International Journal of Gerontology
Volume 3, Issue 1 , Pages 1-8, March 2009

Prescribing at Times of Clinical Transition in Chronic Or Progressive Diseases

  • David C. Currow

      Affiliations

    • Department of Palliative and Supportive Services, Flinders University, South Australia, Australia
    • Southern Adelaide Palliative Services, Repatriation General Hospital, South Australia, Australia
    • Corresponding Author InformationCorrespondence to: Professor David Currow, Southern Adelaide Palliative Services, Repatriation General Hospital, 700 Goodwood Road, Daw Park, South Australia 5041, Australia
    • ,
  • Timothy H.M. To

      Affiliations

    • Southern Adelaide Palliative Services, Repatriation General Hospital, South Australia, Australia
    • ,
  • Amy P. Abernethy

      Affiliations

    • Department of Palliative and Supportive Services, Flinders University, South Australia, Australia
    • Southern Adelaide Palliative Services, Repatriation General Hospital, South Australia, Australia
    • Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA

Accepted 20 February 2009.

Article Outline

SUMMARY 

The goals of all clinical care are based on optimizing a person's comfort and function in physical, emotional, existential, sexual and social domains. Chronic, progressive illnesses generate specific challenges as systemic deterioration shifts the benefit–toxicity balance for the treatment of some long-term comorbid diseases. At every clinical encounter, and especially at times of transition in clinical care (admission to hospital, discharge to the community, a new diagnosis), the opportunity to review the management of comorbid conditions must be taken. This is especially important when a life-limiting illness is first recognized. Careful rationalization of the treatment of chronic comorbid conditions in a systematic way as a person experiences systemic deterioration requires a framework for considering short- and long-term sequelae of both treating and not treating a given condition. The preventative intent of therapy (primary, secondary, tertiary) must be known to make this clinical decision. The numbers needed to treat to avoid one adverse outcome will tend to increase as a person experiences systemic decline and, conversely, the numbers needed to harm will decrease. In addition to reviewing individual medications, consideration must be given to the total burden of prescribing for cumulative effects (e.g., risk of drug–drug interactions, anticholinergic load). Judicious dose reduction or substitution of a more appropriate agent, given the global decline, with continued careful review will allow medications to be titrated to minimize harm at the end of life.

Key Words:  chronic disease , drug prescriptions , drug therapy , iatrogenic disease , palliative care

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 This paper was presented as a plenary in December 2008 at the International Conference on Geriatric Emergency and Intensive Care Medicine, Taipei, Taiwan.

PII: S1873-9598(09)70014-6

doi:10.1016/S1873-9598(09)70014-6

International Journal of Gerontology
Volume 3, Issue 1 , Pages 1-8, March 2009

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