Clearing the Air

I’ve been reading “The Uninhabitable Earth: Life After Warming,” an extensively researched account of where we are headed that begins with the warning: “It is much, much worse than you think.” When I got to the chapter depressingly entitled “Unbreathable Air,” I encountered the following shocking sentence: “Pollution has been linked with increased mental illness in children and the likelihood of dementia in adults.” Now I’ve seen all kinds of things associated with dementia: head trauma, assorted medications (anticholinergic drugs, anti-anxiety drugs, and anti-ulcer drugs), aluminum. Some of those links have become well-established over time, such as head trauma. Some of have been totally debunked, such as aluminum. Others are questionable and I’ve written about them on this blog (drugs). But air pollution? This was a new one to me. 

Most likely, I figured, it would prove to be another spurious association. Probably, I thought, there was some other factor that was associated with both air pollution and dementia. The alleged connection would be like the link between washing machines and colon cancer—a favorite example of a “confounder” from my medical school epidemiology class. People who own washing machines, it turns out, do have a higher rate of colon cancer than people who don’t. But they also vary in where they live and what they eat, which is far more important than their possessing a washing machine. Surely air pollution was likewise a marker for something that did matter. But then, as I read on in Wallace’s book, I came to an even more dramatic statement: “An enormous study in Taiwan found that, for every single unit of additional air pollution, the relative risk of Alzheimer’s doubled.” This I had to look into.

The “enormous study in Taiwan” was published in a minor but respectable journal, the Journal of Alzheimer’s Disease in 2015. It was large: it was a cohort study of 95,690 adults aged 65 and older followed prospectively for 10 years beginning in 2001. Not only was it large, but it was a random sample drawn from Taiwan’s National Insurance Research Database comprised of 23 million people, or 99 percent of the entire Taiwanese population. Moreover, Taiwan has 70 EPA monitoring stations distributed over the island, allowing it to have reasonably accurate measures of both ozone exposure and small (less than 2.5 micrometers) particulate measure. Finally, the population is fairly stable over time, allowing for fairly good estimates of exposure based on home address. The conclusion? The risk of newly diagnosed Alzheimer’s disease (adjusting relevant co-morbidities such as stroke, hypertension, and diabetes) rose steadily with the rate of exposure to ozone or small particulate matter—going up, for example by 211 percent for each 10.91 ppb increase in ozone.

Taiwan isn’t the only place where a relationship between air pollution and dementia has been discovered. In 2017, a similar study entitled “Exposure to Ambient Air Pollution and the Incidence of Dementia: A Cohort Study,” appeared in Environmental International. Carried out in Ontario, Canada and involving a cohort of just over two million adults, this analysis attributed just over six percent of all dementia cases to air pollution. 

Neither study is conclusive, but they’re awfully suggestive. I wondered if there had been any further work on this subject since Wallace wrote his book. Lo and behold, a systematic review was just published by Peters et al from Australia, also in the Journal of Alzheimer’s Disease. These authors found thirteen reasonably well-conducted studies bearing on the question. They concluded that small particulate matter (containing nitrogen) and carbon monoxide are both associated with an increased risk of dementia. 

These reports are very disturbing in light of the Trump administration’s systematic assault on air pollution regulation. According to an article just published in the New York Times, 85 environmental rules are being rolled back, including 24 in the arena of air pollution. Of these 24, 10 have already been undone and another 14 are “in process.” 

We already know that climate change will have an enormous impact on health, principally through its multitudinous indirect effects—for example, by causing drought, which in turn affects agricultural productivity, which in turn results in death. Now there may be another health risk to add to the list of adverse effects of environmental harm. Dementia is such an enormous public health problem that even measures that only slightly affect the risk of developing this devastating condition may be worthwhile. But the good news is that air pollution is an area where we can intervene. We even know how to. The last thing we should be doing is unraveling the progress we have made. So, speak up, tell your senators and representatives to act, and vote wisely to decrease the pollution that threatens us all.

Caveat Emptor!

Quite by accident, I stumbled upon Kurt Eichenwald’s memoir in the new book section of my local library. I remembered the author from his work as an investigative reporter who uncovered massive white collar crime. His book, The Informant, about just such a scandal, became a best seller and a movie starring Matt Damon. When I realized the new work had a medical theme, I was intrigued; when I discovered that much of the story unfolded at Swarthmore College, where Eichenwald had been a student, and where I had been a student some years earlier, I decided I had to read it.

