Hospice & Palliative Care

End Stage Disease Progression and Complications – Pulmonary Disorders (Learning Hospice)

Like heart disease, prognostication for those with chronic lung disease is extremely difficult. The terminal stage is marked by increasing visits to the emergency department and hospitalizations for infections and failing respiratory function.

Respiratory failure occurs when the lungs cannot oxygenate the blood (hypoxemia) and cannot eliminate elevated levels of carbon dioxide (hypercapnia).

  • Hypoxemia causes deteriorating mental status and cyanosis; pulse and blood pressure are initially increased and then diminish as death nears.
  • Hypercapnia has a sedative effect (carbon dioxide narcosis) and increases respirations and air hunger.

End-stage progression of pulmonary disorders often includes:

  • Dyspnea (at rest or with minimal exertion, inability to speak in full sentences): Dyspnea is subjective shortness of breath (SOB) and does not correlate with O2 saturation or respiratory rate.
    • Patients wit hypoxemia may need supplementary oxygen, and opioids may help to relieve the sensation of breathlessness.
    • Patients often breathe more easily with the head of bed elevated with a fan aimed at the patient’s head.
    • Patients may benefit from diuretics (for pulmonary edema) or bronchodilators.
  • Pulmonary cachexia syndrome: This syndrome comprises anorexia, weight loss, fat and muscle wasting, and weakness. The patient begins to appear emaciated and increasingly frail. Patients may benefit from nutritional supplementation, small frequent meals. Some medications may improve appetite, such as progestational agents, corticosteroids, cannabinoids, and metoclopramide.
  • Anxiety and depression: Some patients may benefit from relaxation techniques but others may require medications such as SSRIs.
  • Cough: Upright position and cough medicines may help produce some relief.
  • Stress incontinence (associated with cough): Patients should limit drinks containing caffeine and may need incontinence products.
  • Chest pain: Some patients may need opioids to relieve discomfort.

Factors supporting hospice referral: (Both 1 and 2 below should be present)

  1. Severe chronic lung disease as documented by:
    • Disabling dyspnea at rest, poor or unresponsive to bronchodilators, resulting in decreased functional capacity, bed-to-chair existence, fatigue, and cough.
      • Documentation of FEV1, after bronchodilator, less than 30% of predicted is objective evidence for disabling dyspnea. This is good information to have, but not required.
    • Progression of end stage pulmonary disease, as evidence by increasing ER visits or hospitalizations for infections or respiratory failure or increased physician home visits prior to initial certification.
      • Documentation of serial decreased of FEV1>40ml a year is objective evidence of disease progression. This is good information to have, but not required.
  2. Hypoxemia at rest on room air, as evidenced by PO2 less or equal 55mmHg; or O2 saturation less or equal to 88% determined either by arterial blood gases or oxygen saturation monitors or Hypercapnia as evidence by PCO2 greater or equal to 50mmHG. This information may be obtained from recent (within 3 months) hospital records.
  3. The following factors also lend support to terminal diagnosis of pulmonary disease:
    • Right heart failure (RHF) secondary to pulmonary disease (cor pulmonle) e.g., not secondary to left heart disease or valvulopathy
    • Unintentional progressive weight loss of greater than 10% of body weight over the preceding 6 months
    • Resting tachycardia > 100 bpm

References:

Corridor (2006). Hospice Quickflips: A Guide for Hospice Clinicians

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