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Key Clinical Questions
How does the physician approach a patient with multiple comorbidities? How are they different than other patients?
How do multiple comorbidities and functional status affect a patient’s prognosis?
How does the physician take prognosis into account when formulating treatment plans for patients?
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CASE 105-1
A 79-year-old woman with moderately severe chronic diseases (obstructive pulmonary disease, osteoporosis, osteoarthritis, type 2 diabetes mellitus, and hypertension) was admitted to the hospital for a complicated urinary tract infection. She had recently moved to the area and needed to establish primary care following discharge. Her newly assigned primary care physician requested that “good maintenance medications” be prescribed for her chronic diseases prior to discharge. However, if the relevant clinical practice guidelines were followed, the patient would be prescribed 12 medications (her cost $406 per month) along with a complicated nonpharmacological regimen (see Table 105-1). The patient did not find these recommendations to be practical.
The patient with moderately severe chronic diseases expressed her wishes to keep her medications to a minimum. She did not want to spend the rest of her life eating bland food. She worried about a low blood sugar (HgA1c is 7.3%), particularly since she had been living alone since the death of her husband. Her physicians reduced her glyburide dose to 5 mg, a change likely to be associated with a slightly higher HgA1c. According to the life expectancy tables, she had 4.6 years of life left. A nutritionist educated her how to liberalize her diet to her satisfaction. Her wishes were communicated to her new primary physician who will periodically reevaluate the changes.
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