Synopsis
Integrate multiple long-term conditions around the person's priorities, identify interacting disease and medicine harm, reduce unmanageable treatment workload, and coordinate proportionate evidence-based care without abandoning beneficial treatment.
- Multimorbidity means several conditions whose combined management materially affects daily life; counting diagnoses alone does not measure complexity.
- Treatment burden includes dosing, monitoring, appointments, travel, self-management, adverse effects, equipment and work transferred to carers.
- First-line review asks what matters most, identifies urgent problems and medicines, estimates benefit horizon and creates one prioritised plan.
- Use NICE single-disease guidance as evidence, then adapt recommendations when interactions, frailty, prognosis or burden change net benefit.
- Medication review links every drug to indication, benefit, current harm, renal or hepatic suitability, adherence and monitoring owner.
- Deprescribing is planned withdrawal with shared rationale, taper where required, monitoring and restart criteria; it is not indiscriminate undertreatment.
- Optimise high-value treatments and simplify timing, formulations, monitoring and appointments before concluding that the person refuses care.
- Agree one coordinating clinician and a single problem list so specialists do not create contradictory targets or duplicate tests.
- Capacity is decision-specific; support communication and involve an attorney or best-interests process only when needed.
- Review after any change because stopping one medicine can unmask symptoms or alter another condition.
Key red flags
A new symptom attributed to one known disease may represent a second emergency; avoid diagnostic overshadowing.
Recent discharge, several prescribers, renal decline or duplicate brands creates high risk of omission, interaction and dosing error.
Dizziness, falls, anorexia, confusion, constipation or incontinence may be cumulative medicine harm rather than another diagnosis.
Recurrent hypoglycaemia, postural hypotension or anticoagulant bleeding indicates targets or regimens may be causing immediate net harm.
Non-adherence may reflect impossible workload, dexterity, cognition, cost or beliefs and requires exploration rather than blame.
Carers administering complex treatment without training or respite may be at risk of error and burnout.
Falls, confusion, anorexia, retention or postural symptoms emerge after cumulative or recently changed treatment.
Investigation priorities
Identify desired outcomes and the treatment work that threatens them.
Management branches
Several conditions or medicines create difficult decisions.
- Treat urgent deterioration and ask which outcomes and burdens matter most to the person.
- Reconcile treatment and assess interactions, benefit horizon, adverse effects, feasibility and monitoring ownership.
- Agree a small prioritised set of optimisations with explicit review and contingency criteria.