Course Handouts & Disclosure - homecareinformation.net · 1 COPD: Disease Trajectory and Hospice Eligibility Terri L. Maxwell PhD, APRN VP, Strategic Initiatives Weatherbee Resources

1

COPD:Disease Trajectory and Hospice

Eligibility

Terri L. Maxwell PhD, APRN

VP, Strategic Initiatives

Weatherbee Resources

Hospice Education Network

Course Handouts &

Disclosure

� To download presentation handouts, click on the attachment icon

� Presenter discloses no financial relationships with a commercial entity producing healthcare-related products and/or services. Conflict of interest disclosure and resolution statement is on file with HEN.

� This presentation is for educational and informational purposes only. It is not intended to provide legal, technical or other professional services or advice.

Learning Objectives

� List the stages and clinical course of COPD

� State symptoms experienced by patients with COPD

� Identify “secondary” and “co-morbid” conditions

commonly associated with COPD

� Explain end-of-life issues experienced by COPD

patients and their caregivers

� Describe the basic management and treatment of

COPD

� Name the clinical data points necessary to substantiate

hospice eligibility for patients with COPD

Hospice Education Network - Disease Specific Clinical Eligibility & Documentation: COPD

Hospice Education Network (c) 2012

2

Chronic Obstructive Pulmonary

Disease (COPD)

� Respiratory disorder characterized by

chronic airway obstruction and lung

hyperinflation

� 12 million diagnosed with COPD

� 4th leading cause of death in the US

�Death rate for COPD has doubled over

past 30 yrs, largely due to exposure to

tobacco smoke and is expected to climb to

3rd by 2020

Jemal, Ward, Hao, Thun. JAMA. 2006, 295(4): 393-394.

Key Attributes of COPD

1. Airway obstruction

2. Not fully reversible

3. Progressive disease that generally

worsens over time, even with treatment

4. Abnormal inflammatory response

Celli BR et al. Eur Respir J. 2004;23:932-946.

Pathophysiology of COPD

Small airway diseaseAirway inflammation

Airway remodeling

Parenchymal

destructionLoss of alveolar attachments

Decrease of elastic recoil



3

Factors Determining

COPD Severity

� Degree of symptoms

� Frequency and severity of exacerbations

� Presence of co-morbidities that can lead to complications

� General health status

� Number of medications needed to manage disease

� Severity of spirometric abnormality/airflow limitation

COPD Severity

Severity of airflow

obstruction

FEV1 % Predicted

Mild 50-80%

Moderate 30-40%

Severe <30%

Spirometry is the gold standard for

diagnosing COPD; severity is

measured by FEV1

Note: FEV= Forced Expiratory Volume

Spirometry:

Normal vs COPD



4

Stages of COPD

Stage I: Mild COPD:

� FEV1/FVC < 0.70; FEV1 ≥ 80% predicted.

Patient unaware lung function is abnormal

Stage II: Moderate COPD:

� FEV1/FVC < 0.70; 50% ≤ FEV1 < 80%

predicted. Patient typically seeks medical

attention because of pulmonary symptoms

Adapted from GOLD Guidelines, 2007

Stages of COPD (cont’d)

Stage III: Severe COPD:

� FEV1/FVC < 0.70; 30% ≤ FEV1 < 50% predicted. Greater shortness of breath, reduced exercise tolerance, decreased quality of life

Stage IV: Very Severe COPD:

� FEV1/FVC < 0.70; 30% ≤ FEV1 < 50% predicted plus the presence of chronic respiratory failure. May have signs of cor pulmonale and usually oxygen dependent.

Adapted from GOLD Guidelines, 20072

Natural History of

COPD

FEV1 <70- dyspnea with

exercise

�

FEV1 <45- Exacerbations/

hospitalizations/dsypnea

with ADLs

�

FEV1<30- Systemic

effects/dyspnea at

rest/respiratory failure



5

COPD and Co-morbid

ConditionsCommon co-morbids:

• Cardiovascular

disease

• Lung cancer

• Osteoporosis

• Musculoskeletal

disorders

• Depression/anxiety

• Obesity/type II

diabetes

Systemic Effects of COPD

�Peptic ulceration

�Lung infections/lung cancer

�Weight loss/muscle wasting and

weakness

�Osteoporosis

�Depression

NOTE: If caused by the COPD, these could be

considered “secondary ” (RELATED) conditions.

