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The approach to end-of-life care varies widely throughout the world and is influenced by medical, cultural, social, and legal considerations. The clinician must consider these factors when managing the care of a dying patient.

Dying patients have needs that differ from those of other patients. So that their needs are 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 an aggressive 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 sometimes unpredictable acute exacerbations of the underlying disorder (eg, typical of heart failure or COPD [chronic obstructive pulmonary disease])

An increasing number of patients follow the second trajectory (prolonged indefinite period of severe dysfunction). This is because patients with certain diseases (eg, some types of cancers, end-stage HIV infection, neuromuscular diseases, heart failure, COPD) are living longer due to improved medical treatments that slow disease progression and reduce exacerbations.

With the first trajectory (limited period of steadily progressive functional decline, eg, in aggressive cancer), the course of disease and time of death tend to be more predictable than with the other trajectories. With the second trajectory (prolonged indefinite dysfunction), death may occur suddenly; eg, a person with severe dementia may die suddenly from pneumonia. With the third trajectory (irregularly progressive dysfunction), people who do not appear near death (eg, a person with heart failure) may die suddenly during an acute exacerbation. Therefore, knowing the trajectory of functional decline can help estimate when death will occur but cannot provide a precise timeframe.

More info on approaches to end-of-life care: 

• Communication and Clarification of Goals
• Palliative Care and Hospice
• Advance Planning for Imminent Death
• Financial Concerns and Disability
• Legal and Ethical Concerns
• Supporting Caregivers after Death
• More Information

About the book: First published in 1899 as a small reference book for physicians and pharmacists, The Merck Manual grew in size and scope to become one of the most widely used comprehensive medical resources for professionals and consumers.