Management of Bed-Bound Hospice Patient with COPD

Symptom Assessment and Management

The American Thoracic Society suggests differentiating between hemoptysis and hematemesis in a bed-bound patient, with hemoptysis being frothy and bright to dark red, mixed with sputum, and associated with cough, and hematemesis having a coffee-ground appearance, mixed with food particles, and associated with nausea 1, 2
The Critical Care society recommends administering ondansetron 4-8 mg sublingual or IV for nausea/vomiting as first-line agent in hospice setting, with a strength of evidence level of high 1, 2
The American Journal of Respiratory and Critical Care Medicine suggests positioning patient in semi-recumbent (30-45 degrees) or side-lying position to reduce aspiration risk and facilitate drainage, with a strength of evidence level of moderate 1, 2

The American College of Chest Physicians recommends maintaining oxygen saturation target of 88-92% via nasal cannula (2 L/min maximum) if patient already on oxygen, but prioritizing comfort over numbers in actively dying patients, with a strength of evidence level of low 3, 4
The European Respiratory Society suggests administering morphine 2.5-5 mg subcutaneous/oral every 4 hours for dyspnea and air hunger, which is the primary symptom-relieving intervention in end-stage COPD, with a strength of evidence level of high 1, 2

The National Hospice and Palliative Care Organization recommends explaining to family that brownish secretions and decreased clearance are expected in the terminal phase of COPD, and that comfort measures rather than clearance are the priority, with a strength of evidence level of moderate 1, 2
The American Academy of Hospice and Palliative Medicine suggests reassuring that the patient is not "drowning" if secretions are audible, as this is a common fear, with a strength of evidence level of low 1

The American Geriatrics Society recommends glycopyrrolate 0.2 mg subcutaneous every 4-6 hours or scopolamine patch as antimuscarinic to reduce secretions, with a strength of evidence level of moderate 1
The European Society for Medical Oncology suggests increasing morphine dose by 25-50% from baseline, or initiating at 2.5 mg every 4 hours if opioid-naive, for air hunger despite positioning, with a strength of evidence level of high 1, 2