Covid-19 en la población LGBTIQ+ en Ecuador: Perspectivas de una junta asesora comunitaria.

No disponible.

Geosocial Networking Apps Use Among Sexual Minority Men in Ecuador: An Exploratory Study.

Geosocial networking applications (GSN apps) have become important socialization contexts for sexual minority men (SMM). Despite their popularity, there is limited research carried out in Latin American countries and no single previous study done in Ecuador. To fill this gap, this exploratory study described and analyzed the relationships between the sociodemographic characteristics of SMM using GSN apps, their sought and fulfilled expectations, profile shared and sought characteristics, and the evaluation of their experiences as users including their perceptions of support, and discrimination. We used an online recruited sample of 303 participants enrolled between November 2019 and January 2020. Most respondents used Grindr and reported spending up to 3 h per day using apps. Most common sought expectations were getting distracted, meeting new friends, and meeting people for sexual encounters. The least met expectation was meeting someone to build a romantic relationship with. When asked about their profiles, participants reported sharing mainly their age, photographs, and sexual role. Participants also prioritized these characteristics when looking at others' profiles. When asked about their experiences, most reported having been discriminated against, weight being the main reason for it. Some participants also indicated having received emotional support from other users. Correlation analyses indicated significant but weak relationships among the variables. Results indicated a positive correlation between time as an active GSN app user and higher experiences of discrimination. Likewise, higher number of used apps related positively with levels of received support. These results provide information that could inform future research in the country and the region regarding GSN apps use among SMM, socialization practices, and modern dating tools.

Sexual Behaviors and HIV/STI Prevention Strategies Among Sexual Minority Men in Ecuador Who Use Geosocial Networking Apps.

Around the world, geosocial networking apps have become widely popular among sexual minority men (SMM). This research analyzed the sexual behaviors and HIV and STI prevention strategies (HIV/STI testing, HIV/STI inquiry, and HIV/STI disclosure) of an online-recruited sample of 284 SMM living in Ecuador. Sexting and oral sex were the most common sexual behaviors among SMM in the sample. Most participants had low perceptions of HIV and STI risk; 85% reported being tested for HIV and 70% for STIs. Being older predicted higher odds of being tested for either HIV or STIs at least once. Being single also predicted HIV testing. Future interventions in the country should explore apps' utility as intervention tools to spread information about sexual health and HIV prevention strategies, such as condom use and event-driven PrEP. Apps can also facilitate connections to sexual health services, including programs for PrEP initiation and linkage to HIV treatment. They should also focus on promoting sexual harm reduction conversations among potential app-met sexual partners.

Exploring critical factors in pediatric palliative care in Latin America: A scoping review.

This scoping review aimed to provide an overview of the current landscape of pediatric palliative care in Latin America, including policies, regulations, available resources, challenges, barriers, and evidence-based recommendations. We conducted a comprehensive search for peer-reviewed articles related to pediatric palliative care in Latin America, considering both review and empirical articles published in English, Portuguese, or Spanish within the last decade. Our review initially identified 30 publications, which were subjected to a full-text assessment. The majority of these articles originated from Brazil, Mexico, and Chile, highlighting a regional concentration of research efforts. Notably, we observed a scarcity of comprehensive research and specific studies on pediatric palliative care in Latin America. Our findings revealed significant challenges, including resource limitations, the absence of dedicated policies, and the critical need for interdisciplinary teams to address the multifaceted aspects of pediatric palliative care. In light of our review, we emphasise the necessity for more extensive and representative research efforts, as well as the continuous updating of scientific evidence in the field of pediatric palliative care within the Latin American context. The recommendations derived from this review aim to contribute to the enhancement of pediatric palliative care services and accessibility throughout Latin America.

Emotional experiences in palliative care and professional quality of life: a qualitative approach.

