Components Mechanisms of action Outcomes Figure 1. Components, mechanism of action and outcomes of expert multidisciplinary palliative care Components Assessment and management of symptoms and concerns Mechanisms of action Discussing treatment preferences Promotion of dignity and self-worth Providing education around illness and prognosis Treatments to help patients self-manage symptoms Aids and therapies to improve function ↑ quality of life ↓ symptom burden ↓ health care utilisation ↑ patient and caregiver satisfaction Outcomes Improved understanding of illness Planned care including admission avoidance at end of life Care coordination and liaison More informed treatment decisions Planning for end of life Opportunity to face complex issues collaboratively Labels for circles outside to inside COMPONENTS OF PALLIATIVE CARE MECHANISMS OF ACTION OUTCOMES Text for middle circle Treatments to help patients self-manage symptoms Improved understanding of illness leading to more informed treatment decisions Planned, co-ordinated care including avoidance of hospital admission at end of life Therapy provision to improve function Promotion of dignity and feelings of self-worth Opportunity to face complex issue collaboratively Advocating for patients and families Building relationships with patients and families

Figure 2. The lived experience of patients with advanced COPD Understanding of condition   Insidious onset and normalisation of symptoms Realising life-limiting nature Conflict in wanting information and maintaining hope Lack of discussion around end of life Invisibility in social relations and to services Concerns of family members and friends Sustained symptom burden   Breathlessness Pervasiveness Simple tasks untenable Visibility of symptoms Fatigue Interruption to functioning Altered behaviours Frustration Frailty Loss of capability Disruption to social role Frustration at dependence Psychosocial impact   Anxiety Breathlessness Night time distress Fear of death Social isolation A shrinking world Loss of spontaneity A spectator in life Loss of hope Existing Desolation Maintaining meaning Keeping positive Accepting the situation Taking one day at a time Adapted from Disler et al. J Pain Symptom Manage 2014;48(6):1182-99

Figure 3. Models of integrative working with palliative care for people with COPD Disease trajectory Function Time Ongoing respiratory medicine and primary care Indications for palliative care: Complex troublesome symptoms; unmet family caregiver needs; hospitalisation or transition in place of residence; acute inpatient care for respiratory failure; commencing oxygen therapy; referral for transplantation; acute functional decline; unable to attend pulmonary rehabilitation Potential models for integrative working: Symptom triggered services (e.g. refractory breathlessness) Short-term Integrated Palliative Care (e.g. Breathlessness Support Service) Advanced COPD clinics Integrated Respiratory Care services (e.g. pulmonary rehabilitation, early supported discharge, hospital at home)