Global End-Of-Life Trajectories
Palliative Care physicians are familiar with the four Global End-of-Life Trajectories. Emergency physicians can benefit from an understanding of these trajectories when managing older patients in the ED. It allows us to move beyond the usual “fix the problem” EM approach and provide better care to the patient.
Important Note
The first three account for 85% of all deaths – perhaps more in the older population.
The four Global End-of-Life Trajectories are:
- Terminal Illness
- Organ Failure
- Frailty/Dementia
- Sudden Death
Click on the trajectories below to see the trajectory graphs for each of these End-of-Life Scenarios.
Terminal Illness
A long disease trajectory followed by a shorter phase of sharp decline, occurring over weeks to months. Many patients can function reasonably well until the final decline.
The onset of the end-of-life phase is signalled by progressive inability to function (mobilize, eat, drink, toilet).
Patients in this phase, young and old, may be in the ED needing support with symptom management. The Emerg physician may be the first person to start discussing goals of care as the disease prognosis starts shifting rapidly.
Organ Failure
Organ failure — heart, kidneys, liver, lungs, brain — is a common cause of death. This trajectory is marked by a steady decline in physical function with severe symptom crises. Each exacerbation decreases the patient’s baseline function until death.
These are the “frequent fliers” well known in the Emergency Department. Patients, families and ED staff seem to progressively readjust to the gradual decrease in functional status.
Patients in this trajectory are often in the ED needing symptom management. The Emerg physician may be the first person to notice the steady decline and recognize the change in prognosis with each exacerbation. Discussing goals of care may help the patient and family understand their own wishes better.
Frailty
Frailty is a slower steadier decline — usually associated with dementia or extreme age or post-stroke. Death usually comes from sepsis, renal failure, or progression of another disease.
Patients in this trajectory are in the ED usually because of a crisis that may be life-ending. It often takes everyone by surprise because the decline has been so slowly incremental. Symptom management may be important here. A compassionate discussion of goals of care, based on an understanding of prognosis, will allow patients and families to understand the reality of their situation.
Sudden Death
Of course all death is sudden. However only about 10-15% of all deaths follow this trajectory, probably fewer in older people. In this trajectory the end-of-life phase is abrupt with no preceding decline — myocardial infarction, PE, trauma, intracerebral or large vessel catastrophe.
This is the one trajectory where the skills addressed in this module are probably not relevant — and represents only 10% of all end-of-life care.
End-of-Life Indicators
Important Note
Remember that for the patient and family these conditions may have become “the new normal.” They may not appreciate their significance in the disease trajectory. And for better or worse the Emerg physician may be the first person to address this issue.
These indicators help you establish prognosis.
- Extreme frailty
- Being bed-bound most of the day
- Decreased eating and drinking
- Altered level of consciousness
- Dependent on care for Activities of Daily Living (ADLs)
- Tube feeding
- Acute or progressive renal failure in presence of other active illnesses
- Decubitus ulcers with infection
- Refractory dyspnea
To learn more about this topic, visit the Functional Assessment module.
Discussion: Global End-Of-Life Trajectories
Participate in the discusssion by posting a comment below
You must be logged in to post a comment
k
ok
OK
very helpful
great review
Great review
discussion can start in the ER
eol goals are difficulty and every caregiver should be inserviced and educated
aa
ok
.
ok
death
.
good informetion
ok
d
in geriatric pt’s once dx with terminal illness, they have rapid decline
–
ok
ok
great visuals
OK
ok
.
important to know all grafs to know what to expect in a complex patient
.
I guess we all agree as to the care plan
Ok
Good info.
interesting information
got it
trajectory – good info
It certainly is concerning that EOL decisions end up taking place in the ER despite ongoing chronic disease. I think this is often due to physicians time constraints and the fear of opening up a long discussion.
was not aware. very informative
good information
Such great information.
Aims:
To identify end of life trajectory
To identify functional deficits and symptoms
To establish the patients goals, which are likely to be relief of symptoms and functional support (assuming they accept their diagnosis)
Important Note: Remember that for the patient and family these conditions may have become “the new normal.” They may not appreciate their significance in the disease trajectory. And for better or worse the Emerg physician may be the first person to address this issue.
okay sounds good
yes
interesting information
interesting
intersting facts
Goals of care and end of life discussions should begin a lot earlier than they do
Interesante el modo de mostrar las diferentes fases en forma de gráficos ,se visualiza mejor y se comprende mejor.