Objective: To explore the experiences that significantly impact the professional quality of life of people providing palliative care (PC) in Ecuador. Design: Observational cross-sectional qualitative research. Methods: In September 2022, 10 focus groups were carried out in four cities in Ecuador; each group lasted from 1 to 2 h, was audio recorded, and transcribed verbatim. Recruitment was conducted through convenience sampling, and a total of 71 individuals (15 students, 50 professionals, and 6 volunteers) linked to PC participated. Content analysis with a phenomenological and inductive approach was used to analyze the data. Results: People recognized their experiences in PC as having positive and negative impacts on their professional quality of life. Experiences were mapped as affecting them at individual, relational, and contextual levels. These experiences included personal growth, opportunity to provide care, teamwork, death-related issues, inability to deal with work-related stress, social acceptance of PC, and dealing with inefficient health systems, among others. Conclusion: Despite the positive emotions that arise with caring for others, individuals working and volunteering in PC experience situations that influence their professional quality of life. Addressing these factors to increase satisfaction and ease the burden of PC work is essential. Undergraduate education, continuous professional training, and PC teams should incorporate actions to address these factors at all levels, such as teaching coping skills, fostering social support, and increasing awareness of PC.

How experiences shape professional quality of life in palliative care This study explored how working in palliative care impacts the professional quality of life of people providing palliative care in Ecuador. The research team conducted 10 focus groups in four cities in Ecuador with 71 participants. The results show that people's experiences impact their professional quality of life in positive and negative ways. These experiences also affect people at individual, relational, and contextual levels. This study has identified common experiences that should be addressed to increase satisfaction and ease the burden of working in palliative care. These should be considered in undergraduate education, continuous professional training, and within palliative care teams.

Access to cancer pain management in Ecuador from health workers' perspective: a qualitative study.

Background: Ecuador is facing increasing health-related suffering due to cancer; however, the distributed opioid analgesic in the country is below the global average. Aim: This study explores the access to cancer pain management (CPM) from the healthcare professionals' perspective in a middle-income country. Methods: Thirty problem-centered interviews with healthcare providers were conducted in six cancer facilities and were analyzed thematically. Results: Limited and unequal access to opioid analgesics was reported. Structural weaknesses of the healthcare system restrain access for the poorest, at the primary care level, and for people living in remote areas. The lack of education among the healthcare personnel, patients, and society was identified as the main barrier. Conclusion: Access barriers were interrelated; therefore multisectoral strategies must be considered to improve access to CPM.

The number of patients with cancer in Ecuador is growing. It is known that people with a cancer diagnosis often experience severe pain, which requires opioid analgesics. In this study, we explore the opinion of healthcare providers regarding access to opioid analgesics to alleviate cancer pain in Ecuador. We interviewed 30 healthcare professionals working at six cancer centers in different cities, who deal daily with patients with a cancer diagnosis. We found that it is difficult for cancer patients in the country to access adequate pain therapy and this generates avoidable severe health-related suffering. The structure of the healthcare system makes it difficult to be supplied with the medication they need. That is worst for the country's poor and people in rural areas. The main problem is the lack of knowledge on the subject among health workers, patients and society. We conclude that the obstacles in providing patients access to cancer pain relief lie in different areas, including the healthcare system, the healthcare professionals and the patients and society, all of which are interrelated. All areas must work together to improve the situation.

Variations of work engagement and psychological distress based on three working modalities during the COVID-19 pandemic.

With the onset of the COVID-19 pandemic, the rapid spread of the SARS-CoV-2 virus became a global health threat affecting people's mental and physical health, as well as working conditions and modalities. The reorganization of the work environment also affected work engagement and psychological distress levels. This manuscript assesses how work engagement and distress vary according to gender and age across three working modalities. We used a voluntary response sampling strategy to collect data on psychological distress and work engagement between August 2021 and January 2022. Results are from 542 people working in Ecuador during the COVID-19 pandemic. Overall, participants experienced psychological distress; women and younger participants presented higher psychological distress. Regarding engagement, the sample showed average levels of total engagement, average levels of vigor, and high levels of dedication and absorption. Men presented higher levels of total work engagement and vigor. Psychological distress was significantly and negatively correlated with total work engagement scores and its three factors. There were no differences in work engagement according to the different modalities. However, teleworkers reported significantly higher levels of psychological distress than hybrid workers. Findings are discussed considering ideas for decision-makers to explore the benefits of flexible working practices.

Attitudes Toward Lesbians, Gay Men, and Their Rights in a Sample of Ecuadorian Cisgender Men and Women.

