The disease trajectory in chronic obstructive pulmonary disease (COPD) can be long and uncertain, making it difficult to identify when patients are at the end-stage of the disease. Patients with COPD have been found to experience similar levels of symptom burden to those with lung cancer, yet they are less likely to receive palliative care and treatment with opiates, anxiolytics or antidepressants. This article focuses on pharmacological and non-pharmacological approaches to the management of severe breathlessness in patients with end-stage COPD.