Principles of palliative care for patients with multimorbidity or frailty
Patients with a life-limiting illness often have multimorbidity (the presence of 2 or more chronic conditions) or frailty (loss of physiologic reserve with resultant vulnerability to stressors).
Assess for comorbidities (including frailty) during the initial palliative care assessment by obtaining a history and examining the patient. Although limited evidence supports the use of tools for identifying and assessing comorbidities in palliative care, tools such as the Supportive and Palliative Care Indicators Tool (SPICT) or Clinical Frailty Scale may be helpful. Multimorbidity or frailty may indicate poor prognosisRothman, 2008Zucchelli, 2019.
Multimorbidity and frailty become more common with agePefoyo, 2015Vetrano, 2019 and each can occur alongside a life-limiting illness (eg dementia) or be the primary life-limiting syndromeRothman, 2008Zucchelli, 2019.
Multimorbidity and frailty increase the complexity of providing health care, including palliative care, impacting the patient’s:
- prognosis
- illness trajectory
- physical (functional and symptomatic), psychological, social and spiritual needs
- quality of life
- goals of care
- decision-making capacity
- complication risk (eg falls, cognitive impairment)
- likely treatment outcomes—interventions (such as palliative chemotherapy, haemodialysis, major surgery, admission to intensive care) may offer limited benefits and increase potential harmsBaijal, 2014Corbett, 2019Muscedere, 2017
- care setting—a setting that provides more support may be required for more complex care requirements.
Patients with frailty as their primary life-limiting condition can have similar symptoms (eg pain, fatigue, cachexia and anorexia) and psychological needs as those with cancer. Significant functional impairment is common in frailty, particularly if associated with cognitive impairment. Patients with frailty commonly want to limit medical interventions if their health is deteriorating, but are at risk of these preferences not being followed. All of these issues need to be taken into account when supporting patients with frailtyStow, 2019.