DR REYNOLDS: Mrs D is a 62-year-old woman with
advanced chronic obstructive pulmonary disease (COPD). Mrs D is a widow and
lives with one of her 7 children. She has Medicare and Medicaid insurance.
Mrs D was well until she began experiencing shortness of breath in her
early 40s, when she was a heavy smoker. By her mid 40s, she was diagnosed
as having COPD and was already receiving oxygen by nasal cannula. Over the
ensuing 2 decades, her pulmonary disease worsened steadily. She now has severe
COPD and uses oxygen, 4 L by nasal cannula, around the clock. Her activities
are limited by her severe dyspnea on exertion. She has frequent exacerbations,
often induced by upper respiratory tract infections. She has been hospitalized
more than 20 times in the past 5 years; she has been intubated twice.