The need to improve the care of patients coping with advanced chronic obstructive pulmonary disease (COPD) is well documented. Patients suffering from advanced COPD present a lot of co-morbidities: pulmonary hypertension, cor pulmonarae, coronary heart disease, malnutrition, vascular disease, osteoporosis, skeletal muscle dysfunction. Depression and anxiety, impaired mental function, decrease of cognitive activity may add to patients’ deteriorated self-management, and poor compliance. The insufficient self-management and poor compliance result in unfavorable course of the disease, and frequent exacerbations requiring hospitalization. Not every patient could be supported by the family. Lack of knowledge on the disease itself and on the management of COPD, inability to take everyday care of patient, and in some families the shortages in their income may lead to improper support given to patient by his or her relatives. Integrated respiratory care was defined as the holistic coordinated, patient-focused and multidisciplinary delivery of high-quality, both pharmacological and non-pharmacological care. In practice it means the management of the disease is provided by well cooperated and coordinated team. Such multidisciplinary team usually includes physicians (primary care physician, respiratory specialist), nurses, psychologists, physiotherapists, social workers, volunteers. The care can be organized into five kinds of intellectual and physical activities: assessing, planning, implementing, evaluating, and communicating. These activities must be integrated and often introduced simulatneously. Coordinator plays a pivotal role a care process in patients with advanced COPD.

Adv. Pall. Med. 2011; 10, 1: 11–16