Although medical treatment of COPD has advanced, nonadherence to medication regimens poses a significant barrier to optimal management. Underuse, overuse, and improper use continue to be the most common causes of poor adherence to therapy. An average of 40%–60% of patients with COPD adheres to the prescribed regimen and only 1 out of 10 patients with a metered dose inhaler performs all essential steps correctly. Adherence to therapy is multifactorial and involves both the patient and the primary care provider. The effect of patient instruction on inhaler adherence and rescue medication utilization in patients with COPD does not seem to parallel the good results reported in patients with asthma. While use of a combined inhaler may facilitate adherence to medications and improve efficacy, pharmacoeconomic factors may influence patient’s selection of both the device and the regimen. Patient’s health beliefs, experiences, and behaviors play a significant role in adherence to pharmacological therapy. This manuscript reviews important aspects associated with medication adherence in patients with COPD and identifies some predictors of poor adherence.

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Global chronic obstructive pulmonary disease care Worldwide, chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death [Mannino and Kiri, 2006], although individuals diagnosed with this disease around the globe do not always fare well in the medical community. An article from Japan states that patients with end-stage COPD have more deterioration in quality of life, more dyspnea, anxiety, appetite loss and general fatigue compared with patients with lung cancer [Katsura, 2003]. The article goes on to state that patients with COPD are also more likely to be treated aggressively with lifesustaining therapy, and receive inadequate symptom control [Katsura, 2003]. French authors reveal a similar lack of palliative care for patients with COPD. In 43% of patients with end-stage COPD, there was limited care [du Couedic et al. 2012]. Analysis of interviews showed that the subject of death was rarely or never discussed when the diagnosis was COPD [du Couedic et al. 2012]. Researchers in Australia also noted a lack of palliative care for individuals with COPD [Disler et al. 2012]. An integrated review to determine what approach was used to reduce symptoms at end of life revealed a range of palliative interventions. Although many components were present, there appeared to be limited evidence for health service coordination and active management of palliative care [Disler et al. 2012]. It is clear that medical institutions know how to deliver palliative care, just not always effectively for patients with end-stage COPD. Lack of understanding Palliative care is a term used liberally when discussing hospice and end-of-life care, but not always when addressing symptom control. Many healthcare professionals perceive palliative care to be only for the dying. Spence and colleagues did a qualitative study of professionals delivering palliative care to people with COPD. According to the participants, when treating patients with COPD the focus was on symptom management but predominately using an acute care model [Spence et al. 2009]. The delivery of palliative care was viewed as a specialist's role rather than an integral component of care. Patients with COPD have many bothersome symptoms; dyspnea is just one of them. These symptoms unfortunately exist long before the patient is deemed to have endstage disease. Nonhospice palliative care is a reality and can be offered at the same time as life-extending and curative therapies [Kelley and