End-of-Life CareChallenges in Understanding Functional Decline, Prognosis, and Transitions in Advanced Illness: Dilemmas at the End of LifeDowning, G. Michael MD; Lynd, Patricia Jean PT, BSc; Gallagher, Romayne MD, CCFP; Hoens, Alison PT, MSc, BScAuthor Information Author Affiliations: Palliative Medicine, Victoria Hospice, Victoria, University of British Columbia, Division of Palliative Care, Vancouver, University of Victoria, Victoria, British Columbia Cancer Agency, Vancouver (Dr Downing), Residential Care, Providence Health Care, Vancouver (Ms Lynd), Divisions of Residential and Palliative Care, Department of Family and Community Medicine, Providence Health Care, Vancouver, University of British Columbia, Division of Palliative Care, Vancouver (Dr Gallagher), and Providence HealthCare, Vancouver, University of British Columbia, Department of Physical Therapy, Vancouver (Ms Hoens), British Columbia, Canada. Correspondence: G. Michael Downing, MD, Victoria Hospice Society, 1952 Bay St, Victoria, BC, Canada, V8R 1J8 ([email protected]). Topics in Geriatric Rehabilitation: January/March 2011 - Volume 27 - Issue 1 - p 18-28 doi: 10.1097/TGR.0b013e3181ff6a89 Buy Metrics Abstract This article has 2 purposes: to inform the health care provider's response to the common question asked by older adults with advancing illness, “How long do I have?” and to provide caregivers with a framework which can guide provision of care in advancing illness. Both purposes are addressed by exploring 3 major concepts associated with declining functional ability: (1) common functional changes and strategies to identify and manage these changes, (2) the extent to which prognostic tools provide insight for the prediction of rate of decline, and (3) the transitions in the focus of care that are required with advancing disease. Although the article is focused on the residential care setting the concepts examined can be applied more broadly to other practice settings such as palliative care. Declining functional ability is a common feature of the journey toward end of life. Irreversible decline in function is frequently accompanied by the resident and family's need to understand the probable duration of survival and the caregiver's need to adjust priorities for care. To better inform the clinician's response to the question of “How long do I have?” prognostic tools which incorporate measurement and interpretation of declining function can be utilized to improve the ability to predict survival. A 10-step approach to formulating and discussing prognosis is presented to assist clinicians in predicting rate of decline and sharing difficult news. Finally, in recognition of how declining functional ability affects priorities for provision of care, a framework which advocates the shift in focus from function, to safety, and ultimately to comfort, is provided. © 2011 Lippincott Williams & Wilkins, Inc.