In this article, we delve into the critical topic of functional decline in individuals nearing the end of life. Understanding these changes is invaluable for hospice nurses, , and family members as they provide compassionate care during this delicate phase. We will explore various examples of and emphasize the importance of documenting these changes to aid care provision and decision-making.

Documenting Functional Decline

When a person is nearing the end of life, their physical and mental abilities may decline gradually or rapidly, depending on their illness trajectory. This decline can affect their quality of life, comfort, and care needs. Therefore, caregivers need to keep track of changes in the patient's functional status, such as their ability to perform daily living (ADLs) like eating, bathing, dressing, and moving around. By keeping a journal of these changes, caregivers can document the patient's condition, communicate with healthcare providers, and plan appropriate interventions. The journal should include the following information:

  • Date and Time: Write down the exact date and the approximate time when the change occurred. This will help you monitor the frequency and duration of the changes and identify any patterns or triggers.
  • Concise Description: Describe the change clearly and concisely, using specific details and examples. For example, instead of “the patient was confused,” write “the patient did not recognize me and asked where he was.” This will help you capture the nature and severity of the change and provide useful information for and treatment.
  • Context: Note what happened before the change, such as the patient's mood, activity, medication, environment, or other relevant factors. This will help you understand the possible causes and effects of the change and adjust the accordingly. For example, if the patient becomes agitated after a loud noise, you may want to reduce the noise level and provide soothing music or touch.

Examples of Moderate to Major Decline

As a person approaches the end of life, their body and mind may undergo various changes affecting their functioning and well-being. These changes can be moderate or major, depending on how much they interfere with the person's normal activities and comfort. Some examples of moderate and major declines are:

Moderate Declines

  • Alzheimer's Progression: Alzheimer's disease is a type of dementia that causes memory loss and cognitive impairment. It has seven stages, from mild to severe. A moderate decline in Alzheimer's is when a person moves from stage 7A to stage 7B, which means they lose the ability to speak or smile and need assistance with all essential tasks.
  • Eating Habits: Eating is essential for maintaining health and energy. A moderate decline in eating habits is when a person who used to eat full meals now eats less than half of what they used to. This can be due to loss of appetite, difficulty swallowing, , pain, or depression.
  • Oxygen Requirements: Oxygen is vital for the functioning of the organs and tissues. A moderate decline in oxygen requirements is when a person who could breathe normally now needs supplemental oxygen at night or during the day. This can be due to lung disease, heart failure, or low blood pressure.
  • Mobility: Mobility is the ability to move around and perform physical activities. A moderate decline in mobility is when a person who could walk without help now needs a cane or a walker. This can be due to muscle weakness, joint pain, balance problems, or fatigue.
  • Frequent Falls: Falls are a common cause of injury and disability among older adults. A moderate decline in fall frequency is when a person who rarely falls now falls every one or two weeks. This can be due to vision problems, , dizziness, or confusion.
  • Dietary Changes: Diet is the type and amount of food a person eats. A moderate diet decline occurs when a person who could eat regular food now needs softer food that is easier to chew and swallow. This can be due to dental problems, dry mouth, or swallowing difficulties.
  • Orientation Shift: Orientation is the awareness of oneself and one's surroundings. A moderate decline in orientation is when a person who was fully oriented to person, place, time, and situation now becomes confused about one of these aspects, usually time. This can be due to dementia, , or medication effects.
  • Complexion Alteration: Complexion is the color and texture of the skin. A moderate decline in complexion is when a person who had a healthy skin tone now becomes pale yellow or shows subtle changes. This can be due to liver problems, anemia, or .
  • Sleep Patterns: Sleep is the state of rest and recovery for the body and mind. A moderate decline in sleep patterns is when a person who used to sleep eight to twelve hours a day, including naps, now sleeps twelve to sixteen hours a day. This can be due to depression, pain, or reduced activity.

Major Declines

  • Advanced Alzheimer's: A significant decline in Alzheimer's is when a person jumps from stage 7A to stage 7C or later, which means they lose the ability to respond to their environment, control their movements, or recognize their loved ones.
  • Severe Eating Decline: A significant decline in eating habits is when a person who used to eat full meals stops eating altogether. This can be due to severe , pain, or loss of consciousness.
  • Continuous Oxygen: A significant decline in oxygen requirements occurs when a person who needs supplemental oxygen occasionally needs it continuously. This can be due to respiratory failure, cardiac arrest, or shock.
  • Complete Immobility: A significant decline in mobility is when a person who can walk with assistance becomes completely bedridden. This can be due to paralysis, coma, or severe weakness.
  • Frequent Falls: A major decline in fall frequency is when a person who fell every one or two weeks now falls one or more times a day. This can be due to severe vision problems, medication overdose, seizures, or strokes.
  • Dietary Shift: A significant decline in diet is when a person who could eat softer food now needs pureed food that is easier to swallow. This can be due to severe dental problems, mouth sores, or choking risks.
  • Disorientation: A significant decline in orientation is when a person is confused about one aspect of their situation and becomes entirely disoriented about the person, place, time, and situation. This can be due to advanced dementia, severe , or brain damage.
  • Complexion Changes: A significant decline in complexion is when a person who has a pale yellow or subtle skin tone now becomes dusky, gray, yellow, pale, or waxy. This can be due to organ failure, infection, bleeding, or death.
  • Excessive Sleep: A major decline in sleep patterns is when a person who used to sleep twelve to sixteen hours a day now sleeps more than twenty hours a day. This can be due to coma, sedation, or imminent death.

The speed and extent of these declines can vary from person to person, depending on their illness, age, and other factors. However, they can help clinicians estimate how much time is left for the person before they die. They can also help caregivers prepare for the end of life and provide their loved ones with the best possible care and comfort.

The Importance of Documentation

Keeping a journal of the patient's is a helpful tool for caregivers but also a valuable source of information for healthcare professionals. By documenting the date and time of each change, caregivers can provide accurate and timely reports to the patient's doctor, nurse, or hospice team. This can help them assess the patient's condition, adjust the treatment plan, and determine the eligibility for or other services. Moreover, by tracking the frequency and magnitude of the changes, caregivers can estimate how fast the patient is approaching the end of life and prepare themselves emotionally and practically for the final stage.


In summary, comprehending functional decline is pivotal for caregivers providing end-of-life care, particularly in hospice settings. By diligently documenting moderate to major changes in a patient's condition, caregivers can assist in recertification visits and gain insights into the pace of decline. This article offers comprehensive examples of such declines, ranging from eating habits to mobility and mental status. Caregivers must report any moderate or significant changes to healthcare practitioners promptly. Ultimately, monitoring functional decline contributes to better preparation for patients and their families as they navigate the end-of-life journey.


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