This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (126)  • Contact me when this article is cited  Related Content  • Similar articles in JAMA  Topic Collections  • Aging/ Geriatrics  • Patient-Physician Relationship/ Care  • End-of-life Care/ Palliative Medicine  • Alert me on articles by topic  Social Bookmarking   What's this?

June R. Lunney, PhD, RN; Joanne Lynn, MD, MA, MS; Daniel J. Foley, MS; Steven Lipson, MD; Jack M. Guralnik, MD, PhD

JAMA. 2003;289:2387-2392.

Context  Clinicians have observed various patterns of functional decline at the end of life, but few empirical data have tested these patterns in large populations.

Objective  To determine if functional decline differs among 4 types of illness trajectories: sudden death, cancer death, death from organ failure, and frailty.

Design, Setting, and Participants  Cohort analysis of data from 4 US regions in the prospective, longitudinal Established Populations for Epidemiologic Studies of the Elderly (EPESE) study. Of the 14 456 participants aged 65 years or older who provided interviews at baseline (1981-1987), 4871 died during the first 6 years of follow-up; 4190 (86%) of these provided interviews within 1 year before dying. These decedents were evenly distributed in 12 cohorts based on the number of months between the final interview and death.

Main Outcome Measures  Self- or proxy-reported physical function (performance of 7 activities of daily living [ADLs]) within 1 year prior to death; predicted ADL dependency prior to death.

Results  Mean function declined across the 12 cohorts, simulating individual decline in the final year of life. Sudden death decedents were highly functional even in the last month before death (mean [95% confidence interval {CI}] numbers of ADL dependencies: 0.69 [0.19-1.19] at 12 months before death vs 1.22 [0.59-1.85] at the final month of life, P = .20); cancer decedents were highly functional early in their final year but markedly more disabled 3 months prior to death (0.77 [0.30-1.24] vs 4.09 [3.37-4.81], P<.001); organ failure decedents experienced a fluctuating pattern of decline, with substantially poorer function during the last 3 months before death (2.10 [1.49-2.70] vs 3.66 [2.94-4.38], P<.001); and frail decedents were relatively more disabled in the final year and especially dependent during the last month (2.92 [2.24-3.60] vs 5.84 [5.33-6.35], P<.001). After controlling for age, sex, race, education, marital status, interval between final interview and death, and other demographic differences, frail decedents were more than 8 times more likely than sudden death decedents to be ADL dependent (OR, 8.32 [95% CI, 6.46-10.73); cancer decedents, one and a half times more likely (OR, 1.57 [95% CI, 1.25-1.96]); and organ failure decedents, 3 times more likely (OR, 3.00 [95% CI, 2.39-3.77]).

Conclusions  Trajectories of functional decline at the end of life are quite variable. Differentiating among expected trajectories and related needs would help shape tailored strategies and better programs of care prior to death.

Author Affiliations: Laboratory of Epidemiology, Demography, and Biometry, National Institute on Aging, National Institutes of Health, Bethesda, Md (Drs Lunney and Guralnik and Mr Foley); Washington Home Center for Palliative Care Studies, Washington, DC (Dr Lynn); Hebrew Home of Greater Washington, Rockville, Md (Dr Lipson).

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

On dying and human suffering
Kellehear
Palliat Med 2009;23:388-397.
ABSTRACT  

Making Difficult Discussions Easier: Using Prognosis to Facilitate Transitions to Hospice
Finlay and Casarett
CA Cancer J Clin 2009;0:caac.20022v1-NA.
ABSTRACT | FULL TEXT  

Pain Management Within the Palliative and End-of-Life Care Experience in the ICU
Mularski et al.
Chest 2009;135:1360-1369.
ABSTRACT | FULL TEXT  

The Hope Experience of Older Bereaved Women Who Cared for a Spouse With Terminal Cancer
Holtslander and Duggleby
Qual Health Res 2009;19:388-400.
ABSTRACT  

Hospitalizations at the End of Life Among Long-Term Care Residents
Menec et al.
J Gerontol A Biol Sci Med Sci 2009;64A:395-402.
ABSTRACT | FULL TEXT  

Cardiovascular disease and cancer in very old age
Strandberg
BMJ 2008;337:a2521-a2521.
FULL TEXT  

Illness trajectories: an important concept in the management of kidney failure
Murtagh et al.
Nephrol Dial Transplant 2008;23:3746-3748.
FULL TEXT  

Practical Guidance for Evidence-Based ICU Family Conferences
Curtis and White
Chest 2008;134:835-843.
ABSTRACT | FULL TEXT  

Palliative and end-of-life care for patients with severe COPD
Curtis
Eur Respir J 2008;32:796-803.
ABSTRACT | FULL TEXT  

Nationwide Veterans Affairs Quality Measure for Cancer: The Family Assessment of Treatment at End of Life
Finlay et al.
JCO 2008;26:3838-3844.
ABSTRACT | FULL TEXT  

Challenges of Noncancer Patients Transitioning to Hospice
Brunker
Home Health Care Management Practice 2008;20:400-403.
ABSTRACT  

Care for all at the end of life
Murray and Sheikh
BMJ 2008;336:958-959.
FULL TEXT  

Can't We Improve on Advance Directives?
Perkins
ANN INTERN MED 2008;148:406-406.
FULL TEXT  

Evidence for Improving Palliative Care at the End of Life: A Systematic Review
Lorenz et al.
ANN INTERN MED 2008;148:147-159.
ABSTRACT | FULL TEXT  

Absence of Cancer Diagnosis and Treatment in Elderly Medicaid-Insured Nursing Home Residents
Bradley et al.
JNCI J Natl Cancer Inst 2008;100:21-31.
ABSTRACT | FULL TEXT  

