NUR3500 Chap.2 Models of Care and Illness Trajectories
Models of Care and Illness Trajectories
A model of care is a claim about timing
The three models contrasted in this course disagree about one thing only: at what point palliative input begins relative to treatment aimed at the disease. In the traditional model it begins after curative treatment ends, sequentially, and support covers the end of life only. In the integrated model it runs alongside curative care on a parallel track across the whole illness.
In the bow tie model the two run concurrently with a gradual, patient led shift in emphasis from disease management towards comfort and bereavement support.
Each model has a characteristic failure and those are worth learning as carefully as the definitions. The sequential model guarantees that the first palliative contact happens during a crisis, with no relationship and no plan.
The integrated model lets two teams plan separately unless coordination is deliberate. The bow tie model can be described in a meeting and never actually enacted, so the balance never shifts.
Why the sequential model survives
It is rarely defended in writing and it is still common in behaviour, because a referral made after active treatment stops feels tidy.
The cost lands on the family, who learn that a palliative referral means the clinicians have run out of options, and that lesson makes every later conversation harder.
Three trajectories, three prognostic problems
Function plotted against time produces three shapes. Progressive cancer preserves function for a long period and then falls steeply over weeks or months.
Chronic organ failure shows long term limitation with acute exacerbations, each of which may be fatal, so the timing of death often looks sudden. Frailty and dementia show a prolonged dwindling from a low baseline with no clearly identifiable terminal phase.
The clinical value of these shapes is that they tell you when to have a conversation, not when someone will die.
In organ failure the exacerbation that brings a person into hospital is the natural moment to ask what they would want if the next one were worse. In frailty nothing marks the transition, so the conversation has to be scheduled rather than triggered.
In cancer the curve misleads in the opposite direction, because preserved function reads to a family as time in hand.
Two cautions about the curves
These are population shapes. An individual may carry two at once, and where they do, the steeper one governs the planning.
A curve also says nothing about suffering: a person on the slow frailty path may have years of unrelieved pain and caregiver strain, which is exactly the group that historically received least specialist input because no single moment ever looked urgent.
Putting the two ideas in one sentence
The trajectory tells you how much warning the illness will give.
The model tells you whether your service is organised to act on that warning before it disappears. A referral prompt such as complex symptom needs, psychosocial or spiritual distress, caregiver burden, or deterioration despite optimal treatment is the point where both questions become live at once.
What this chapter covers
- 01
Traditional, integrated and bow tie models
- 02
The characteristic failure of each model
- 03
Cancer, organ failure and frailty trajectories
- 04
Choosing the moment for the conversation
- 05
Referral prompts and settings of care
Choosing the model and the moment
- 3Name her trajectory and identify which part of the pattern carries prognostic weight.
- 2Say what would follow if the sequential model were used instead.
- 2Describe what integrated involvement would add now.
Key terms
- Traditional model
- A sequential arrangement in which palliative care begins only after curative treatment has ended, so support covers the end of life alone.
- Integrated model
- A parallel arrangement in which palliative care runs alongside curative treatment across the whole illness trajectory.
- Bow tie model
- A concurrent arrangement in which disease management narrows while comfort and bereavement support widen, with the balance shifting gradually.
- Illness trajectory
- The characteristic shape that function takes over time in an advanced illness, used to judge how much warning the illness gives.
- Organ failure trajectory
- Long term limitation punctuated by acute exacerbations, each potentially fatal, with a baseline that does not fully recover.
- Prolonged dwindling
- The slow decline from a low baseline seen in frailty and dementia, with no clearly identifiable terminal phase.
Models of Care and Illness Trajectories FAQ
How do I know when to start the goals of care conversation?
Use the trajectory. In organ failure an acute exacerbation is the natural trigger, because instability and engagement coincide. In frailty and dementia nothing dramatic marks the change, so the discussion must be scheduled. In cancer the steep late fall means planning should happen while function still looks preserved.
Does an integrated approach mean stopping active treatment?
No. The two tracks run together, so respiratory treatment, dialysis or chemotherapy can continue while a second team works on symptoms, on what matters to the person and on support at home. Withdrawing treatment is a separate decision made on its own merits.
Why do two patients with the same diagnosis need different planning?
Because individuals can carry more than one trajectory at once, and the steeper shape governs the timeline. Someone with dementia who develops cancer should be planned around the cancer curve rather than the dementia curve.
Exam move
Draw the three curves from memory on one axis, then label each with the conversation it demands and the moment that conversation is easiest to have. Next, write the three models as three sentences about timing, and add the failure each one produces.
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