Advance care planning and symptom control in severe COPD
A 79-year-old man has severe COPD with FEV1 36% predicted. He is on salbutamol, umeclidinium/vilanterol, budesonide/formoterol, tiotropium, bisoprolol for atrial fibrillation, ramipril, furosemide, codeine phosphate 30 mg four times daily for breathlessness, and lactulose. He has had four hospital admissions in the past year, two requiring non-invasive ventilation. He lives with his wife, who has arthritis and is exhausted from caring for him. He is breathless on dressing, with a CAT score of 27 and mMRC grade 3. He tells you he never wants 'the mask' again. His wife asks what will happen if he deteriorates at night, and whether he can be kept comfortable at home. He has capacity and is not depressed.
1. How would you structure an advance care planning conversation, and what would you document?
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Clarify what he means by 'the mask'. He may be rejecting non-invasive ventilation, intubation, or both, and these are different decisions. Explore his understanding of his illness and its trajectory, his fears, and what matters most-staying at home, avoiding hospital, being able to talk to his wife. Explain that a ceiling of 'not for intubation or ICU' does not mean no treatment: antibiotics, oxygen, opioids for breathlessness and a trial of non-invasive ventilation for comfort can still be offered. Discuss CPR separately and explicitly.
Involve his wife with his consent, and check whether he wants anyone else present. Confirm he has capacity. Document the specific decisions, the reasons, who was present, and the date. Record a nominated decision-maker and share the plan with out-of-hours services, the ambulance service and the hospital, with his consent. Give him and his wife written copies. Review the plan if his condition changes, and frame the conversation as 'hope for the best, plan for the worst' rather than withdrawal of care.
2. What medication changes would you make for symptom control and deprescribing?
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Stop codeine. It causes constipation, nausea and respiratory depression and is a poor choice for chronic breathlessness. Start low-dose oral morphine, for example 2.5–5 mg every four hours as needed, with a regular laxative, and explain that it treats the sensation of breathlessness rather than shortening life. Stop the duplicate long-acting muscarinic antagonist: he is on both tiotropium and umeclidinium. Continue the LAMA/LABA and inhaled corticosteroid because he has frequent exacerbations. Review bisoprolol for rate control versus any contribution to breathlessness, and review furosemide depending on fluid status.
Prescribe anticipatory medications: morphine for breathlessness and pain, midazolam for agitation or distress, glycopyrronium for secretions, and an antiemetic such as haloperidol or metoclopramide. Provide a written exacerbation action plan and ensure the medications are available at home. Refer to community palliative care and pulmonary rehabilitation if he is able. Assess his wife's carer burden and arrange respite and practical support.
3. What safety-netting and coordination would you put in place for an overnight deterioration?
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Give a written plan stating whom to call, day or night, and what treatments are authorised. Ensure the out-of-hours service and ambulance control can see the advance care plan. Explain that if he becomes more breathless, drowsy, confused or distressed, the priority is comfort: adjust morphine, use the anticipatory medications, and avoid unnecessary hospital transfer unless he or his wife wants it or symptoms cannot be controlled.
Arrange a follow-up review in one to two weeks and after any change. Confirm the anticipatory medications are in the house and that his wife knows how to use them. Provide oxygen safety advice only if he is on long-term oxygen therapy. Document the discussion, his capacity, and his wife's understanding. Consider a referral to the community respiratory team and ensure the palliative care team has the plan.