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forms of care, from primary care up to specialized health care, should be carefully discussed

particularly in giving the safest and most favorable care in any level.

Providing information on disease management will allow carers to further understand and out

into practice a number of treatments, necessary medications, and safety measures to avoid

unnecessary hospitalizations or emergency care. For instance, being trained to assess the

patients respirations, pulse rate, lung sounds, and cough will help determine the level of severity

of the disease. Being informed with the available treatment and medications as well as the proper

diet, exercise, breathing techniques, and various daily activities for COPD patients will improve

the carers management of their patients conditions. Daily reports are also advised in order to

monitor the progress, changes, improvements, and concerns of the patients conditions for their

doctors to come up with timely and appropriate measures.

The Role of Caregivers

Carers normally assume the role of improving their patients quality of life (Hirst, 2005). They

can accomplish their primary goal by guiding their patients towards healthful actions. One of the

most important interventions for COPD patients is smoking cessation with which they

immediately stop smoking. Both carers and their patients can attend smoking cessation programs

for both sides to understand the effects of tobacco smoke on the lungs. Training carers how to

accomplish pursed-lip and diaphragmatic breathing will aid them in teaching their patients how

to do these breathing techniques which may help improve their quality of breathing. Because

patients can develop fullness when eating, being informed with the proper nutrition and fluid

therapy is essential for those who provide care for COPD patients. Caregivers should be able to

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encourage their patients to eat nutritious and healthy meals at the same time recognize the

benefits offered by daily water therapy. Moreover, carers should also be taught how to develop a

plan of activities for their patients. Despite the fact that COPD patients may experience a low

tolerance of energy during certain periods of the day, it is important that they still be involved in

structured activities such as gentle exercises. Training programs for caregivers should also

include information on other health conditions such as the colds and pneumonia to name a few so

that the carers could encourage their patients to take the annual vaccine shots to avoid the flu and

other conditions that may aggravate their state. When caregivers are taught about their

responsibilities and tasks for their patients, they will further be capable of educating their patients on how to decrease or avoid the risks associated with COPD, limit or prevent recurrent

exacerbations, maintain good health, and eventually improve quality of life.

End-of-Life Issues and Advanced Plans

Care utilization during the older adults last year of life is very important, though only a small

number of studies have given emphasis on this subject. Most often, research conducted for this

subject take on a political and economical point of view, focusing on the costs involved. In other

words, the last year of life is more expensive when it comes to care utilization compared to the

earlier years of life (Serup-Hansen, Wickstrom and Kristiansen, 2002). Aside from costs,

knowing the types and determining the appropriate health care utilization during the last year of

life is very important. Health conditions and the utilization of health care during the end of life is

normally complex (Bickel, 1998); however, identifying these factors will significantly aid in

facilitating the proper allocation and management of health care for individuals who are

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considered to be in their last year of life. This will then create a significant impact on the patients

themselves as well their carers including physical, psychological, social and financial effects.

Caregivers should then be trained to anticipate and assess the end-of-life needs of their patients.

As COPD progresses and symptoms worsen, families and carers of patients tend to move away

from lifesaving support and on to comfort care. It should be recommended to caregivers that they

write instructions regarding the preferences of their patients with regards to medical care at the

end of life. This is ideal especially when they are still capable of communicating their desires.

Combining these advanced directives with their medical charts and reports will allow carers to

become aware of the necessary actions to be done in any situation or emergency. Focusing oncomfort and care is sometimes more favorable than life extensions as excessive medications and

treatment may worsen the pain that is suffered by the patient. Training programs may suggest to

caregivers that comfort care and pain management be provided to their patients especially during

the last year of life when they are no longer capable of clearly communicating or have developed

further severe health complications.

Living Well with the Disease

Coping well with COPD requires that patients incorporate healthful actions in their daily living.

Therefore, it is necessary that carers be trained and educated with regards to their patients diet,

the situations that have to be avoided, proper medication-taking habits, and the suitable activities.

It is a must that carers should provide enough support for the eating habits for their patients, the

foods that should be included in the meals, the foods to avoid, the number of times their patients

should take their meals, and so on. Guiding their patients to avoid crowded places during the

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cough and colds season, frequently clean their hands and used things, or decrease exposure to

irritants such as dust and other pollutants may generally help in improving the patients COPD

conditions. It is also necessary that education programs inform their caregivers about the

appropriate treatment for them to accurately know which medications should be taken at which

time as well as their effects on their patients. Moreover, carers being trained to perform gentle

activities, such as gardening or dancing, with patients will be more advantageous.

