Medical and moral considerations regarding complex medical decisions in older patients with multimorbidity: a compact deliberation framework

摘要

In health care for older adults, patients with multimorbidity usually receive the same interventions as those patients without multimorbidity. However, standard curative or life-sustaining treatment options have to be considered carefully in view of the maximally attainable result in older and frail patients. To guide such complex medical decisions, we present a compact deliberation framework that could assist physician(s) in charge of the medical treatment of a specific elderly patient to systematize his own thinking about treatment and decisional responsibilities, in case of an intercurrent disease. The framework includes four questions to be addressed when deciding on a single urgent standard curative or life-sustaining intervention in acute medical problems of an elderly patient with multimorbidity: 1) What is known about the patient’s aims and preferences? 2) Will the intervention be effective? 3) Will the intervention support the aims and preferences of the patient? 4) In view of the aims and preferences, will the risks and benefits be in balance? If all four considerations are answered favorably, the intervention will fit patient-centered and appropriate care for frail older patients with multimorbidity. Application to a patient case illustrates how our framework can improve the quality of the shared decision-making process in care for older people and helps clarify medical and moral considerations regarding how to appropriately treat the individual patient.