Our patient was 55 years’ old when she was admitted to the nursing home with end stage chronic obstructive pulmonary disease (COPD) in November 2007. She had had the disease since 1997, and she had participated in a pulmonary rehabilitation programme seven times (in 1998, 2000, 2001, 2002, 2005 (×2), and 2006). In 2000 she underwent lung volume reduction surgery. That same year she also had a stroke, which resulted in paralysis of her left arm and pain in the left side of her body. She was prescribed long term oxygen therapy in 2006.

In February 2007, she was admitted to the nursing home for an intensive patient tailored interdisciplinary management programme, which improved her health status and daily functioning. She was sent home in April of that year. After discharge, however, she was admitted to the hospital several times because of acute exacerbations. She was prescribed non-invasive positive pressure ventilation because of progressive respiratory failure.

At her second admission to the nursing home in November 2007, she was hopeful that intensive treatment and physical training would again enable her to improve her daily functioning and allow her to live in her own home. However, within two months she deteriorated progressively, despite an intensive patient tailored interdisciplinary management programme aimed at improving health status and daily functioning. Discharge was not possible.

Because of the progressive decline in her health status and increasing daily burden of symptoms, a palliative approach was increasingly offered alongside curative treatment. It consisted of managing daily symptoms and care needs, and discussing prognosis and advanced directives. She had already decided to refuse resuscitation or admission to an intensive care unit. Now, …