Prioritizing care for older adults with multiple comorbidities: working in the ‘zone of complexity’

Abstract

Prioritizing care for older adults with multiple comorbid conditions is a challenging act of clinical judgment owing to the multidimensional and dynamic nature of each patient’s health status. This clinical process is analogous to working within a complex adaptive system, where an intervention or change in one condition can produce unexpected outcomes. Except for decisions characterized by a high degree of professional agreement (e.g., influenza vaccination), most medical decisions affecting older adults occur within a ‘zone of complexity’ characterized by imperfect agreement regarding best practices and outcomes. An example is setting individual glycemic targets. Decisions within this zone are at best bounded by a few principles: first, ascertain the patient’s preferences and goals; second, determine health status by identifying relevant comorbid conditions, function and frailty; third, consider the risks and benefits, and estimate the likelihood that any intervention will achieve the patient’s healthcar...