Caring for a Person with a Long-term Condition

Caring for a Person with a Long-term Condition

Caring for a person with a long-term condition

 

The Department of Health (DOH) England, defines a Long-Term Condition (LTC) as “one that cannot currently be cured but can be controlled with the use of medication and/or other therapies” (Department of Health, 2010, p. 4). According to Roddis et al (2016), there are around 20 million people who have a LTC in England. Furthermore, NHS England (2015) states those with a LTC are the biggest users of the NHS. Therefore, this case study will explore the holistic care given to an individual with the LTC Chronic obstructive pulmonary disease (COPD) and the impact it has on them, their family and society. In accordance with Nursing and Midwifery Council (NMC, 2018) guidelines, confidentiality will be maintained throughout using pseudonyms Alice for the patient and Emily for their daughter.

Alice, a 56-year-old female, has been living with COPD for several years, which has recently worsened, resulting in frequent hospital admissions. Alice is a heavy smoker and has been for most her life, which could indicate the cause of the COPD (WHO, 2016). However, evidence suggests Alice’s occupation in a factory environment also has a major impact on the COPD symptoms (Thorne, 2016; De Matteis et al, 2016; Sadhra et al, 2017). Additionally, Alice suffers from depression and anxiety, Pumar et al (2014) suggests these are regularly occurring comorbidities in COPD patients. Alice’s daughter, Emily is her foremost carer assisting with attending appointments, financial assistance and general companionship. Emily has her own family and work commitments; however, she struggles to effectively support her mother, finding it hard to commit to appointment times and evidently portrays feelings of guilt with the need to support her mother at the hardest times.

COPD is defined as an umbrella term for chronic progressive lung diseases obstructed by airflow (WHO, 2016). The British Lung Foundation (BLF) (2018) states you are most likely to develop COPD if you’re over 35 and are, or have been, a smoker, although there are other factors contributing (NHS Digital). Additionally, COPD can cause various other physical symptoms, resulting in a loss of functionality and high levels of psychosocial distress (Gardner et al, 2018).

According to Snell et al (2016), COPD epidemiology continues to represent an extensive burden on the NHS. Furthermore, a report conducted by The BLF, analyses the economic burden of COPD in the UK, revealing the financial cost to the NHS, averaging £1.9 billion per year (BLF, 2018; NHS Digital). Moreover, studies predict COPD will be the leading cause of death worldwide, estimating an increase to NHS costs by 2030, which has significantly risen from previous data (WHO, 2016; Lozano, 2012; McClean et al, 2016). Comparatively, local data for NHS Walsall CCG (COPD: QOF prevalence) states a rise since previous reports and is significantly above the National average. Therefore, thus predicting COPD is a worsening condition and the number of people diagnosed will increase extensively, suggesting services need to adapt to this increasing demand.

Research suggests smoking is generally known to be the leading cause of COPD. Therefore, it could be argued that Alice’s occupation and lifestyle choices such as smoking, has contributed to the worsening of her LTC (Jiménez-Ruiz et al, 2015). Furthermore, studies suggest occupations where individuals are exposed to dust, fumes and chemicals can also contribute to developing COPD, such as industrial work (Thorne, 2016; De Matteis et al, 2016; Sadhra et al, 2017). However, COPD can also develop from the inherited enzyme alpha-1-antitrypsin deficiency (AADT). A genetic condition which can make individuals increasingly more vulnerable to the effects of inhaling toxic materials (Haitham et al, 2017; Brode et al, 2012). According to recent studies, COPD often goes undiagnosed among at-risk patients until symptoms are pronounced because many patients attribute their worsening symptoms to the natural process of ageing (Lindgren, Storli and Wiklund-Gustin, 2014). Therefore, although genetically, COPD development is rare, with the exposure to toxic materials, the plausibility in developing COPD is likely to increase, due to lifestyle choices, the ageing population, social and economic detriments of health, (NHS, 2015).

