Approach To Long Term Conditions Health And Social Care Essay

This piece of work will explore the holistic journey of a patient with chronic obstructive pulmonary disease (COPD) from diagnosis to end of life and will, firstly, look at Pathophysiology then briefly; living for today, transition/progression and end of life stages, with the diagnosis stage explored in greater detail. These will be achieved in a logical flow and order. COPD is an umbrella term covering a number of health conditions and is a progressive disease involving air flow obstruction of the airways (Nice 2010). A literature search strategy will be utilized using a wide range of relevant academic sources and supported by current literature. This will be achieved by using books, journals (both paper and electronic) research papers and using electronic databases, such as CINAHL and Medline. Using search terms to get more accurate and relevant results. An example search term is COPD diagnosis.

Pathophysiology/Incidence

COPD encompasses a range of conditions, which affect the respiratory system and the health and safety executive (2012) estimates that there are over one million people who have COPD in the UK. However, Small et al. (2012) states that there is estimated to be over three million people who have this condition. It is evident that the actual number of people with this condition may not be fully known. Furthermore; this is an umbrella term that encompasses the following diseases; chronic bronchitis, parenchyma destruction (emphysema), long standing asthma that is unresponsive to treatment and small airway disease (obstructive bronchiolitis) (Bellamy & Booker, 2004; Gold, 2010). This can also be caused by a genetic disorder resulting in alpha-1 antitrypsin deficiency, which then causes emphysema (Halpin, 2008). COPD causes inflammation that affects the central airways, peripheral airways, pulmonary vasculature, lung parenchyma and alveoli. This results in a number of changes to the patient’s physiology. Additionally; these changes are narrowing and remodelling of the airways, increased quantity of goblet cells, and enlargement of mucus-secreting glands of the central airways and subsequent vascular bed changes that lead to pulmonary hypertension (Faffe & Zin, 2009). These potentially have a severe impact on the inspiration and expiration of airflow to and from the lungs being limited due to the obstructive nature of the disease (Nice, 2010). This condition is usually progressive and has an enhanced response that is chronic and inflammatory affecting the airways and lungs due to harmful particles or gases (Gold, 2013).

Diagnosis

When a patient has to start the journey of being diagnosed with chronic obstructive pulmonary disease (COPD) They may go to their general practitioner with the following symptoms; chest infections that keep happening, persistent cough with or without production of sputum and breathlessness on exertion (Cornforth, 2012). or if the situation is at a more severe level, then they go to the accident and emergency department where they will be assessed and possibly admitted.

The diagnosis of what may be wrong with their health can be started either by the general practitioner or nurse and must fall within a diagnostic criterion. In addition; the medical team will use the following, National Institute for Health and Care Excellence COPD pathway (Nice 2013) to guide their actions along the diagnosing journey.  Moreover; all processes must be carried out in a fully holistic way and be patient centred and giving as much support and information as the person needs and requires.

The process of the diagnosis journey will include a history taking and data-gathering exercise. Then a full physical examination and any required investigative tests would be initiated and finally, once diagnosis is confirmed.  The persons support, and educational needs will have to be established.  So that the nurse can give fully tailored holistic support to help them come to terms and accept the diagnosis and understand what they may need to do change or adjust in their lifestyles to manage the condition. Moreover, the person's education experience should be carried out throughout the whole journey (Gruffydd-Jones, et al. 2010). This will also involve their family.

