What is the best approach to manage the care of a 78-year-old female patient with multiple comorbidities, including depression, anxiety, CHF, CAD, COPD, DMII, ESRD, and HTN, who is on dialysis and has a history of sepsis and acute renal failure?

Management of a 78-Year-Old Female with Advanced Multimorbidity on Dialysis

This patient requires immediate palliative care integration alongside disease-directed therapy, with a focus on symptom management, advance care planning, and a multiprofessional team approach rather than aggressive single-disease guideline adherence, given her advanced age, ESRD on dialysis, multiple end-stage organ diseases, and limited functional status. 1

Immediate Priority Actions

Advance Care Planning (Urgent - Within This Visit)

• Initiate advance directive completion immediately, as progressive cognitive decline from neurogenic bladder complications and recurrent sepsis may impair future decision-making capacity 1
• Provide the Five Wishes booklet and direct patient to prepareforyourcare.org for structured advance care planning 2
• Document specific preferences regarding: hospitalization frequency, intensive care, mechanical ventilation, cardiopulmonary resuscitation, artificial nutrition/hydration, and preferred location of death 1
• Given strained family dynamics, facilitate a family meeting with social work present to clarify healthcare proxy and decision-making authority 2

Palliative Care Referral (Immediate)

• Refer to palliative care for co-management today, not as end-of-life care but as concurrent supportive care alongside nephrology and cardiology 1
• Palliative care will address: dyspnea management (currently on 6L NC with DOE), pain assessment (patient denies pain but has multiple pain-causing conditions), psychosocial support for anxiety and depression, and care coordination across multiple specialists 1
• The KDIGO guidelines emphasize that comprehensive conservative care should be delivered by a multiprofessional team including nephrologist, nurse, psychosocial worker/counselor, dietician, and integration with specialist supportive care 2

Prognostic Assessment and Goals of Care

Life Expectancy Discussion

• This patient's life expectancy is significantly limited, likely 6-18 months, based on: age >75 years, ESRD on dialysis, HFrEF (EF 38%), recurrent sepsis, wheelchair-bound status, and multiple hospitalizations 2, 1
• The KDIGO conference noted that survival advantage of dialysis disappears in patients over 75 years with high comorbidity burden and poor functional status 2
• Frame discussions around "what matters most" to the patient rather than disease-specific targets 2

Domain-Based Assessment Framework

Apply the American College of Cardiology's four-domain model at each visit 2:

Medical Domain:

• Review all medications for appropriateness using Beers Criteria given polypharmacy risk 2
• Assess dialysis tolerance and symptom burden from ESRD 2
• Monitor HFrEF symptoms (currently has 1+ pitting edema suggesting suboptimal volume management) 1

Physical Functioning Domain:

• Patient is wheelchair-bound, ambulates only 50 feet with PT - this indicates severe functional limitation 2
• Fall risk is high (history of fall with wrist fracture, wheelchair-bound, on 6L oxygen) 2
• Stage 2 pressure ulcer on left buttocks requires wound care consultation and pressure relief optimization 2

Mind and Emotion Domain:

• Refer to psychiatry for depression and anxiety management as requested 2
• Depression and anxiety are undertreated in patients with COPD and cardiovascular disease, and psychological interventions probably reduce both depression (SMD -0.36) and anxiety (SMD -0.57) 3, 4
• Screen for cognitive impairment using Mini-Cog at next visit given age, recurrent sepsis, and multiple hospitalizations 2

Social and Physical Environment Domain:

• Recent move to assisted living with strained family dynamics creates care coordination challenges 2
• Assess health literacy and ensure patient understands complex medication regimen 2
• Evaluate financial toxicity of multiple medications and dialysis treatments 2

Disease-Specific Management Priorities

Heart Failure Management

• Optimize diuretic therapy as primary intervention for 1+ pitting edema, recognizing dialysis may be primary volume management tool 1
• Continue current HFrEF medications but do not aggressively uptitrate given limited life expectancy and risk of adverse effects 2
• Target blood pressure <140/80 mmHg (not more aggressive targets) to avoid fall risk and hypotension 1

ESRD and Dialysis Management

• Continue current dialysis schedule but reassess goals: is dialysis improving quality of life or prolonging suffering? 2
• Comprehensive conservative care (dialysis withdrawal) should be presented as a viable option if dialysis is not meeting patient's goals 2
• Coordinate with nephrology regarding medication dosing adjustments for renal function 1

Neurogenic Bladder and Infection Prevention

• Continue indwelling catheter given history of urinary retention and recurrent UTIs with self-catheterization 2
• Ensure proper catheter care education for assisted living staff to prevent catheter-associated UTIs 2
• Consider urology consultation if catheter-related complications develop 2

Depression and Anxiety

• Psychological interventions may moderately improve mental health quality of life (SMD 0.63 for MCS) 4
• Consider antidepressant therapy, though evidence in COPD patients with comorbid depression is inconclusive 3
• Pulmonary rehabilitation and collaborative care models show promise for reducing depression/anxiety in COPD patients 3

Pressure Ulcer Management

• Stage 2 pressure ulcer requires wound care consultation 2
• Optimize nutrition (patient reports "fair" appetite - may need nutritional supplementation) 2
• Ensure pressure relief with appropriate wheelchair cushion and repositioning schedule 2

Care Coordination Structure

Establish Patient-Centered Medical Home

• Designate yourself as primary care coordinator to prevent fragmented care across multiple specialists 2
• Create a single medication list reconciled with patient's actual bottles at next visit (bring daughter 30 minutes early for this) 2
• Establish communication system with nephrology, cardiology, psychiatry, wound care, and palliative care 2

Interdisciplinary Team Composition

The team should include 2:

• Primary care physician (you) as care coordinator
• Nephrologist for dialysis management
• Palliative care for symptom management and advance care planning
• Psychiatry for depression/anxiety
• Physical therapy for mobility optimization
• Social work for family dynamics and care transitions
• Wound care nurse for pressure ulcer
• Dietician for nutritional optimization

Avoid Common Pitfalls

• Do not apply single-disease guidelines rigidly - CPG-based care may be cumulatively impractical or harmful for patients with multimorbidity 2
• Do not pursue aggressive disease-modifying interventions that prioritize survival over quality of life in this patient with limited life expectancy 1
• Do not delay palliative care referral - early integration improves symptom management and quality of life 1
• Do not assume all medications are necessary - polypharmacy review may identify medications causing more harm than benefit 2
• Do not wait for crisis to discuss goals of care - advance care planning should occur while patient has decision-making capacity 1

Follow-Up Plan

Next Visit (2-4 Weeks)

• Review completed advance directive 1
• Medication reconciliation with patient's bottles and daughter present 2
• Assess response to psychiatry referral for depression/anxiety 3, 4
• Evaluate pressure ulcer progression with wound care 2
• Reassess volume status and HF symptoms 1

Ongoing Monitoring

• Reassess goals of care every 3 months or with any significant change in clinical status 2, 1
• Monitor for dialysis-related complications and symptom burden 2
• Track functional status and quality of life rather than disease-specific metrics 2