The dying patient

[Rihanna]

Dying patients can have needs that differ from those of other patients. So that their needs can be met, dying patients must first be identified. Before death, patients tend to follow 1 of 3 general trajectories of functional decline:

A limited period of steadily progressive functional decline (eg, typical of progressive cancer)
A prolonged indefinite period of severe dysfunction that may not be steadily progressive (eg, typical of severe dementia, disabling stroke, and severe frailty)
Function that decreases irregularly, caused by periodic and sometimes unpredictable acute exacerbations of the underlying disorder (eg, typical of heart failure or COPD)

With the first trajectory (eg, in progressive cancer), the course of disease and time of death tend to be more predictable than with the other trajectories. For example, with prolonged dysfunction (eg, severe dementia), death may occur suddenly because of an infection such as pneumonia. With irregularly progressive dysfunction (eg, heart failure), people who do not appear near death may die suddenly during an acute exacerbation. As a result, although knowing the trajectory of functional decline can help, it is still often difficult to estimate with any precision when death will occur. Thus, clinicians are advised to consider patients that fulfill both of the following criteria as potentially dying patients, recognizing that these criteria may be overly inclusive:

Presence of illness that is serious and expected to worsen
Death within 1 year would not surprise the clinician

If a patient is recognized as potentially dying, the clinician should

Communicate the likely course of disease, including an estimation of the length of survival, to the patient, and, if the patient chooses, to family, friends, or both
Discuss and clarify the medical goals of care (eg, palliation, cure)
Discuss and clarify what matters most to the patient and loved ones (eg, being home, being at a future event, staying mentally clear)
Arrange for desired palliative and hospice care, including supportive services (eg, home-delivered meals)
Plan what to do when death is imminent
Treat symptoms
Help address financial, legal, and ethical concerns
Help patients and caregivers deal with stress

Patients should be involved in decision making as much as they can. If patients lack capacity to make health care decisions and have a durable power of attorney for health care, the person appointed by that document makes health care decisions. If patients have no authorized surrogate, health care practitioners usually rely on the next of kin or even a close friend to gain insight into what the patient