Since 1997, Ecuador has undergone a series of changes to ensure family rights to sexual minorities. However, there is still limited research regarding attitudes toward them. This study focused on the attitudes toward lesbians (L), gay men (G), and their rights. A sample of 318 cisgender Ecuadorians who responded to an online survey was recruited. Analyses indicated that men, heterosexuals, who practice their religion, attend more frequently to religious services, and identify as conservative showed higher levels of prejudice against LG as well as less support toward their rights. Further, participants who did not have LG acquaintances, friends, family members, and those who did not know any LG parented family showed less support toward these populations. Multiple regression analyses indicated that believing that a person's sexual orientation is learned significantly predicted the attitudes measured in our study. Implications of these findings to help reduce prejudice against LG individuals are discussed.

Beliefs About Morphine in Palliative Care: Results From an Ecuadorian Sample.

Background: Previous research unambiguously establishes the importance of knowledge and education about opioids and pain management in medical care. This article aimed at describing the perception of the general public on the uses and the risks of morphine in palliative care in an Ecuadorian sample, where training and access to those services is limited. Methods: We used an online recruited sample of 257 participants for this cross-sectional descriptive study. Participants responded to an online self-report survey regarding morphine's effects and its relationship with addiction and death in a palliative care context. Results: Analyses indicate that there is a lack of understanding about the effectiveness of morphine and that, overall, participants did not associate morphine with death and dying. Results also show that people in health-related occupations did not differ from the general public in beliefs about the addiction and the effectiveness of morphine. However, occupation and education effects were noted for several other items, as well as whether the participants had direct experiences with palliative care as either a patient or a caregiver. Conclusions: There is still misinformation about opioids such as morphine in the general public and health professionals in Ecuador. Although personal experiences with pain control and palliative care are linked to better knowledge about opioids, education is still necessary to overcome the myths around them. Future research could address the found misconceptions to increase health literacy through education policies and interventions.

Procrastination during the COVID-19 Pandemic: A Scoping Review.

Procrastination involves voluntarily or habitually delaying unpleasant tasks for later. It is characterized by short-term benefits and long-term costs. The COVID-19 pandemic set specific circumstances that may have influenced procrastination behavior. This scoping review identified the existing peer-reviewed literature in English or Spanish about procrastination during the COVID-19 pandemic (January 2020 to April 2021) in six electronic databases. To conduct the review, a five-step methodological framework, as well as established PRISMA guidelines, was followed. A total of 101 articles were found. After removing duplicates and reviewing the articles, only 13 were included in the review. Findings indicate that procrastination was studied mostly in academic contexts in various parts of the globe. Procrastination behavior was related to anxiety, distress, time management, self-control, and other variables. There is limited information about interventions to prevent or decrease procrastinating behaviors in the context of confinement or in the living conditions generated by the pandemic. Future research should consider how procrastination evolved during the pandemic using longitudinal methodologies. Individual differences related to procrastination also should be identified, and the evaluation of the efficacy of existing interventions is still needed. This information might help in the creation of appropriate interventions that target detrimental procrastination behaviors.

A Comparison of Working Conditions and Workers' Perceptions among On-Site, Telework, and Hybrid Workers in Ecuador during the COVID-19 Pandemic.

The COVID-19 pandemic has forced many companies to adopt different work modalities to ensure their operation during this period. In this study, we described and compared working conditions and perceptions among face-to-face workers, teleworkers, and hybrid workers in Ecuador. A cross-sectional study was conducted with a sample of 542 participants, using a self-report survey to assess sociodemographic data, working conditions, and workers' perceptions. Variables were described and then compared by the Chi-square test, ANOVA, and the Kruskal-Wallis test. The results indicated a higher proportion of on-site workers without higher education and in the public sector compared to the other modalities. At the same time, there was evidence of increased perceived productivity. People in the hybrid modality tended to have more than one job, earning a higher monthly salary, perceiving a decrease in productivity, an increase in daily working hours, and a lower capacity for time management. In addition, most teleworkers reported fair working conditions, a dedicated workspace, and easy adaptation to this work mode. This study builds a more in-depth understanding of how workers perceived their working conditions among work modalities for organizational decision-making because the evolution of the COVID-19 pandemic is modifying the ways of working permanently.

