TABLE 4.

Most common barriers and facilitators endorsed by patients and physicians

	Patients	Physicians
Barriers	Patients focused on staying alive [18, 21, 37] Patients not certain of which doctor would be taking care of them [21, 37] Patients do not know what kind of care they would want in the future [21, 37] Limited understanding of palliative care and COPD [5, 29] Denial of health status and of the possibility of dying [15, 18, 24] Emotional distress of conversations and of palliative care [18, 29, 38] Patients' readiness to discuss palliative care [37]	Lack of time in appointments to discuss all topics [18, 37] Discussions may take away patients' hope [37] Lack of feedback and documentation [18, 30, 40, 45] Lack of thorough knowledge of the patient [3, 18] Difficulty to start conversations and to choose the right time [3, 18, 22, 26, 30, 39, 40, 44, 45] Difficulty for patients to understand and accept information in short periods of time [3, 29, 52] Vision of palliative care as confined to the last days of life and exclusive of life sustaining treatments [29, 30] Uncertainty to prognose in COPD [5, 18, 22, 39, 40, 45] Reluctance of palliative care services to care for patients with COPD [29] Complex discharge planning for COPD patients [18]
Facilitators	Patients who had relatives or friends who had died recently [37] Patients' trust in their physician [37] Patients interpret physicians' skills as very good [37] Patients' belief that physicians truly care about the patient [37]	Good patient-physician relationship [29, 37] Physicians who cared for many patients with lung disease [37] Physicians who care for patients with previous acute episodes [37]

COPD: chronic obstructive pulmonary disease.