Individuals who are dying do not move toward death at the same rates or in the same ways. Different causes of death are associated with different patterns of dying.[1] These patterns, referred to as dying trajectories, indicate the path of the individual’s dying experience. Attitudes and behaviors of people caring for the patient are strongly influenced by the perception of the patient’s dying trajectory. Trajectories will also affect the types of emotional responses and coping mechanisms patients and their families will display, as well as the interventions that will be initiated. For these reasons, the purpose of understanding one’s dying trajectory is to anticipate and implement appropriate interventions.

The dying process can be described in terms of duration and shape. Duration refers to the time involved between the onset of dying and the arrival of death. Shape designates the course of the dying process (i.e., whether one can predict how the process will advance, and whether the approximate timing of the death is expected or unexpected).

The following examples of trajectories have been described:

• The gradual slant characterized by a long slow decline, sometimes lasting over a period of years.
• The downward slant represented by a rapid decline towards death in which the chronic phase of the illness is either short or nonexistent.
• The peaks and valleys trajectory, in which there are alternating patterns of remission and relapse.
• The descending plateaus trajectory, indicated by long, slow periods of decline followed by restabilization. Patients in this trajectory must repeatedly adjust to different levels of functioning.

Deaths associated with cancer are often lengthy processes, and may be linked with long-term pain and suffering, and/or a loss of control over one’s body or mental faculties. Protracted deaths are more likely to drain a family’s physical and emotional resources as caregivers will be required to provide care for longer periods of time. The spectrum of chronic care needs of these patients and their caregivers may benefit from referral to a palliative care service, where resources more appropriate to their needs may be provided as compared to the more cure-centered focus of high-tech medical facilities.[2]

Uncertain trajectories are more difficult to cope with than certain trajectories, since ambiguity generates anxiety and is often more difficult to cope with than certainty.

References

1. Glaser BG, Strauss AL: Time for Dying. Chicago: Aldine, 1968. 
   
   
2. McGrath P: Caregivers' insights on the dying trajectory in hematology oncology. Cancer Nurs 24 (5): 413-21, 2001.  [PUBMED Abstract]
   
   

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