When is enough is enough? appropriate care at the end of life

Ngaire Kerse, PhD, MBChB

Professor, General Practice and Primary Health Care, University of Auckland

NATURE|Vol 464|25 March 2010|doi:10.1038/nature08984

death rates are falling in all age groups.

Mortality, by age, by calendar year, New Zealand men, non-Maori 1900 - 2006

Years of life left 1935 (75yrs) 1925 (85 yrs) Women Men Women Men

Age 80 10.3 9.5 9.8 8.1 Age 85 7.4 7.0 7.0 5.9 Age 90 5.2 5.3 4.9 4.7 Age 95 3.5 3.6 3.3 3.2 Age 100 2.0 1.7 2.0 1.6

Proportion remaining after 1 year 1935 (75yrs) 1925 (85 yrs) Women Men Women Men

Age 80 96% 95% 96% 93% Age 85 93% 91% 91% 88% Age 90 88% 88% 87% 85% Age 95 80% 81% 78% 78% Age 100 69% 70% 68% 66%

Age and variation

Birth Older age

Context

Fortune, Mood,~ 1/3

Habits, Fitness, ~ 1/3

Society, Healthcare ~1/3

Of those 85+

• 75% independent in community• 23% working• 60% driving• 10% (in community) significant disability• 67% with CVD, 30% 5y CVD mortality• co-morbidities common

To avoid

• Long term non-steroidal anti-inflammatory drugs– Gastrointestinal haemorrhage,

renal impairment, hypertension• Benzodiazepines

– Falls caused by impaired balance

• Anticholinergic drugs – Unmasking Alzheimer’s

disease, urinary retention• Tricyclic antidepressants

– Orthostatic hypotension, sedation

• Chlorpropramide – Hypoglycaemia

• Doxazosin – Orthostatic hypotension, dry

mouth, urinary problems

Milton, BMJ 2008

Often underprescribed

• Warfarin for Afib• ACE and β blockers

for LVF• Statins for high

cholesterol• Bisphosphonates for

osteoporosis• Aspirin

Milton, BMJ 2008

CVD events Serious adverse event

CVD events Serious adverse event

Selak, Elley, 2010, JPHC

Atrial Fibrillation and warfarin

• Even Mike said he would take warfarin

When is enough enough?

• When the patient says so