1. Downing, G. Michael MD
  2. Lynd, Patricia Jean PT, BSc
  3. Gallagher, Romayne MD, CCFP
  4. Hoens, Alison PT, MSc, BSc


This article has 2 purposes: to inform the health care provider's response to the common question asked by older adults with advancing illness, "How long do I have?" and to provide caregivers with a framework which can guide provision of care in advancing illness. Both purposes are addressed by exploring 3 major concepts associated with declining functional ability: (1) common functional changes and strategies to identify and manage these changes, (2) the extent to which prognostic tools provide insight for the prediction of rate of decline, and (3) the transitions in the focus of care that are required with advancing disease. Although the article is focused on the residential care setting the concepts examined can be applied more broadly to other practice settings such as palliative care. Declining functional ability is a common feature of the journey toward end of life. Irreversible decline in function is frequently accompanied by the resident and family's need to understand the probable duration of survival and the caregiver's need to adjust priorities for care. To better inform the clinician's response to the question of "How long do I have?" prognostic tools which incorporate measurement and interpretation of declining function can be utilized to improve the ability to predict survival. A 10-step approach to formulating and discussing prognosis is presented to assist clinicians in predicting rate of decline and sharing difficult news. Finally, in recognition of how declining functional ability affects priorities for provision of care, a framework which advocates the shift in focus from function, to safety, and ultimately to comfort, is provided.