At first glance, you might think that A Mind Unraveled has no relevance for geriatrics. The diagnosis and misdiagnosis of Eichenwald’s temporal lobe epilepsy as well as the shockingly misguided treatment by ostensibly reputable physicians all took place in the early 1980s, when the author was a teenager or in his early twenties. Unfortunately, the book’s messages are all too relevant for older patients today. Distilled to their essence, those messages are first, that not all doctors are created equal and second, that communication is key. The long, complicated, and riveting story of lying, arrogance, and sheer incompetence that led to those conclusions is worth reading. I read the entire 380-page book in a single weekend, devouring it much as I would a spy thriller.

The not-all-doctors-are-created-equal conclusion is particularly relevant to older individuals because even physicians who are competent within their sphere of expertise often have little knowledge or understanding of geriatric issues. In my last post, commenting on recent data indicating that despite all we have learned about preventing falls, older people are falling—and injuring themselves—at higher rates than ever before,  I suggested that a critical weakness of prevailing fall-prevention systems is that they hinge on the knowledge and interest of physicians, both of which are often absent. Identifying a physician who is a good diagnostician, a kind person, and who actually knows about falls, confusion, polypharmacy, cognitive impairment, incontinence, and other common geriatric syndromes is imperative, particularly for frail older people. Finding such a person can be challenging, and being confident s/he has the requisite expertise is also challenging. Board certification in geriatrics is one indicator; working with a multidisciplinary team including a nurse practitioner is another; word of mouth is a third. Trial and error may prove the only way to be certain you have found the right person: come to your first appointment with a checklist of topics the physician should be sure to address such as functional status and advance care planning. If the physician doesn’t address those issues during an annual physical exam, absent a compelling need to focus on an acute medical problem, it’s probably time to find someone else.

The communication-is-key conclusion is relevant to all physician/patient interactions, but is especially important for older people, many of whom have hearing problems or cognitive impairment. It took multiple tries before Eichenwald found a neurologist who understood that given that all the medications used in the treatment of epilepsy have potential side effects, choice of which drug to use involves balancing risks and benefits. The patient’s preferences, which side effects s/he finds tolerable in exchange for how much benefit, are essential in making a choice of drugs. For geriatric patients, the role of preferences is often paramount in medical decision-making. The assumption that the goal of treatment is cure may simply not apply to an 88-year-old with multiple medical problems; maintaining or bolstering his ability to remain independent may, for example, outweigh the benefits of disease eradication. Or cure may be irrelevant, as with some cases of prostate cancer, if the odds are that the patient will die of some unrelated problem long before his prostate cancer metastasizes, but the risk of surgical treatment causing incontinence or impotence now is great. 

Regrettably, the dismissive attitude of Eichenwald’s physicians to him as a person are all too familiar to many older individuals. Just as many of the neurologists in A Mind Unraveled failed to take their patient seriously as a person with anxieties, concerns, and understanding, so too do physicians often neglect to treat their older patients with respect and sensitivity. To find a physician who listens you cannot rely on board certification. Word of mouth can help (if the mouths belong to people you trust, preferably people whose personalities and medical problems are similar). But once again, trial and error may be the best path. Don’t hesitate to use yourself as a barometer. Only you can gauge whether you “clicked” with the physician. Just as you should be reluctant to listen to the shoe salesman who assures you that those very uncomfortable shoes will improve with time, you should ignore at your peril the internal voice that tells you to stay away from a particular physician.

I would like to believe that Eichenwald’s experience was highly unusual. Most physicians who treat epilepsy know that a negative EEG doesn’t mean there’s no seizure disorder (but the presence of characteristic electrical changes indicates there is). Most physicians would monitor blood counts when prescribing a medication that has a “black box warning” from the FDA stating that the drug can cause life-threatening bone marrow depression and that regular blood tests are required. No competent clinician would offer a diagnosis of a brain tumor based solely on a few of the patient's behavioral quirks. And I haven’t even touched on the arrogance and prejudice that animated members of the Swarthmore administration, leading to their expelling young Eichenwald—and then readmitting him when faced with the prospect of what for them was an unwinnable suit charging civil rights violations (in particular, violation of Section504 of the Rehabilitation Act of 1973 requiring educational institutions to meet the needs of students with disabilities). 

We can only hope that the behavior described in this memoir is extraordinarily rare in colleges and universities today. But we do know that just as systematic racism persists today, so too does systematic ageism. Caveat emptor! 

