Clinical Review

Illness trajectories and palliative care

BMJ 2005; 330 doi: http://dx.doi.org/10.1136/bmj.330.7498.1007 (Published 28 April 2005) Cite this as: BMJ 2005;330:1007
  1. Scott A Murray, clinical reader (Scott.Murray@ed.ac.uk)1,
  2. Marilyn Kendall, research fellow1,
  3. Kirsty Boyd, honorary clinical senior lecturer1,
  4. Aziz Sheikh, professor of primary care research and development1
  1. 1 Division of Community Health Sciences, General Practice Section, University of Edinburgh, Edinburgh EH8 9DX
  1. Correspondence to: S Murray
  • Accepted 22 February 2005

Introduction

When people with life threatening illnesses and their carers ask about prognosis (“How long have I got?”), they are often doing more than simply inquiring about life expectancy. Within this question is another, often unspoken, question about likely patterns of decline (“What will happen?”). One aid to answering both questions may be through the use of typical illness trajectories. Thinking in terms of these trajectories provides a broad timeframe and patterns of probable needs and interactions with health and social services that can, conceptually at least, be mapped out towards death.

Such frameworks may help clinicians plan and deliver appropriate care that integrates active and palliative management. If patients and their carers gain a better understanding by considering illness trajectories this may help them feel in greater control of their situation and empower them to cope with its demands. An important implication for service planners is that different models of care will be appropriate for people with different illness trajectories. We review the main currently described illness trajectories at the end of life and draw out key clinical implications.

Methods

We searched our own database of papers, conducted a Medline search, and approached experts for additional published references (further details available from SAM). We also re-examined primary data relating to illness trajectories from our previous studies investigating the palliative care needs of people with advanced lung cancer and heart failure.1

Different trajectories for different diseases

A century ago, death was typically quite sudden, and the leading causes were infections, accidents, and childbirth. Today sudden death is less common, particularly in Western, economically developed, societies. Towards the end of life, most people acquire a serious progressive illness—cardiovascular disease, cancer, and respiratory disorders are the three leading causes—that increasingly interferes with their usual activities until death.

Three distinct illness trajectories have been described so far for people …

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