How to move to a palliative approach to care for people with multimorbidityBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e6324 (Published 21 September 2012) Cite this as: BMJ 2012;345:e6324
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We read with interest the editorial by Burge et al. on a palliative approach to care.
As no studies investigated this topic by using an administrative database, we analyzed a cohort of elderly people (65-94 years old) recorded in the Prescription Administrative Database of the Lombardy Region (North of Italy) who died in 2010.[2,3] The aim was to evaluate the prevalence of drug utilization and the hospitalization rate occurred in the last year before the death, in order to highlight what treatment could be revised in the light of what has been explained by the authors.
In 2010, 70 145 elderly people died. The mean age was 81.5±7.3 years, 40% of the elderly were aged 85 years or more, and in the last year before the death 86% of them received at least one drug; 75% were exposed to polypharmacy (defined as exposure during the last year before the death to five or more different drugs) and 54% to chronic polypharmacy (defined as exposure during the last year before the death to five or more different chronic drugs, classified as the prescription of four packages with the same drug). Comparing with patients alive in 2010, the prevalence of polypharmacy and chronic polypharmacy rose from 53% to 75% and from 28 to 54%, respectively. Out of them, 73.8% received a prescription of drugs for the cardiovascular system, followed by 68.0% for the alimentary tract and metabolism and 64.4% for blood and blood-forming organs. Antithrombotic agents (56.8%) and drugs for peptic ulcer and gastro-oesophageal reflux disease (56.26%) were the most prescribed.
52 712 individuals (75% of elderly people included in the analyses) were hospitalized at least once in the last year of life, with 2.6 (±2.2) hospitalization per person. When the last hospitalization was considered, the most frequent reason was palliative care (4.2%). Grouping the diagnoses of the last hospital admission according to the main chapters of International Classification of Disease, Ninth Revision (ICD-9), patients hospitalized for illnesses of cardiovascular system were 22.8%, followed by those hospitalized for neoplasms (19.5%), and respiratory system diseases (15.4%).
Analysing the most frequently prescribed drugs in each group, patients with hospital admission for cardiovascular disease received above all antithrombotic agents (78.5%), drugs for peptic ulcer and gastro-oesophageal reflux disease (64.6%) and high-ceiling diuretics (54.6%). Patients with tumors showed an increased use of opioids (50.4%), corticosteroids for systemic use (47.1%), anti-inflammatory and anti-rheumatics products (39.7%), and antidepressants (21.1%), but antithrombotic agents and drugs for peptic ulcer and gastro-oesophageal reflux disease still remained most prescribed (75.2 and 59.9% respectively). Patients with a hospital admission for respiratory system illness were still more treated with antithrombotic agents (72.0%) and drugs for peptic ulcer and gastro-oesophageal reflux disease (69.2%), but quinolone antibacterials and inhalants for obstructive airway diseases and adrenergics rose to 50.2%, 36.1% and 34.0%.
As suggested by Burge et al, at the end-of-life it should trigger a discussion with patients and caregivers about beginning a review of goals of care, with consequent revision of treatments and limitations in investigations. Avoiding or discontinuing drugs is usually common sense in end-life care, especially when the time needed to obtain the expected benefits from the drug is longer than the life expectancy. A list of drugs that have been considered to be usually inappropriate in end-of-life care include lipid-lowering drugs, ACE inhibitors and ARBs, and anti-platelet drugs.4 Our results suggested an increased tendency in drug prescription in people at the end-of-life, also for prescribing drugs that are clearly not appropriate with this span of life.
1. Burge F, Lawson B, Mitchell G. How to move to a palliative approach to care for people with multimorbidity. BMJ 2012;345:e6324
2. Franchi C, Sequi M, Bonati M, Nobili A, Pasina L, Bortolotti A, Fortino I, Merlino L, Clavenna A. Differences in outpatient antibiotic prescription in Italy's Lombardy region. Infection. 2011;39:299-308.
3. Franchi C, Tettamanti M, Marengoni A, Bonometti F, Pasina L, Cortesi L, Fortino I, Bortolotti A, Merlino L, Lucca U, Riva E, Nobili A. Changes in trend of antipsychotics prescription in patients treated with cholinesterase inhibitors after warnings from Italian Medicines Agency. Results from the EPIFARM-Elderly Project. Eur Neuropsychopharmacol. 2012 Aug;22(8):569-77.
