to the editor: As a family physician turned hospice team physician, I read with interest the article and accompanying patient education handout on the effectiveness of medications for chronic obstructive pulmonary disease (COPD). The Journal of Family Practice also recently published a supplement on the diagnosis and multifaceted management of COPD.¹ Family physicians strive to have a whole-patient approach to illness that includes continuity of care across the disease spectrum and addresses quality of life even as death approaches. I was hopeful to see this continuity approach applied here. Unfortunately, I feel both articles stopped short of this goal.

The focus of the article in American Family Physician was to examine the effectiveness of medications in achieving stated goals of treatment: “improve quality of life, exercise tolerance, sleep quality, and survival; and to reduce dyspnea, nocturnal symptoms, exacerbations, use of rescue medications, and hospitalizations.” The fact that the article focuses on evaluating treatments to improve survival and quality of life highlights that the disease is progressive and ultimately can result in untimely death.

For this reason, I believe both articles missed an opportunity to remind us that we should be continually reviewing those treatments that hope to extend life and should also remain aware of disease progression and identification of “nodal points” for considering transition to palliative therapies. Recognizing factors that identify when patients may receive limited benefit from therapy and/or have a life expectancy of less than one year will remind us to have meaningful discussions with our patients about goals of care before treatment decisions are demanded urgently in intensive care unit settings.²

The exclusion of this type of information in articles that discuss active treatments, and in patient education handouts, perpetuate situations whereby patients with chronic illness and gradual deterioration are seen by residents and family physicians to be “suddenly dying” only in the penultimate hospitalization despite multiple signs of impending mortality.³ This late recognition of disease progression leads to missed opportunities for closure, symptom control, patient and family support, and the “good death” we all hope for.