Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

We need to stop looking for something that is not there….

Dear Sirs,

We have read with interest the paper by Epiphaniou et al.,1 which highlights the challenge of providing care for people with very severe chronic obstructive pulmonary disease (COPD) as they approach the end of their life, and agree with the response from Crawford et al.2 when they highlight that a key problem is ‘defining a transition point for the initiation of end-of-life care services’.

However, we disagree with their conclusion that the solution is to try and identify yet more prognostic indicators in an attempt to identify a transition point. Our qualitative data3 found that identifying a time point for transition to palliative care had little resonance for people with COPD or their clinicians as they lived with their lifelong condition with its imperceptibly slow but inexorable decline. Our conclusion is echoed in a recent systematic synthesis of the experiences of living and dying with COPD,4 which conceives the trajectory of COPD as a ‘roller coaster’, with ‘no one specific event demarcating the ‘end-of-life’ stage, except perhaps the final acute exacerbation, which is difficult to predict and may be relatively brief’.

Starting from the perspective of services designed for cancer, and looking in ever more detail for a transition point that is not there, is unlikely to be the solution. Maybe we need to take a step back, listen to the messages from the extensive qualitative literature35 and ask ourselves ‘if we started with a blank sheet of paper, how would supportive care for people with COPD look?’

We might then concentrate on developing services that integrate supportive care into the routine care of people living (perhaps for many years) with severe COPD.


  1. 1

    Epiphaniou E, Shipman C, Harding R, Mason B, Murray SA, Higginson IJ et al. Coordination of end-of-life care for patients with lung cancer and those with advanced COPD: are there transferable lessons? A longitudinal qualitative study. Prim Care Respir J 2014; 23: 46–51.

    Article  Google Scholar 

  2. 2

    Crawford E-J, Moudgil H, Srinivasan K, Naicker T, Ahmad N . Coordination of end-of-life care for patients with lung cancer and those with advanced COPD: a letter of response. NPJ Prim Care Respir Med 2014; 24: 14030.

    Article  Google Scholar 

  3. 3

    Pinnock H, Kendall M, Murray SA, Worth A, Levack P, Porter M et al. Living and dying with severe chronic obstructive pulmonary disease: multi-perspective longitudinal qualitative study. BMJ 2011; 342: d142.

    Article  Google Scholar 

  4. 4

    Giacomini M, DeJean D, Simeonov D, Smith A . Experiences of living and dying with COPD: a systematic review and synthesis of the qualitative empirical literature. Ont Health Technol Assess Ser 2012; 12: 1–47.

    CAS  PubMed  PubMed Central  Google Scholar 

  5. 5

    Disler RT, Green A, Luckett T, Newton PJ, Currow D, Davidson PM . Experience of advanced chronic obstructive pulmonary disease: metasynthesis of qualitative research. J Pain Symptom Manage 2014; (e-pub ahead of print 26 April 2014; DOI: 10.1016/j.jpainsymman.2014.03.009).

    Article  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Hilary Pinnock.

Ethics declarations

Competing interests

HP is an Associate editor of npj Primary Care Respiratory Medicine, but was not involved in the editorial review of, nor the decision to publish, this article. The remaining authors declare no conflict of interest.

Rights and permissions

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Kendall, M., Buckingham, S., Ferguson, S. et al. We need to stop looking for something that is not there….. npj Prim Care Resp Med 24, 14031 (2014).

Download citation

Further reading


Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing