having had an end-of-life conversation with their doctor (last thing on your list to talk about GP)

Question 18

Research tells us

Answer 18

Most patients are not uncomfortable discussing end-of-life issues, and some have already accepted their own mortality (know/accepted outcome of having bad diagnosis)
It is important that the topic of APC is raised appropriately, with good knowledge and communication skills

Question 19

Why make a plan?

Answer 19

For own “peace of mind” - a plan can give a sense of relief and comfort, relieve pressure from family, suffering at the end-of-life, and ensure that non-medical wishes are known

• 60% of people say that making sure their family is not burdened by tough decisions is “extremely important”
• However, 56% have not communicated their end-of-life wishes (children dont want to talk about it)

Question 20

Barrier which stop people from having this “tricky” end-of-life conversation

Answer 20

1. Fears
2. Beliefs/attitudes
3. Skills/abilities
4. Environment (rehab> EC/busy hospital ward)

Question 21

Legal aspects of Advanced Care Planning

Answer 21

An advanced Care plan is not legally binding- can only be actioned when the person is unable to take part in medical decision making does have to be signed)
-An advance care plan is used as a “guide only” by the treating health team

Question 22

Legally binding documents

Answer 22

Advanced Directives are legally binding

• Conversations: increasing ACP awareness
• Advance Care plan containing a plan in the centre of their guide where they can write down their wishes
• -> Advanced Directive: “in these circumstances i do not want..” quite specific
• plans put onto computers.
• raise national medical warning on NHI is person is in hospital, indicating that a person has a ACP

Question 23

Advanced Directives

Answer 23

An advances directive is consent of refusal to specific treatment(s) which may or may not be offered int he future when the person no longer has capacity
Three criteria must be met:
-Informed
-Competent
-Voluntary

Question 24

Using an advanced Directive

Answer 24

Clinician must determine if the directive is valid
-person must have intended the Advanced Directive to apply in current circumstances
-When created, the clinician is confident that the person was Informed, Competent and Free of undue influence
In the absence of reasonable grounds to doubt validity, it should ordinarily be honoured

Question 25

The conversations that count

Answer 25

AIM: “encourage families and communities to think and talk about the treatment and care they want at the end-of-life”
(Day in April to increase awareness. when buying house/young retiree)
ROLE: This is done be the training volunteers to be Communicators
-Role of the Communicator “… is to help community groups hold their own discussions about planning for death and dying in a positive and productive way”

Question 26

Advance care planning resources

Answer 26

Advance care planning- preparing for end of life 2011
Making the most of your final years- practical and spiritual things to think about and plan for end of life. 2011
My advance care plan
Advance care planning guide- planning the midical treatment and care you want in the future

Question 27

Arthurs plan

Answer 27

Wants tubes removed
Family to be allowed in
Keep comfortable
Offer something that aids comfort
Dont want medication that causes pain
Look after my spiritual needs (cultural aspect. some not accepting)
(maori not cremated)
-can update as thinking changes
-daughter to remove conflict. (Money box passed on without conflict (distribute to other family members))

Question 28

Costs

Answer 28

Many people in South Auckland cannot afford to have a Will as it costs to go through a lawyer

• Expensive to have a Enduring power of attorney
• No cost involved with Advanced directive or ACP (do with doctor or download online)