Charmaz (1983) suggests those with a LTC suffer from leading restricted lives, social isolation, being discredited and the feeling of burdening others. Additionally, an individual’s personality and outlook on life can have an impact on their LTC. However, Ansari et al (2014) states COPD patients have difficulty recognising its importance and long-term implications. The revised framework of Kubler-ross and Kessler (2014) “the five stages of grief”, relate accordingly to those with COPD with several studies encapsulating these elements of grief, for instance; denial after diagnosis (Papava et al, 2016), guilt for past habits (Lindqvist and Hallberg, 2010), and acceptance of the LTC (Ansari et al, (2014).

Alice’s daughter Emily entrusts the care giving role, providing support and evidently encounters her own anxiety and hardship. Schulz and Eden (2016) suggests families depend on one another to provide emotional support and assistance when they can no longer function independently. Additionally, Cruz et al (2017) states family members are the primary source of support for relatives with COPD, frequently coordinating care tasks, including management of their symptoms, mobility and personal care. However, Gardener (2018) argues, the caring role entrusted by family members, harbours potential strain on those relationships and carer support is not always necessary for those with COPD. Furthermore, Mi et al (2017) suggests symptoms of anxiety and depression in COPD patients and their carer are significantly associated. Moreover, the presence of anxiety and depression appears to correlate with symptoms such as dyspnoea and fatigue, consequently, worsening prognosis and compliance (Yohannes, 2017; Miravitlles, 2017), resulting in higher hospital attendances (Uchmanowicz et al, 2016). Additionally, Gardener et al (2010) states, individuals are restricted not just by the physical effects of their symptoms, but also by the fear associated with worsening symptoms. Therefore, Alice’s current presenting symptoms concludes the likeliness of experiencing these psychological conditions, are due to fears about dyspnoea, subjectively making symptoms worse.

NICE guidelines (2010) and the Five-Year Forward View (2014) identified the role of the multi-disciplinary team (MDT) in COPD management (NICE, 2010; DOH, 2014), suggesting the MDT are important to assist in treatment and management of the LTC. Kruis (2014) states, MDTs have recently been more prominent in the management of patients with COPD. Furthermore, Kuzma (2008) describes patients can benefit from MDT involvement with roles complementing each other and contributing to the ultimate goal of providing high quality holistic care. However, studies suggest the role of the nurse in particular as being invaluable in providing advice, education and support as they are involved in all stages of their care and particularly in preventing unnecessary hospital admissions(Yorke, 2017; Fletcher Birthe and Dhal, 2013). Therefore, it’s appropriate for Alice to have an interprofessional collaboration involved in her care, consisting of general nurses, specialist respiratory nurses, physiotherapists, dietitians, psychologists and doctors. Together, focusing on reinforcing Alice’s care plan, providing education, support and management of the LTC.

Arguably, Boulet (2016) states the concept of “expert patient” has recently been developed defining a patient as having significant knowledge of their LTC and treatment in addition to self-management skills. Thus suggesting, Alice is the expert in her own LTC. Nonetheless, the management of COPD is particularly challenging, due to complex health and social needs, it requires life-long monitoring and treatment. Therefore, expert advice needs to be given to patients within the community and MDTs need to work together along with the “expert patient” to avoid further hospital admissions and costs to the NHS (Partridge, 2015)

Vesbto and Lange, (2015) suggest little has been done in order to identify if certain patients would benefit more from one type of preventive strategy than another. Furthermore, Starren et al (2012) state healthcare support alone cannot improve the situation on its own. Therefore, understanding the support needs of individuals with COPD is important for the delivery of holistic care (Gardener et al, 2018). Concordantly, Alice was provided relevant treatment needed such as medical management including medications to treat exacerbations. However, to prevent further hospital admissions and improve quality of life it would be beneficial for Alice to receive further assistance to relieve anxiety symptoms such as psychological support, advised on smoking cessation programmes and referred to charities and support groups. Comparatively, The Wolverhampton Integrated Respiratory Lifestyle (TWIRL), provides weekly meetings for COPD patients to diminish social isolation and offer advice and support.

