Psychological Aspects of Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease

Abstract

As a leading cause of disability that often leads to death, chronic obstructive pulmonary disease (COPD) can be characterized as both a chronic illness and a life-threatening one. As a result, the experience of individuals with COPD can include psychological concerns that are associated with both rehabilitation and palliative care. At the same time, the often-uncertain trajectory of COPD obscures a clear transition from rehabilitation to palliative care. It is not surprising, therefore, that treatments aimed at addressing patients’ rehabilitative and palliative needs largely proceed independently of each other. This dissertation contains two studies conducted with patients participating in a pulmonary rehabilitation program for COPD (N = 242). Separately, each study stems from a research tradition grounded in either the rehabilitative or palliative approach to treatment. Together, the studies highlight an opportunity for a model of more integrated care. Study 1 is derived from the rehabilitation literature and focuses on the issue of “catastrophizing” about breathlessness. Catastrophizing is characterized by a magnification of a symptom’s threat value, rumination about its perceived negative impact, and a sense of helplessness in addressing it. In some medical conditions with a primary symptom, such as chronic pain, catastrophizing demonstrates a strong relationship with the development of disability. Study 1 examines whether this relationship is found in the context of breathlessness. The study also reports the initial validation of the Breathlessness Catastrophizing Scale (BCS) as a means of assessing this phenomenon. Study 2 has its conceptual basis in the palliative care literature and highlights patients’ existential concerns around loss of dignity. Loss of dignity is a central construct in recent health care debates, because it is a primary reason underlying the requests of terminally ill individuals to seek medically hastened deaths (i.e., euthanasia or assisted suicide). Until now, however, loss of dignity has only been examined among patients with cancer. Study 2 examines whether loss of dignity is as prevalent among those with advanced COPD, and whether it improves with treatment. In Study 1 the BCS was found to be a reliable measure of breathlessness catastrophizing, with good convergent validity and sensitivity to change. Interestingly, it appears that breathlessness catastrophizing need not be a barrier to functional improvement in COPD. In Study 2, a “fractured” sense of dignity was found among 13% of patients with advanced COPD, suggesting that it is at least as prevalent as among those receiving palliative cancer care. It was also evident that loss of dignity is amenable to change with appropriate rehabilitation. This finding is important for societal debates regarding the provision of medically hastened deaths, which are often described as offering “death with dignity”. Together these studies demonstrate that in an interdisciplinary environment, such as the pulmonary rehabilitation program, not only is collaboration possible, but the distinct rehabilitative and palliative needs of patients can be met.