Emergency medicine training prepares us well for managing acute events in our patients’ lives. In fact, combined improvements in public health and general health care integration have resulted in major shifts in how patients live and die in the United States. Many years ago, infection and trauma claimed lives quickly, and life expectancies were short. Now, medical and surgical advancements have transformed health care, benefitting most of us with longer lives.¹

Although many seniors still enjoy a high quality of life, the individuals we meet in the emergency department are generally not so lucky. Individuals with cardiopulmonary disease, cancer, neurologic failure (dementia, stroke, or combined syndromes), and their related complications have become the predominant populations in many EDs.¹

Additionally, there are just more seniors. Since 2013, and predicted through 2019, more than 10,000 baby boomers turn 65 every day. In 2010, the US Census Bureau reported more than 40 million citizens were 65 and older. By 2050, those number of those patients is projected to double to more than 85 million. Although the full impact of our country’s aging population on health care is not yet known, we do know the incidence of advanced chronic illness is already on the rise.¹

As this population increases, how do we navigate clinical challenges these patients pose? How should we answer when worried caregivers ask us, “Why does she keep ending up in the hospital? What comes next?”

Illness Trajectory

Illness trajectories are general paths that chronic conditions usually take.^2–4 These trajectories give insight into prognosis and the likelihood of significant recovery. By discussing these paths with patients, we empower them with information about their clinical course. This shared understanding fosters appropriate health care decision making that aligns with the clinical picture.

By understanding the path these conditions take, emergency physicians can potentially advance the dialogue from fixing the unfixable to caring for a loved one at the end of life.²

Figure 1: Cardiopulmonary trajectory
Reprinted with permission from BMJ. 2005;330:1007–1011.

The cardiopulmonary trajectory (see Figure 1) is one of the most well-known to ED providers because severe exacerbations are common and dramatic. Areas helpful to recognize on this trajectory are patients’ long-standing functional limitations and their decreasing physiologic reserve. These patients and families often have difficulty recognizing the severity of their illnesses because they have survived hospitalizations before. As exacerbations occur at closer intervals, families may describe the sensation of being trapped in a cycle between rehabilitation or nursing home and subsequent hospitalizations. It is helpful to note that, while they may get close, patients generally do not return to their baseline after a hospitalization and progress on a course of general decline.^3,4