COPD Signs & Symptoms

�Dyspnea

�Wheezing

�Cough

�Hypoxemia and rising CO2 levels

�Pulmonary hypertension that may

progress to right ventricular

hypertrophy and cor pulmonale

(right-sided heart failure)



6

Acute COPD Exacerbation

� Definition: Sustained worsening of symptoms from

patient’s usual condition; acute in onset

� Symptoms

� Increased shortness of breath

� Increased sputum production and/or increase in

purulence

� Increase cough

� Increased wheeze/chest tightness

� Decreased exercise tolerance

� Increased fatigue

� Altered mental statusNICE GUIDELINES 2004

IV: Very SevereIII: SevereII: ModerateI: Mild

Therapy at Each Stage of COPD

• FEV1/FVC < 70%

• FEV1 > 80%

predicted

• FEV1/FVC < 70%

• 50% < FEV1 <

80%

predicted

• FEV1/FVC <

70%

• 30% < FEV1 <

50% predicted

• FEV1/FVC < 70%

• FEV1 < 30%

predicted

or FEV1 < 50%

predicted plus

chronic respiratory failure

Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation

Add inhaled glucocorticosteroids if repeated exacerbations

Active reduction of risk factor(s); influenza vaccination

Add short-acting bronchodilator (when needed)

Add long term oxygenif chronic respiratory

failure. Consider

surgical treatments

Adapted from GOLD Guidelines.

http://www.goldcopd.com/Guidelineitem.asp?

l1=2&l2=1&intId=989

Management of COPD

Stage IV: Very Severe COPD

Characteristics Recommended

Treatment• FEV1/FVC < 70%

• FEV1 < 30%

predicted or FEV1 <

50% predicted plus

chronic respiratory

failure

• Short-acting bronchodilator as needed

• Regular treatment with one or more LA bronchodilators

• Inhaled glucocorticosteroidsif repeated exacerbations

• Treat complications

• Rehabilitation

• Long-term O2 therapy if respiratory failure

• Consider surgical options

Adapted from GOLD

Guidelines, 2007



7

Advanced COPD Management

� Long-acting and short-acting

bronchodilators (albuterol)

� Anticholinergics (ipatropium bromide or

tiotropium)

� Methylxanthines (theophylline)

� Combination inhaled therapies

(formoterol/budesonide)

� Inhaled corticosteroids- note: long term oral

steroids are not recommended; however,

7-10 day course of prednisone may be helpful

for exacerbationsAdapted from GOLD Standards, 2007

Management of Advanced

COPD (cont’d)

� Antibiotics – reserved to treat infections;

do not use prophylactically

� Opioids – oral and parenteral

(not nebulized) to treat dyspnea

� Anxiolytics – helpful in managing

anxiety associated with dyspnea

� Oxygen therapy – should be worn

15 hrs or > per day for greatest benefit

End of Life Issues� Prognosis is difficult to predict

� Palliative care should be based upon patient

symptoms and functional status

� Frequent exacerbations requiring trips to the ED

and/or hospitalizations

� Patients and family members frequently do not

comprehend the terminal nature of the illness

� Lack of communication and advanced care

planning

� Isolation/depression/anxiety



8

Signs that Patient Requires

Palliative Care

� FEV1 < 30% predicted

� History of 2 or more exacerbations in

past year

� Frequent hospitalizations

� Progressive shortening of intervals

between admissions

� Limited improvement after hospitalization

Supporting

Indicators

• Declining functional

status/homebound

• Presence of

co-morbidities such as

heart failure or diabetes

• On maximum therapy

and dependence on

oxygen

LCD Guidelines for

Hospice Eligibility and

Recertification

for COPD

NGS LCD Number L25678

CGS LCD Number L32015

NHIC LCD Number L29881



9

Non-disease Specific

GuidelinesBoth A & B must be met:

A. Impaired functional status- KPS <70 or

PPS <70

B. Dependence on assistance for 2 or > ADLs

C. Presence of co-morbidities that contribute to

disease burden

� HF

� Diabetes

� Dementia, etc.

