Background Three trajectories of physical decline have been identified towards the end of life: (i) a short period of evident decline typically experienced by patients with cancer; (ii) long term limitations with intermittent serious episodes typically experienced by patients with organ failure; and (iii) prolonged dwindling typically experienced by patients with frailty or dementia. An understanding of these trajectories will facilitate anticipatory care planning and decision-making as end-of-life approaches.

Aim To determine the dominant illness trajectories of nursing care home residents, and to explore multimorbidities in this patient group.

Method We collected data as part of a larger project to improve palliative care in South Edinburgh care homes. Eight participating care homes completed an after death audit form for the last ten residents who died prior to the project starting. This included their cause of death and main and other diagnoses.

Results Data on 77 residents was reviewed. The illness trajectory of 90% of residents was characterised by prolonged dwindling, although 30% of residents experienced mixed illness trajectories. About half of those with a mixed trajectory experienced dementia and cancer while half experienced dementia and organ failure. 67% of residents experienced two or more chronic morbidities. Overall, 78% had dementia.

Conclusion Nine out of ten nursing home residents experienced prolonged dwindling prior to death. Most had multiple morbidities and high symptom burden. Traditionally palliative care services have been modelled on the needs of patients with malignant disease. Interventions to improve palliative care in nursing homes need to be modelled on patients who experience prolonged dwindling characterised by dementia.