Tell Me A Story

Come then, and let us pass a leisure hour in storytelling, and our story shall be the education of our heroes. (Plato)

The story—from Rumpelstiltskin to War and Peace—is one of the basic tools invented by the human mind for the purpose of understanding. There have been great societies that did not use the wheel, but there have been no societies that did not tell stories. (Ursula Leguin)

In his new book, The Conversation, my friend and colleague, Angelo Volandes, makes the case for using videos to help patients and their families understand what lies in store for them as they approach life's end. He quotes one of his patients—a working class Irish-American with advanced brain cancer: “if a picture is worth a thousand words, a video is worth hundreds of thousands.” And Angelo’s videos can be very helpful: they are designed to be clear, short and accurate, to show real patients with real diseases undergoing actual treatment for their illness. But the irony is that the power of this book, and it is powerful, is all in the words.

Joining the ranks of other prominent writer-physicians such as Abraham Verghese, Oliver Sacks, Jerome Groopman and Atul Gawande, Volandes tells stories. His most engaging are those that are the most intensely personal: the wife of a professor he worked for as an undergraduate who terrified her husband—and the young student preparing meals for them—as she coughed up blood and struggled to breathe; and his own father, who decided after a series of debilitating cardiac events that he would not want to undergo attempted CPR. The stories illustrate with great poignancy the different ways that patients experience the final stage of their lives. His message is that it’s important to write your own story: whether you have a good ending or a bad one depends not so much on the path you follow as on whether you chose that path. As he puts it, “there are no right and wrong decisions about medical care at the end of life; rather, the value lies in making a fully informed choice.”

Really? Are all choices equally good? In The Conversation, we learn about 10 patients, among whom 6 make explicit decisions about what kind of medical treatment they want, and 4 are unable to make decisions so the care they receive is what their families or their doctors recommend. Most of the patients in the book who make their own choices, either after watching Angelo’s videos or after going on a guided tour of the ICU or dialysis unit to see what lies ahead (nobody in this book thought about their preferences any time before the end was imminent), choose to focus on comfort; only 2 persist in their wish that the doctors “do everything.” And the 4 patients who did not participate in the decision-making themselves, all of whom underwent aggressive, sometimes “brutal” treatment in their last weeks or months of life, are presumed to have gotten treatment that they couldn’t possibly have wanted, had they only been engaged in the process of deciding.

Consider the Italian matriarch who had a feeding tube and repeated courses of treatment for pneumonia after developing advanced dementia. She suffered mightily in her “last miserable weeks” of life, as did her family. Or take the elderly Ukrainian-American with lung cancer who underwent repeated attempts at CPR and assorted invasive procedures even though he had “one foot in the grave.” Young Angelo, the physician at the center of these resuscitative efforts, describes the treatments as putting “terminal cancer patients through torture.” The presumption is that if only these patients had known the truth about what modern high tech medicine does to dying patients, and if only they had then been asked what they wanted, they would have opted for comfort care.

So it’s not just that most patients don’t want treatment that has virtually no chance of doing anything for them other than causing extreme discomfort; it’s that no patients want this. The reason that any of Angelo’s patients opted for maximal medical treatment is that even though they understood what the treatment entailed, they didn’t fully  accept their own situation: they did not believe that they were dying. The husband of a young woman dying of metastatic breast cancer comments that “you never know what new chemo is on the way,” even though his wife has hours to live and no drug is going to descend from the lab deus ex machina to save her. The 79-year old African American with end-stage kidney disease says he’s “been through harsher things than this” and “God has given me a second chance before.”

Physicians cannot force patients to accept our diagnoses and prognoses, assessments made based on scientific training and clinical judgment. We cannot require them to accept our recommendations for treatment. Nor, in contemporary society, can we withhold what we believe to be futile treatment as long as we are not 100% certain that it cannot possibly prolong life, even by a few hours. But we can do a better job informing patients and families of the reality as we see it so that they can choose wisely. Videos can help, but above all, so can stories, stories that acknowledge our mortality and capture the realities of advanced illness.The real power and the beauty of The Conversation stem not from its exhortation to have a conversation about preferences for end of life care, and not from its discussion of videos that can jump start the conversation, but rather from the stories themselves.

From Dust to Dust (or Dustbin?)

