Discussion

Death is inevitable. Death is sometimes preventable, but ultimately it is only postponed. This existential truth applies to us all. More immediately, the logic applies to patients with severe COPD just as it does to patients with disseminated malignancy. The only difference between these situations is that the trajectory towards end of life is less predictable in COPD; the distinction between preventable and inevitable death is more difficult to make. However in ‘frequent flyers’ with severe COPD, the distinction is crucial in deciding how to provide best possible care. Just because it is difficult does not mean that the challenge should be avoided. How we manage life-threatening exacerbations of COPD should be appropriate and we need to be prepared to adapt our approach as the patient nears the end of life. Such responsiveness will impact positively on the quality of care received by patients and perceived by families.

Many studies have highlighted the predictors for mortality for COPD. The underlying assumption is that by identifying these factors, we will focus our efforts on high-risk patients with a view to reducing mortality. The most reliable predictor of mortality is the frequency of exacerbations, and the most reliable predictor of exacerbations is the frequency of exacerbations …