There are many health professionals involved in the diagnosis of COPD, such as; general practitioners, nurse, respiratory specialists, x-ray technologist and radiologist who will liaise with all members of the multidisciplinary team to make sure the diagnosis is as accurate as possible. An example of how a healthcare professional such as the nurse will be involved in carrying out a diagnosis is as follows; Firstly, they will go through a step by step process to get a full understanding of the life and medical history of the patient.  This will be done to determine smoking habits, if there has been exposure to pollutants that may have irritated the respiratory system, their family history to determine if there is a link with alpha-1 antitrypsin deficiency (Silverman, and Sandhaust 2009; Carroll et al. 2012; Stoller and Brantly, 2013). There will also be in-depth examinations that will look at the person's appearance, the sounding of the lungs and using the percussion technique if qualified to do so. This will allow the examiner to check the chest to see if there are any abnormal sounds that may be present , this will aid in the diagnosis of either COPD or other respiratory issue. Thirdly, there will be a test that checks the pulmonary function; which is known as the spirometry test and will be used is to check the severity of the condition. This consists of four stages that range from mild, with or without symptoms to severe chronic respiratory failure and will be assessed throughout the diagnostic journey (University of Maryland Medical Centre, 2009; Gold, 2010; Lindberg et al.2012).  

To start with a history taking and data-gathering exercise must be carried out and done as accurately and as detailed as possible. The nurse can use the following when assessing the patient who may have COPD. This acronym SOFTMASH is a mnemonic that stands for symptoms, occupation, family history, triggers and treatment, medications taken, atrophy, allergies and activity and history (Cornforth, 2012).  The nurse will do this in a fully holistic way, covering all areas shown below and will advise on how to manage any issues they may have.

Firstly; physical, is the person having issues with any form of activity, such as walking and helping family. The nurse can advise on what the person may be able to do by suggesting light to moderate exercising, postural control to help lugs function better, for example; sitting properly rather than slouching. The nurse can also advise that they can refer to a physiotherapist who can assist the patient in gaining their physical ability by formulating techniques and exercises the person can use, and instilling confidence in the person.

Secondly; physiological, if there may be other health issues that may be impacting the person's condition further. For example; anxiety, stress, depression and could have additional comorbidities, such as heart disease. The nurse could advise various ways in which their issues could be relieved. For instance; talking therapies, supplemental medication if situation warrants this and the nurse would explain that they may need to investigate how all conditions could be managed effectively so to promote the person's quality of life, and they can also refer the person to a specialized person or team that can help further in this matter.

Thirdly; social, is the individual still managing to do social activities or do they feel their health issues are stopping them from doing this? The nurse could advise on support organisations that could assist the person and help them get more involved in social activities.

Fourthly; spiritual, how does the person feel about their current life situation, for example? Do they feel they have lost meaning in their life and what makes them feel fulfilled? The nurse can help by suggesting that they may want to try, for instance; talking therapies where the person can work through what is happening and potentially find a new path to fulfilment, also speaking to other people who may have similar experiences as this would allow the individual to understand that they are not alone.

Finally; cultural, what is the effect on the individual of their health issues? For example; the potential shame they may feel that they have these issues, and feeling devalued as they may think they are not being valued as before. The nurse can help with this by offering cultural support and speaking to their family if the person wishes as they can explain what is going on and may be able to resolve any issues the family members may have.

Furthermore; the person will be assessed completely, and this will take in all medical issues and their full needs. This is extremely significant in the patient diagnosis journey as there may be more than one health issue. For this reason;  the nurse plays an important part in collection information from the patient and family. They will potentially be the main MDT member. Who can pass on relevant information or refer the person to any other members of the MDT, who may have to be involved or consulted in the current and future care of the patient? (Kennedy, S., 2011; Kaufman, G., 2013).  

The diagnosis process would have to be systematic and go through a step by step process to establish that this actually is COPD as this can be commonly misdiagnosed as asthma (Walters et al. 2011). There are a number of similar symptoms that make accurate diagnoses a challenge. Even though there are some differences that will eventually lead to the correct diagnosis (Nepal & Bhattarai, 2008). The differences include; current or ex-smoker, rare to have symptoms less than 35 years of age, productive cough that is chronic and persistent and progressive breathlessness (Booker, 2008; Loveridge, 2012). In addition; It can be misdiagnosed as other medical issues, such as myocardial infarction, and heart failure (Hawkins et al.2009).

