Multimorbidity and palliative care: the role of goals of care

A blog post written by Dr. Dimity Pond

In 2019 Raechel Damarell wrote about clinical decision-making in the context of multimorbidity and life-limiting illness. An excellent blog with which I fully agree. However, while the importance of patient-centredness was discussed the intervening COVID-19 pandemic has brought us all a new awareness of social and psychological multimorbidity in addition to medical multimorbidity. The recently updated palliAGED Evidence and Practice pages on this topic also emphasise the importance of eliciting a person’s preferences and priorities, and the emerging role of supported-decision-making as part of that process. But also noted is the ongoing need to identify the ‘best’ structured approaches for establishing and documenting such discussions. So, here I want to look at multimorbidity and palliative care from within that broader framework.

There are many issues that arise. There are so-called “medical” ones, around prescribing and so on, and there are psychological ones including the importance of:
 

• facilitating psychological preparation for dying when that is possible (an important role for the primary care team, as it often doesn’t happen in hospital settings),
• social aspects of care, including mending or addressing old family rifts, dealing with the immediate social and carer stress around dying, financial issues and other life factors that influence our provision of palliative care, including the desire to die at home.
   

As noted by Raechel, multimorbidity can place GPs in the centre of discussions around revision of complex goals of care and how to adapt the palliative approach to these revisions. For example, I have seen doctors speak about reviewing medium- and long-term goals for optimal control of blood sugar and cholesterol levels to prevent strokes and heart attacks for a person in the last few months of life. This is difficult and confronting for doctor and patient alike. But handled sensitively, it can facilitate deprescribing at a time when the burden of pill taking may be difficult for the patient.

It is entirely appropriate to engage the patient in reviewing their goals of care in the context of life limiting illness, and indeed recent literature has pointed to the importance of establishing goals of care for all our patients with complex multimorbidity (Muth et al, 2014). Often multiple chronic diseases and associated multiple specialists’ inputs, each with their own goals of care, can produce conflicting medication regimes and a high burden of “work” for the patient in terms of self-care and managing their medications (Corbin & Strauss, 1985). While the doctor may make some executive decisions when such conflict is apparent, a more patient-centred approach includes a discussion around the person’s goals of care, which can then guide medication decisions. This is even more apparent in the palliative setting.

Inevitably such discussion will reveal a need for the patient to make meaning of their life, as they review their life goals. I have frequently listened to patients’ stories about their life as they move towards their life’s end. This may be a form of “accommodative coping”:

“Accommodative coping refers to flexibly adjusting goals to constraints and impairments. This may take the form of re-appraising the nature of the loss or limitation, re-evaluating the importance and meaning of particular goals, and directing resources to alternative attainable goals. Accommodation involves revising values and priorities, constructing new meaning from the situation, and potentially transforming personal identity .” ( Cappeliez, & Robitaille (2010, p808)). The GP can be enormously helpful here, simply by recognising the process, facilitating it by listening and reflection back to the patient, and translating it into revised goals of care for the patient and the family.

These goals, as with all the goals in our care plans, may encompass more than just physical health. They will involve that person’s value system (for example, do they want to take one last trip to visit family overseas, or hold off dying until that last grandchild graduates?) and the physical care we recommend - including prescribing - can be guided by that. Like all goals, they may need to be modified along the way (maybe that distant brother simply does not want to talk to them even though he knows they are dying). The GP can help to make meaning from that (“You should be pleased that you tried your best”, for example). New goals may emerge (“I just want to be able to …one last time.. – how can we make that happen?”).

Case conferencing with the team can also promote the achievement of goals of care. Agar (2017) examined case conferencing with the family, GP and residential aged care staff, for end of life care for patients with dementia. While results were mixed, the systematic approach pointed towards better assessment of the patients in the group with case conferencing as part of their care, compared with those patients without case conferencing.

So, in cases of multimorbidity in palliative care there is benefit from a focus on goals of care. This can be facilitated by the GP in promoting values discussions along the way, and discussion with as many as possible of the family and caregiver team. These goals can then guide the GP and other team members in medical and non-medical management that aligns with patient values. The increased focus on better understanding a person’s priorities is a welcome addition to the updated palliAGED pages. As the evidence emerges it is hoped that this will grow to include guidance on supporting psychosocial and medical needs alike in the context of multimorbidity.



Dr. Dimity Pond
Professor of General Practice (2003 - 2022)
University of Newcastle



Agar M, Luckett T, Luscombe G, Phillips J, Beattie E, Pond D, et al. (2017) Effects of facilitated family case conferencing for advanced dementia: A cluster randomised clinical trial. PLoS ONE 12(8): e0181020. https://doi.org/10.1371/journal.pone.0181020.

Cappeliez, P., & Robitaille, A. (2010). Coping mediates the relationships between reminiscence and psychological well-being among older adults. Aging & Mental Health, 14(7), 807–818.

Corbin J, Strauss A. Managing Chronic Illness at Home: Three Lines of Work Qualitative Sociology, 8(3), Fall 1985.

Rachael Demmerel; General-practitioner-clinical-decision-making-for-patients-with-life-limiting-illness-does-the-presence-of-complex-multimorbidity-make-a-difference (caresearch.com.au).

Muth, C., van den Akker, M., Blom, J.W. et al. The Ariadne principles: how to handle multimorbidity in primary care consultations. BMC Med 12, 223 (2014). https://doi.org/10.1186/s12916-014-0223-1.