Populations who die without specialist palliative care: does lower uptake equate with unmet need?
Currow et al.
Palliat Med 2008;22:43-50.
ABSTRACT  

Comparison of the Health and Functional Status Between Older Inpatients With and Without Cancer Admitted to a Geriatric/Internal Medicine Unit
Retornaz et al.
Journals of Gerontology Series A: Biological Sciences and Medical Sciences 2007;62:917-922.
ABSTRACT | FULL TEXT  

Choice and place of death: individual preferences, uncertainty, and the availability of care
Munday et al.
JRSM 2007;100:211-215.
FULL TEXT  

Terminal Trajectories of Functional Decline in the Long-Term Care Setting
Chen et al.
Journals of Gerontology Series A: Biological Sciences and Medical Sciences 2007;62:531-536.
ABSTRACT | FULL TEXT  

Health Care Use at the End of Life Among Older Adults: Does It Vary by Age?
Menec et al.
Journals of Gerontology Series A: Biological Sciences and Medical Sciences 2007;62:400-407.
ABSTRACT | FULL TEXT  

Dying trajectories in heart failure
Gott et al.
Palliat Med 2007;21:95-99.
ABSTRACT  

End-of-Life Care: Findings From a National Survey of Informal Caregivers
Wolff et al.
Arch Intern Med 2007;167:40-46.
ABSTRACT | FULL TEXT  

Dying in hospital of terminal heart failure or severe dementia: the circumstances associated with death and the opinions of caregivers
Formiga et al.
Palliat Med 2007;21:35-40.
ABSTRACT  

The Ethics of Palliative Sedation as a Therapy of Last Resort
National Ethics Committee, Veterans Health Adminis
AM J HOSP PALLIAT CARE 2007;23:483-491.
ABSTRACT  

Care at the End of Life: Focus on Communication and Race
Zapka et al.
J Aging Health 2006;18:791-813.
ABSTRACT  

Frameworks for Approaching Prescribing at the End of Life
Currow and Abernethy
Arch Intern Med 2006;166:2404-2404.
FULL TEXT  

Palliative care for frail older adults: "there are things I can't do anymore that I wish I could . . . ".
Boockvar and Meier
JAMA 2006;296:2245-2253.
ABSTRACT | FULL TEXT  

ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death)
Developed in Collaboration With the European Heart et al.
J Am Coll Cardiol 2006;48:e247-e346.
FULL TEXT  

ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: A report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society
Writing Committee Members et al.
Europace 2006;8:746-837.
FULL TEXT  

End-of-Life Decisions Among Cancer Patients Compared With Noncancer Patients in Flanders, Belgium
Van den Block et al.
JCO 2006;24:2842-2848.
ABSTRACT | FULL TEXT  

Bridging the Continuum: Nutrition Support in Palliative and Hospice Care
Fuhrman and Herrmann
Nutr Clin Pract 2006;21:134-141.
ABSTRACT | FULL TEXT  

The effect of prior disability history on subsequent functional transitions.
Hardy et al.
Journals of Gerontology Series A: Biological Sciences and Medical Sciences 2006;61:272-277.
ABSTRACT | FULL TEXT  

Identification in Administrative Databases of Women Dying of Breast Cancer
Gagnon et al.
JCO 2006;24:856-862.
ABSTRACT | FULL TEXT  

The future of geriatric medicine in an era of patient choice
Metz and Labrooy
Age Ageing 2005;34:553-555.
FULL TEXT  

Integrated care pathway for the last days of life
Shah
Palliat Med 2005;19:351-352.
 

Illness trajectories and palliative care
Murray et al.
BMJ 2005;330:1007-1011.
FULL TEXT  

Transitions between States of Disability and Independence among Older Persons
Hardy et al.
Am J Epidemiol 2005;161:575-584.
ABSTRACT | FULL TEXT  

Integrating Palliative Care Into Heart Failure Care
Hauptman and Havranek
Arch Intern Med 2005;165:374-378.
ABSTRACT | FULL TEXT  

Resurrecting Treatment Histories of Dead Patients: A Study Design That Should Be Laid to Rest
Bach et al.
JAMA 2004;292:2765-2770.
ABSTRACT | FULL TEXT  

A Comparative Study of Variables That Have an Impact on Noncancer End-of-Life Diagnoses
Dobratz
Clin Nurs Res 2004;13:309-325.
ABSTRACT  

Decision Making at a Time of Crisis Near the End of Life
Weissman
JAMA 2004;292:1738-1743.
ABSTRACT | FULL TEXT  

Pattern of Care at the End of Life: Does Age Make a Difference in What Happens to Women With Breast Cancer?
Gagnon et al.
JCO 2004;22:3458-3465.
ABSTRACT | FULL TEXT  

Hospice pharmaceutical cost trends
Nowels et al.
AM J HOSP PALLIAT CARE 2004;21:297-302.
ABSTRACT  

Dementia, Prognosis, and the Needs of Patients and Caregivers
Covinsky and Yaffe
ANN INTERN MED 2004;140:573-574.
FULL TEXT  

Medicare Program Expenditures Associated with Hospice Use
Campbell et al.
ANN INTERN MED 2004;140:269-277.
ABSTRACT | FULL TEXT  

Supporting Family Caregivers at the End of Life: "They Don't Know What They Don't Know"
Rabow et al.
JAMA 2004;291:483-491.
ABSTRACT | FULL TEXT  

Disability and the Future of Medicare
Cutler
NEJM 2003;349:1084-1085.
FULL TEXT  

Trajectories of Health for Older Adults over Time: Accounting Fully for Death
Diehr and Patrick
ANN INTERN MED 2003;139:416-420.
ABSTRACT | FULL TEXT