Furthermore; the nurse or other professional would give the patient a full explanation at a level they will understand, on all the procedures, which need to be carried out so they can gain fully informed consent. These include spirometry, which is used to determine the air flow limitations of the lungs (Quanjer & Ruppel 2011). Chest x-ray to establish if there are other underlying medical, and sputum test to determine if there are any other signs of infection (Dewar and Curry, 2006; Gold, 2013).  Depending on how severe the patient's condition is, the subsequent tests may be carried out; Electrocardiogram (ECG) may be done to establish if there may be issues with the heart that may contribute to the person's health issues (Agarwal et al.2008). Oximetry to establish the oxygen concentration within the blood is at a normal level or if the person requires supplemental oxygen.  Arterial blood gases (ABG) will also be checked  to establish if there is enough oxygen (SP02) within the blood or a raised carbon dioxide (CO2) level, which can cause the resulting health issues; hypoxemia and hypercarbia which are indicative of respiratory failure (Adam, Odell,  and Welch, 2010). This would be done regularly by the nurse if the patient is already on oxygen to make sure this is benefiting the patient and finally transfer factor for carbon monoxide. This test is used to establish whether the lungs have been damaged and by how much (Rodrigues-Roisin and MacNee, 2006; Hughes and Pride, 2012).

If COPD is confirmed, the nurse would be heavily involved in the patient education and will explain what treatment and medication may be available and the routes of administration to see what they think may be best for them. In addition; they will need to be informed of any risks and benefits associated with these, so that the patient can make an informed choice. The nurse may suggest that they try certain medications, to find what is best suited to the person’s health issues and will also advise the patient on the correct technique of using any required aids. For example; inhaler spacer, inhalers, which include pressured metered, dry powder and spring loaded (Pearce, 2011). The nurse will also use training aids that will help with the patient educational journey. These can include placebo inhalers, equipment that allows the patient to use their own inhaler and inhalation monitor and multimedia training material (Lavorini et al.  2010).

Living for today

The person must look after themselves both physically and mentally as they may have additional comorbidities that will make living with the condition a challenge. Moreover; the nurse can play a very important part in this by empowering the person and allowing them to lead the way in what support and help they require and want.  In addition; the nurse can achieve this by using motivational interviewing and working in a holistic way that will allow the individual to be in full control. Moreover; they will be encouraged to follow a self-management plan or keep a COPD diary which will help to maximize their independence and quality of life (Hickey, 2010; NHS Lothian, 2011b; Johnston, O’Byrne, and Kolb, 2011; Silva, 2011). This will allow the patient to self-manage their symptoms and ongoing treatment.

Furthermore; this will help identify any trends and monitor any unexpected issues or exacerbations that may arise from the condition. By self-managing they can work with the MDT team in a more productive way allowing for better management of symptoms and any issues to be addressed in a timely manner and giving them the optimum support throughout their journey (Nice, 2010).

Additionally; the nurse can ask what life changes they can or want to make at this time?  The patient may state that they want to give up smoking, and the nurse can offer assistance by supplying appropriate literature and referring to smoking-cessation services. They can also discuss what the benefits will be (Wilson, Elborn and Fitzsimons, 2011; Osthoff, Jenkins, and leuppi, 2013).

The nurse can also do the following holistically and help with any psychological and emotional issues  they may have as this is a common issue for people with long term conditions such as COPD (NHSConfed, 2012). One such issue is depression, which can impact their activities of daily living (Zang et al. 2011). Moreover; this must be monitored closely by the nurse to determine if there are any issues which the person may be unaware of and to pick up any signs that may be present, The nurse can also discuss with the person what support services may be available to support them.

Transition/progression

As the patient progresses to and through this stage, the nurse must make sure the patient, carer and family are involved in all aspects of the care and help them manage any issues they may be experiencing. The patient may require additional support as they may have comorbidities that will mean they may need more intermittent and specialist support as they may have to spend more time in the hospital. The support can be delivered by a number of agencies involved in the care. These can include voluntary and health agencies, which will require effective communication to make sure the holistic care is fully optimized for the person.

Additionally; the nurse plays an import role within this as they may be the central figure within the MDT team involved in the care of the individual. Moreover; they not only give tailored holistic support but can also liaise with other members of the MDT team that are involved in the overall care. This will help to minimize any communication issues, which may arise.  

