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END STAGE PULMONARY DISEASE (e.g. COPD) Symptom control for patients with end-stage COPD should continue in conjunction with optimal COPD treatment. This is the first step to achieving good symptom control. This may include the use of inhalers, nebulisers, steroids, antibiotics and so on as long as these medications remain appropriate. SYMPTOM RELIEF Breathlessness See general palliative care algorithms There is evidence that concerns around suppression of respiration are unfounded if appropriate doses of opioids are used. Pain See general palliative care algorithms Cough See general palliative care algorithms Tenacious sputum Mucodyne Nebulised saline 0.9% Nausea and Vomiting See general palliative care algorithms Constipation See general palliative care algorithms Anxiety Drug therapies may be helpful to break the anxiety cycle and restore sleep o Anxiolytics e.g. Lorazepam 0.5mg sublingually for panic attacks o Night sedation e.g. Lorazepam 0.5 - 1mg nocte Confusion / Restlessness Oxygen may help to reduce confusion secondary to hypoxia Haloperidol 1mg tds END SATGE PULMONARY DISEASE (e.g. COPD) THE LAST FEW DAYS OF LIFE It is important to try and recognise patients who appear to be approaching the terminal phase of their illness. It is more difficult to diagnose dying in COPD than in many terminal cancer patients. Indicators o o o o of the terminal phase include: Significant co-morbidity (particularly Cardiac Failure) Severe COPD – FEV1 < 30% of predicted No identifiable reversible precipitant Receiving optimum tolerated conventional drugs Place of care If recovery is uncertain, this needs to be shared with patient and family and the patients wishes explored in terms of options for care and place of care. The most important issue is likely to be where the patient should be cared for and whether admission is appropriate and desirable or not. As the patient becomes weaker and has difficulty swallowing every effort should be made to continue medication providing symptomatic relief. None essential medications should be stopped. Consideration should be given to the advantages / disadvantages of continuing drug treatments of co-morbidities e.g. hypoglycaemics. Conversion of oral medication to CSCI via syringe pump may also be indicated. If the patient is considered to be in the last few days of life conversion of oral analgesia, antiemetics and anxiolytics to CSCI via syringe pump should be considered with PRN doses also available (see general palliative care guidelines). Consideration of sub cutaneous dexamethasone if steroids felt to be of value (750 micrograms dexamethasone~ 5mg prednisolone) Addition of an anti-secretory agent should also be considered. (see Breathlessness Algorithm)