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

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.

[Hip fracture in patients with dementia: surgery is not always the best alternative]. / Heupfractuur bij patiënten met dementie; opereren niet altijd vanzelfsprekend.

Patients with dementia are at risk of hip fracture. The prognosis of rehabilitation after surgery is less favourable than in the general population, because of higher mortality, more complications and a longer rehabilitation period. We present 2 female patients with dementia (77 and 86 years old) who each received a different therapy: one surgical, the other conservative. Dutch elderly care physicians make use of advance care planning to determine how to make medical decisions. The policy for treatment might be curative, palliative or symptomatic. When making a medical decision, it is important to consider if a treatment is effective, proportional and if the intended outcome is desirable. In some cases of hip fracture in patients with dementia, conservative treatment and withholding surgery can be good care. More investigation is needed for further evidence-based decision-making.