Disease Specific Guideline:

Pulmonary Disease

1. Severe chronic lung disease as documented

by both a and b:

a. Disabling dyspnea at rest, poorly responsive

or unresponsive to bronchodilators, resulting in

decreased functional capacity, e.g., bed-to-chair

existence, fatigue, and cough. (Documentation of

FEV1, after bronchodilator, less than 30% of

predicted is objective evidence for disabling

dyspnea, but is not necessary to obtain.)

Pulmonary, Cont’d.

b. Progression of end stage pulmonary disease, as evidenced by:

� increasing visits to the emergency department or hospitalizations for pulmonary infections and/or

� respiratory failure or

� increasing physician home visits prior to initial certification.

(Documentation of serial decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain.)



10

Pulmonary, Cont’d.

2. Hypoxemia at rest on room air as evidenced by:

� pO2 less than or equal to 55 mmHg; or

� oxygen saturation less than or equal to 88%;

or

� hypercapnia as evidenced by pCO2 greater than or equal to 50mmHg.

(These values may be obtained from recent [within 3 months] hospital records.)

Pulmonary (supportive)

3. Cor pulmonale (right heart failure)

secondary to pulmonary disease (e.g., not

secondary to left heart disease or valve

disease)

4. Unintentional progressive weight loss of

greater than 10% of body weight over the

preceding 6 months

5. Resting tachycardia >100/min

Establishing, Evaluating,

and Explaining

Eligibility Based upon Burden of Illness in COPD



11

Assessing and Documenting

Disease Burden in COPD

� Sustained tachypnea (RR>30

breaths/min)

� Sustained tachycardia (RR>100

beats/min)

� O2 saturation <88% on room air or

patient’s usual supplemental oxygen

� Hypotension <100mm Hg or 20% lower

than patient’s usual

� Severe impairment of ADLs

ADL Documentation

Describe:

�How much caregiver support?

�None

�Minimal

�Moderate

�Total

�Time-to-completion of tasks



� Inability to speak in full sentences

� Sustained use of accessory muscles of

respiration at rest

� Decreased ability to eat or sleep due to

respiratory distress

� Repeated lung infections/courses of

antibiotic therapy

� Hemoptysis/increased sputum

production/cough



12



� Sustained increase in

patient’s usual degree of

dyspnea

� Medication changes-

addition or titration of

opioids, anxiolytics, etc.

� Altered mental status-

lethargy, confusion

� Increased caregiver

stress/burden

Documentation example

“Patient is now completely bed-bound and is having new episodes of urinary incontinence. Caregiver providing maximal assist with all ADLs. Pt now severely dyspneic with minimal activity, including trying to speak. Sleeping on avg18/24 hrs per day. Po intake reduced due to coughing/choking episodes. Using MSO4 q 4 ATC with moderate relief.”

Conclusion

� COPD is the 4th leading non-cancer diagnosis in

hospice

� Although irreversible and progressive, COPD

prognosis is difficult to predict

� Hospice eligibility based on pulmonary function

(FEV1), degree of hypoxemia, dyspnea

unresponsive to therapy, functional status, recent

ED/hospitalization/physician visits for recurrent

infections, or respiratory failure

� Initial and ongoing comprehensive patient

assessment with documentation is necessary for

enrollment and recertification



13

References

1. Jemal, Ward, Hao, Thun. Trends in the leading

causes of death in the United States, 1970-2002.

JAMA. 2006, 295(4): 393-394.

2. Global Initiative for Chronic Obstructive Lung

Disease (GOLD). Global Strategy for the Diagnosis,

Management, and Prevention of Chronic Obstructive

Pulmonary Disease (2007). www.goldcopd.com

3. Poole, PJ, Veale, AG, Black, PN. The effect of

sustained-release morphine on breathlessness and

quality of life in severe chronic obstructive

pulmonary disease. Am J Respir Crit Care Med

1998: 157: 1877-80.

Course Evaluation

& Post Test

Thank you for viewing this course on the

Hospice Education Network

The course evaluation and post test are

available from your course catalog page

Thank You!

Terri Maxwell PhD, APRNVP, Strategic Initiatives

Weatherbee Resources Inc. & Hospice Education Network

[email protected]



Documents

Course Handouts & Disclosure - homecareinformation.net · 1 COPD: Disease Trajectory and Hospice Eligibility Terri L. Maxwell PhD, APRN VP, Strategic Initiatives Weatherbee Resources