As previously evaluated, smoking is recognised as the most common cause of COPD. Analytically, approximately 50% of COPD patients are smokers (Wu and Sin, 2011; WHO, 2016). However, Public Health England’s latest tobacco report reveals a reduction in smokers since 2011 (PHE, 2017). Furthermore, research suggests self-management interventions can improve quality of life, reduce hospital admissions, and improve symptoms (Kaptein et al, 2014; Russell et al, 2018). Therefore, successfully managing COPD may include making multiple lifestyle changes such as smoking cessation and starting an exercise regime as well as medication adherence, although this may be hard to achieve in some.

The strategy of the Global Initiative for COPD (GOLD, 2013) encourages early detection and prompt diagnosis which should increase enrolment in smoking cessation programmes. According to Tonnesen (2012) this is the best way to increase survival, decrease mortality and diminish the effects of COPD. However, Eklund et al (2012) argues, although individuals are aware of the risks, those with COPD find it hard to quit smoking due to lifelong habits and lacking internal motivation. Therefore, with the correct advice and support from relatives and care providers Alice has a higher chance of quitting her long-term habit, ultimately increasing her chances of an improved quality of life.

Non-pharmacological strategies for preventing exacerbations could potentially have a significant effect on risk reduction (Vestbo and Lange, 2015). Brein et al, (2016) suggests, non-pharmacological interventions such as Pulmonary Rehabilitation (PR) and Cognitive Behavioural Therapy (CBT) may help if accepted and targeted appropriately, although these are under-used and sometimes declined by patients. Furthermore, Yohannes (2017) suggests, the use of CBT and PR is useful for short term management but not effective for long term management. Additionally, Thomas et al, (2015) suggests non-pharmacological music therapy such as community singing programs may improve quality of life for breathless people. However, Luhr (2018) argues self-management programmes do not serve as means to influence patients’ experience of patient participation in the care of their LTC. Therefore, suggesting further studies are needed to what facilitates patient participation.

Additionally, valuable support and advise is easily accessible and available for patients and their families, such as; The British Lung Foundation and COPD Foundation. Online communities are also available such as Patientslikeme.com and Patient.co.uk providing reassurance and concerns with others experiencing the same LTC. Moreover, The Care Workers Charity is available for those in the caring role such as Emily is for Alice. However, Gardener (2010) argues although COPD patients have regular contact with health services and are given advice, access to specialist services is poor due to lack of understanding of the condition and particularly denial.

Regulations in pharmacological interventions suggest, treatment for early stages of COPD should begin with inhalers and/or nebulizers, if these are ineffective regular medications such as steroids will be prescribed. Nonetheless, the most frequently prescribed are inhalers and are considered the most essential of COPD management (Matteo and Usmani, 2015). However, GOLD (2017) and NICE (2018) recommends the pharmacological treatment of COPD should be complemented by non-pharmacological interventions such as smoking cessation, exercise, PR, and CBT for treatment and managing symptoms to be effective (Fernandes, 2017; Singh et al, 2018)

Additionally, long-term oxygen therapy (LTOT) and non-invasive ventilation (NIV) are routinely prescribed for those with severe COPD (Ankjærgaard, 2016; Alifano et al, 2010) and is given to improve life expectancy and hypoxaemia at rest (Ekstrom et al, 2016). However, research suggests, the use of LTOT at home can be dangerous for the patient and their family, for instance; tripping over equipment and fires or burns from cigarette smoking (Albert et al, 2016). Furthermore, a Cochrane review found LTOT had uncertain effects on dyspnoea and did not improve quality of life (Ekstrom et al, 2016). Therefore, NICE (2018) recommends, risk assessments should be conducted prior to offering LTOT as the risks to them and the people they live with outweigh the potential benefits. Alice did not yet require LTOT, however it is likely to be needed and will have a more negative impact on her life, especially since Alice currently still smokes.

To conclude, patients can improve self-efficacy by taking control of self-care. Healthcare professionals need to empower patients in managing their LTC. For COPD self-management to be effective, patients’ psychosocial needs must be prioritised alongside medication and exacerbation management. In addition, patients’ personal beliefs regarding COPD and its management should be reviewed periodically to avoid problematic behaviours and enhance positive adaptions to the disease. Finally, practitioners require greater education, training, and support to successfully assist patients in managing their LTC.

