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Research
shows that distinct patterns of functional decline in the last year of
life indicate the need for different approaches to palliative care National
Institutes of Health, May 13, 2003 New scientific evidence shows consistent patterns of decline of
functioning for four different types of dying. These findings suggest that
different pathways to death require more flexibility of healthcare and
hospice services to meet the needs of critically ill patients whose time
until death is unpredictable. Led by investigator Dr. June Lunney, the research team analyzed data
from 4,190 participants 65 years of age and older in the Established
Populations for Epidemiologic Studies of the Elderly (EPESE). The article
on the study, Patterns of Functional Decline at the End of Life,
appears in the May 14 issue of JAMA.
The study was funded by the National Institute of Nursing Research
and conducted in the Laboratory of Epidemiology, Demography and Biometry
of the National Institute on Aging. Both
institutes are part of the NIH, Department of Health and Human Services. In discussing the study, Dr. Lunney stated, “A ‘one size fits all’ model for end-of-life palliative
care doesn’t work. People
usually assume a terminal illness when thinking about the end of life. Yet only 23% of
Americans die of cancer, the most common illness with a distinct terminal
phase. Most, particularly
those who are chronically ill, are not diagnosed as ‘terminal,’” she
added, “yet they may also need palliative care.” Palliative care
offered mainly by hospice emphasizes compassionate therapies focused on
physical, psychological, social and spiritual needs of the patient, family
and caregiver. Currently, those services may not be available, because
reimbursement for hospice requires a diagnosis that predicts a life
expectancy of six months or less if the terminal illness runs its normal
course. The four pathways to death used in the study and their patterns of
decline during a one-year period were: MORE ·
Sudden death.
There was no functional decline for this group. ·
Expected death in the short
term from cancer. The cancer
patients had good functional status early in their final year that
degenerated markedly three months prior to death.
·
Entry-reentry deaths, where
people slowly get worse but go home between hospital stays.
These patients have a serious chronic illness that presents an
ongoing threat of sudden exacerbation and death caused by organ failure. ·
Lingering, expected deaths, associated with frailty in old age.
Patients have no reserve defenses, and either die when an
unpredicted medical challenge occurs or decline so gradually that signs of
the end cannot be clearly identified.
Twenty percent were classified as frail in the study, and they were
relatively disabled throughout the year before death.
These patients typically resided in nursing homes. According to Dr. Patricia A. Grady, Director of the NINR, “Clearly
end-of-life palliative care needs to have a more extensive focus.
This study shows that because of the different ways people die,
palliative care should start earlier for those who need it, and should
involve health and social services that are adjusted to fit the
anticipated patterns of illness and death.” The data used in the study were based on interviews of participants, who
were asked about common activities of daily living, such as bathing,
dressing, using the toilet, or walking across a small room.
The study found that while dependency increased at older ages, the
level of dependence followed similar declines within each age group.
Females were more disabled than males, but their slope of decline a
year prior to death was the same. There
were no differences in functional decline according to level of education
or race. CONTACT:
Linda Cook, NINR
(301) 496-0209 cookl@mail.nih.gov Copyright
© 2002 Global Action on Aging
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