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222 conducted a timely online survey among pulm­ onologists who were members of the Polish Re­ spiratory Society to inquire about EOL, including their attitude, symptomatic treatment, and com­ munication between physicians and patients with advanced COPD or lung cancer. A list of the par­ ticipants was obtained from the Polish Respira­ tory Society, who were contacted by email. A self­ ­administered survey questionnaire was adopted from a previous study by Gasper et al12 conduct­ ed among Portuguese pulmonologists. The ques­ tions were prepared specifically to explore the fol­ lowing themes: palliation of symptoms, frequen­ cy and topics of EOL communication, timing and initiators of EOL communication, and obstacles to EOL communication. A total of 139 responses (27.2%) were obtained from 639 physicians who were predominately pulmonologists (90%) (in­ cluding allergology and palliative medicine spe­ cialists). The average age was 49 years, over 40% (n = 102) of the participants were women. About 28% of the participants reported that they used opioids to relieve pain symptoms in advanced COPD always or often, compared with 87% in pa­ tients with lung cancer. Similarly, about a third of the participants reported the use of opioids to relieve distressing symptoms of dyspnea in advanced COPD, compared with 79% in patients with lung cancer. Moreover, 79% of the partici­ pants believed that discussion about EOL care in advanced COPD was essential, but 1 in 5 respon­ dents initiated these conversations often or al­ ways. Furthermore, about 82% of the respondents reported that they always or often referred pa­ tients with lung cancer for PC or to a PC specialist for consultation, compared with less than 1 in 5 in the case of patients with advanced COPD. About half of the participants (often or always) discussed EOL care issues only with the caregivers or family of patients and excluded patients from the discus­ sion. The most commonly reported and perceived Chronic obstructive pulmonary disease (COPD) is a major cause of disability, impaired quality of life, and premature mortality in old age.1,2 Patients with advanced COPD are most likely to experience symptoms of excessive dyspnea with minimal ex­ ertion, generalized pain, elevated psychological distress and fatigue, and increased comorbidi­ ties.3-5 These, cumulatively or individually, may increase disability, acute exacerbations, the use of emergency care, and admissions to the hospital and intensive care facilities.6,7 There is a growing interest and awareness of the value of integrated palliative care alongside usual care, as shown by recent national and international COPD guide­ lines that recommend palliative care (PC) and advance care planning (ACP) as part of a holistic, patient ­centered, and disease ­directed care for patients with advanced COPD.8,9 However, there are limited data available on the use of PC and ac­ cess to a PC specialist for patients with advanced COPD as part of end ­of ­life (EOL) care in the years or months prior to death as compared with can­ cer patients. This is in part due to the lack of ac­ cess to PC services (for nonmalignant diseases), lack of adequate training, prognostic uncertain­ ty as to when to provide PC for patients with ad­ vanced COPD by clinicians, including other subtle barriers as shown in TABLE 1. In contrast, a recent systematic review and meta ­analysis in patients with advanced cancer showed that PC was relat­ ed with reduced symptom burden and improved quality of life in patients as well as increased care­ giver satisfaction and reduced health care utili­ zation.9,10 Despite these promising results in pa­ tients with advanced cancer, the unmet needs of PC for patients with advanced COPD often re­ main unaddressed. In this issue of the Polish Archives of Internal Medicine (Pol Arch Intern Med), Brożek et al11 re­ port their findings from data collected in an on­ line survey among Polish pulmonologists. They EDITORIAL

Sobering reality of palliative care provision for patients with advanced chronic obstructive pulmonary disease