 

References

  • Albert, R., Au, D., Blackford, A., Casaburi, R., Cooper, J., Criner, G., Diaz, P., Fuhlbrigge,  A., Gay, S., Kanner, R., MacIntyre, N., Martinez,  F., Panos, R.,  Piantadosi, S., Sciurba, F., Shade, D., Stibolt, T., Stoller, J., Wise, R., Yusen, R., Tonascia, J., Sternberg, A. and Bailey, W. (2016) A Randomized Trial of Long-Term Oxygen for COPD with Moderate Desaturation. The New England journal of medicine 375(17), pp.1617-1627
  • Alifano, M., Cuvelier, A., Delage, A., Roche, N., Lamia, B., Molano, L C., Couderc, L J., Marquette, C H., Devillier, P. (2010) Treatment of COPD: from pharmacological to instrumental therapies. European Respiratory Review. vol 19 issue 115 pg.7-23
  • Ankjærgaard, K. L., Tønnesen, P., Laursen, L. C., Hansen, E. F., Andreassen, H. F., & Wilcke, J. T. (2016). Home Non Invasive Ventilation (NIV) treatment for COPD patients with a history of NIV-treated exacerbation; a randomized, controlled, multi-center study. BMC pulmonary medicine, 16, 32. doi:10.1186/s12890-016-0184-6
  • Ansari, S., Hosseinzadeh, H., Dennis, S. and Zwar, N. (2014). Patients’ perspectives on the impact of a new COPD diagnosis in the face of multimorbidity: a qualitative study. NPJ primary care respiratory medicine, 24, 14036
  • Boulet, L. (2016) The Expert Patient and Chronic Respiratory Diseases, Canadian Respiratory Journal, 9454506.
  • Brien, S. B., Lewith, G. T., & Thomas, M. (2016). Patient coping strategies in COPD across disease severity and quality of life: a qualitative study. NPJ primary care respiratory medicine, 26, 16051
  • Brode, S. K., Ling, S. C., & Chapman, K. R. (2012). Alpha-1 antitrypsin deficiency: a commonly overlooked cause of lung disease. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 184(12), 1365-71.
  • Charmez, K.  (1983). Loss of self: a fundamental form of suffering in the chronically ill. Sociology of health and illness. 5(2), pp.168-195
  • Cruz, J, Marques, A., Figueiredo, D. (2017). Impacts of COPD on family carers and supportive interventions: a narrative review. Health and social care in the community 25(1). pp.11-25
  • Dave Singh, Peter J. Barnes, Robert Stockley, Maria Victorina Lopez Valera, Claus Vogelmeier, Alvar Agusti (2018), Pharmacological treatment of COPD: the devil is always in the detail. European Respiratory Journal 51 (4) 1800263;
  • De Matteis, S., Jarvis, D., Hutchings, S., Darnton, A., Fishwick, D., Sadhra, S., Rushton, L., Cullinan, P. (2016). Occupations associated with COPD risk in the large population-based UK Biobank cohort study. Occup Environ Med. 73(6):378-84.
  • Department of Health. (DOH) (2014) The Five-Year Forward Plan. DH 2014.
  • Department of Health. Improving the health and well-being of people with long term conditions. World class services for people with long term conditions – information tool for commissioners. London: Crown; 2010
  • Department of Health. The Expert Patient: A new approach to chronic disease management in the 21st Century. The Stationery Office 2001.
  • Dretzke, J., Blissett, D., Dave, C., Mukherjee, R., Price, M., Bayliss, S., Wu, X., Jordan, R., Jowett, S., Turner, A., and Moore, D. (2015) Health technology assessment. The cost-effectiveness of domiciliary non-invasive ventilation in patients with end-stage chronic obstructive pulmonary disease: a systematic review and economic evaluation.18(81)
  • Eklund, B., Nilsson, S., Hedman, L., Lindberg, I. (2012) Why do smokers diagnosed with COPD not quit smoking? Tobacco Induced Diseases. 10(1), pp.1
  • Ekstrom, M., Ahmadi, Z., Bornefalk-Hermansson, A., Abernethy, A., and Currow, D. (2016) Oxygen for breathlessness in patients with chronic obstructive pulmonary disease who do not qualify for home oxygen therapy. The Cochrane database of systematic reviews 11, CD006429
