Editorials

How to move to a palliative approach to care for people with multimorbidity

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e6324 (Published 21 September 2012) Cite this as: BMJ 2012;345:e6324
  1. Fred Burge, professor of family medicine1,
  2. Beverly Lawson, senior research associate1,
  3. Geoffrey Mitchell, professor of general practice and palliative care2
  1. 1Dalhousie University, Family Medicine, NS, Halifax, Canada, B3H 2E2
  2. 2University of Queensland, Ipswich, QLD 4305, Australia
  1. fred.burge{at}dal.ca

Doctors must actively guide patients in decisions to scale back treatment when appropriate

In the first editorial in this series, Mangin and Jamoulee commented on a recent Institute of Medicine report, Living Well with Chronic Illness, which called for a paradigm shift from disease based models of care to one focused on care for patients.1 Recently, Haggerty, when discussing continuity of care for patients with multimorbidity, highlighted that patients can experience chaotic care.2 As patients with multimorbidity age and healthcare providers face increased problems with delivering complex care, doctors must identify when it is appropriate to broach the subject of scaling back or stopping treatment; they must then decide in what particular order to taper or eliminate treatments. How can clinicians and patients move through the change from disease modifying treatment to a palliative approach to care with the strong continuity Haggerty suggests?

Consider an elderly woman with five illnesses who lives alone. She has heart disease, severe osteoarthritis and rheumatoid arthritis, hypertension, and a foot ulcer; she is also poor and socially isolated, with no children living nearby. The key question for the coordinating clinician to ask is: “Would I be surprised if this person were to die in the next 12 months?”3 If the answer is “no” it should trigger a discussion with the patient and caregivers about beginning a review of goals of care, with consequent revision of treatments and limitations on investigations. For patients who have borne a large burden of multiple drug treatments, frequent diagnostic testing, and numerous healthcare appointments, support in making this transition is often a relief.

An approach to identifying those who may benefit from scaling back treatment, assessing their needs and goals, and planning and communicating care is outlined in the gold standards framework for people nearing the end of life.4 Taking this approach ensures a “palliative approach” to care that begins much earlier in the denouement of peoples’ lives than is usual when palliative care is limited to active engagement of specialised palliative or hospice programmes. Palliative care generally aims to improve the quality of life for people with life limiting illnesses and for their families by reducing their suffering though early identification and the assessment and treatment of pain as well as physical, cultural, psychological, social, and spiritual needs.5 We recommend that such a palliative approach be taken much earlier in the trajectory of life limiting illnesses. A key part of embarking on the palliative approach to care is communicating the plan to other members of the healthcare team, so that unnecessary interventions do not go ahead as routine. Strong continuity of primary care in advanced disease has been shown to be associated with fewer emergency room visits and a greater chance of the patient’s dying out of hospital.6 7

A recent study in Scotland estimated that only 29% of all those who die have been identified and placed on a general practice palliative care register.8 Considering the prevalence of multimorbidity, particularly with increasing age, this suggests that only a small proportion of people who may benefit from a palliative approach to care get it. Tools to support the identification of patients who are at risk of dying within a year are only just emerging. Examples are the supportive and palliative care indicators tool (SPICT) and Scottish patients at risk of readmission and admission (SPARRA), which uses hospital based electronic data.9 10 Evaluation of such tools that integrate information from multiple sources about individual patients at risk is needed.

Once patients are identified as being suitable for a palliative approach an active strategy to engage patients and families in this process is needed. A tool recently developed by Scott and colleagues to help minimise unnecessary medication (polypharmacy) in older people is useful.11 More of these tools are needed to help with making decisions within the palliative approach to care and in communicating the decisions to others.

Over the past few decades doctors have become slaves to single disease guidelines and their recommendations and, often, to the financial incentives that accompany them. We worry that we might be seen as inadequate providers if we do not follow individual best practice guidance. It is vital, however, that we build methods to integrate contextual evidence into shared decision making for those with multimorbidity.12 Most importantly, we must enable and support healthcare providers in their professional responsibility to guide decisions on moving towards a palliative approach to care and we must support them to actively make recommendations in this regard.

The transition to a palliative approach to care is not a “transition” from one form of care to another. Just as the early symptom experience, the diagnosis, patient education, and chronic disease self management are all phases through which we progress, the palliative approach is the last phase in the continuum of good care for patients with multimorbidity in whom multiple active treatments are no longer appropriate. The best doctors know when to help patients understand that it is time to stop active treatment. They also know when to have gentle, caring, supportive conversations to realise a new set of shared goals. At times these conversations may be easy and at times they are hard, but they shouldn’t be avoided because goal oriented person centred care is the only sensible approach to caring for those with multiple chronic conditions who are approaching the end of life.

Notes

Cite this as: BMJ 2012;345:e6324

Footnotes

  • Competing interest: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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