Interesting to see the graphs, helps increase understanding, would consider using these with patients and families
I find drawing the trajectory of the illness out like this for patients or families can be quite helpful
concept of “new normal” is something to keep in mind
The longer the process is drawn out, as in organ failure or frailty, the more important symptom management becomes.
ok
good review
ok
good points
a good review
great points
good review
thanks
great points
To me it is sad that many of the issues of expected course of their condition and end of life decisions have not occurred with the patient or the family prior to an urgent probllem that brings them to ER. I often feel this is something patients ned to have time to think about and I am not the best person to have that discussion. Patients need support and answers from their family physician/oncologist/surgeon about the big decisions. It is then much easier for us to do our part
End of life care is more stressful than critical care
Such a sad concept.
info on establishing prognosis pertinent
not always clear to ED doctor
I am so happy goals of care are being addressed and respecting those wishes are being discussed but recognizing it is an ongoing discussion. This helps the patients and family understand the reality and not have false hope but address concerns and offer a treatment plan.
good to know
very true end of life is a difficulty conversation
end of life discussion is a tough conversation to have but needs to happen.
Ideal world. End of Life discussion w should be initiated when deterioration is noted by the treating physician or General Practitioner. But this does not happen, despite best of intentions. Hence it falls on Ed physician to do this when the patient , family are vulnerable. It is a skill to develop, as it involves empathy but clear message as to the prognosis and limitations of care, so as not to encourage any false hopes.
it is interesting to note that clients with terminal illness or fraility or organ faiure should havae received cousneling before they actually presented to emerg
Ok
Interesting to see in a graphic
end-of-life indicators are very informative
lot of the discussion should be made with the family doctor at the begginning
i completely agree
buenas recomendaciones
perfecto
Complete and integrated evaluation is needed
rr
🙂
I agree with ” old fart”
no time like the present
xx
ss
I think this is an important issue to discuss with patient and his/her family earlier in time not in ER.
I agree with the the discussion above that EOL discussions are best suited for their MRP (LTC or FD). However, it may be the rare case that EOL has yet to be discussed with the family, in that case depending on how acutely they are presenting it may be appropriate for a Palliative Care referral or if deemed imminent then the ER physician.
often patients and family need to hear it from someone else/ or another doctor, maybe they were in denial and weren/t ready to hear it from their primary health provider
I disagree with the “trajectory” graphs, especially the Terminal illness one. Often these patients follow a similar trajectory to the “organ failure” one and have a steep decline at the end.
Often, family docs in the community or LTC have indeed addressed end of life issues, goal of treatment, disease trajectories etc, despite patients and family being seemingly unaware of these issues in the ER. As mentioned, the patient’s condition can become “the new normal” for themselves and for family members, and there is often denial and some lack of insight regarding the reality of their condition and prognosis, despite best efforts from primary care physicians. Sometimes it takes a crisis before these individuals are willing to accept the reality of their condition.
where is the family physician in all this. He should be the first to discuss these issues arranging home care support etc. Often times the family and patient initially wish to “die at home” but many times at the terminal event they come to the ER for admission to hospital.
ER may not be ideal setting to discuss about the goal of family/patients themselves but certainly we can advise them to persue with family doctor.
I think if a pt is in the ed with an acute crises from organ failure for example, EOL discussion could be deferred with referral to palliative team or the family MD, on the other hand if a very frail patient is seen in ED with end of life indicators, it certainly is the time to initiate discussion and you may be suprised how many family will support a comfort approach rather than the million dollor work up.
I strongly agree that end-of-life discussions and goals of care discussions should be taking place for all patients declining from organ failure. However, I’m not in agreement with these discussions taking place in the ED during a patient crisis. Frequent flyers should be referred instead for consultation with a palliative care consultant who can collaborate with the patient, the patient’s loved ones and treating clinicians to develop a care plan consistent with patient goals elucidated when a patient is in stable condition.
What you describe is certainly the ideal. However it is sometimes/often the case with the patient in the ED that that consultation has not happened. Surprisingly it is occasionally/often the case that the Emerg physician is the first person to have this necessary discussion when the patient is in crisis. I would argue that it is never too early or the “wrong” time to start having a goals of care discussion. Deferring it to a “better” time is rarely a good idea.
i agree with warrenlewin having this discussion in the ER when sometimes we can not explain all the resources that might be available to then is not fair to the patient r to the ED MD. Also agree that frequent flyers should have a set care of plan but without forgetting to check for new development. We already use this approach with mental health.
I feel that the end of life discussions should be started from the community , however there will be times when they will be discussed in ER after a review of the medical surgical issues , drugs functional status previously stated directives should be used in Er
all this information can be gathered from family, caregivers and then after assesement and a goal setting and treatment plan can be worked with patient family caregivers