  • Fernandes, F., Cukier, A., Camelier, A. A., Fritscher, C. C., Costa, C., Pereira, E., Godoy, I., Cançado, J., Romaldini, J. G., Chatkin, J. M., Jardim, J. R., Rabahi, M. F., Nucci, M., Sales, M., Castellano, M., Aidé, M. A., Teixeira, P., Maciel, R., Corrêa, R. A., Stirbulov, R., Athanazio, R. A., Russo, R., Minamoto, S. T.,  Lundgren, F. (2017). Recommendations for the pharmacological treatment of COPD: questions and answers. Jornal brasileiro de pneumologia : publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia, 43(4), 290-301.
  • Fletcher, M., Birthe, H., and Dahl, B. (2013). Expanding nursing practice in COPD: key to providing high-quality, effective, and safe patient care? Primary care respiratory journal.
  • Gardener, C., Ewing, G., Kuhn, I., and Farquhar, M, (2018) Support needs of patients with COPD: a systematic literature search and narrative review. International journal of chronic obstructive pulmonary disease 13 pp.1021—1035
  • Gardiner, C., Gott, M., Payne, S., Small, N., Barnes, S., Halpin, D., Ruse, C., Seamark, D. (2010) Exploring the care needs of patients with advanced COPD: An overview of the literature. Respiratory Medicine. 104(2) pp.159-165
  • Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2013). [Accessed 8th October 2018]. Available at: <http://www.goldcopd.org/>
  • Haitham S., Ashry, A I., Strange, C. (2017) COPD in individuals with the PiMZ alpha-1 antitrypsin genotype. European Respiratory Review. 26(146) 170068
  • Jiménez-Ruiz, C, A., Andreas, S., Lewis, K, E., Tonnesen, P., Van Schayck, C, P., Hajek, P., Tonstad, S., Dautzenberg, B., Fletcher, M., Masefield, S., Powell, P., Hering, T., Nardini, S., Tonia, T., Gratziou, C. (2015) Statement on smoking cessation in COPD and other pulmonary diseases and in smokers with comorbidities who find it difficult to quit. European Respiratory Journal. 46 (1) 61-79;
  • Kaptein, A., Fischer, M. J., and Scharloo, M. (2014) Self-management in patients with COPD: theoretical context, content, outcomes, and integration into clinical care. International journal of chronic obstructive pulmonary disease. 9 pp.907-17. doi:10.2147/COPD.S49622
  • Kruis, A, L., Soljak, M.,Chavannes, N, H., Elkin, S, L. (2014) COPD Multidisciplinary Team Meetings in the United Kingdom: Health Care Professionals’ Perceptions of Aims and Structure. COPD: Journal of Chronic Obstructive Pulmonary Disease. vol 13 issue 5, pg.639-641
  • Kubler-Ross, E., & Kessler, D. (2014). Finding the Meaning of Grief through the Five Stages of Loss. On Grief and Grieving. London Simon & Schuster
  • Kuzma AM, Meli Y, Meldrum C, et al. Multidisciplinary Care of the Patient with Chronic Obstructive Pulmonary Disease. Proceedings of the American Thoracic Society. 2008;5(4):567-571.
  • Lindgren, S., Storli, S. L., & Wiklund-Gustin, L. (2014). Living in negotiation: patients’ experiences of being in the diagnostic process of COPD. International journal of chronic obstructive pulmonary disease, 9, pp.441-51
  • Lindqvist, G., Hallberg, L R. (2010) Feelings of guilt due to self-inflicted disease: a grounded theory of suffering from chronic obstructive pulmonary disease (COPD). J Health Psychol. 15(3):456-66.
  • Lozano, R. et al. (2012) Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. Volume 380, ISSUE 9859, pp. 2095-2128
  • Luhr, K, A, Marie Holmefur b, Kersti Theander c, Ann Catrine Eldh d, e (2018) Patient Education and Counseling Patient participation during and after a self-management programme in primary healthcare – The experience of patients with chronic obstructive pulmonary disease or chronic heart failure. Volume 101, Issue 6, Pages 1137-1142
