Time Course of Dying
A prognosis is a prediction of the probable course and outcome of a disease or the likelihood of recovery from a disease. People often think that the doctor knows and can predict how long an ill person will live. The truth is that, generally, no one knows when an ill person will die. Families should not press for exact predictions or rely on those that are offered. Such exact predictions are often wrong because there is so much variation in how long people can live with a disease. Sometimes very sick people live a few months or years, well past what seems possible. Other people die quickly. If a dying person wants a particular person there at the time of death, arrangements may have to accommodate that wish for an indefinite amount of time. However, estimating a range of time in which a person is likely to die is sometimes necessary. For example, hospice care usually requires a doctor’s prognosis of less than 6 months to live.
Rather than asking their doctor “How much time do I have?” or “Am I likely to die within 6 months?,” it might be better for people to ask for the typical range of survival—the shortest and longest amount of time a person is reasonably likely to live.
Sometimes, doctors offer hope by describing remarkable recoveries without also mentioning the high likelihood that most people who have such serious conditions will die much more quickly. If doctors try to be too optimistic or unrealistic, gravely ill people and their families eventually find this "hope" to have been misleading and belittling. Instead, ill people and their family members are entitled to the most complete information available and the most realistic prognosis possible. However, they may have to clearly express their preference for such information rather than an excessively optimistic account.
Symptoms progress differently with different diseases. For example, in some people dying of cancer, energy, function, and comfort usually decrease substantially only in the last month or two before death. During this time, the person is visibly failing, and the fact that death is near becomes obvious to all. Other diseases, such as Alzheimer disease, liver failure, and kidney failure, may follow a more gradual decline from the beginning but sometimes at a rate that is unpredictable. Severe heart disease and chronic obstructive pulmonary disease cause a steady decline but with episodes of serious worsening. These episodes are often followed by improvement, but usually death comes after an episode or worsening that develops within a few days of being stable.
Many people find it difficult to discuss death openly with a dying person, mistakenly believing that the dying person does not want to discuss death or will be hurt by such a discussion. However, people living with eventually fatal conditions usually do better when family members continue to speak with them and include them in decision making. The following suggestions can help people feel more comfortable when communicating with a dying person:
Listen to what the person is saying. Ask, for example, “What are you thinking?” rather than shutting down communication with such comments as “Don’t talk that way.”
Talk about what the person would envision for surviving family members at a time long after death has occurred and work back toward events nearer to death. This allows for a gentle introduction to a discussion of more immediate concerns, such as the person’s preferences regarding funeral arrangements and support for loved ones.
Reminisce with the dying person because this is a way of honoring the person’s life.
Continue to speak with the dying person, even if the person is unable to speak. Other ways of communicating, such as holding the person’s hand, giving the person a massage, or just being near the person, can be very comforting.