It's one thing to understand how, say, a parent's or spouse's diabetes should be managed. But what about when that same person also has hypertension, a history of depression, and the beginnings of memory loss – and then suffers a heart attack? Suddenly you're swimming in medical advice, prescriptions, and confusion.
A few days ago, the New York Times illuminated a subject I hear about often from families dealing with people caring for aging family members: [How to treat multiple health problems] (http://www.nytimes.com/2009/03/31/health/31sick.html). Multimorbidity, doctors call it. I tend to say, "multiple system failure," although both terms sound unnecessarily grim.
Typically, the situation quickly becomes too complicated for the patient to follow on his or her own. And it's no easier on you. The main problem is that medicine has grown so specialized and aggressive, there aren't well-defined protocols for approaching these complex – but make no mistake, very common -- cases.
Here are 6 starting-place questions to ask the doctor treating your loved one:
- How will your findings be communicated to his or her other medical care providers? I'll never forget the nephrology team arriving at my late mom's hospital room, jubilant that her kidney issue had been resolved – on the very morning she'd signed herself into hospice because of metastatic cancer. She was confused: How can I be dying if these doctors "fixed" me? The problem, of course, was that one group of (less relevant) specialists wasn't in such great communication with another. In a hospital setting, ask who's the case's care coordinator, but even then, assume nothing. Speak up when you confer with docs about what their colleagues treating other ailments have shared.
- Can you recommend a good geriatrician or palliative care clinician? A caring primary-care doc can do a great job of coordinating and ferreting through complex care. Or she may defer to specialists when the complexities get thorny. Geriatricians give you an edge because they're physicians who specialize in the unique and multiple diseases of aging. They'll take into account the person's lifestyle and the side effects of a given treatment, and balance that against other issues the person faces. The downside is that they're scarce and in high demand. Palliative care is medical or comfort care provided by doctors, nurses, or social workers that focuses on reducing discomfort and disease severity while improving quality of life. It's a useful option for people who have incurable diseases but aren't necessarily at death's door.
- Are we treating the forest or the trees? My mom's coordinating internist gave me this useful analogy. The person is the forest. Each of the multiple conditions is a tree. Rather than going along on autopilot with the customary treatment for each disorder, probe about each one. Is it really worth treating, say, high cholesterol or osteoporosis or even slow-growing prostate cancer in an 85-year-old with advancing dementia? There aren't always easy or clear answers, but it's always worth pondering.
- What are the goals here? To get everyone (including, of course, the person being treated) on the same page, it helps to articulate together the aims for treatment. Doctors zero in on disease management and cure. Don't overlook or discount lifestyle goals like, "To help Dad live alone as long as possible" or "To allow Gran to remain alert and eventually die at home."
- Are there meds here we really don't need? Facing eight or 10 prescriptions is a huge cost, a coordination and swallowing hassle, and psychological downer – and that's before considering possible dangerous drug interactions. Make sure you understand the purpose of each, and get the doctor to justify it in consideration of the whole scene. Even justifiable meds may not be necessary in some cases.
- When should I schedule another appointment to discuss this in detail? Physicians are time-pressed. If you're feeling brushed off by a complicated case, ask to come back to pursue it with conference time especially allotted for the purpose.
Have other questions that helped you?