Dr Lim Zee Nee MBChB(UK) MRCP(UK) Palliative Care Physician, Hospis Malaysia 2nd June 2012 10th Malaysian

Hospice Congress

Prevalence and types of co-morbidities Impact of co-morbidities Case study General guidance on managing comorbidities at the end of life Conclusion

A case study of 15,626 patients with cancer 1984-1992 in Detroit (Ogle KS 2000et al): 1. 68.7% had co-morbidity 2. 32.6% had 2 co-morbidities 3. Co-morbidity more common in the elderly, smokers, African-American, lower socioeconomic status

COPD

Diabetes Mellitus

Osteoporosis

Co-morbidities

Arthritis

Heart disease Hypercholesterolaemia Hypertension Stroke

Depression Dementia Schizophrenia

World

Deaths in millions 7.25 6.15 3.46 3.28 2.46

% of deaths 12.8% 10.8% 6.1% 5.8% 4.3%

Ischaemic heart disease

Stroke and other cerebrovascular disease Lower respiratory infections Chronic obstructive pulmonary disease Diarrhoeal diseases

HIV/AIDS
Trachea, bronchus, lung cancers Tuberculosis Diabetes mellitus Road traffic accidents

1.78 1.39
1.34 1.26 1.21

3.1% 2.4%
2.4% 2.2% 2.1%

morbidity and mortality Affects clinical presentation of the illness and recognition of clinical syndromes Affects cancer treatment

Both cancer and presence of co-morbidity are independently associated with greater symptom burden Symptom burden with the number of comorbidities

Psychological impact 1. Depression is linked to a variety of comorbidities (21.5% in heart failure, 30% in stroke, 20% in dementia) 2. It is prevalent among cancer patients with multiple co-morbidities

Little guidance for health care professionals Disease-specific / subspecialty care model does not address the complexity of problems encountered at the end of life

Mr. GP, 85 year old gentleman Diagnosed with Lung Cancer, metastases to bone and brain Comorbidities (prior to diagnosis of cancer) 1. Hypertension 2. Ischaemic heart disease (ejection fraction 34%) 3. Stroke 4. Upper GI bleed 5. End stage renal failure (on dialysis for 2 yrs)

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 drugs may lead to problems

Formulating a prognosis is difficult It improves treatment decision at the end of life Different disease trajectory Different models of prognosis

Murray S A et al. BMJ 2005;330:1007-1011

How does this disease behave with and without intervention ? How does this disease usually progress over time ?

Is the course of the disease (either cancer or comorbidity) influenced by current interventions ? What is the risk of acute deterioration if treatment for co-morbidity is reduced or withdrawn ?

Number needed to treat (NNT) can be used to decide about starting treatment Number needed to harm (NNH) can be used to decide to stop treatment

What is the aim of treating comorbidities ? Primary, secondary or tertiary prevention ? Are we achieving patients goals ? Are we improving or maintaining patients quality of life ?

Feelings of abandonment Fear of complications of the co-morbidity Further confrontation with mortality A sense of futility of previous efforts with compliance

Addressed physical symptoms Addressed patient and familys psychosocial and spiritual issues Assessed for depression Giving information to help improve familys understanding

Conflict resolution finding a common goal Medication benefit versus burden Addressed issue regarding artificial nutrition at the end of life PRN medications prescribed

Multidisciplinary approach to care Nursing care Preferred place of care - at home

Co-morbidity is common in advanced lifethreatening illnesses Assessment has to be individualized and multidimensional in order to achieve treatment decisions at the end of life, taking into considerations the patients goals of care and his quality of life

Management of co-morbidities at the end of life include good symptom control, reducing polypharmacy and addressing any psychosocial and spiritual issues concerning the patient and family