Moreover; the nurse can also offer information on the anticipatory care planning service, as this is another service that can assist with their condition management (Goeman, Walters, and Ross 2012). Furthermore; the person should still be encouraged to monitor their condition for any changes (Walters et al. 2012).

Additionally; lack of physical activity is a common issue for people with COPD. This is a component of the holistic care given and the nurse can assist the patient to do as much exercise as their able, and also refer them to the physiotherapist who can arrange exercise routines at a level that is best suited to the individual. Accordingly, the nurse can monitor that this is benefiting the individual. In addition; people with this condition generally don’t do a lot of physical activity due to breathlessness and the feeling that they cannot do strenuous activities, even though there is evidence that doing exercise can reduce hospital admission and has other benefits (Garcia-Aymerich et al. 2006; Seidel, et al. 2012).

End of life

As the patient moves to the end of life stage the care must be fully holistic and optimized to meet the individuals, carer and families, overall needs (Barnett, 2012) and will encompass all professionals involved in the care. Even so, the person who may be the main participant assisting will be the nurse. The nurse will assist with any advanced care planning requirements (Patel, Janssen and Curtis, 2012) and will advise the patient and family on what may need to be put into place. For instance; end of life planning and living will. Does the person have any particular wishes on where they want to end their life, namely, home, hospital or hospice and how things should be handled upon their death?  Furthermore; the nurse will also need to discuss with patient and family, if resuscitation should be done and explain any implications to the individual, e.g. would it be beneficial? A DNR (do not resuscitate) form should be completed if the individual decides they want this (Tsang, 2010). This will all be done very sensitively and with the utmost respect. Moreover; their preferences will always be acknowledged (Spathis & Booth, 2008). Additionally;

The nurse will also discuss if the person or family has any cultural, spiritual and religious beliefs that should be incorporated at this stage of care and how this could be done, using both motivational interviewing and active listening skills. This will allow the nurse and any other member of the care team to give tailored person centred and optimized care for the patient and their family through this difficult time. (Curtis, 2008). Consequently; The nurse will work to manage any pain and symptoms the patient may present and gives physiological, social, spiritual, physical and cultural support as required. The Liverpool care pathway (LCP) can be implemented as it encompasses the care mentioned above and is used to manage all aspects of care in the final days or hours of life (Veerbeek et al. 2008; NHS Lothian, 2011a). By doing the above, the person will have the best end of life experience possible, for themselves and their family (Seamark, Seamark, and Halpin, 2007).

Conclusion

After careful examination of each stage of the patient journey, it is evident that being diagnosed with COPD can be life changing. Moreover; each part of the journey can be overwhelming and traumatic for the individual and their family. Additionally; what issues that may be faced by said individuals. Moreover; how the care and treatment may have to change as the condition and any comorbidities progress. That being said, it is evident that there are support services available, which would help the patient, carer and family throughout their journey. The importance of the nurse's role within the MDT team cannot be emphasized enough as they can facilitate the individuals holistic care and be a central point within the healthcare team to ease communication. What is more;

The knowledge gained while doing this piece of work will be of benefit as one has a better understanding of the issues that a person and family may experience when going through each stage of the journey. Moreover; how this may affect the overall health and lifestyles of both the patient and their families. Furthermore; this will help one to give full holistic support in future practice as a greater understanding has been achieved on just how important this is and how it benefits the individuals concerned and can positively help with the patient journey and experience.

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Adam, S., Odell, M., and Welch, J., (2010). Essential clinical skills for nurses. Rapid assessment of the acutely ill patient. Chichester: Wiley-Blackwell.

Agarwal, RL., Kumar, D., Gurpeet, K., Agarwal, DK., and Chabra, GS., (2008). Diagnostic Values of electrocardiogram in chronic pulmonary disease. Lung India.25 (2) pp. 78-81. [Online]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2822322/ [Accessed 29th Marcg 2013].

