The recent article1 on patients dying of chronic cardiorespiratory disease demonstrates an important defect in our provision of services. The associated leading article2 stated that symptom patterns for patients with cancer or cardiorespiratory disease are similar, including depression, cachexia, fatigue and generalised pain, in addition to the severe breathlessness that characterises advanced heart and lung disease. In fact, quality of life, psychological morbidity and debility often appear to be worse in patients with non-malignant disease. For instance, in a comparison of patients dying of lung cancer and of COPD, 90% of the patients with COPD and 52% of the patients with cancer had clinically important anxiety or depression.3 Despite this, McKinley found that the inverse care law applied: 45% of patients with cancer and 12% of patients with non-malignant disease received antidepressants.1 Opioids provide effective relief from dyspnoea, with relatively few adverse effects:4 opioids were given to 57% of patients with cancer, but only 13% of patients with cardiorespiratory disease.1
To improve the lot of patients dying from cardiorespiratory disease, the first step is for established treatments to be provided by existing services. In addition, there is a need for continuity of care and expertise, best provided by nurse outreach teams, to promote good palliative care. Palliative care should start early in COPD — smoking cessation, education and self-management affect quality of life and outcomes.5 Pulmonary and cardiac rehabilitation are not routinely available despite strong evidence of benefit.6 Only if resources for palliative care services are spread more equitably between cancer and non-malignant disease will our long-suffering patients with COPD and heart failure be given the care their symptoms deserve.
- © British Journal of General Practice, 2005.
