in their own right, as are concerns about loss of control and abandonment. The discussion attempts to provide a broad perspective on strategies for helping people live well while dying, but it does not attempt to serve either as a palliative care text or as more than an overview of the sources of support and comfort that lie outside the health care system. It also acknowledges that, particularly for those dying at home, professional caregivers may not have a substantial presence and that some may find medical care intrusive, especially if caregivers are not alert to patient and family wishes. Still, many patients and those close to them welcome an attentive medical presence, and for some, the absence of supportive and effective medical care may lead to despair and thoughts of suicide.

Differences in Dying Pathways: Illustrative Cases

Over 300 years ago, the playwright John Webster wrote in The Duchess of Malfi, "I know death hath ten thousand several doors for men to take their exits." The doors to death remain many and varied, although, as Chapter 2 described, today's most common patterns of death differ in key ways from the past. This section supplements the definitional and statistical discussions presented in Chapters 1 and 2 with a more qualitative consideration of how people may die and how care for dying patients may need to be adjusted to their circumstances.

Figure 1.1 depicted three prototypical trajectories of dying: sudden and unexpected; steady decline; and slow decline marked by periodic crises, one of which brings death. In addition to those people who are recognized as incurably ill with a clearly defined disease such as cancer or amyotrophic lateral sclerosis, two other groups are of interest. One consists of very old people who are functioning reasonably well but who are frail and have limited reserves to face an acute illness such as influenza or an injury such as a broken hip. Although these people initially may be expected to recover from the acute problem and their dying would not have been seen as likely in advance, a relatively minor event can precipitate a catastrophic cascade of complications that lead to death. The other group likewise consists of very old people whose organ systems are slowly deteriorating and who seem to just "wear out." That is, they have gradually diminishing cardiac function combined with osteoarthritis or some other condition that limits stair climbing, then housekeeping, and then other self-care tasks. Alzheimer's disease may develop, or stroke or renal failure, and pneumonia or other infections may become more frequent with flagging immune response. Whatever organ system is most relentlessly failing may be labeled the primary cause of death, but this is in the context of other less obviously failing organ systems.

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