Chronic obstructive pulmonary disease (COPD) is unique among leading causes of death in Western society. While the impact of other major diseases are on the decline, the prevalence, associated morbidity and attributable mortality of COPD continue to rise. The emotional burdens to patients and care-givers and financial burdens of COPD to our healthcare system are substantial. The traditional biomedical approach to COPD is failing with its focus on the underlying pathophysiology, and treatment of acute exacerbations. This failure necessitates a review of our approach to advanced COPD, of care models and goals of care and interventions for patients who live with progressing and sometimes intractable dyspnoea. Closing the gaps between diverging goals of care becomes increasingly important as COPD progresses to the point where palliation and support become very much more important than predictable perturbations of physiology.