Barnett, M., (2012). End of life issues in the management of COPD. Journal of community nursing. 26 (3). pp. 4-6. [Online]. Available from: http://search.proquest.com/britishnursingindex/docview/1019626710/fulltextPDF/13D7C8B376C8637646/2?accountid=26447 [Accessed 17th April 2013].

Bellamy, D, & Booker, R, (2004). Chronic Obstructive Pulmonary Disease in Primary Care. All you need to know to manage copd in your practice 3rd Ed. London: Class Publishing.

Booker, R., (2008). The primary care face of COPD. Primary health care. 18 (5). pp. 37-47. [Online]. Available from: http://primaryhealthcare.rcnpublishing.co.uk/archive/article-the-primary-care-face-of-copd [Accessed 29th March 2013].

Carroll, TP., O’Connor, CA., Reeves, EP., and McElvaney, NG., (2012). Alpha-1 antitrypsin deficiency – a genetic risk factor for COPD. Chronic Obstructive Pulmonary Disease - Current Concepts and Practice. Intech. [Online]. Available from: http://cdn.intechopen.com/pdfs/30167/InTech-Alpha_1_antitrypsin_deficiency_a_genetic_risk_factor_for_copd.pdf [Accessed 7th April 2013].

Chest, heart and stroke (2013). Chest information. [Online]. Available from: http://www.chss.org.uk/chest/ [Accessed 2nd April 2012].

Cornforth, A., (2012). Diagnosis and management of copd. Nurse prescribing. 10 (2) pp. 64-71.

Dewar, M., and Curry, RW., (2006). Chronic obstructive pulmonory disease: diagnostic consideration. University of Florida college of medicine, health and service center.73 (4) pp. 669-676 [Online]. Available from: http://www.aafp.org/afp/2006/0215/p669.pdf [Accessed 29th March 2013].

Faffe, DS., Zin, WA., (2009). Lung parenchymal mechanics in health and disease. [Online]. Available from: http://physrev.physiology.org/content/89/3/759.full [Accessed 5th February 2013].

Garcia-Aymerich, J., Lange, P., Benet, M., Schnohr, P., and Anto, JM., (2006). Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population study. Thorax. 61. pp. 772-778. [Online]. Available from. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2117100/pdf/772.pdf [Accessed 19th April 2013].

Global initiative for chronic obstructive lung disease (2013). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. {Online]. Available from: http://www.goldcopd.org/uploads/users/files/GOLD_Report_2013_Feb20.pdf [Accessed 27th February 2013].

Global strategy for the diagnosis, management, and prevention of COPD, (2010). [Online]. Available from: http://www.goldcopd.org/uploads/users/files/GOLDReport_April112011.pdf [Accessed 5th February 2013].

Goeman, Walters, and Ross (2012). Anticipating the outcomes and care choices for people living with COPD. Primary care respiratory journal. 21 (3). pp. 241-251. [Online]. Available from: http://www.thepcrj.org/journ/vol21/21_3_241_251.pdf [Accessed 19th April 2013].

Graham, H., (2004). Socioeconomic inequalities in health in the UK: evidence of patterns and determinants. A short report for the diability right commission.[Online]. Available from: http://disability-studies.leeds.ac.uk/files/library/graham-socioeconomic-inequalities.pdf [Accessed 27th March 2013].

Gruffydd-Jones, K., Haughney, J., Jones, R., & O’Kelly, N., (2010). Diagnosing and management of COPD in primary care. The primary care respiratory society UK. [Online]. Available from: http://www.google.co.uk/url?sa=t&rct=j&q=patient%20education%20through%20the%20diagnosis%20process%20of%20copd&source=web&cd=5&cad=rja&ved=0CFIQFjAE&url=http%3A%2F%2Fwww.pcrs-uk.org%2Fresources%2Fcopd_guidelinebooklet_final.pdf&ei=swdTUf-VNYfI0AWO44DQCw&usg=AFQjCNEw5EM_cdb0qkmUXyNy4dIExKcFQw&bvm=bv.44342787,d.d2k [Accessed 27th March 2013].