The new IOM report, “Dying in America,” is a masterpiece. Written in the matter-of-fact language typical of non-partisan reports by committees of experts, it makes recommendations with which no rational person could possibly disagree. Of course a few extremists have already gone on record as disagreeing: a spokesman for the National Right-to-Life movement was quoted in the NY Times as claiming that the report’s alleged focus on “cost slashing” would reinforce “well-founded fears” that advance care planning is intended to “push patients to accept premature deaths.” The truth is that the report says relatively little about cost and what it does say is simply that a side effect of following its recommendations, suggestions made in the spirit of improving the quality of care and assuring that patients’ wishes are followed, will likely be a fall rather than a rise in the cost of health care.

The report includes “clinician-patient communication and advance care planning” as the topic of one of its 5 recommendations, and it is presumably this section that is the core of the right wing critique. But the explicit goal of advance care planning is to enable patients to participate in decisions about their health care and to make those decisions in accordance with their values, goals, and (informed) preferences. The report rightly recognizes that this isn’t going to happen unless clinicians take the initiative and that all the planning in the world will be inconsequential unless it is implemented when you become ill. The idea that discussing what kind of medical care you want near the end of life is tantamount to suicide is patently absurd. It would be more accurate to say that failing to discuss your wishes is tantamount to assuring you will spend your final days in the hospital, tethered to machines, and in pain.

While the recommendations of “Dying in America” are straight-forward and unobjectionable, they are also cleverly designed to be “actionable,” to lead to concrete steps to promote change. Its recommendation regarding the delivery of care states that “government health insurers and care delivery programs, as well as private health insurers, should cover the provision of comprehensive care for individuals with advanced serious illness who are nearing the end of life.” This is in marked contrast to the language of the IOM’s 1998 report, “Approaching Death: Improving Care at the End of Life,” which addressed the same theme by urging that “people with advanced, potentially fatal illnesses and those close to them should be able to expect and receive reliable, skillful, and supportive care.” The only way that patients can “expect” to receive this kind of care is if the delivery system provides it.

In a similar spirit, “Dying in America” tackles professional education and development by urging that certification, licensure, and accreditation of clinicians require evidence of competency in palliative care. By contrast,  the earlier report exhorted educators and other health professionals to “initiate changes in undergraduate, graduate, and continuing education to ensure that practitioners have relevant attitudes, knowledge, and skills to care well for dying patients.” Without specifying what those changes are or requiring that they be reflected in licensing exams or accreditation processes, not very much will—or did—happen.

Finally, the new report singles out payment systems as critical to promoting change, suggesting that health care delivery systems—the networks of hospitals, doctors, and clinics that actually provide medical care—must provide the services that comprise comprehensive palliative care and health insurers must pay for them. The preceding report acknowledged the role of financing, but embedded its recommendation amongst a series of quality improvement measures and spoke in very general terms of the need to “revise mechanisms for financing care so that they encourage rather than impede good end-of-life care.”

The weakest recommendations of both old and new reports on dying are for ongoing public education and engagement. Other than the specific suggestion that professional societies should publish brochures and that government agencies should support relevant research, there is little beyond a vague exhortation that faith-based organizations, consumer groups and others talk about the end of life. Previous public engagement campaigns, of which the Robert Wood Johnson’s multi-million dollar “Last Acts” program was the most spectacular and the “Conversation Project” the most recent, proved disappointing. Perhaps the forthcoming campaign, to be supported by the same anonymous donor who subsidized (but had no control over the contents of) the current report, will elaborate further.

My main concern is that this spectacular report will be filed away, as happens with so many comprehensive, thoughtful reports on all sorts of topics Certainly the IOM has had some notable successes. “To Err is Human: Building a Safer Health System,” issued in 1999, did shine a bright light on medical errors and catalyzed efforts to make American hospitals safer. But the IOM has produced 898 reports, according to its website. How many of those have had an impact and how much impact have they had?

I could just as well ask: What makes a book a best seller? Why do certain fashions catch on and not others? Publicists have their own ideas about how to sell books (which, speaking from experience, tend to be pretty unimaginative and outdated); Madison Avenue has its model for advertising campaigns and marketing strategies. Malcolm Gladwell, in his book “The Tipping Point,”itself a bestseller, argued that to create a “social epidemic,” you need 3 crucial kinds of people (connectors, mavens, and salesmen), you need to make sure the content is “sticky enough” to be retained by those who are affected, and you need to be sure the context is right. 

“Dying in America” lays out the facts and the arguments. It offers "actionable" recommendations, but the question is whether anyone will act on them.  The implementation campaign must begin now, otherwise this magnificent report on “dust to dust” will go into the dustbin.

