General practitioner clinical decision making for patients with life-limiting illness: does the presence of complex multimorbidity make a difference?

A blog post written by Raechel Damarell, PhD Candidate, College of Nursing and Health Sciences, Flinders University

As the Australian population ages, general practitioners are increasingly required to manage patients burdened by multiple chronic conditions, or 'multimorbidity'. For many of these patients, at least one of their conditions will be non-curable, life-limiting, and progressive. The continuity of care provided by general practice can place GPs at the centre of sensitive discussions around uncertain disease trajectories, changing goals of care, and the initiation of a palliative approach nearer the end of life. We currently know little about the influence of significant multimorbidity on GP management decisions in this context, or if a different care approach is even required. 

The patient and carer experience of multimorbidity
Patients with multimorbidity and their carers are known to experience a reduced quality of life and often report worse experiences of general practice. [1] This could be due to the significant burden of treatment and self-management placed on patients with multimorbidity, adding to an already heavy symptom burden, or even disability. Patients are usually required to attend multiple health appointments crossing all sectors of the health care system, follow complex, perhaps conflicting drug regimens, while dealing with any adverse side effects. One Australian study placed the time required for such activities as high as 5-8 hours per day. [2] 

The general practitioner experience of multimorbidity
The existing literature highlights a number of unique and emerging challenges faced by general practitioners in providing the bulk of care for patients with multimorbidity:  

• The research evidence available to GPs for therapeutic decision making is based largely on studies involving younger, healthier patients with single - not multiple - conditions. This means GPs must generalise research conclusions based on non-representative participants to very different real-world patients. [3]
• Research studies to date have little to say about what happens at the intersection between different chronic conditions and how drugs prescribed for a specific condition might impact on both another condition and the drugs taken for its treatment. In this way, the faithful application of 'high level' evidence can pose real risks to patients in terms of adverse interactions and an imposed burden of treatment. [4]     
• GPs may lack experience or confidence initiating conversations around changing goals of care when active treatment is no longer beneficial. This includes discussions of advance care planning and perhaps even deprescribing medications that the patient still believes important.

Until funded research begins to prioritise questions around care for patients with multimorbidity, GPs may have to live with a certain degree of clinical uncertainty in their therapeutic decision making, relying to a greater extent on their own clinical judgement and expertise in interpreting written guidance at the individual patient level.

Evidence Based Medicine vs Patient Centred Care
This epidemiological shift towards greater patient and care complexity may necessitate a move away from a reliance on the standardised (some say 'industrialised' [5]) application of evidence towards a greater appreciation of the particular goals and preferences of individual patients and their unique personal contexts. This 'patient-centred' approach places the patient-family unit, its motivations and concerns, at the centre of the healthcare experience, rather than an array of services or even the traditional authority of clinicians. Patient-centredness also emphasises the importance of shared decision making.
 
The patient-centred approach is not without challenges for GPs. There is currently little consensus on the most effective way to elicit patient/carer preferences, especially within the limited time of a consultation. [6] There is also little supporting guidance on how best to communicate uncertainty about the potential harms and benefits of therapies. Furthermore, we know that shared decision making, and tools for facilitating it, are still underutilised in the clinical consultation. [7] 

A recent study into the effectiveness of the patient-centred approach for multimorbidity care found significant improvements in patients' experiences of care [8] but no improvements in patient outcomes such as quality of life. This begs the question: might improvement in care experience be a desirable end in itself? 

My program of research
My PhD program of research will investigate Australian GP experiences of managing patients with multimorbidity and a life-limiting illness. It will seek to understand GP perceptions of their own role in providing such care within our healthcare system, as well as the ways in which they negotiate the challenges of reconciling available research evidence with the values, goals, and preferences of patients and their families.

If you would like more information about this study, please contact Raechel.Damarell@flinders.edu.au

References

1. Paddison CAM, Saunders CL, Abel GA, Payne RA, Campbell JL, Roland M. Why do patients with multimorbidity in England report worse experiences in primary care? Evidence from the General Practice Patient Survey. BMJ Open. 2015;5(3).              
2. Jowsey T, McRae IS, Valderas JM, Dugdale P, Phillips R, Bunton R, et al. Time's up. Descriptive epidemiology of multi-morbidity and time spent on health related activity by older Australians: a time use survey. PLoS One. 2013;8(4):e59379.
3. Guthrie B, Payne K, Alderson P, McMurdo ME, Mercer SW. Adapting clinical guidelines to take account of multimorbidity. BMJ. 2012;345:e6341.
4. Hughes LD, McMurdo ME, Guthrie B. Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity. Age Ageing. 2013;42(1):62-9.
5. Salisbury C. Multimorbidity: redesigning health care for people who use it. Lancet. 2012;380(9836):7-9.
6. Wieten S. 'What the patient wants': an investigation of the methods of ascertaining patient values in evidence-based medicine and values-based practice. J Eval Clin Pract. 2018;24(1):8-12.
7. Stacey D, Légaré F, Lewis K, Barry MJ, Bennett CL, Eden KB, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2017;2017(4): CD001431
8. Salisbury C, Man MS, Bower P, Guthrie B, Chaplin K, Gaunt DM, et al. Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. Lancet. 2018; 392:41-50.

Raechel Damarell, PhD Candidate, College of Nursing and Health Sciences, Flinders University