Halpin, DMG, (2008). Your questions answered COPD. Edinburgh: Churchill Livingston.

Hawkins, NM., Petrie, MC., Jhund, PS., Chalmers, GW., Dunn, FG., and McMurray, JJV., (2009). Heart Failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology. European journal of heart failure. 11 pp. 130-139 [Online]. Available from: http://eurjhf.oxfordjournals.org/content/11/2/130.full.pdf+html [Accessed 29th March 2013].

Health and Safety Exective (ND). Copd causes – occupations and substances. [Online]. Available from: http://www.hse.gov.uk/copd/causes.htm [Accesssed 27th March 2013].

Health and Safety Executive (2012). Chronic Obstructive Pulmonary Disease (COPD). [Online]. Available from: http://www.hse.gov.uk/statistics/causdis/copd/copd.pdf [Accessed 27th March 2013].

Hickey, S., (2010). Strategies for reducing exacerbations of COPD. Practice nursing. 21 (2). pp. 78-83. [Online]. Available from: http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=147464c1-fe5e-4bd0-b8a8-285abf06cb0f%40sessionmgr15&vid=1&hid=20 [Accessed 17th April 2013].

Hughes, MB., and Pride, NB., (2012). Examination of the carbon monoxide diffusing capacity (DL

CO) in relation to its Kco and VA Components. American journal of respiratory and critical care medicine. 186, pp. 132-139. [Online]. Available from: http://www.pneumonologia.gr/articlefiles/diffusion_AJRCCM_2012-1.pdf [Accessed 6th April 2013].

Johnston, N., O’Byrne, P., and Kolb, M., (2011). The promise of electronic data capture in respiratory medicine. European respiratory journal. 37 (2). pp. 228-230. [Online]. Accessed from: http://erj.ersjournals.com/content/37/2/228.full [Accessed 5th April 2013].

Kaufman, G., (2013). Chronic obstructive pulmonary disease: diagnosis and management.Nursing Standard. 27 (21) pp. 53-62.

Kennedy, S., (2011). Caring for a patient newly diagnosed with COPD: a reflective account.

Nursing Standard. 25 (49) pp. 43-48.

Lavorini, F., Levy, ML., Corrigan, C., and Crompton, G., (2010). The ADMIT series – issues in inhalation therapy. 6) Training tools for inhalation devices. Primary care respiratory journal. 19 (4). pp. 335-341. [Online]. Available from: http://www.thepcrj.org/journ/vol19/19_4_335_341.pdf [Accessed 29th March 2013].

Lindberg, A., Larrson, LG., Muellerova, H., Ronmark, E., and Lundback, B., (2012). Up-to-date on mortality in COPD – report from the OLIN COPD study. BMC pulmonary medicine. 12 (1). pp. 1-7. [Online]. Available from: http://www.biomedcentral.com/content/pdf/1471-2466-12-1.pdf [Accessed 17th April 2013].

Loveridge, C., 2012). The diagnosis and assessment of COPD. Practice nursing. 23 (10) pp. 500-506. d

National Health Service Lothian (2011a). Person centred, safe, effective & efficient care. NHS Lothian quality improvement strategy, 2011-2014. [Online]. Available from: http://www.nhslothian.scot.nhs.uk/OurOrganisation/Strategies/Documents/NHSLothianQualityImprovementStrategy2011-2014.pdf [Accessed 2nd April 2013].

National Health Service Lothian (2011b). Self management plan for COPD. NHS lothian respiratory managed clinical network. [Online]. Available from: http://www.lothianrespiratorymcn.scot.nhs.uk/wp-content/uploads/2011/07/Self-Management-Plan-for-COPD_Final.pdf [Accessed 5th April 2013].

National Institute for Health and Care Excellence (2010). Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. CG101. London.

National Institute for Health and Clinical Excellence, (2013). Diagnosis COPD pathway. [Online]. Available from: http://pathways.nice.org.uk/pathways/chronic-obstructive-pulmonary-disease/diagnosing-copd [Accessed 5th February 2013].

