Careful delineation of models of f...

Careful delineation of models of functional decline may help tailor expectations, care plans, and organizational approaches to the care of patients at the fall of the curtain of life. Recognizing that functional decline before death differs by the agency of age and medical condition, Lunney and colleagues unfolded a study to understand the influence of different diseases upon patterns of dependency before dying.

Using data from the Established Populations for Epidemiologic Studies of the somewhat old (EPESE), the authors identified 4190 decedent who happened to be interviewed within common year of dying. These participants had been asked about their ability to perform activities of daily living, other physical tasks, and health issues. Participants were divided into 12 cohorts, based forward the number of months between their final interview and death. The form into groupss were also divided into four categories related to the cause of death: cancer, organ failure, frailty, and unanticipated death, with methodologic measures taken to account for overlap. Patients who could not be categorized were included as the "other" group

There were 649 patients (15 percent) in the rapid death group, who were younger than the mean age; 897 patients (21 percent) in the cancer form into groups constituting the youngest group; 817 (20 percent) organ failure patients, 837 patients (20 percent) who were frail, the oldest form into groups in this study; and 990 patients (24 percent) in the other group

While the overall plain of dependency was greater with increasing age in the last year of life, the trajectory of decline in activities of daily living exhibited internally according to each group was similar, irrespective of age. Those in the unusual death group remained independent and retained function until death. Cancer patients remained functional until about three month before death, at which point they became markedly more disabled. Organ failure and frail patients also exhibited substantial decline in the last three month moreover organ failure patients had an erratic decline in the last year overall, and frail patients were more disabled relative to the other assemblages for the entire year before dying. The other assemblage showed a modest, gradual decline in the last year, greatest in number closely matching patients with ischemic heart disease, when these patients were analyzed as a separate collection A higher proportion of the other assemblage had ischemic heart disease than the well stocked [i]or[/i] provided decedent pool. Overall, the frail dispose was eight times more likely to be contingent than those who died unexpectedly even after controlling for age and other factors.

These findings advise that cancer patients are the simply ones who fit into the hospice prototype of expected death. Given that solitary 23 percent of the U population dies of cancer, end-of-life care should focus more upon patients who are likely to die unpredictably, including patients with chronic illnesses and those who become increasingly frail, unruffled without a diagnosis of life-threatening illness.

Lunney JR et al. Patterns of functional decline at the completion of life. JAMA May 14 2003;289:2387-92

COPYRIGHT 2004 American Academy of Family Physicians

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