Before seeing a patient with advanced COPD, fibrotic interstitial lung disease or severe bronchiectasis, ask yourself one question: would I be surprised if this person died within the next twelve months?
If the answer is no, that consultation should contain something it probably does not currently contain — a symptom assessment covering breathlessness, fatigue, appetite and mood rather than spirometry alone; a check on whether anyone has explained the trajectory of the illness; a question about how the person at home is coping; and, where the patient is willing, a beginning of advance care planning.
The question works because it bypasses prognostic scores, which perform poorly in chronic respiratory disease, and uses the clinical impression that is actually available. It also catches the specific failure mode of these clinics: a patient attending for years, deteriorating gradually, with every visit spent on inhaler technique and none on what is happening to them.
Asking it takes no time. Acting on a negative answer takes one consultation, and it is the consultation these patients almost never get.
- Ask the question before the consultation, not during it
- On a 'no', assess symptoms beyond breathlessness: fatigue, appetite, mood, sleep
- Check what the patient has actually been told about where the illness is heading
- Ask specifically about caregiver strain; it is a referral criterion in its own right
- Record the discussion so the next clinician does not start again from spirometry
Why it matters
Chronic respiratory disease has a worse symptom burden than lung cancer and a fraction of the palliative input, largely because nobody names the point at which it should start.
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