Stress Management

Numerous studies have shown how assuming a caring role will give carers more stress and

pressure rather than personal satisfaction, particularly depending on the severity of their patients

conditions, their behaviors, their frequency of demands, and so on (Ramirez, Addington-Hall and

Richard, 1998). Most often, carers experience a level of fear and uncertainty when dealing with

the concerns of their patients, especially when caring for a family member. Financial pressures

are also a consideration while little time alone for oneself may further increase levels of stress.

Constant care and demand to attend to their patients may also be a great burden to these carers.

Therefore, it is a great need that training programs incorporate stress management practices for

caregivers as these individuals should be able to care for themselves as well. Staying informed

about a patients condition is essential so carers will know what to expect. Attending seminars

and education programs should be recommended so caregivers will have as much information as

they can to completely understand the effects of COPD and its consequences. Being aware will

somehow reduce their level of stress. Being able to physically, mentally and emotionally take

care of themselves is also necessary for these people to effectively manage their caretaking role.

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Carers should be encouraged to take up a hobby that will accommodate their interests outside the

role of a caregiver and at the same time maintain their social interaction with others as well.

Outside training programs that provide practical information, it is also recommended that

religious programs are carried out for caregivers as a number of studies have shown how religion

and spirituality can help reduce stress and improve satisfaction. A spiritual community will aid in

strengthening a caregivers capability of providing unconditional care for his or her patient.

Empirical Studies for COPD Care

Chronic obstructive pulmonary disease (COPD) has been reported to be one of the major causes

of death both in developed and developing nations. Although many COPD patients are provided

with optimum therapy, the relief that they experience is often temporary as recurrent symptoms

exist which result to a significant reduction in ones quality of life (Au, Edris, Fihn, McDonnell

and Curtis, 2008). Reports have also showed how many patients receive insufficient palliative

care which may be caused by a number of reasons such as poor communication between patients

and physicians when it comes to palliative and end-of-life care (Gore, Brophy and Greenstone,

2000). The difficulty in predicting the future situations of COPD patients is also a contributing

factor in the inaccurate diagnosis and inadequate treatment of these individuals. Furthermore,

such patients, their families and caregivers do not always know how severe COPD can

permanently affect quality of life. The study of Curtis (2008) focused on the palliative and end-

of-life care for COPD patients and through a qualitative review of related literature, findings

showed that people who are suffering from COPD may be provided with poor quality palliative

care due to the fact that many patients and their physicians do not discuss end-of-life care with

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each other, what should be done, what is preferred, and so on. Whenever communication about

this subject occurs, it usually happens during late illness, as Curtis, Engelberg, Nielsen, Au and

Patrick (2004) assert. Moreover, there is a lack of training programs for physicians when it

comes to communicating with their patients with regards to end-of-life (Block, 2005). Therefore,

understanding these factors that negatively affect patient-physician communication may help

improve this form of information exchange. Palliative care for COPD patients should also

require the recognition of the effects of anxiety and depression in order to come up with

strategies that will combat these negative emotions. Findings have also suggested that advanced

directives and good advance care planning provide an opportunity to enhance the quality of palliative care obtained by COPD patients. It is also critical for clinicians and all other health

care providers to find ways with which they can fully utilize hospital and palliative care services

to improve the end-of-life care for individuals suffering from severe COPD (Curtis, 2008).

In another study by Roberts, Sieger, Buckingham and Stone (2008) with its main focus on the

end-of-life care for COPD patients, the research was carried out with the aid of the National

Chronic Obstructive Pulmonary Disease Resources and Outcomes Project (NCROP) which is a

4-year program that has been conducted in the United Kingdom. This project aimed to evaluate

the COPD services available in UK hospitals. As part of the said program, a survey was

conducted in 2007 among 100 hospitals to evaluate palliative care services they offer COPD

patients as well as to raise health care standards regarding care for COPD patients. Outcomes of

the survey showed that 42% of the hospitals that were surveyed made use of formal palliative

care services for their patients who suffer COPD; meanwhile, 59% planned to make further

arrangements for their COPD care services to be further enhanced (Roberts et al, 2008). By

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analyzing the data collected, four examples of good practice were identified- teams that consist

of specialized members and undergo adequate training; care pathways that include formal

policies and communication with patients; service components which refer to the general and

specialist services and resources provided to patients; and linkages that exist across departments

in secondary care as well as between the acute and community settings. Being able to identify

examples of good COPD care practices may help contribute further information to the

development of standards in terms of palliative care for patients who are suffering severe COPD

(Roberts et al 2008).

