Recomendaciones sobre la atención al final de la vida en pacientes con EPOC

Abstract

Over the last 20 years, advances in the treatment of patients with chronic obstructive pulmonary disease (COPD) have improved survival even among patients in the most advanced stages of the disease, such as those requiring domiciliary oxygen therapy.1,2 This improvement—in principle a positive development—has given rise to considerable clinical problems associated with the establishment of a therapeutic ceiling and the difficulty of determining prognosis in some of these patients. In this situation, the clinician should consider introducing palliative care, that is, care aimed at improving symptom control, communication, physical activity, and emotional support, in order to achieve the best possible quality of life for the patient. Palliative care is generally associated with the advanced stages of a disease’s natural history, but in the case of COPD it is important to emphasize it does not necessarily mean that death is imminent. The lack of a generally accepted definition for “end-stage COPD” makes it difficult to compare studies.3 Table 1 defines the basic concepts. Improving the management of advanced-stage COPD not only has a direct impact on the quality of care received by the patient, but also has a positive effect on the health care system as a whole in that it reduces hospital admissions shifts the burden of care from the hospital to the community, and reduces unnecessary and unscheduled admissions to intensive care units.4 Many patients with COPD remain undiagnosed, and some of those diagnosed do not fulfill the accepted criteria, and it is therefore extremely difficult to establish how many patients actually have very severe COPD, though it is estimated that the proportion may range between 3% and 15% of the total.5,6 The concern with broadening the clinician’s approach beyond actions taken primarily to prolong the patient’s life has developed more recently in the context of COPD in comparison with other diseases. Nonetheless, and despite the lack of precise definitions and the unpredictability of this disease, this broader approach should be an indispensable component of good practice in pulmonology. Figure 1 summarizes the final stages of life in patients with COPD.