Education And Debate

Managing comorbidities in patients at the end of life

BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7471.909 (Published 14 October 2004) Cite this as: BMJ 2004;329:909
  1. James Stevenson, registrar1,
  2. Amy P Abernethy, assistant professor2,
  3. Cathy Miller, staff specialist3,
  4. David C Currow (david.currow@rgh.sa.gov.au), professor4
  1. 1 Southern Adelaide Palliative Services, Repatriation General Hospital, 700 Goodwood Road, Daw Park, South Australia 5041, Australia
  2. 2 Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA Division of Medical Oncology
  3. 3 Division of General Medicine, Repatriation General Hospital
  4. 4 Flinders University, Adelaide, Australia Department of Palliative and Supportive Services
  1. Correspondence to: D C Currow
  • Accepted 5 July 2004

Chronic conditions require careful management in patients who develop a life limiting illness. Doctors need to consider both the physical and psychological effects of treatment

Introduction

A 68 year old woman with extensive small cell lung cancer and rapid weight loss also has long term mild hypertension with no evidence of end organ damage. What would you do about her antihypertensive treatment?

  1. Stop drug treatment because she has a terminal illness

  2. Continue the drugs because you would not want her blood pressure to get worse (and the conversation about stopping them may be difficult because last year you told her she would be taking these drugs for the rest of her life)

  3. Wait until she develops postural hypotension and then consider reducing her drugs

  4. Reduce her drugs and watch carefully.

People with progressive life limiting illnesses are often also taking drugs for treatment or prevention of long term conditions.1 However, little guidance exists to help clinicians consistently and systematically manage chronic comorbidity. Some clinicians stop drugs for chronic conditions arbitrarily because the person has a progressive life limiting illness. At the other end of the therapeutic spectrum, some clinicians do not stop any long term treatments until the patient is unable physically to take them or suffers adverse effects. Competent care for people with life limiting illnesses requires careful management of their long term drugs. We outline some key considerations.

Patients with life limiting illness

Life limiting illnesses include advanced cancer, end stage organ failure, neurodegenerative disease, and AIDS. Common conditions that need active management at the end of life include hypertension, atrial fibrillation, hypercholesterolaemia, thromboembolic disease, dementia, osteoporosis, diabetes mellitus, and arrhythmia. Patients may also be taking hormone replacement therapy, immunosuppressive therapy after transplantation, or drugs to prevent opportunistic infections in people who are immunocompromised. Both the life limiting illness and comorbidity change clinically …

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