COPD Nursing Interventions: Patient and Family Coping

Introduction to COPD and Its Psychosocial Burden

Chronic obstructive pulmonary disease (COPD) is a progressive illness characterized by airflow obstruction and dyspnea that affects over 12 million people and represents a leading cause of death in the United States. Not surprisingly, COPD is often associated with emotional distress and reduced psychosocial adjustment, which can negatively affect physical functioning and impair quality of life. However, the psychosocial consequences of COPD remain largely untreated (Blumenthal et al., 2009).

Coping with COPD and the Impact on the Patient's Family

The Journal of Family Practice article by Fisher and Weihs (2000) reports that the National Working Group on Family-Based Interventions in Chronic Disease identified potential mechanisms by which the relational context of the family affects disease management, and how characteristics of family relationships serve as risk or protective factors. The data suggest that approaches to the management of chronic disease should be expanded to include the broader relational context in which disease management takes place. As Fisher and Weihs explain:

"A family-focused approach to the management of chronic disease stands in sharp contrast to traditional patient-focused approaches. It emphasizes: (1) defining and assessing the relational context in which disease management takes place; (2) including the family environment and other family members as potential targets for intervention; (3) addressing the educational, relational, and personal needs of the patient and other members of the family; (4) viewing the disease not as a series of acute episodes, but as an ongoing process that requires continuity of care between the health care team and the family; and (5) including the patient and other family members as part of a comprehensive program of outcomes assessment." (Fisher and Weihs, 2000, p. 1)

Anne H. Boyle, RN, PhD, CNE, in her 2009 integrated review of nineteen articles on the impact of COPD on families, notes that research in this area is limited compared to chronic disease impact research more broadly. Researchers have found that COPD patients are "significantly less satisfied with life, less socially active, and more disabled than persons with coronary artery disease, and have a lower mental health status than persons with peripheral vascular disease" (Boyle, 2009, p. 1). Additional evidence indicates that "adjustment and morale of wives with disabled or chronically ill husbands is similar to their spouses — with poor health linked to having an ill spouse" (Boyle, 2009, p. 1).

COPD is characterized by irreversible airway obstruction and typically occurs after years of cigarette smoking, producing symptoms later in life (Boyle, 2009). The challenges faced by individuals with COPD include dyspnea, fatigue, cough and mucus production, disturbed sleep, and altered appetite, all of which can negatively affect quality of life (Boyle, 2009, p. 1). Shortness of breath limits mobility and restricts the patient's ability to perform common daily activities. In addition, individuals with COPD experience psychological distress, high rates of anxiety and depression, and impaired cognitive functioning. Families who live with and care for COPD patients must also deal with these challenges, as society increasingly expects care and support of chronically ill elders to be provided by the family (Boyle, 2009, p. 1).

Psychological Effects of Chronic Lung Disease

Kelly and Lymes (2008), in their work "Psychological Effects of Chronic Lung Disease," observe that while identification and management of the physical signs and symptoms of chronic lung diseases has improved, the psychosocial burden is often unrecognized and neglected (p. 1). Dyspnea, a central symptom of COPD, is described as "a very complex phenomenon, with patients experiencing a mix of physiological, psychological, social, environmental and behavioral responses. Therefore, it follows that successful treatment of dyspnea should not be restricted to bronchodilators or other physiological interventions" (Kelly and Lymes, 2008, p. 1).

The physical symptoms, their persistent nature, and the degenerative trajectory of the disease all contribute to psychological responses that affect patients' quality of life (Kelly and Lymes, 2008, p. 1). The experience of living with COPD includes anxiety and stress, depression, fear of dying, panic, altered body image, altered role in the family, loss of independence, lifestyle changes, altered relationships, low self-esteem, denial, anger, loss of dignity, frustration, guilt, loss of intimacy, and irritability (Kelly and Lymes, 2008, p. 1).

Research also indicates that "patients with respiratory disease often fare worse than patients with cancer" in terms of psychological outcomes (Blumenthal et al., 2009, p. 1). The work of Arne et al. (2007), which used grounded theory to interview patients with COPD about their experiences at the time of diagnosis, found that shame was the main theme and was related to the perception that the disease was self-inflicted — an obstacle when seeking medical advice. This psychological impact early in the disease trajectory suggests that psychological morbidity may be equal to or even greater than the effect of early physical symptoms (Blumenthal et al., 2009, p. 1).

Patients with COPD often view themselves as a burden, frequently due to guilt associated with a history of smoking. Even in patients who have never smoked, a stigma exists because the disease involves coughing and production of phlegm, which tends to generate negative attitudes from the public and from healthcare professionals alike. Caregivers of those with COPD may experience psychological problems similar to those of the patient, stemming from "stress in relation to feeling restricted, anxious and profoundly helpless in the face of dyspnea, accompanied by a sense of preoccupation with their relative and a debilitating hypervigilance" (Blumenthal et al., 2009, p. 1).