Chapter 1 16 category of trajectories includes functional decline with intermittent serious episodes, such as exacerbations of chronic obstructive pulmonary disease and heart failure. The patient’s functioning can improve after each episode with adequate treatment, but the level of functioning will not be at the same level as before the episode. At some point, a patient will not be able to recover from the exacerbation because of organ failure, resulting in rapid decline and death. Palliative care can prepare patients and their family for the last phase of their disease trajectory when they reach the terminal stage of their condition, e.g., GOLD stadium IV in patients with chronic obstructive pulmonary disease, or NYHA class IV in patients with heart failure. The third category of trajectories concerns frailty and dementia, characterised by a gradual functional decline, leading to death from old age or frailty of the brain and other organs. Since these trajectories can take years, there are several possibilities to timely prepare patients and their families from the moment of diagnosis of dementia, or when functional decline presents. Murray also graphed the trajectory of multidimensional palliative care needs for these three disease trajectories: physical, social, spiritual, and psychological.44 • All conditions Fig. 1. The three main trajectories of decline at the end of life. From Murray S A, Sheikh A. Care for all at the end of life BMJ 2008; 336 :958, Figure 1.43 The palliative care “trajectory” model by Lynn and Adamson shows three phases within a palliative care trajectory (Fig. 2): • disease-modifying phase, in which treatment is directed at slowing down the incurable disease; • symptom-management phase, in which treatment is aimed at symptom-relief and supportive care;
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