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Time Course of Dying

By Elizabeth L. Cobbs, MD, Professor, Medicine, Geriatrics and Palliative Care;Chief, Geriatrics, Extended Care and Palliative Care, George Washington University;Washington DC Veterans Administration Medical Center ; Karen Blackstone, MD, Assistant Professor, Medicine, Geriatrics and Palliative Care;Director, Palliative Care, George Washington University;Washington DC Veterans Administration Medical Center ; Joanne Lynn, MD, MA, MS, Director, Center for Elder Care and Advanced Illness, Altarum Institute

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.

Did You Know...

  • Doctors usually cannot accurately predict precisely how long an ill person will live.

  • Doctors are often more helpful by giving the boundaries of reasonably anticipated outcomes—the best and the worst that would not be surprising.

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 over 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.

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