There are more than one million people living with chronic obstructive pulmonary disease (COPD) in the UK. COPD does not follow a predictable course and differs from person to person. It is often difficult to determine the stage that a person has reached in the condition: while some patients will present with a gradual decline, others may remain stable for years, and some will require hospital admission for respiratory support. The uncertainties around the nature and progression of COPD make decisions about end-of-life (EOL) and starting EOL care challenging. This article explores some of the indicators of decline in a person with COPD, including exacerbations, cognitive dysfunction, sarcopenia, depression and anxiety. It also discusses the importance of starting appropriate EOL discussion with patients, as well as the many benefits of multidisciplinary team working when it comes to recognising care needs and enhancing patients’ quality of life.
This article discusses the considerations and actions taken to facilitate the discharge of a ventilated end-of-life patient called Michael, whose name has been changed for confidentiality, from a critical care unit (CCU) to his expressed preferred place of care. It focuses on how the district nurse (DN) and the single point of access (SPA) for end-of-life care teams by working between primary and secondary care services and across organisational service units were able to facilitate this discharge and achieve the wishes of Michael to die peacefully at home. For all services involved, this proved to be a complex discharge and following completion of the care episode a root cause analysis was undertaken to capture the lessons learnt and advise the CCU at a services debreif how discharges to the community from the CCU could be improved.
The phasing out of the Liverpool Care Pathway and the introduction of the Leadership Alliance for the Care of Dying People’s (LACDP’s) five priorities of care has enabled clinicians working in end-of-life care to step back and re-evaluate their practice (LACDP, 2014). The review of end-of-life care services, More Care, Less Pathway (Neuberger, 2013) highlighted areas that needed urgent improvement. These included recognising when a person is dying but understanding the need for ongoing assessment; having a senior named clinician for all patients; and improving the communication skills of all clinicians involved in end-of-life care through the development of educational programmes. Non-malignant diseases are particularly challenging and in these cases it can be hard to recognise when a person is nearing the end of his or her life. Community matrons have their own unique relationship with the people on their caseload and can often provide untapped expertise and support as their condition deteriorates.
Chronic obstructive pulmonary disease (COPD) is a condition commonly seen in the community, with symptoms including breathlessness, chronic cough and wheezing. There is much that community nurses can do to support COPD patients through an acute exacerbation (AECOPD) and to optimise their care when stable. Community nurses can take an active role in providing advocacy for the patient and ensuring that their professional knowledge is updated to provide admission and a key area for COPD is a leading cause of hospital admission and a key area for service development in the community. Investment in education and clinical leadership in community nursing is vital to prepare the workforce to deal with the needs of people with COPD in the future.
Interstitial lung disease is a wide-ranging category of respiratory illness that includes many different lung conditions, such as interstitial pneumonia, idiopathic pulmonary fibrosis, non-specific interstitial pneumonitis and hypersensitivity pneumonitis. All interstitial lung diseases affect the interstitium, a delicate network of tissue that extends throughout the lungs and which supports the microscopic air sacs within the lungs (alveoli). Unfortunately, some forms of interstitial lung disease have a very poor prognosis, therefore it is important that community nurses are aware of the signs and symptoms of interstitial lung disease so that prompt referral, assessment and treatment can be started.
End of life can be a frightening and uncertain time for patients and families and the role of the community nurse can be vital in easing this phase of life. This article outlines some of the issues that community nurses should be aware of when caring for a patient who is dying at home. It identifies the signs which signify that death is approaching, and explains the need for a change in care emphasis at this point. The author also outlines some key management aspects that can improve the quality of a patient’s death, including communication, care coordination, symptom and pain control, and support for nurses and carers.
