Background The different considerations involved in decisions regarding whether or not to initiate mechanical ventilation for patients with severe chronic obstructive pulmonary disease are challenging for health professionals. Aim To investigate the considerations and values that influences decision-making regarding mechanical ventilation in older patients with severe to very severe COPD. Furthermore, it aims to elucidate how physicians involve their patient in decision-making process. Participants and setting Seven intensive care physicians and seven physicians working in the respiratory units at two university (...) hospitals and two district hospitals in Norway. Methods This study had a qualitative design consisting of focus group interviews with 14 physicians. The data was analysed according to the interpretative contexts: self-understanding, critical common-sense understanding and theoretical understanding. Results Decisions regarding mechanical ventilation were mainly based on the physicians' own experiences, their perceptions of the patients' situation, and biomedical data. The patients were not involved in the decision-making and such decisions were only occasionally made in a multi-professional context. Conclusion To decide whether older patients with severe COPD should be treated with mechanical ventilation is both medically and ethically challenging for physicians. Decision making in this context seems to be mainly driven by a paternalistic attitude, since the physicians interviewed in our study, in general, make such decisions without involving either the patient, their next of kin or the nurses. There is a need for broader cooperation between health professional and for the involvement of patients in the decision-making process regarding mechanical ventilation in cases of late stage COPD. (shrink)