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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