Reply
SIR—We are grateful to Baptista et al. for their interest in our paper. However, we feel that they have misinterpreted our suggestion that the accurate predication of mortality in end-stage chronic obstructive pulmonary disease (COPD) could be useful in targeting palliative care.First, we entirely agree that a mortality predictor is likely to be useful in targeting active therapy in an attempt to reduce mortality, and indeed we make this point in the introduction to our paper. We would therefore support the suggestion of Baptista et al. of carrying out an evaluation of the psychological acceptance of ‘intensified’ therapy for patients with advanced COPD. Secondly, we do not suggest that patients should ‘only’ be referred to palliative teams. Palliative care is not necessarily synonymous with terminal care, and can be offered at the same time as active medical treatment.
Thirdly, and most importantly, we stand by our decision to highlight the issue of palliative care in COPD. This group of patients, despite having a prognosis worse than that of many cancers (and greater disability, lower quality of life and higher levels of anxiety and depression than age-matched subjects with terminal non-small cell lung cancer [1]), at present seldom receive holistic care from palliative care services, medical services and social services [2–4]. Accurate prediction of impending mortality is a first step towards planning (by the patient, physician and family) of good end of life care. Currently the physician may ‘inadvertently fall into the trap of prognostic paralysis’ [1]. The clinical question ‘would I be surprised if this patient died within the next year’ has been advocated as a useful prompt for care planning, discussion with the patient and family, and in decision making [4]. COPD is a chronic incurable disease, and many patients with COPD will eventually die of their condition. Our current therapies, even when used, targeted and directed skilfully, cannot prevent this in every patient, and there will come a time for many when continued active care is intrusive and futile. The decision as to when this time has come is not purely a medical one and should be arrived at jointly by patient, family and physician (or multidisciplinary team). Nonetheless, accurate prognostic information is a vital element in informing this decision.
2 Metropolitan University of Manchester, Manchester School of Physiotherapy, Manchester, UK
3 Department of Old Age Psychiatry, University of Manchester, Manchester, UK
1 Department of Medicine, University of Manchester, Manchester, UK
Address correspondence to: M. J. Connolly. Email: Martin.Connolly{at}cmmc.nhs.uk
References
- Murray SA, Boyd K, Shiekh A. Palliative care in chronic illness. Br Med J 2005; 330: 611–2.
[Free Full Text] - Gore JM, Brophy CJGMA. How well do we care for patients with end stage chronic obstructive pulmonary disease (COPD)? A comparison of palliative care and quality of life in COPD and lung cancer. Thorax 2000; 55: 1000–6.
[Abstract/Free Full Text] - Shee CD. Palliation in chronic respiratory disease. Palliative Med 1995; 9: 3–12.
[Abstract/Free Full Text] - Kite S, Hicks F. Palliative medicine for the cancer and non-cancer patient. Clin Med 2005; 5: 626–9.[Web of Science][Medline]
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