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]

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]