Life After Death PART IX (Prediction)

Predicting when a person will die of a chronic disease is sometimes necessary. Health insurance often does not cover comfort care for chronic disease, except for hospice care, which usually requires a prognosis of less than 6 months-an arbitrary time that may be difficult to predict accurately.
Doctors can make a fairly accurate short-term prognosis for an average patient with certain conditions, based on statistical analysis of large groups of patients with similar conditions. For example, they may accurately estimate that 5 out of 100 patients with similar critical conditions will survive and leave the hospital. But predicting how long a particular person will survive is much more difficult. The best prediction a doctor can make is based on odds and the degree to which the doctor is confident in those odds. If the odds of survival are 10 percent, people should acknowledge the 90 percent likelihood of dying and should make plans accordingly.

When statistical information isn't available, a doctor may be unable to predict a prognosis or may make one on the basis of personal experience, which may be less accurate. Some doctors prefer to offer hope by describing remarkable recoveries without also mentioning the high likelihood that most people who have such serious conditions will die. However, gravely ill people and their families are entitled to the most complete information available and the most realistic prognosis possible.
Often the available choices are between dying sooner but remaining comfortable and living slightly longer by receiving aggressive therapy, which may prolong the dying process, increase discomfort and dependence, and decrease the quality of life. Nevertheless, patients and their families may feel that they must try such therapies if any chance of survival exists, even when hope of cure is unrealistic. Questions of philosophy, values, and religious beliefs come into play when such decisions are made by and for a dying patient.
TIMING THE COURSE OF DYING
Dying may be marked by deterioration over a long period of time, punctuated with bouts of complications and side effects, as in some people who have cancer. Usually about 1 month before death, energy, function, and comfort decrease substantially. The person is visibly failing, and the fact that death is near becomes obvious to all.
Dying follows other time courses. Sometimes, a person being treated aggressively for a serious illness in a hospital abruptly worsens and is known to be dying only a few hours or days before death. Increasingly common, however, is dying with a slow decline in capabilities over a long period of time, perhaps with episodes of severe symptoms. Neurologic diseases such as Alzheimer's disease follow this pattern, as do emphysema, liver failure, kidney failure, and other such chronic conditions. Severe heart disease disables people over time and causes severe symptoms intermittently, but it usually kills suddenly with a disturbance in the heart's rhythm (arrhythmia).
Knowing the likely time course of a disease enables a person who has the disease and the family to make plans. When death from an arrhythmia is likely, they should be prepared for death at any time. For people who have cancer, the decline that precedes death usually gives some warning that the final days have arrived.