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.
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
- Sudden Death
Click on the trajectories below to see the trajectory graphs for each of these End-of-Life Scenarios.
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 — 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 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.
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.
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.