Yawn and Wollan (2008) also conducted their own study on COPD care, particularly on the

primary care that is provided by physicians on COPD patients. Primary care physicians provide

at least 80% of health care for over 20 million American patients with both recognized and

unrecognized COPD as noted by Mannino (2002). It has been reported by GOLD (2007) that

current management does not go well with the recommended care for patients with recognized

COPD. Meanwhile, for individuals with unrecognized COPD, opportunities to prevent

exacerbations and enhance quality of life are not provided due to the failure to recognize and

diagnose the disease (Lindberg, Eriksson and Larsson, 2006). A number of barriers exist that

may hinder the implementation of COPD management such as unclear recommendations for

COPD screening as well as the lack of primary care guidelines for managing patients with

diagnosed COPD (Hansen-Flaschen, 2007). The research carried out by Yawn and Wollan

(2008) made use of a survey that was carried out among attendees of 3 CME programs in 3

different US states with which participants were asked to complete a survey before a 70-minute

talk on COPD diagnosis and management. The researchers therefore believe that the information

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provided by the participants was based on their prior knowledge regarding COPD, and not on

their knowledge that will be obtained during the lecture. Only a small percentage of the

respondents reported that they knew or made use of COPD guidelines. Barriers to COPD

recognition and diagnosis that were reported included the failure of patients to report their COPD

symptoms, the common morbidities among many COPD patients, and the inadequate knowledge

and training when it comes to COPD diagnosis, management and treatment. Only a few of the

participating physicians reported that they perceived COPD treatment to be useful in providing

relief (3%), improving conditions (15%), and reducing exacerbations (3%). Nonetheless, 13%

stated that they perceived COPD treatment as a satisfactory means of extending the lives of COPD patients. Therefore, Yawn and Wollan (2008) suggest that due to a lack of understanding

and use of COPD guidelines as well as a lack of awareness of the importance of COPD

treatment, significant improvement in COPD diagnosis and management will only be

accomplished when such issues are addressed.

The study conducted by Barr et al (2009) focused on how COPD symptoms has been given

treatment as numerous reports have shown how COPD can also lead to other conditions such as

osteoporosis or hypertension. COPD is often left under-treated while the overlapping conditions

can, on the other hand, be provided with adequate treatment. The researchers assessed the

prevalence of such comorbid conditions as well as the knowledge, diagnosis, management, and

treatment of COPD conditions. Through the use of a survey among 1,003 patients suffering from

COPD, 41% of them reported being hospitalized before being diagnosed with COPD while 61%

reported that they experienced moderate to severe dyspnea (shortness of breath).55% reported

that they experienced hypertension as a co-morbid condition, 52% with hypercholesterolemia,

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37% for depression, 31% with cataracts, and 28% with osteoporosis. 72% of the participants

reported that they were taking medications to reduce exacerbations and improve COPD

conditions, often using a short-acting bronchodilator. 87% of COPD patients with hypertension

took antihypertensive medications while those suffering from both COPD and

hypercholesterolemia (72%) were taking a statin. However, despite these treatments and

hospitalizations for COPD patients, a low level of COPD self-knowledge was evident and COPD

was untreated compared to less morbid conditions such as osteoporosis or hypertension (Barr et

al, 2009).

Empirical Studies for Training Effectiveness

Training programs intended to help carers manage stress have been one of the strategies

implemented to improve the performance of these individuals who have assumed the caregiving

role. The study of Brodaty and Gresham (1989) has focused on collecting information to reduce

the psychological stress as well as to enhance the coping skills of carers who provide care and

support for relatives who have dementia. Research had been conducted in a psychiatry unit

located in a Sydney teaching hospital wherein patients were not more than 80 years old, suffered

mild to moderate dementia, and lived at home with a carer. Out of all the 96 patient-carer pairs

that were used as a sample, 33 were included in the dementia carers program group, 31 for the

memory retraining group, and 32 in the wait list group. In the dementia carers program, the

carers had been provided with training with regards to dealing with the challenges of managing

patients with dementia (Brodaty and Gresham, 1989). Meanwhile, the carers under the memory

retraining program received 10 days of vacation from their work. In the wait list group, carers

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had to wait for six months for them to undergo any carers program. Findings showed that the

follow-up conducted after 12 months reported that those who were included in the carers

program had a reduced level of psychological stress compared to those in the memory retraining

program (Brodaty and Gresham, 1989). The level of stress experienced by those who were in the

wait list group was stable as there were no changes.