Self-Esteem, Happiness, and Flourishing in Times of COVID-19: A Study During the Lockdown Period in Ecuador.

Objective: Several studies have investigated the negative toll the pandemic has had on people's mental health. However, there is limited research on the pandemic's effect on positive mental health variables. This article reports on the levels of self-esteem and well-being (flourishing and happiness) in a sample of adults living in Ecuador and their relationships with the characteristics of their personal situation and the effects of the COVID-19 pandemic had on their personal lives. Methods: A total of 766 adults completed an anonymous online survey between March and August 2020. Results: Participants reported average scores in the flourishing scale, the majority considered themselves to be happy or very happy people, and more than half presented high levels of self-esteem. Age, education, socioeconomic status, time spent using mobile phones and on hobbies, among others, explained self-esteem, happiness, and flourishing. Conclusion: The relationships between sociodemographic and situational variables of confinement during the pandemic are discussed, as well as the possible predictors of happiness, flourishing, and self-esteem.

Teachers' Mental Health and Self-Reported Coping Strategies During the COVID-19 Pandemic in Ecuador: A Mixed-Methods Study.

PURPOSE: This study assessed the psychological distress, life satisfaction, and perceived stress of Ecuadorian teachers who adopted online learning in response to the COVID-19 pandemic. It also aimed to qualitatively report the coping strategies used to maintain their mental health and well-being. METHODS: A web-based cross-sectional survey was conducted from June to mid-August 2020. RESULTS: In total, 394 teachers completed the questionnaire, and from those, 320 also completed an optional open-ended question included in the survey. More than half of the participants reported taking care of children under 11 years and/or adults over 65 years. At the time of the study, most of the participants were teaching in higher education settings. Age was significantly correlated with all the psychological variables, females presented higher levels of perceived stress, and teachers with home care responsibilities presented higher psychological distress as well as perceived stress. Teachers who had previous training and experience with online teaching presented lower levels of distress, perceived stress as well as higher levels of life satisfaction. The most used coping strategies included seeking social support, exercising, and engaging in leisure activities. CONCLUSION: The results provide useful information to help develop initiatives that promote teacher well-being. Future studies should consider using a more diverse sample and dedicate attention to work-family conflicts as well as social and structural inequalities that may have a toll on teachers' mental health and performance.

Psychological Inflexibility and Loneliness Mediate the Impact of Stress on Anxiety and Depression Symptoms in Healthcare Students and Early-Career Professionals During COVID-19.

Background: The current mental health state of healthcare professionals and students during the COVID-19 pandemic in Ecuador remains understudied and how to improve their mental health is a challenge. Objective: This study aimed to explore the anxiety and depressive symptomatology among healthcare students and professionals in Ecuador and to examine the role of psychological inflexibility, loneliness, and psychological stress as predictors of anxiety and depression symptoms. Methods: A total of 191 undergraduate and graduate healthcare students in clinical practice (early-career healthcare professionals) in Ecuador were surveyed between January and March 2021 using standardized measures of psychological stress (PSS), psychological inflexibility (AAQ), loneliness (UCLA), alcohol consumption (AUDIT-C), and anxiety and depressive symptomatology (PHQ). Macro Process for SPSS (models 4 and 7) were used to test mediation effects. Results: Alcohol consumption varied between men and women and anxiety and depression symptomatology was generally low among the sample. Psychological inflexibility and loneliness mediated the impact of stress on anxiety and depressive mood in participants, regardless of gender and previous personal history of COVID-19. Discussion: Implications of psychological inflexibility and the prevention and coping with stress in healthcare professionals during COVID-19 are further discussed.

Professional Quality of Life, Engagement, and Self-Care in Healthcare Professionals in Ecuador during the COVID-19 Pandemic.

