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Dr Lim Zee Nee MBChB(UK) MRCP(UK)Palliative Care Physician, Hospis Malaysia
2nd June 201210th Malaysian Hospice Congress
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Prevalence and types of co-morbidities Impact of co-morbidities
Case study
General guidance on managing co-morbidities at the end of life
Conclusion
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A case study of 15,626 patients with cancer1984-1992 in Detroit (Ogle KS 2000et al):
1. 68.7% had co-morbidity
2. 32.6% had
2 co-morbidities3. Co-morbidity more common in the elderly,
smokers, African-American, lowersocioeconomic status
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COPD Diabetes Mellitus
Osteoporosis Arthritis
Heart disease DepressionHypercholesterolaemia DementiaHypertension SchizophreniaStroke
Co-morbidities
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World Deaths in millions % of deathsIschaemic heartdisease
7.25 12.8%
Stroke and othercerebrovasculardisease
6.15 10.8%
Lower respiratoryinfections 3.46 6.1%
Chronic obstructivepulmonary disease
3.28 5.8%
Diarrhoeal diseases 2.46 4.3%
HIV/AIDS 1.78 3.1%
Trachea, bronchus,lung cancers 1.39 2.4%
Tuberculosis 1.34 2.4%
Diabetes mellitus 1.26 2.2%
Road traffic accidents 1.21 2.1%
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morbidity and mortality Affects clinical presentation of the illness and
recognition of clinical syndromes
Affects cancer treatment
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Both cancer and presence of co-morbidity are
independently associated with greatersymptom burden
Symptom burden with the number of co-morbidities
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Psychological impact
1. Depression is linked to a variety of co-morbidities (21.5% in heart failure, 30% in
stroke, 20% in dementia)
2. It is prevalent among cancer patients withmultiple co-morbidities
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Little guidance for health care professionals
Disease-specific / subspecialty care model
does not address the complexity of problemsencountered at the end of life
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Mr. GP, 85 year old gentleman Diagnosed with Lung Cancer, metastases to
bone and brain Comorbidities (prior to diagnosis of cancer)1. Hypertension2. Ischaemic heart disease (ejection fraction
34%)3. Stroke4. Upper GI bleed5. End stage renal failure (on dialysis for 2 yrs)
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Changes take place at the end of life Polypharmacy risk of drug interactions (risk
> 80% with > 7 drugs prescribed)
Withdrawal of drugs or continuation of drugsmay lead to problems
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Formulating a prognosis is difficult It improves treatment decision at the end of
life
Different disease trajectory
Different models of prognosis
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Murray S A et al. BMJ 2005;330:1007-1011
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How does this disease behave with andwithout intervention ?
How does this disease usually progress over
time ?
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Is the course of the disease (either cancer orcomorbidity) influenced by currentinterventions ?
What is the risk of acute deterioration iftreatment for co-morbidity is reduced orwithdrawn ?
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Number needed to treat (NNT) can be used todecide about starting treatment
Number needed to harm (NNH) can be usedto decide to stop treatment
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What is the aim of treating comorbidities ? Primary, secondary or tertiary prevention ?
Are we achieving patients goals ?
Are we improving or maintaining patientsquality of life ?
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Feelings of abandonment
Fear of complications of the co-morbidity
Further confrontation with mortality
A sense of futility of previous efforts withcompliance
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Addressed physical symptoms Addressed patient and familys psychosocial
and spiritual issues
Assessed for depression
Giving information to help improve familysunderstanding
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Conflict resolution finding a common goal Medication benefit versus burden
Addressed issue regarding artificial nutritionat the end of life
PRN medications prescribed
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Multidisciplinary approach to care Nursing care
Preferred place of care - at home
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Co-morbidity is common in advanced life-threatening illnesses
Assessment has to be individualized andmultidimensional in order to achievetreatment decisions at the end of life, takinginto considerations the patients goals of careand his quality of life
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Management of co-morbidities at the end oflife include good symptom control, reducingpolypharmacy and addressing anypsychosocial and spiritual issues concerning
the patient and family