Summary of Conversation

We need to ask questions in an open ended non-judgmental way, phrased to make them comfortable to admit non-adherence. You may ask them:

• "It can be difficult to manage to get in the habit of using this every day (or twice a day). How do you manage with that?"
• "Thinking back these past couple of weeks, if you had to rate yourself out of 10 (10 being the best) for whether you managed to use your inhaler the expected number of times, what number would you give yourself" [Less than 8 may be considered non-adherent and needing help]

Listen actively. Reflect back what the patient has said or what you think they meant to let them know that you are listening.

We know that often intentional non-adherence is due to a perceived lack of need. You may ask them:

“Sometimes we are not very good at explaining how COPD can affect a person. Can you tell me a bit about how COPD affects you? What kind of symptoms do you have?”

It is important to listen to understand what the patient understands about COPD or whether in fact they may believe they do not have COPD. Don’t correct any misunderstandings here just listen. For example:

Perceived lack of need: The patient may not understand that COPD has a range of symptoms which they have that can be improved with regular inhaler use. COPD is not just about the breathing, but can affect how they sleep, how they may be limited in doing regular activities because they get short of breath.  If the patient/family does not believe they need the medication or no not believe they have COPD, ask them open –ended questions to identify presence of COPD symptoms (that they may not be attributing to condition): e.g. decreased energy, difficulty sleeping, inability to do usual activities, afraid of leaving the house, getting out of breath when walking up stairs, chest tightness, phlegm, cough.

We also know that often intentional non-adherence is due to a perceived lack of benefit. You may ask them:  “Sometimes we are not very good at explaining how medications help people. Can you tell me a bit about how regular use will help you? “

Listen to get a sense of patient/family’s understanding, don’t rush to correct yet.

• Perceived lack of benefit. The patient may not believe the inhalers help them (especially if they think an immediate improvement in breathing is expected – this will not occur with long-acting agents as they work to prevent COPD flare-ups and improve symptoms over the longer term). The patient may then think that their inhalers just do not help them or even falsely conclude they do not even have COPD.
• It is important for the patient/family to know this so they stay motivated to use properly and regularly (even if they feel well). Don’t correct any misunderstanding here, just listen.
• Later, on, on the patient version of the inhaler sheet, you will need to write for them, how they will benefit from regular use of that specific inhaler.
• Regular use of long-acting medications is needed to reduce exacerbation risk even if the patient feels well and COPD symptoms are controlled. They work to prevent future COPD flare-ups and improve COPD symptoms and quality of life over the long term. The patient may not believe their inhalers help them if they are expecting an immediate improvement in shortness of breath, or they may not believe that they have COPD. See this document for a Table summarizing benefit by pharmacologic category. Each inhaler sheet specifies benefit for each medication available in that device.

Listen actively. Reflect back what the patient has said or what you think they meant Summarize their perceived need and benefit of the inhalers.

After asking any clarifying questions to understand their beliefs/knowledge then ask permission to offer information. Pause regularly and ask them to provide feedback.

“Mr Lee would it be OK with you if we talk a bit more about how COPD affects people. I think there may be things that you can do to help reduce your chances of coming to hospital again”.

Often we may not spend enough time explaining the purpose of using the inhalers and the two kinds of benefits these long-acting agents have. Regular use will:

1) Reduce your chances of having a COPD flare-up and needing to see your doctor or coming to hospital
2) Help improve the symptoms of COPD that you just mentioned

Mastering proper technique is needed to achieve the above benefits. Improper technique is an independent risk factor for COPD exacerbation.

"So just for me to check that I have explained things clearly. If your family asked why you need this inhaler what would you tell them?"

Do you have any concerns or questions? Is there anything that you can think of that would make this inhaler difficult for you to use it?

After reviewing technique. Ask the patient if they have any concerns about the inhaler, can they think of anything that would make it difficult to use? Then ask, how confident are they that they can and will use their inhaler? If less than 8/10, what can they think of that will help them be an 8/10?

• Before coming to hospital did the patient use an action plan? For nurses working in an Emergency Department asking the patient about whether they had done anything when they noticed their COPD/asthma symptoms were worsening (followed an action plan) will help them understand that this is a tool that could help them to decrease their risk of further hospital admissions/ ED visits.
• Action Plans guide patients on how to recognize and respond to early symptoms of COPD /asthma worsening, and which medications to take or which inhalers to adjust and when to seek medical help. These symptoms of COPD / asthma worsening are described as “yellow level symptoms” on the action plans (Link).
• For COPD: In response to shortness of breath/more sputum, they should have a 5 day course of oral prednisone. In addition, if their sputum changed colour they may have been asked to take an oral antibiotic
• For asthma: In response to worsening of symptoms, patients should either quadruple their steroid inhaler dosage or be taking formoterol/budesonide up to 12 x per day for SOB. (Some patients may have been asked to take oral steroid if they had history of severe exacerbations).

• Future ability to use an action plan? For patients admitted to an in-patient unit, while speaking with the patient and family consider whether they have the capacity to identify worsening of COPD symptoms to be able to use an action plan.
• Yellow level symptoms, requiring the patient to take action and adjust their medications are:

For COPD:

• Symptoms: A) increased shortness of breath for 2 days, or increased phlegm/sputum production  for 2 days: B) Change in colour of sputum to green, yellow or rust
• Action: A) Take prednisone for 5 days B) Take an antibiotic (if prescribed)
• COPD action plan

For Asthma:

• Symptoms: shortness of breath, wheezing, daytime cough or chest tightness more than 3 x per week ; asthma symptoms at night or early am more than 1 x per week; use of SABA more than 3 x per week, limited physical activities.
• Action: Either quadruple inhaled steroids or use budesonide/formoterol 12x per day as needed
• Asthma action plan.

Note, the action plan would be provided by a physician, pharmacist or community RT, but by mentioning that this is something they could do, may help spark their interest as a tool that can help them.