  • Matteo B, Usmani O. (2015) The importance of inhaler devices in the treatment of COPD Biomed Central The open access publisher. COPD Research and Practice 1:9
  • McLean, S., Hoogendoorn, M., Hoogenveen, R. T., Feenstra, T. L., Wild, S., Simpson, C. R., Mölken, M. R., Sheikh, A. (2016). Projecting the COPD population and costs in England and Scotland: 2011 to 2030. Scientific reports, 6, 31893
  • Mi, E., Mi, E., Ewing, G., Mahadeva, R., Gardener, A C., Holt-Butcher, H., Booth, S., Farquhar, M. (2017) Associations between the psychological health of patients and carers in advanced COPD. International Journal of Chronic Obstructive Pulmonary Disease. Vol 12
  • Miravitlles, M., and Ribera, A. (2017) Understanding the impact of symptoms on the burden of COPD. Respiratory Research Volume 18
  • NICE (2004). Chronic obstructive pulmonary disease. NICE clinical guidelines on management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax 59(1):1-232.
  • NationaI Institute for Clinical Excellence. (2010) COPD and management in over-16s. [CG101]
  • National Institute Clinical Excellence (NICE, 2018) Chronic obstructive pulmonary disease in over 16s: diagnosis and management: evidence reviews for Referral criteria for oxygen therapy in people with stable [Accessed 10th October 2018]
  • NHS Digital. Accessed Online 23rd October 2018. Available at: <https://digital.nhs.uk/>
  • NHS England: (2015) Overview of potential to reduce lives lost from Chronic Obstructive Pulmonary Disease (COPD)
  • Nursing and Midwifery Council (NMC) (2018) The Code: Professional Standards of Practice and Behaviours for Nurses and Midwives: London. NMC
  • Papava, I., Oancea, C., Enatescu, V. R., Bredicean, A. C., Dehelean, L., Romosan, R. S., & Timar, B. (2016). The impact of coping on the somatic and mental status of patients with COPD: a cross-sectional study. International journal of chronic obstructive pulmonary disease, 11, 1343-51.
  • Partridge, M R. (2015) Integrated care: delivering better outcomes for patients with respiratory disease. British Journal of Healthcare Management. 21:1, 7-9
  • Public Health England (2017) Local Tobacco Control Profiles for England. Accessed online 28th December 2018. Available at:<https://fingertips.phe.org.uk/profile/tobacco-control>
  • Public Health England (2017). Inhale – INteractive Health Atlas of Lung conditions in England, COPD Indicators. Accessed online 28th December 2018. Available at: <https://fingertips.phe.org.uk/profile/inhale/data#page/4/gid/8000003/pat/46/par/E39000033/ati/153/are/E38000191/iid/253/age/1/sex/4>
  • Pumar, M. I., Gray, C. R., Walsh, J. R., Yang, I. A., Rolls, T. A., & Ward, D. L. (2014). Anxiety and depression-Important psychological comorbidities of COPD. Journal of thoracic disease, 6(11), pp.1615-31.
  • Roddis, J. K., Holloway, I., Bond, C., and Galvin, K. T (2016) Living with a long-term condition: Understanding well-being for individuals with thrombophilia or asthma. International Journal of Qualitative Studies on Health and Well-Being, 11:1 article number 31530.
  • Russell, S., Ogunbayo, O J., Newham, J J., Heslop-Marshall, K., Netts, P., Hanratty, B., Beyer, F., Kaner, E. (2018) Qualitative systematic review of barriers and facilitators to self-management of chronic obstructive pulmonary disease: views of patients and healthcare professionals. npj Primary Care Respiratory Medicine. volume 28, Article number: 2
  • Sadhra, S., Kurmi, O. P., Sadhra, S. S., Lam, K. B., & Ayres, J. G. (2017). Occupational COPD and job exposure matrices: a systematic review and meta-analysis. International journal of chronic obstructive pulmonary disease, 12, 725-734. doi:10.2147/COPD.S125980
