Approach to managing comorbidities in palliative care

This topic provides a general approach to managing comorbidities in palliative care. The Palliative Care guidelines also provide advice on managing the following life-limiting conditions, which may be the primary condition or a significant comorbidity:

• cancer
• dementia
• heart failure
• kidney disease
• liver disease
• motor neurone disease
• Parkinson disease
• respiratory disease
• stroke.

Treatment of comorbidities in palliative care depends on the patient’s prognosis, goals and preferences, which may change over time.

Starting palliative care does not always require a change in comorbidity management. Sometimes changing management can worsen symptoms, increase palliative needs and decrease quality of life. For example, it is ideal to continue management of major psychiatric disorders (eg schizophrenia) for as long as possible because of the risk of relapse if treatment is withdrawn.

Changes to drug therapy for comorbidities are often needed as life-limiting illnesses progress, because of pharmacokinetic or pharmacodynamic changes, swallowing difficulties or interactions with other drugs or conditions. For guidance on managing changes to drug therapy, see Medication rationalisation in palliative care and Principles of medication management in palliative care.

As appropriate, consider relaxing treatment targets, reducing monitoring or stopping treatments—see Withdrawing or withholding treatment in palliative care. Ensure treatments continue to provide benefit while minimising burdens and harms. This may involve medication rationalisation or focusing management on different priorities. For example, a patient with an advanced life-limiting illness who has hypertension and type 2 diabetes may be at higher risk of harm from adverse effects (eg hypotension, hypoglycaemia) associated with the treatment of these conditions than the complications associated with the conditions themselves. This is particularly relevant in the last months of life during which it may be appropriate to relax dietary restrictions and treatment targets and minimise interventions to avoid short-term complications of hyperglycaemia and hypertension.

Ideally, a multidisciplinary team, in consultation with the original treating specialists or teams, should guide comorbidity management in palliative care—see Coordination of palliative care. When changes to management are proposed, if possible, engage in shared decision-making with the patient or supported decision-making with the patient and their support person. Discuss, as relevant:

• the potential benefits and harms of continuing versus withdrawing therapy, relaxing treatment targets or reducing monitoring
• the process of withdrawing therapy, relaxing treatment targets or reducing the frequency of monitoring—highlight this process is a trial and therapy can be resumed if required
• any fears and concerns of the patient, their substitute decision-maker and carer about changing the approach to management.

For further information on decision-making in palliative care, see Overview of decision-making and ethical challenges in palliative care.

If a change is agreed, make a plan with the patient or their substitute decision-maker, the patient’s carers, and relevant healthcare professionals.

Continue to review the harms and benefits of management throughout illness progression. As a patient’s condition deteriorates, changes to management are often required; make a plan to address anticipated problems—see General care planning.