Subinternship Medicine · Year 4 · from Subinternship Medicine

Case 3: End-Stage COPD with Goals of Care Complexity

Clinical Presentation

Patient Demographics: 71-year-old female

Chief Complaint: "I can't keep doing this"

History of Present Illness: Mrs. Thompson is a 71-year-old female with very severe COPD (GOLD Stage IV, FEV1 22% predicted) on 4L home oxygen who presents with her third COPD exacerbation in 6 months. She reports 5 days of worsening dyspnea, increased sputum production (yellow-green), and fatigue. She was discharged from the hospital 3 weeks ago. During this visit, she tearfully states, "I don't want to keep living like this. I can barely make it to the bathroom."

Past Medical History:

  • Very severe COPD, oxygen-dependent
  • Heart failure with preserved EF (55%)
  • Pulmonary hypertension (moderate)
  • Osteoporosis with kyphosis
  • Anxiety and depression
  • Malnutrition (BMI 18.5)
  • 3 hospitalizations in past 6 months
  • 1 ICU admission 4 months ago (required BiPAP for 3 days)

Current Medications:

  • Tiotropium 18 mcg daily
  • Fluticasone/salmeterol 500/50 BID
  • Albuterol PRN
  • Prednisone 10 mg daily (chronic)
  • Azithromycin 250 mg MWF (prophylaxis)
  • Furosemide 40 mg daily
  • Sertraline 100 mg daily
  • Lorazepam 0.5 mg TID PRN anxiety
  • Morphine sulfate 5 mg Q4H PRN dyspnea
  • Calcium/Vitamin D
  • Home oxygen 4L NC continuous

Functional Status:

  • Essentially bedbound, only transfers bed to chair
  • Requires assistance with all ADLs
  • Has not left home in 2 months
  • Husband (age 75, with his own health issues) is sole caregiver
  • Receiving home health nursing weekly

Physical Examination:

  • Vital Signs: Temperature 37.4C, HR 96 bpm, BP 108/68 mmHg, RR 26/min, SpO2 88% on 4L NC
  • General: Cachectic, fatigued, speaking in 2-3 word sentences
  • Lungs: Diffuse wheezes, prolonged expiration, accessory muscle use
  • Cardiovascular: Distant heart sounds, JVP 10 cm
  • Extremities: 1+ edema, muscle wasting
  • Mood: Tearful, expresses hopelessness

Prognostic Assessment

Markers of Poor Prognosis in COPD:

  • FEV1 < 30% predicted
  • Frequent exacerbations (3 in 6 months)
  • Hospitalizations increasing
  • Functional decline (now bedbound)
  • Malnutrition (BMI < 20)
  • Chronic hypoxemia despite oxygen
  • Cor pulmonale (pulmonary hypertension, edema)

BODE Index: Score 8-10 (indicates 50% 4-year mortality)

Estimated Prognosis: Months to approximately 1-2 years

Goals of Care Conversation

Opening: "Mrs. Thompson, you mentioned you don't want to keep living like this. Can you tell me more about what you mean?"

Patient's Expressed Goals:

  • Does not want to suffer at the end
  • Wants to stay home as much as possible
  • Worries about being a burden on her husband
  • Does not want to be on a breathing machine again
  • Wants to see her grandson graduate high school (in 4 months)

Goals of Care Discussion Framework:

Explore:

  • "What is your understanding of where you are with your illness?"
  • "When you think about the future, what worries you most?"
  • "What brings you the most joy or meaning right now?"

Inform:

  • "Based on how things have been going, I'm worried that your COPD is getting harder to control. You've needed to be in the hospital three times in six months."
  • "I want to be honest with you - even with all our treatments, your lungs are very fragile."

Recommend (based on her goals):

  • "Given what you've told me about wanting to stay home and not suffer, I think we should focus our treatments on keeping you comfortable. I'd recommend we talk about hospice, which could provide extra support at home."

Treatment Plan

Acute Management:

  1. Treat current exacerbation (steroids, bronchodilators, antibiotics)
  2. Optimize comfort medications (continue morphine, adjust PRN)
  3. Palliative care consultation

Goals-Concordant Planning:

  1. Code Status Discussion:
  • Explained that CPR/intubation very unlikely to be successful given severity
  • Patient elects DNR/DNI
  • Documents wishes in POLST form
  1. Hospice Referral:
  • Meets criteria (prognosis < 6 months with supportive criteria)
  • Patient agrees to hospice enrollment
  • Will provide: home nursing, aide services, medications, equipment, 24/7 support
  1. Symptom Management Plan:
  • Continue morphine for dyspnea (may increase as needed)
  • Lorazepam for anxiety/dyspnea
  • Continue oxygen for comfort
  • Reduce unnecessary medications

Family Meeting:

  1. Included husband to ensure understanding of prognosis and plan
  2. Social work for caregiver support resources
  3. Discussed what to expect and when to call hospice vs. 911

Clinical Image

Image Description: Chest radiograph in a patient with severe COPD demonstrating hyperinflated lungs with flattened diaphragms, increased anterior-posterior diameter, and attenuated vascular markings.

Image Source: Radiopaedia - "Chronic obstructive pulmonary disease"

  • URL: https://radiopaedia.org/articles/chronic-obstructive-pulmonary-disease
  • License: Educational use - Radiopaedia.org

Discussion Questions

  1. Competing Priorities: In Case 1, the patient's heart failure treatment (aggressive diuresis) directly conflicts with preserving kidney function. How do you approach this treatment dilemma? What role do the patient's goals play?
  1. Polypharmacy Management: In Case 2, multiple medications contributed to delirium. How would you approach deprescribing with the family, particularly the home sleep medication the patient has taken for years?
  1. Prognosis Communication: In Case 3, how would you respond if the family says "Don't tell her how serious it is - it will take away her hope"?
  1. Discharge Planning: For Case 2, the patient cannot return to independent living. How would you approach this conversation with the patient and daughter who expected her to go home?
  1. Goals of Care: What is the difference between a patient saying "I don't want to suffer" versus "I want everything done"? How do these statements guide your treatment recommendations?

All cases for this lecture as Markdown