Living and dying with severe chronic obstructive pulmonary disease: multi-perspective longitudinal qualitative studyBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d142 (Published 24 January 2011) Cite this as: BMJ 2011;342:d142
- Hilary Pinnock, senior clinical research fellow1,
- Marilyn Kendall, senior research fellow2,
- Scott A Murray, St Columba’s Hospice chair of primary palliative care2,
- Allison Worth, senior research fellow, research manager1,
- Pamela Levack, consultant in palliative medicine3,
- Mike Porter, senior lecturer4,
- William MacNee, professor of respiratory and environmental medicine5,
- Aziz Sheikh, professor of primary care research and development1
- 1Allergy and Respiratory Research Group, Centre for Population Health Sciences: GP Section, University of Edinburgh, Edinburgh, UK
- 2Primary Palliative Care Research Group, Centre for Population Health Sciences: GP Section, University of Edinburgh, Edinburgh, UK
- 3NHS Tayside, Ninewells Hospital, Dundee, UK
- 4Centre for Population Health Sciences: GP Section, University of Edinburgh, Edinburgh, UK
- 5MRC Centre for Inflammation Research, University of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, UK
- Correspondence to: H Pinnock, Allergy and Respiratory Research Group, Centre for Population Health Sciences: GP Section, University of Edinburgh, Doorway 3, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
- Accepted 10 November 2010
Objectives To understand the perspectives of people with severe chronic obstructive pulmonary disease (COPD) as their illness progresses, and of their informal and professional carers, to inform provision of care for people living and dying with COPD.
Design Up to four serial qualitative interviews were conducted with each patient and nominated carer over 18 months. Interviews were transcribed and analysed both thematically and as narratives.
Participants 21 patients, and 13 informal carers (a family member, friend, or neighbour) and 18 professional carers (a key health or social care professional) nominated by the patients.
Setting Primary and secondary care in Lothian, Tayside, and Forth Valley, Scotland, during 2007-9.
Results Eleven patients died during the study period. Our final dataset comprised 92 interviews (23 conducted with patient and informal carer together). Severe symptoms that caused major disruption to normal life were described, often in terms implying acceptance of the situation as a “way of life” rather than an “illness.” Patients and their informal carers adapted to and accepted the debilitating symptoms of a lifelong condition. Professional carers’ familiarity with the patients’ condition, typically over many years, and prognostic uncertainty contributed to the difficulty of recognising and actively managing end stage disease. Overall, patients told a “chaos narrative” of their illness that was indistinguishable from their life story, with no clear beginning and an unanticipated end described in terms comparable with attitudes to death in a normal elderly population.
Conclusions Our findings challenge current assumptions underpinning provision of end of life care for people with COPD. The policy focus on identifying a time point for transition to palliative care has little resonance for people with COPD or their clinicians and is counter productive if it distracts from early phased introduction of supportive care. Careful assessment of possible supportive and palliative care needs should be triggered at key disease milestones along a lifetime journey with COPD, in particular after hospital admission for an exacerbation.
We are grateful to Janet Winter, Colette Lamb, and Anne Aitken, who undertook the initial clinical assessments, and to Marie Pitkethly, Colette Fulton, and June McGill, from Scottish Primary Care Research Network, who helped with recruitment. Susan Buckingham provided administrative support, and David Chinn assisted with coordination of the project within the work of the Primary Palliative Care Research Group. We thank the members of the lay advisory group, recruited by Wendy Halley from the local British Lung Foundation Breathe Easy groups, who worked with us throughout the study, and Patrick White, Declan Cawley, and Tony Davison for their perceptive comments on our draft manuscript.
Contributors: HP initiated the idea for the study and led development of the protocol, securing of funding, study administration, data analysis, interpretation of results, and writing of the paper. MK undertook all the data collection and analysis. All authors had full access to all the data and were involved in interpretation of the data. HP and MK wrote the initial draft of the paper, to which all the authors contributed. HP and MK are study guarantors.
Funding: This study was supported by the Chief Scientist’s Office of the Scottish Government. HP is supported by a primary care research career award from the Chief Scientist’s Office of the Scottish Government.
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Ethical approval: Ethical approval was provided by the Multicentre Research Ethics Committee for Scotland (B), and governance approval was obtained from NHS Lothian, NHS Tayside and NHS Forth Valley. Informed written consent was obtained from all patients at the beginning of the study and reviewed verbally before each interview. Informal and professional carers identified by the patient were asked independently for their consent to participate.
Data sharing: We do not have consent to share data.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.