Advance Directives for Patients with Chronic Obstructive Pulmonary Disease (COPD)

What Are Your Options? What Would You Want?

What medical procedures would you want if you were too ill to speak for yourself? That is the basic question all advance directives address. But it is unanswerable for anyone who is not both a physician and a fortuneteller, who knows what illness you will have and what therapy options you will face.

What is your goal?

The overarching guideline to an advance directive is the patient’s goals of care. Goals of care change as chronic obstructive pulmonary disease reveals itself, has flare-ups with partial recovery and eventually becomes terminal.

You and your physician should talk about antibiotics for exacerbations or infections, and about what treatments may be efficacious or futile as your disease progresses. Talk about mechanical ventilation and complications near the end of life. Talk about hospice. These discussions should be ongoing, because chronic obstructive pulmonary disease waxes and wanes; your choices may change as your disease does.

If the goal of care is to be at home with family, it is not in your best interest to call an ambulance or be admitted to the hospital. Your doctor can sign a Do Not Leave Home (DNLH) order that tells emergency medical technicians you do not want to be taken to the emergency department or admitted to the hospital. See below for other physician orders.

Only in the event of serious illness

Even with an advance directive in place, if you become ill or injured with expectation of a full recovery and a return to your regular routine, your advance directive is not pertinent. An advance directive is enforceable only when you are seriously ill and cannot speak for yourself.

Care you do want

Listing the therapies you do not want does not preclude you from getting the treatment you do want. While the natural dying process is permitted to occur, maximum comfort should be assured for the patient. Family members, or those you consider family, also receive comfort care during this time.

Comfort care can include the following, and more:

• Treatment for pain
• Treatment for nausea
• Preventing/addressing bedsores
• Spiritual care for patient and family
• Psychological care and emotional support for patient and family
• Any care that eases pain and suffering
• Receiving skin care with body lotions
• Receiving routine moistening of mouth and eyes when drying occurs
• Having loved ones be able to visit at any time
• Receiving gentle massage and passive range-of-motion exercise to prevent stiffness
• Having favored music played
• Arrangements to donate your organs after your death
• Arrangements to undergo an autopsy after your death

Physician orders

Some orders must come from your physician, who uses a specific form recognized by the medical community. A Do Not Resuscitate (DNR) order is probably the most familiar, but there are others used to convey a patient’s wishes. For example, active comfort care orders might include Allow Visitors Extended Hours (AVEH) and Inquire About Comfort b.i.d. (IAC twice daily).

Any physician order in your medical or personal files should be re-evaluated periodically. Does it reflect your wishes? Does it reflect your current medical needs?

Physician orders include:

• Allow Visitors Extended Hours (AVEH) order
• Full Comfort Care Only (FCCO) order
• Do Not Intubate (DNI) order
• Do Not Defibrillate (DND) order
• Do Not Leave Home (DNLH) order
• Do Not Resuscitate (DNR) order, also called an Allow Natural Death (AND) order
• Do Not Transfer (DNTransfer) order
• Inquire About Comfort (IAC) order
• No Intravenous Lines (NIL) order
• No Blood Draws (NBD) order
• No Feeding Tube (NFT) order
• No Vital Signs (NVS) order (Source, 6-5-2015)

Put your thoughts in writing

As you complete your advance directive, think about the benefits and burdens of these therapies, and put your thoughts into your advance directive. In the event that you cannot speak for yourself, your advance directive will help your healthcare surrogate, your family and your physicians know what your values are and what choices you have made.

Therapies for Patients and Families

• Antibiotics—for infections in the urinary tract, due to bedsores, from aspiration pneumonia, or the like
• Artificial nutrition—nutrients provided via a tube into the stomach, intestine or vein
• Chemical code—permits the use of drugs, but not cardiopulmonary resuscitation (CPR), for resuscitation
• Continuous positive airway pressure/Bilevel positive airway pressure (CPAP/BiPAP)—delivery of oxygen through a mask
• Cardiopulmonary resuscitation—mouth-to-mouth resuscitation
• Defibrillator or pacemaker—a device implanted in the patient to deliver a therapeutic electric shock to treat irregular heartbeats
• Dialysis—kidney machine
• Do Not Resuscitate order—instructions not to perform cardiopulmonary resuscitation if heart or breathing stops
• Feeding tube—nutrition through a tube down your throat
• Intravenous (IV) fluids—nutrition via fluid through a vein
• Total parenteral nutrition (TPN)—nutrition delivered through a needle or catheter placed in a vein. Also referred to as hyperalimentation
• Transfusions—often of blood or blood products
• Ventilator—breathing machine