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Figure 2: Cancer trajectory
Reprinted with permission from BMJ. 2005;330:1007–1011.

Cancer has a different trajectory than cardiopulmonary disease (see Figure 2). Cancer patients who were fairly healthy before an early-stage diagnosis often continue to do well through their treatments and hopefully progress to a cure. People can return to baseline if they only require symptomatic treatment for simple challenges like chemotherapy-induced dehydration or nausea and vomiting. However, if prolonged immunocompromise or significant metastatic spread occurs, patients eventually reach a physiologic tipping point. When this happens, decline is usually rapid, and patients will not revert back to their previous quality of life.^3,4

Figure 3: Neurologic failure trajectory
Reprinted with permission from BMJ. 2005;330:1007–1011.

Neurologic failure may be related to dementia or other irreversible and progressive neurologic conditions (see Figure 3). Stroke may also cause neurologic failure if either a massive stroke is survived or is superimposed on another progressive neurologic condition, leading to acceleration of a patient’s functional decline. These patients live with low levels of functional and physiologic reserve. Opportunistic infections (eg, urine, respiratory) or minor falls lead to disproportionate levels of morbidity and mortality. Neurologic failure most often progresses to the constellation of bedbound status, opportunistic infection, dysphasia, weight loss, and death. During decline, families and caregivers may become confused because patients have “good days and bad days.” Despite these minor fluctuations, established neurologic failure is terminal and not reversible. ^2,3

Putting Trajectories Into Practice

Although it may seem difficult to move beyond the acute exacerbation during a long shift, emergency physicians can begin discussions of these trajectories and what they may mean for our patients and their caregivers. Sharing disease trajectory information empowers providers and the patients we treat to make the best decisions possible, whether moving forward with a procedure or a consultation for palliative care.¹ (See sidebar for a sample conversation.)