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. Author manuscript; available in PMC: 2018 Nov 1.
Published in final edited form as: Geriatr Nurs. 2017 Apr 28;38(6):531–536. doi: 10.1016/j.gerinurse.2017.03.016

Table 4.

Summary of Trajectories

Goals Advance Care Plan Symptom Burden Rehabilitative & Skilled Care Medical Care Outcome
Comfort Care Continuity
N=2		 Comfort Natural Death Low -Therapy Evaluation
-OT		 4 provider visits (range 1–3 each)
No transfers		 Death (N=2)
Exemplar Quote “Keep her as comfortable as possible–we’re trying to avoid sending her back to the hospital because it is—it’s hard on her. No need to transport her back and forth to the hospital.”
Focus on Rehabilitative Care
N=10		 Aggressive interventions to improve or maintain condition Various

  • Life Sustaining Treatment

  • Natural Death

  • Feeding tube despite advance directives or verbal directions opposing

 High -PT/OT/ST
-Wound care
-Intravenous therapy
-Feeding Tube		 47 provider visits (range 1–9 each)
9 transfers		 Death (N=4)
Alive (N=3)
Alive with feeding tube (N=3)
Exemplar Quotes “I’ve been [pause] the hospitalization where you saw my father was his tenth hospitalization since August 20th. Ten times he’s been in the hospital.”
“I’ve had recently a lot of vomiting. I mean I’ve been throwin’ [sic] up and been—vomiting a lot.”
“He needs a lot more therapy than he gets, but he’s only entitled to certain amounts.”