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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.
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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
Mortality, by age, by calendar year, New Zealand men, non-Maori 1900 - 2006 death rates are falling in all age groups.
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
Warfarin for Afib ACE and β blockers for LVF Statins for high cholesterol Bisphosphonates for osteoporosis Aspirin Often underprescribed 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