The fact that chronic obstructive pulmonary disease (COPD) is a terminal illness comes as no surprise to clinicians on acute medical wards, especially as the winter takes hold. Why then are patients surprised when end of life issues are raised or referrals made to hospice services? In the linked study (doi:10.1136/bmj.d142), Pinnock and colleagues postulate that patients passively accept their lot and see the increasing disability as part of normal ageing.1 The researchers found that, unlike patients with other diseases (such as cancer and heart failure)—who can tell the story of how the illness occurred, events that have unfolded, and their current disease status2—patients with COPD seem to lack this narrative story. The realisation of illness, or “biographical disruption” to their life, is not a conscious thought for these patients. There is no clear point of diagnosis, especially one with a poor prognosis⇓.

This lack of biographical disruption stops patients …