  • Schulz R and Eden J, (2016). Committee on Family Caregiving for Older Adults; Board on Health Care Services; Health and Medicine Division; National Academies of Sciences, Engineering, and Medicine; Washington DC national academies press  https://www.ncbi.nlm.nih.gov/books/NBK396401/
  • Snell N, Strachan D, Hubbard R, et al. (2016) S32 Epidemiology of chronic obstructive pulmonary disease (COPD) in the uk: findings from the british lung foundation’s ‘respiratory health of the nation’ project.  Thorax 71:3
  • Starren, E S., Roberts, N J., Tahir, M., O’Byrne, L., Haffenden, R., S Patel, I S., Partridge, M R. (2012) A centralised respiratory diagnostic service for primary care: a 4-year Primary Care audit. Respiratory Journal. volume 21, pages 180–186
  • The British Lung Foundation (BLF) (2018) Available at < https://www.blf.org.uk/> Accessed: 23rd October 2018
  • Thomas R, Williams H, Stern M.  P137 ‘I really live for coming here’. The effect of a long-term singing group on control of breathlessness, social empowerment and psychological wellbeing of patients with respiratory disease: a qualitative study.  Thorax 2015;70:A145.
  • Thorne, P S., Er, M., Emri, S A., Demir, A U., Karakoca, Y., Bilir, N., Baris, I Y. (2016) Byssinosis and COPD rates among factory workers manufacturing hemp and jute. International Journal Occupational Medical Environment Health;29(1):55-68
  • Tomas, L, H, S. (2011) Emphysema and chronic obstructive pulmonary disease in coal miners, Current Opinion in Pulmonary Medicine. 17(2): pg. 123–125
  • Tonnesen, P. (2012). Smoking cessation and COPD. European Respiratory Society. vol. 22 no. 127 37-43
  • TWIRL (2016) Wolverhampton CCG [Accesses 8th October 2018]. Available at https://wolverhamptonccg.nhs.uk/your-health-services/twirl
  • Uchmanowicz, I., Jankowska-Polanska, B., Motowidlo, U., Uchmanowicz, B., & Chabowski, M. (2016). Assessment of illness acceptance by patients with COPD and the prevalence of depression and anxiety in COPD. International journal of chronic obstructive pulmonary disease, 11, 963-70.
  • Vestbo, J. & Lange, P. (2015) Prevention of COPD exacerbations: medications and other controversies. ERJ Open Research vol 1 issue 1
  • World Health Organization (WHO) (2016) Chronic obstructive pulmonary disease Available at: < http://www.who.int/respiratory/copd/en/ > [Accessed 21st October 2018]
  • Wu, J., & Sin, D. D. (2011). Improved patient outcome with smoking cessation: when is it too late? International journal of chronic obstructive pulmonary disease, 6, 259-67.
  • Yohannes AM, Junkes-Cunha M, Smith J, Vestbo J. (2017) Management of Dyspnea and Anxiety in Chronic Obstructive Pulmonary Disease: A Critical Review. Journal of post-acute and long term medicine 1;18(12) Pages 1096.e1–1096.e17
  • Yorke J, Prigmore S, Hodson M, et al. (2017) Evaluation of the current landscape of respiratory nurse specialists in the UK: planning for the future needs of patients.  BMJ Open Respiratory Research;4:e000210. doi: 10.1136/bmjresp-2017-000210

 

Charities accessed online mentioned in this paper

  • Patients like me. Accessed Online 18Th October 2018. Available at: <https://www.patientslikeme.com/>
  • Patient info. Accessed online 18Th October 2018. Available at <https://patient.info/>
  • The Care Workers Charity. Accessed online 18th October 2018. Available at: <https://www.thecareworkerscharity.org.uk/>
  • The COPD Foundation. Accessed online 18th October 2018. Available at: <https://www.copdfoundation.org/>

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