Time Course of Dying
People often think that the doctor knows how long a person will live but is withholding this information from them. However, no one knows when an ill person will die. Families are advised not to press for exact predictions or to rely on those that are offered. Sometimes very sick people live a few months or years, well past what seemed possible. Other people die quickly. If a patient wants a particular person there at the time of death, arrangements may have to be made to accommodate that person for an indefinite time. Yet, predicting when a person will die of a disease is sometimes necessary. Health insurance often does not cover comfort measures for chronic disease, except for hospice care, which usually requires a prognosis of less than 6 months to live--an arbitrary time that may be difficult to predict accurately.
Doctors can make a fairly accurate short-term prognosis for an average person with certain conditions, based on statistical analyses of large groups of people with similar conditions. For example, they may accurately estimate that 5 out of 100 people 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 for 6 months are 10%, people should acknowledge the 90% likelihood of dying and should make plans accordingly.
When statistical information is not 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 certain serious conditions will die. Gravely ill people and their families are entitled to the most complete information available and the most realistic prognosis possible. However, it may sometimes be necessary for them to express their desire for such information, rather than only for optimistic accounts.
Dying may be marked by deterioration over a long period of time, punctuated with bouts of complications and side effects. For people dying of cancer, energy, function, and comfort usually decrease substantially only in the last month or two before death. The person then is visibly failing, and the fact that death is near becomes obvious to all. However, dying usually 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 serious complications. Neurologic diseases, such as Alzheimer's disease, follow this pattern, as do emphysema, liver failure, kidney failure, and other 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).
 See the sidebar Communicating With a Dying Person.
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