It's natural to assume that we see death coming in old age; that we slow down, become disabled and then die. But that's not necessarily the case, according to an enlightening study published Thursday in the New England Journal of Medicine.
Researchers identified five distinct trajectories in the last year of life -- no disability, catastrophic disability, accelerated disability, progressive disability and persistently severe disability. But they found these trajectories varied widely among people and their conditions. Only advanced dementia was really predictable. Those people had high levels of disability throughout the last year of life.
For five other categories (cancer, organ failure, frailty, sudden death and other conditions), from 26.8% to 80% of people were not disabled or had very low levels of disability until only a few months before death. Overall, more than half of the 383 study participants were not disabled 12 months before death. A high number of people who died of cancer, for example, were not disabled during the last year of life.
"These results indicate that for most decedents the course of disability at the end of life does not follow a predictable pattern based on the condition leading to death," the authors, from Yale University School of Medicine, wrote.
The study raises some important points. First, for policymakers, it's hard to know how to allocate resources for healthcare services when disability varies so much in the last year of life. Second, for patients and families, the unpredictable nature of this final year suggests the need to plan for a variety of scenarios. Another study, also in the current issue of the New England Journal of Medicine, found that advance directives, documents that specify the kind of medical care desired, or not desired, at the end of life, work fairly well and are valued by patients and their families. Given the unpredictability of the last year, it seems prudent to have an advance directive prepared in old age, no matter how good you're feeling.
For more on end-of-life care, see this recent L.A. Times Health section.
-- Shari Roan
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