Case vignette of a chronic obstructive pulmonary disease (COPD) patient for whom a treatment pathway has to be chosen

An 83-year-old somnolent patient with a markedly impaired general condition and very poor nutritional status is presented to you.
The patient is tachycardic, responds only to a limited extent, has pronounced dyspnoea with paradoxical breathing, lack of lung sounds on auscultation and hypersonorous percussion sounds over both lungs. The legs are not swollen.
Peripheral oxygen saturation (with 6 L O2·min−1) is 84%.
Patient history reveals the development of an increasing resting dyspnoea in the last 4 days. There has been COPD (Global Initiative for Chronic Obstructive Lung Disease stage IV) and chronic heart failure (New York Heart Association functional class III) for years. One year ago, long-term oxygen therapy was initiated. Inhalation and drug therapies have already been maximised.
In recent months, the patient has increasingly presented for respiratory distress and COPD exacerbations, and therefore has been hospitalised repeatedly.
6 weeks ago, he had to be intubated in a critical condition and ventilated for 12 days. The patient found this intensive care unit stay to be very stressful. He subsequently refused the initiation of nocturnal home noninvasive ventilation because it would affect him too much.
He also refused to be transferred into a nursing home. He is cared for by a home nurse several times a day.
According to a telephone message from the family doctor, the patient has become increasingly enervated since his last stay in intensive care, and spends more and more of his days in bed due to his shortness of breath.
Which of the specified treatment pathways would you most likely choose?
(Regardless of your locally available options)
 Noninvasive ventilation
 Conservative treatment attempt (without ventilation)
 Palliative approach
What additional information would you have wanted for your decision?

The complete survey (in German) is available in the supplementary material.