Nepal, M., & Bhattarai, MD., (2008). Misdiagnosis of COPD in middle aged asthmatics in Nepal. The internet journal of pulmonary medicine. 10 (1). [Online]. Avaialble from: http://archive.ispub.com/journal/the-internet-journal-of-pulmonary-medicine/volume-10-number-1/misdiagnosis-of-copd-in-middle-aged-asthmatics-in-nepal.html#sthash.TpbytLWv.dpbs [Accessed 29th March 2013]

Osthoff, M., Jenkins, C., and Leuppi, JD., (2013). Chronic obstructive pulmonary disease – a treatable disease. Swiss medical weekly. 143. pp. 1-8. [Online]. Available from: http://www.smw.ch/scripts/stream_pdf.php?doi=smw-2013-13777 [Accessed 17th April 2013].

Ortiz, MLM., and Morera, J., (2012) COPD: differential diagnosis, chronic pulmonary disease- current concepts and practive. Intech. [Online]. Available from: http://www.intechopen.com/books/chronic-obstructive-pulmonary-disease-current-concepts-and-practice/copd-differential-diagnosis [Accessed 29th March 2013].

Patel, K., Janssen, DJA., and Curtis, R., (2012). Advanced care planning in COPD. Respirology. 17, pp. 72-78. [Online]. Available from: http://www.fcconventions.com.au/TSANZ2012/asm2012ts02.pdf [Accessed 8th April 2013].

Pearce, L., (2011). How to teach inhaler technique. Nursing times. 107 (8). pp. 16-17.

Quanjer, PH., & Ruppel, GL., (2011). Diagnosisng COPD: high time for a paradigm shift. Respiriratory care. 56 (11) pp. 1861-1863.

Rodriguez-Roisin, R., and MacNee, W., (2006). Pathophysiology of chronic obstructive pulmonary disease. European repsiritory monograph. 38, pp. 177-200 [Online]. Available from: http://www.ecc-book.com/SEC12.body. [Accessed 6th April 2013].

Seamark, DA., Seamark, CJ., & Halpin, DMG., (2007). Palliative care in chronic obstructive pulmonary disease: a review for clinicians. Journal of the royal society of medicine. 100 pp. 225-233.

Spathis, Booth, S., (2008). End of life care in chronic obstructive pulmonary disease: in search of a good death. International journal of COPD. 3 (1). pp. 11-29. [Online]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528206/pdf/copd-0301-11.pdf [Accessed 2nd April 2013].

Seidel, D., Cheung, A., Suh, ES., Raste, Y., Atakhorrami, M., and Spuit, MA., (2012). Physical inactivity and risk of hospitalisation for chronic obstructive pulmonary disease. The International Journal of Tuberculosis and Lung Disease. 16 (8). pp. 1015-1019. [Online]. Available from: http://docstore.ingenta.com/cgi-bin/ds_deliver/1/u/d/ISIS/73849693.1/iuatld/ijtld/2012/00000016/00000008/art00005/F61657CB0C630D831366367405C421D0F98936C9AD.pdf?link=http://www.ingentaconnect.com/error/delivery&format=pdf [Accessed 19th April 2013].

Silva, DD., (2011). Helping people help themselves: a review of the evidence considering whether it is worthwhile to support self-management. The health foundation inspiring improvement. [Online]. Available from: http://www.health.org.uk/public/cms/75/76/313/2434/Helping%20people%20help%20themselves.pdf?realName=8mh12J.pdf [Accessed 5th April 2013].

Silverman, EK., and Sandhaust, RA., (2009). Alpha-1 antitrypsin deficiency. The New England journal of medicine. pp. 2749-2757. [Online]. Available from: http://phes.co/Newengland/Gastroenterology/Alpha1-Antitrypsin%20Deficiency,%2006-25-09.pdf [Accessed 7th April 2013].