Dollars for Dying

A recent article in the Huffington Post focused attention on an often neglected part of the American health care scene, hospice. Unfortunately, by relying largely on interviews, chiefly with angry and very vocal family members of patients who died while enrolled in hospice, and very little on data, the article distorts reality.

The article:  “..Dying became a multibillion dollar industry.”

The reality: Just under 2.5 million Americans die each year, three-quarters of them over age 65. It’s about time we started to spend money on taking care of them competently and compassionately. Hospitals are also a multi-billion dollar industry. Is that bad?

The article: “Many providers are imperiling the health of patients in a drive to boost revenues and enroll more people;” i.e., the problems are due to for-profit hospices.

The reality: 63% of the 5500 hospices in existence today are for-profit, along with a growing proportion of hospitals and medical practices, but despite several studies comparing the quality of for profit hospices to that of not-for-profit hospitals, it’s been impossible to pinpoint any important areas where ownership status predicts quality. A study by Wachterman et al in JAMA in 2011 showed that the median length of stay was longer in for-profit hospices (20 days vs 16 days), largely reflecting a larger proportion of patients with dementia and a smaller proportion of patients with cancer. But does this demonstrate poor quality? Don’t patients with Alzheimer’s disease deserve to be enrolled in hospice? Isn’t the median length of stay in hospice widely held to be excessively short, with 35% of patients dying within a week of enrollment? And don’t other health care institutions deliberately offer some lucrative services (think hospitals providing a transplant program) in order to subsidize money-losing services (think mental health programs?) What’s so surprising or unfortunate about for-profit hospices having the business savvy to compensate for the low per diem reimbursement (Medicare paid hospices $153/day for home care in 2012, which was supposed to pay for nursing visits, home health aides, social work care, medications, and supplies)? Another study in 2011 reported the results of a national survey of hospice programs and found adherence to National Quality Forum measures of quality to be high, with for-profit hospices doing better in some areas and not-for-profit hospices in others. 

The article: Hospice representatives “troll the halls” of hospitals in search of patients.

The reality: Since the seminal SUPPORT study of 1995 documenting the large proportion of American hospitalized patients who die in pain, burdened by invasive and ultimately non-beneficial care, there has been widespread acknowledgment that Americans receive too little palliative care. One study done in nursing homes found that when attending physicians received a note informing them that a patient met the criteria for hospice, the rate of hospice referral soared from 1% of eligible patients to 20%. Are reminders to physicians overly intrusive? Is having a hospice representative available at the hospital to discuss their program with patients promptly when called by the attending physician aggressive? Or does it facilitate a quick and smooth transition from curative care to comfort care?

That said, anyone who has taken care of patients enrolled in hospice is aware that the quality of hospice care is not uniformly excellent, despite surveys revealing that 75% of families with a relative under hospice care at the time of death rated quality as excellent, compared to only 49% of families whose dying relative was cared for in the hospital. What can we do to further improve the hospice experience?

Three approaches come to mind, regulatory, economic, and educational. The regulatory tack, advocated in the Huffington article, is reasonable—if exercised cautiously. Nursing homes were transformed from unsanitary firetraps warehouses for elderly individuals to sterile, medicalized facilities. They are now the most highly regulated American industry; some have claimed more tightly regulated than nuclear power plants. In the process, they stopped being homes and became institutions. The majority of hospice care is delivered in the home. The challenge will be to design regulations that promote quality and prevent abuses without destroying the essence of hospice care. 

The economic strategy is what MedPAC (the Medicare Payment Advisory Commission) advocates. At MedPAC’s recommendation, the ACA includes a provision allowing Medicare to change its current uniform daily rate to a higher rate for the first few days and the final days a patient is enrolled in hospice, with a lower rate for the intervening days. This will make enrolling patients with dementia less financially attractive, thus ensuring compliance with hospice’s current eligibility criteria, though whether this will improve quality is questionable. 

The educational strategy, really an approach to communication, translates the claim that hospices enroll people who “don’t  belong in hospice” into a concern about poor communication. I have watched hospital discharge planners and hospice representatives promote hospice to patients. They describe all the services that hospice will provide: nursing visits, home health aide hours, respite care, bereavement services, prescription medications, and so forth. They typically say less about what hospice does not provide, such as (with the exception of so called open access hospice) palliative radiation or palliative chemotherapy or blood transfusions. When I broach hospice care with a patient, I start by determining the patient’s overriding goal of care. Is it to live as long as possible? Is it to focus exclusively on comfort? Or is it somewhere in between—mainly wanting comfort but being willing to put up with certain kinds of unpleasant medical treatments in exchange for living longer? Only once I know what the patient wants—and ideally am satisfied that the family accepts the patient’s perspective—do we talk about the best way to achieve their goals. If hospice is the best way, then I tell them so. If it’s not, we discuss what approach would be most conducive to their goals.