This suggests that the intervention program implemented for carers of patients suffering from

dementia can benefit from a training program that included reminiscence therapy, environmental

reality orientation, general ward activities and memory retraining. Assessments of their physical

and psychological states were carried out. The difficulties that they experienced in being a carer

for a dementia patient were discussed such as lack of support, psychological distress, inadequate

information regarding diagnosis, treatment and management of dementia patients, legal and

financial matters, safety at home, as well as poor coping skills. To address these issues, the

training program made use of group therapy, training for management skills and assertiveness,

discussion of what their roles should be comprised of, basic principles for behavior modification,

and other use of activities. The study of Brodaty and Gresham (1989) imply that when carers are

provided with a comprehensive training especially for managing problems and coping with

stressful events, their psychological stress will be significantly reduced and the possibility of

placing their patients in an institution will be less likely to happen.

Informal carers of cancer patients were also found to have an implication on restructuring

training programs for these care givers. The study conducted by Soothill et al (2001) aimed to

assess the previous training received by caregivers who worked with cancer patients and further

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identify their training needs. Such needs of the carers of cancer patients have been recognized as

an increasing concern in health care policies though only limited research exists to address this

issue. A descriptive cross-sectional survey was conducted among 195 carers with which

psychosocial factors had also been analyzed. 43% of the respondents showed that they were not

satisfied with the training that had been provided for them because they had been experiencing

various challenges in their caring roles (Soothill et al, 2001). Carers who had low levels of

satisfaction in their experience were shown to be in poor health as well. Many of the respondents

desired for training programs and other opportunities that will allow them to establish good

relationships with other healthcare professionals as well as obtain adequate and accurateinformation. They also believed that training programs should always include ways with which

carers can manage their daily lives along with their emotions and social identity (Soothill et al,

2001).

Kalra et al (2004) also focused on evaluating the effectiveness of the training that is offered to

carers who provide informal care support to disabled stroke patients. It has been estimated that

25-74% of patients who have survived stroke are in great need of help with their regular

activities from caregivers, most often their own family members (Anderson, Linto and Stewart-

Wynne, 1995). Care giving can often generate physical, psychological, social, financial and

emotional benefits; however, the needs of carers in terms of stroke patient management have

often been overlooked. Due to advances made in stroke rehabilitation, the level of severe

disability and hospitalization among stroke survivors has significantly been reduced, thereby

increasing the number of stroke patients living at home with their carers. However, Kerr and

Smith (2001) assert that many of them have been living with carers who are incapable of

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providing superior care due to a lack of adequate training and information, as well as a lack of

support after patient discharge. To examine these issues, Kalra et al (2004) conducted a study

among 300 carers for stroke patients using a single, randomized controlled trial. Through this

procedure it has been demonstrated that caregivers who received more training experienced less

anxiety, depression and caregiving burden. Rather, they experienced a higher level of quality of

life. Providing carers with sufficient training for moving and handling, facilitating activities on a

daily basis, and nursing tasks can significantly reduce their burden of care and enhance quality of

life not just in the caregivers but in the patients as well. Moreover, through training, education

and family support, the emotional health of caregivers can also be improved to reduce the costsof stroke care and improve the patients quality of life as well (Kalra et al, 2004).

Research carried out by Kamiru, Ross, Bartholomew, McCurdy and Kline (2009) also focused

on evaluating the effectiveness of a training program provided for health care providers in sub-

Saharan Africa. The assessment of any training program is necessary in order to identify the

components that are in need of improvement. The study aimed to evaluate the Baylor

International Pediatric AIDS Initiatives (BIPAI) HCP training program. 101 health care

providers were used as a sample and data was collected through a pretest-posttest survey along

with semi-structured interviews with 7 trainers from a particular college of medicine and 16

other health care local providers. By analyzing the gathered information, it has been proven that

the training had a satisfactory coverage, a successful deliver, and brought about improvements in

work. The training program helped increase the health care providers information regarding

HIV/AIDS; it also enhanced their effectiveness as well as their attitudes towards AIDS patients.

Therefore, the study of Kamiru et al (2009) showed the effective delivery of the BIPAI training

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program in Swaziland particularly in providing information about health care facilities,

increasing HCP skills and improving attitudes towards AIDS patients.