4. Cruz-Jentoft AJ, Boland B, Rexach L. Drug therapy optimization at the end of life. Drugs Aging. 2012 Jun 1;29(6):511-21. doi: 10.2165/11631740-000000000-00000. Review.
Competing interests: No competing interests
As a doctor working in the field of palliative care I found the editorial by Burge et al (1) thought-provoking. However, I would go further and say that palliative care is not the ‘last phase in the continuum of good care’ but is the essence of good care. The BMJ is currently full of articles about the over treatment of patients and the hubris syndrome that medicine is currently afflicted by. Life is a terminal condition and there is very little in medicine that is truly ‘curative’, though the voice of hubris may make us believe otherwise. The essence of palliative care is to comfort and enable, in this light does not the concept of palliative care extend to even the 30 year old man coming to the GP surgery with a viral throat infection seeking antibiotics? Surely in this scenario the doctor is weighing up the benefit of an intervention, in this case antibiotics, recognising it may not achieve its intended outcome, relaying this knowledge to the patient and coming up with a mutually agreed plan that eases symptoms and upholds the patient’s ability to manage life over the course of their illness.
So in summary palliative care can’t be just about ‘stopping active treatments’ as this article concludes. Most of our treatments are palliative keeping symptoms or disease at bay never really curing them. It is about clinicians being very clear about whether any single intervention will achieve its intended outcome and at what ‘cost’, the latter can only really be decided in conjunction with the patient and the cost will certainly change over time especially if the patient gets more frail. As Guthrie et al have suggested, this also means a very critical look at the evidence; how does the specific disease related guidance relate to patients with multi-morbidity(2).
Maybe there needs to be a new mantra in medicine: care always; palliate often; cure sometimes. This may allow patients and their doctors to see healthcare in a truer light.
1.Burge F, Lawson B, Mitchell G. How to move to a palliative approach to care for people with multimorbidity. BMJ 2012;345:e6324
2. Guthrie B, Payne K, Anderson P, McMurdo M, Mercer S. Adapting clinical guidelines to take account of multimorbidity. BMJ 2012;3345:e6341
Competing interests: No competing interests
I was fascinated to read Burge, Lawson and Mitchell’s editorial on a palliative approach to care. As an FY2 in general practice I completed an audit of the deaths in the practice that had occurred in the previous year. My aim was to identify how many of these patients had been identified as ‘palliative’ prior to death and in those that had not, whether there was evidence to suggest they should have been.
On the one hand, my results were encouraging – 40% of patients who had died were on the practice palliative care register at the time of death, an improvement on the quoted 29%. Furthermore, using a subjective assessment of predictability of death, a more impressive 67% of ‘predictable’ deaths were included on the register.
What was concerning however, were the discrepancies between those who appeared on the palliative care register and those who didn’t. The average age of patients included on the palliative care register was 62 years, compared to an average of 83 years in those not registered at the time of death. This 21 year age gap was concerning to me – it suggested that older patients were less likely to be identified as nearing the end of life and requiring palliative care. This appeared to be particularly the case if the patient did not have one main, life limiting illness – general decline in older patients seemed to be poorly identified.
Furthermore, only one of the patients included in my audit had a recorded preferred place of death on the GP records. A study carried out in 2004 looked at the preferred place of death of 41 patients (Thomas C Morris SM Clark D Place of death: preferences among cancer patients and their carers Soc Science and Med 58 (2004) 2431-2444). 36% of patients identified home as their preferred place of death with none identifying hospital as where they would like to die. Although 25% of the patients I audited died at home, the majority (55%) died in hospital. The figures on the Gold Standards Framework website state that 60% of patients do not die where they choose – if we are not asking patients this important question, how are we supposed to try and meet their needs?
My audit was limited by small numbers and subjectivity but the results suggested to me that we are not yet identifying patients early enough who may be nearing the end of life as recommended by the Gold Standards Framework. In particular, there may be a number of older patients who are not being appropriately identified as suitable for palliative care, an intervention which could vastly improve the quality of their remaining weeks, months or years.
Competing interests: No competing interests