Small, N., Grdiner, C., Barnes, S., Gott, M., Halpin, S., and Seamark, D., (2012). "you get old, you get breathless, and you die": chronic obstructive puilmonary disease in Barnsley, UK. Health & place. 18 (6). pp. 1396-1403. [Online]. Available from: http://www.researchgate.net/publication/233754004_Small_2012_Health__Place/file/79e4150b3362688b91.pdf [Accessed 7th April 2013].

Spathis, A., and Booth, S., (2008). End of life care in chronic obstructive pulmonoary disease: in search of a good death. International journal chronic obstructivepulmonary disease.3 (1). pp. 11-29. [Online]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528206/ [Accessed 17th April 2013].

Stoller, JK., and Brantly, M., (2013). The challenge of detecting Alpha-1 antitrypsin deficiency. Journal of chronic pulmonary disease. 10 (S1). pp. 26-34. [Online]. Available from: http://informahealthcare.com/doi/pdf/10.3109/15412555.2013.763782 [Accessed 7th April 2013]. d

Telescot, (2011). Chronic obstructive pulmonary disease: the impact of a temetric COPD monitoring service. TELEmetric supported Self-monitoring of long term COndiTions. [Online]. Available from: http://www.telescot.org/uploads/4/5/9/4/4594120/telescot-copd-protocol.pdf [Accessed 5th April 2013].

Tsang, JYC., (2010). The DNR order: what does it mean?. Clinical medicine insights: circulatory, respiratory and pulmonary medicine.4 pp. 14-23. [Online]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998928/pdf/ccrpm-2010-015.pdf [Accessed 8th April 2013].

University of Maryland Medical Centre, (2009). Chronic Obstructive Pulmonary Disease- Diagnostic tests. [Online.] Available from: http://www.umm.edu/patiented/articles/what_diagnostic_tests_chronic_obstructive_lung_disease_000070_7.htm [Accessed 5th February 2013].

Veerbeek, L., Zuylen, LV., Swart, SJ., van der Mass, PJ., de Vogel-Voogt, E., van der Rijt, CCD., & van der Heide, A., (2008). The effect of the Liverpool care pathway for the dying: a multi-centre study. Palliative medicine. 22 pp. 145-151. [Online]. Available from: http://www.lcp.nu/blanketter/rapporter/The%20effekt%20of%20LCP.pdf [Accessed 2nd April 2013].

Voice of carers across lothian (VOCAL) (nd). Carer support groups in Edinburgh. [Online]. Available from: http://www.vocal.org.uk/assets/files/downloads/VOCAL%20publications/CarerSupportGroups.pdf [Accessed 2nd April 2013].

Walters, JA., Walters, EH., Nelson, M., Robinson, A., Scott, J., Turner, P., and Wood-Baker, R., (2011). Factors associated with misdiagnosisof COPD in primary care. Primary care respiritory journal. 20 (4). pp. 396-402. [onlione]. Available from: http://www.thepcrj.org/journ/vol20/20_4_396_402.pdf [Accessed 29th March 2013].

Walters, EH., Walters, J., Wills, KE., Robinson, A., and Wood-Baker, R., (2012). Clinical diaries in COPD: compliance and utility in predicting acute exacerbations. International journal of COPD. 7, pp. 427-435. [Online]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3402058/ [Accessed 8th April 2013].

Wilson, JS., Elborn, JS., and Fitzsimons, D., (2011). ‘It’s not worth stopping now’: why do smokers with chronic obstructive pulmonary disease continue to smoke? A qualitative study. Journal of clinical nursing. 20 (5/6). pp. 819-827. [Online]. Available from: http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=d49305b6-bcdc-495e-b765-1ddfef312ba8%40sessionmgr4&vid=1&hid=20 [Accessed 17th April 2013].

Zang, MWB., Ho, RCM., Cheung, MWL., Fu, E., & Mak, A. (2011). Prevalence of depressive symptoms in patients with chronic obstructive pulmonary disease: a systematic review, meta-analysis and meta-regression. General Hospital psychiatry. 33 (3) pp. 217-223. [Online]. Available from: http://www.sciencedirect.com/science/article/pii/S0163834311001174 [Accessed 31st March 2013].