Sense and nonsense of treatment of comorbid diseases in terminally ill patients.
Sense and nonsense of treatment of comorbid diseases in terminally ill patients.
复制标题
绝症患者合并症治疗的意义与废话。
作者：
E. Geijteman;Teun van Gelder;L. van Zuylen
Story From the Front Lines A 69-year-old woman was diagnosed as having metastatic pancreatic cancer. She had a history of type 2 diabetes mellitus, which was diagnosed 7 years earlier. Initially, her diabetes was controlled by strict adherence to a healthy lifestyle. For example, she had stopped eating ice cream, which she was very fond of. Two years prior to the cancer diagnosis, she had started metformin therapy, and hemoglobin A1c level measurements of 6.8% were achieved. She was treated with palliative chemotherapy, and during each cycle she received dexamethasone to reduce associated nausea. During the first 2 cycles, her blood glucose level rose as high as 288 mg/dL (to convert to millimoles per liter, multiply by 0.0555), for which she received short-acting insulin. At home, without dexamethasone use, her measured blood glucose levels were occasionally slightly above the upper limit of target values. During the third treatment cycle, the patient’s husband told the ward physician that his wife treated the slightly high blood glucose levels by not eating until the levels came down to normal. The physician—who had an interest in palliative care—told the patient and her husband that higher glucose levels were not a problem as long as they caused no symptoms. Because of her limited life expectancy, development of long-term organ damage was unlikely. This information was very disconcerting to the patient, who subsequently asked the nurse whether the physicians had thrown in the towel and whether she was going to die soon. She had always been told that it was of utmost importance that glucose levels do not exceed target values. The physician repeated that higher glucose levels were unlikely to do her any harm, especially in the absence of symptoms of hyperglycemia. He emphasized that her caregivers were not going to abandon her. In contrast, they were in fact applying tailored therapy. The patient appreciated this explanation, and despite her nausea, she was keen to eat her beloved ice cream, ignoring its effect on blood glucose level. Teachable Moment Pharmacotherapy is the appropriate use of drug therapy aimed at preventing and treating a disease or to relieve symptoms. In the final phase of life, the goals of treatment change, and drugs used to prevent or treat chronic diseases need to be reconsidered.1 In diabetic patients without complications, no benefit of tight glucose control can be expected for at least a decade.2 In addition to limiting burden and adverse effects, discontinuing drug use in patients with limited life expectancy may actually improve quality of life and survival. In a recent randomized trial, discontinuation of statins in patients with a life expectancy of less than 1 year led to improved quality of life and a trend toward longer life span compared with continued use of these drugs.3 Continuing medication use at the end of life also has important impacts on health care costs. Discontinuing statin therapy alone in patients with a life expectancy of less than 1 year could save the US health care system $603 million annually.3 General considerations when prescribing medication for patients at the end of life include the patient’s life expectancy, time until potential benefit of treatment, goals of care, and treatment targets.4 Guidelines for treatment of diabetes in terminally ill patients recommend reducing or eliminating frequent blood glucose measurement, considerably increasing tolerated glucose levels, and minimizing or discontinuing use of medications.5 As in our patient, decreasing or discontinuing medication use at the end of life may run counter to previous management and lead patients to worry that they are being abandoned.1 Physicians need, therefore, to consider both the physical and psychosocial effects of withdrawing treatment. In our case, the physician initially failed to address the patient’s fears, but after receiving a full explanation of the altered aims of treatment, she was very satisfied with her care. Pharmacotherapy in terminally ill patients is not a simple task because physicians must adapt drug treatments to new objectives.1 This case illustrates that such adapted management may improve quality of life and potentially reduce unnecessary and costly pharmacotherapy.
胰岛素和糖尿病。
DOI：
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发表时间：
1986
期刊：
Transactions of the Association of American Physicians
影响因子：
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作者：
Mako,ME;Rubenstein,AH
通讯作者：
Rubenstein,AH