8.2 Multimorbidity and Prioritization

ANCC does not give you a 22-year-old with one problem and a clean guideline. Domain III Planning is built for the person who already has too many guidelines. A typical scored vignette looks like this: 78 years old, heart failure with reduced ejection fraction, CKD, type 2 diabetes, depression, osteoarthritis, eleven medications, a daughter who wants “all the numbers at target,” and a 20-minute slot. If you try to satisfy ADA, ACC/AHA, KDIGO, AGS Beers, and the pain guideline in one visit, you will write an elegant plan the patient cannot swallow, cannot afford, and that may land them in the hospital.

Multimorbidity is not “several problems on the list.” It is interacting diseases, interacting drugs, competing outcomes, and a treatment burden that is itself a disease. Planning means choosing what to optimize now, what to monitor, and what to deliberately leave imperfect. Single-disease guidelines (Section 7.2) are still required knowledge. They are not a stack you execute from the top.

You cannot fire every guideline at once

The FNP priority is not “the newest society statement.” It is a rank.

Three ranking questions (use them in this order)

1. What will kill or disable first? Near-term mortality and irreversible disability outrank cosmetic numbers. In the 78-year-old, decompensated HF, hyperkalemia, hypoglycemia, AKI, and a hip fracture from a fall beat a 0.4-point A1c improvement and beat a screening colonoscopy you should have stopped considering given frailty and a short benefit horizon. Write the kill/disable list before you write the prescription list.

2. What does the patient say matters most? After safety, function and stated goals win. “I want to walk to the mailbox and stay in this house” is a better north star than “A1c 6.8%.” Ask it out loud. If the daughter wants every number at target and the patient wants fewer pills and less dizziness, the patient (if they have capacity) owns the values. Document the goal in the plan so the next clinician does not undo it.

3. Which drugs are already fighting each other? Before you add, look for:

• NSAID in CKD or HF, and the ACE + loop + NSAID triple whammy.
• Stacked hypotensives — ARNI + loop + SGLT2 + MRA + a leftover thiazide, sitting SBP 96, “lightheaded when I stand.”
• Sliding-scale insulin complexity in an older adult who cannot see the syringe, lives alone, and has variable intake. Beers: do not use sliding scale as the sole insulin plan.
• Duplicate serotonergic or anticholinergic loads (diphenhydramine PM + oxybutynin + amitriptyline for “nerve pain”).
• Glyburide or other long-acting sulfonylureas that convert diabetes into a fall-and-hypoglycemia disease.

If a new prescription does not survive those three questions, it does not go on today’s plan, even if a single-disease app flashes red.

The 78-year-old, worked

R. is 78. HFrEF EF 35%, eGFR 32 and falling slowly, A1c 8.1% on metformin 500 mg daily and sliding-scale lispro “when the number is high,” PHQ-9 of 14, bilateral knee OA, 14 medications including ibuprofen 600 mg three times daily, lisinopril 40 mg, furosemide 40 mg, metoprolol succinate 50 mg, sertraline 50 mg, and aspirin 81 mg (no prior ASCVD). BP 108/64 sitting, 90/58 standing. She has gained 4 lb in 5 days. She says, “I want to stop feeling awful and I do not want another specialist visit this month.”

Today’s kill/disable list: volume overload / HF exacerbation, orthostatic hypotension and fall, NSAID-related AKI and HF worsening, hypoglycemia from sliding scale, depression that is already impairing function. A1c 8.1% is not the emergency. The aspirin is primary prevention in a 78-year-old — a deprescribing candidate, not a quality-measure win.

A coherent plan for this visit, not for the entire year:

• Treat the HF now: daily weights, red flags of about 2–3 lb overnight or 5 lb in a week, adjust the loop, review salt and NSAID, and decide whether she is wet enough for same-week cardiology or the ED.
• Stop the ibuprofen. Offer acetaminophen first-line, a topical NSAID only if you judge systemic exposure acceptable, physical therapy, and a later discussion of intra-articular injection. Do not “just add a PPI and keep the ibuprofen.”
• Stop sliding-scale-only lispro. Either a simple basal plan if insulin is truly needed, or no insulin if A1c 8.1% is acceptable for this person; teach hypoglycemia.
• Deprescribe aspirin unless a hidden ASCVD history appears.
• Do not add a second oral hypoglycemic today just because ADA’s healthier-adult target is <7%. Consider an SGLT2 later — it helps HF and CKD — but not on the afternoon she is hypotensive and wet.
• Name depression as a priority for the next visit if today is full, or start/adjust if she identifies mood as the thing that matters most and you have five clean minutes. Do not start a second serotonergic agent on autopilot.
• Time-box: HF safety + NSAID stop + insulin simplification + one patient-identified goal. Everything else goes on a written sequence.

That plan will look “incomplete” to a student who grades themselves against five guidelines. On ANCC, incomplete-and-safe beats complete-and-harmful.

Deprescribing is a plan, not a failure

Deprescribing has an indication, a taper when needed, a monitor, and a follow-up, just like starting a drug. Put it in the plan in those four parts. Chapter 20.2 will go deeper on outcome-driven deprescribing; Planning is where you decide that stopping is today’s intervention.

Write “we are not intensifying A1c because hypoglycemia risk exceeds microvascular benefit at age 78 with HF” in the note. That sentence is the plan. It prevents the covering NP from adding glipizide next Tuesday.

The one-problem-per-visit myth versus time-boxed agenda setting

“One problem per visit” is a clinic-throughput slogan, not a standard of care, and it is a bad ANCC answer in multimorbidity. The interacting problems are the visit. Refusing to hear the second problem is how NSAID-in-HF gets missed.

The adult skill is agenda setting with a clock:

1. Ask: “What are the two things that must be better when you leave?”
2. Add your non-negotiable safety item (the 4 lb gain, the potassium, the suicidal-ideation screen).
3. Say the time out loud: “We have 20 minutes. We will do the swelling and the ibuprofen today. Your A1c and the depression medication get a visit next week. If something worse starts tonight, here is exactly what to do.”
4. Give a written sequence so the patient does not experience the deferral as dismissal.

Do not confuse agenda setting with ignoring red flags. If the “second problem” is chest pain or new unilateral weakness, it becomes the only problem and the destination is the ED (Section 8.3).

A related trap is the opposite: the FNP who tries to close every open quality metric because the dashboard is red. Dashboard A1c, BP, and statin checkboxes do not outrank syncope, AKI, or hypoglycemia. Sequence the metrics across visits and document why a metric is intentionally not met.

Competing guidelines → FNP priority rule

Exam shorthand: kill/disable first, goals second, interactions third, everything else sequenced. If an option in the stem intensifies three guidelines at once in a dizzy 78-year-old, it is almost never correct. If an option stops the NSAID, simplifies insulin, and books a short-interval HF follow-up, it is usually the plan ANCC wants.