Hospice is far from perfect and my natural tendency is to be suspicious of for-profit health care. But what's wrong with hospice care and how to fix it are not quite so obvious. We need more data and better analysis before we act.

Lotsa Lumps

Geriatrics would be a good deal easier if every older person suffered from just one medical condition. But most elderly people have more than one chronic disease and the older they are, the more chronic conditions they are likely to have. Since “multiple chronic conditions” is a mouthful, researchers coined the term “multimorbidity,” an only slightly less awkward way of expressing what is probably one of the most critical features of geriatric existence. It’s so critical because the best medical treatment, known as “evidence-based medicine,” is founded on studies of patients who don’t have multimorbidity at all. They are generally perfectly healthy except for the single disease being studied. So when we tell a patient that “studies show’ that blood pressure should be below 140 and that the best medication to take if the blood pressure is elevated is a diuretic, we mean that if the only problem is high blood pressure, then taking the diuretic is the best way to lower the risk of bad outcomes such as strokes and heart attacks. But if the patient also has another chronic condition, say Parkinson’s disease, which is being treated with the medication L-dopa (Sinemet), then giving that patient a diuretic to lower blood pressure could backfire—long before any heart attacks or strokes were prevented, the patient might fall down (both L-dopa and diuretics contribute to sudden falls in blood pressure when a person stands up) and break a hip. Simply assuming it makes sense to apply multiple guidelines to a patient with multiple problems can result in medication lists a mile long that cost a fortune and that cause more problems than they solve. So multimorbidity is a big deal in geriatrics. Now, for the first time, multimorbidity is getting the attention it deserves.

A couple of years ago, the American Geriatrics Society set up a task force to develop an approach to multimorbidity for physicians. This group generated a report that lays out the basic principles that should underlie care for a patient with multiple chronic conditions. And a recent symposium brought together physicians and researchers from a variety of backgrounds to come up with strategies for generating a better evidence base, for designing new guidelines, and for carrying out appropriate systematic reviews for patients with multimorbidity. The results of the symposium are published as 3 articles along with an editorial in the April issue of the Journal of General Internal Medicine. 

I wish I could report that these new guidelines-for-producing- guidelines came up with the solution to the problem of multimorbidity. I wish I could summarize the gist of these papers. They constitute a valiant attempt to find an answer to a vexing problem. They go far in enumerating the many obstacles to a solution. They provide an exhaustive list of all the issues that must be addressed in the future. But in the end, they advocate a technical solution to a dilemma that can only be addressed by eliciting patient preferences and by use of clinical judgment.

There are just too many different clusters of chronic diseases for physicians to come up with recommendations that clearly and unambiguously apply to a given patient. Consider just the 10 most common chronic diseases. For any group of 10 diseases, there are 45 pairs of diseases and 120 groups of 3 diseases and 210 groups of 4 diseases—and that doesn’t include clusters of greater than 4, even though plenty of older people have, say, arthritis, diabetes, heart disease, emphysema, and kidney problems. Even if it were practical to design a guideline for all the most common groupings, which it isn’t, that wouldn’t be good enough. What matters is not just how many diseases you have, but how sick you are and how well you can go about your day to day business (what geriatricians call your functional status). Someone who lives independently and shops and cooks for herself is in far better shape—and able to withstand a new medication or a brief hospitalization—than her counterpart with the same underlying chronic conditions who lives in a nursing home and needs help with all her daily activities.

I tend to agree with an article in the British Medical Journal that argues that “multimorbidity introduces clinical uncertainty in a way that is unlikely to be resolved by ever more sophisticated guidelines.” The authors advocate listening to patients to find out what matters to them and using clinical judgment to try to achieve their ends. A similar recommendation came from the American Geriatrics Society task force,  which even created a pocket card summarizing their key conclusions: consider patient preferences, consider prognosis, consider interactions among treatments, review the entire care plan, and communicate and decide on treatment together with patient and family. 

More research that measures quality of life outcomes as well as survival outcomes is of course important. But empirical studies alone will not solve the multimorbidity problem. Talking to patients about their overall health status and their goals of care, and figuring out together what tests and treatments make most sense in light of their status and their goals, just might.