Learning point from this station: ​

There is no universally accepted definition of “end-stage COPD,” and predicting life expectancy in COPD remains challenging.  Most patients experience a pattern of gradual functional decline with acute flare-ups that can increase the risk of dying. Tools such as those from the Gold Standards Framework can support healthcare professionals in identifying patients who are likely approaching the end of life.

The management of end-stage COPD focuses on palliative care, with an emphasis on symptom control. 

For breathlessness — the most reported and distressing symptom. Both non-pharmacological and pharmacologicalstrategies should be considered.

Non-pharmacological measures include:

• Keeping the room cool and improving air circulation (e.g. using a fan or opening a window).
• Referral to a physiotherapist for home-based input on breathing control techniques, relaxation strategies, and light physical activity adapted to the patient’s capabilities. Even in bedbound patients, minimal movements (e.g. standing briefly or leg exercises) can improve tolerance and preserve function.

Pharmacological treatments:

• Opioids are first-line for refractory breathlessness. Immediate-release oral morphine is typically used, with subcutaneous morphine or diamorphine (via bolus or syringe driver) considered if oral administration is not feasible. Opioids should be prescribed alongside regular laxatives and consideration of an anti-emetic to manage side effects.
• Benzodiazepines can be offered if anxiety or agitation is contributing to breathlessness; choice of medication depends on the severity of anxiety, the desired onset of action, and the stage of terminal disease. Lorazepam may be used for acute relief (short-acting), diazepam for ongoing anxiety symptoms (longer-acting), and midazolam can be considered for intractable breathlessness, either as needed or via syringe driver in a palliative care setting.    
• Home oxygen may be considered only after failure of other pharmacological approaches and in cases of symptomatic hypoxaemia (SpO₂ ≤ 92%). According to British Thoracic Society guidelines, oxygen may be beneficial if it raises SpO₂ above 92%, but hypoxaemia should ideally be confirmed with arterial or capillary blood gases. Given the practical difficulties of blood gas testing in palliative settings, NICE CKS recommends using clinical judgment supported by pulse oximetry and advice from respiratory or palliative care specialists to guide oxygen initiation.

Cough management depends on whether the cough is dry or moist

For dry cough:

• Start with simple, non-pharmacological measures such as humidifying the room air and trying Simple Linctus BP cough syrup. (Note: although called a cough syrup, Simple Linctus contains citric acid and is considered a symptomatic remedy rather than a true pharmacological treatment, as it does not contain any active drug that interacts with receptors or alters physiological processes in the body).
• If symptoms persist, consider a weak opioid cough suppressant (unless the patient is already on strong opioids for pain), such as Pholcodine linctus BP (10 mL [5–10 mg] three to four times daily), Codeine linctus BP (5–10 mL [15–30 mg] three to four times daily), or Codeine phosphate tablets (15–30 mg every 4 hours).
• If the cough remains persistent despite the use of weak opioids, switch to oral morphine every 4 hours and as needed. For opioid-naive patients, start at 1–2.5 mg every 4 hours; for those with prior opioid use, start at 2.5–5 mg every 4 hours.

For moist (productive) cough:

• If infection is suspected, treat with an appropriate broad-spectrum antibiotic.
• Consider nebulised saline to loosen tenacious secretions; this may be used in conjunction with physiotherapy to aid clearance.
• Use a mucolytic, such as carbocisteine, to reduce secretion viscosity. The recommended starting dose of carbocisteine is 750 mg three times a day. Review effectiveness after 4 weeks and stop if no benefit is seen.
• Consider humidifying air or oxygen in patients with dry mouth and persistent productive cough.
• In patients at the terminal stage who are unable to expectorate, reposition them to avoid lying supine; instead, place them on one side with the upper body elevated to promote postural drainage, and consider suctioning if available and appropriate.
• If non-pharmacological measures are ineffective, consider a trial of antisecretory agents to dry excessive secretions, such as Glycopyrronium bromide, Hyoscine butylbromide, or Hyoscine hydrobromide (with caution, as it may cause sedation or confusion).
• In cases where secretions remain problematic and the patient is too weak to cough effectively, morphine may also serve as a cough suppressant. However, cough suppressants should generally be avoided in moist cough, except in dying patients who are unable to expectorate and are experiencing distress or exhaustion.

Other common end-of-life symptoms include pain, insomnia, anxiety, and depression. These should be managed according to standard palliative care protocols.

Advance Care Planning remains central in this setting and should include discussions about the ceiling of care, DNACPR decisions, completion of the SR1 form, providing the patient with contact details for palliative care support, exploring future treatment preferences and goals, introducing anticipatory medications if appropriate, and coordinating with community teams, district nurses, carers, and family members to support comfort and dignity at home or in the patient’s preferred place of care.