Prescribing at Times of Clinical Transition in Chronic Or Progressive Diseases

SUMMARYThe goals of all clinical care are based on optimizing a person's comfort and function in physical, emotional, existential, sexual and social domains. Chronic, progressive illnesses generate specific challenges as systemic deterioration shifts the benefit–toxicity balance for the treatment of some long-term comorbid diseases. At every clinical encounter, and especially at times of transition in clinical care (admission to hospital, discharge to the community, a new diagnosis), the opportunity to review the management of comorbid conditions must be taken. This is especially important when a life-limiting illness is first recognized. Careful rationalization of the treatment of chronic comorbid conditions in a systematic way as a person experiences systemic deterioration requires a framework for considering short- and long-term sequelae of both treating and not treating a given condition. The preventative intent of therapy (primary, secondary, tertiary) must be known to make this clinical decision. The numbers needed to treat to avoid one adverse outcome will tend to increase as a person experiences systemic decline and, conversely, the numbers needed to harm will decrease. In addition to reviewing individual medications, consideration must be given to the total burden of prescribing for cumulative effects (e.g., risk of drug–drug interactions, anticholinergic load). Judicious dose reduction or substitution of a more appropriate agent, given the global decline, with continued careful review will allow medications to be titrated to minimize harm at the end of life.