The COVID-19 pandemic has highlighted the importance of healthcare workers and their professional quality of life. This quantitative cross-sectional study aims at exploring the professional quality of life, work engagement, and self-care of healthcare workers during the COVID-19 pandemic in Ecuador. A convenience sample of 117 participants completed an online voluntary and anonymous survey between April and July 2020. It contained a sociodemographic section, the Professional Quality of Life questionnaire V, the work engagement scale, and the scale of self-care behaviors for clinical psychologists. Results show that healthcare workers have an average quality of life with high levels of compassion satisfaction and average levels of compassion fatigue and burnout. Data also indicate that the sample frequently engaged in self-care practices and had high levels of work engagement. The regression analyses reveal that gender, the number of patients per week, the perceived fairness of the salary, among other variables are possible predictors of professional quality of life, frequency of self-care practices, and engagement. This study contributes to the understanding of these variables among healthcare professionals in Ecuador. These results should be considered when planning policies and prevention intervention efforts to promote professionals' wellbeing.

Empathy and COVID-19: Study in Professionals and Students of the Social Health Field in Ecuador.

Empathy plays a fundamental role in health related occupations. In this study, we analysed empathy levels in professionals (117) and students (170) from various healthcare fields in Ecuador during the COVID-19 pandemic. The Interpersonal Reactivity Index was used in an online survey. The results show high levels of empathy in both groups, influenced by age and gender. The students presented higher levels of personal distress, and their age was negatively correlated to empathy. Additionally, professionals working in physical health scored higher levels of personal distress compared to those in the field of emotional health. COVID-19 has placed social health systems in great stress. Despite this, the personal capacities for empathy of both students and health professionals have not been diminished.

Knowledge of Palliative Care in Ecuador.

Palliative care is a holistic approach to care for people with chronic, advanced, and life-threatening illnesses. It improves the quality of life of patients and their caregivers. However, there is still limited access to palliative care in many countries. Knowledge about palliative care is key to increase its availability. Thus, this article aimed to explore the knowledge of the general population about palliative care in Ecuador. The study had a descriptive cross-sectional design. Through snowball sampling, between September 2019 and January 2020, 257 people completed an anonymous online questionnaire about general and specific aspects of palliative care. Descriptive and ANOVA analyses indicate that people have many misconceptions about palliative care and how it should be provided. Gender, education, training, occupation, and experience as caregivers were related to the total level of knowledge about palliative care. Regression analyses show other variables as predictors of knowledge. This study highlights the lack of knowledge about specific issues within palliative care in the general population in Ecuador. It also shows the need to develop and implement education measures to fill these gaps and enhance access to palliative care in health systems.

Psychological Factors, Leisure Activities, and Satisfaction during the COVID-19 Pandemic: A Cross-Sectional Study in Eleven Spanish-Speaking Countries.

The COVID-19 pandemic has affected the lives of millions of people worldwide. This study aimed to analyze the effects of several psychological factors (self-esteem, self-control, and emotional stability) over lifestyle-related variables (time spent on leisure activities) and the levels of satisfaction (family, friends, work, and leisure satisfaction) experienced during the COVID-19 outbreak. Data for this article were retrieved as part of a cross-sectional international study conducted in eleven Spanish-speaking countries between March and September 2020. The analyses were conducted using the responses of 9500 persons (65.95% women, 34.05% men). Structural equation modeling was used to test the direct and indirect effects of the psychological variables on satisfaction variables mediated by the time engaged in leisure activities. Our model indicated that psychological factors significantly predicted the amount of time spent in leisure activities and satisfaction. Overall, results indicate that self-esteem is a relevant psychological factor to consider in the development of psychological interventions directed at promoting healthy lifestyles. Nevertheless, further research is needed to validate the direction of the associations found in this study.

Supervision Model of Mental Health Telecare Volunteers During the Covid-19 Pandemic.

The COVID-19 outbreak is a pandemic that has strained significantly the capacity of many public and private health systems. To alleviate the burden, many students of health-related professions volunteered to offer their expertise to attend to the health needs of the public. This brief article aims to share a replicable supervision model that is currently in place to care for those volunteers in telecare mental health. The key aspects of this supervision model are the team composition, ongoing group supervision, formally structured supervision sessions, and the objective monitoring of members' well-being.

Development of a cognitive-existential intervention to decrease compassion fatigue in formal caregivers / Desarrollo de una intervención cognitiva-existencial para disminuir la fatiga por compasión en cuidadores formales

Abstract Palliative care aims to improve the quality of life of patients with chronic and advanced illnesses and their families. This requires a multidisciplinary approach from formal caregivers. Though caring for others could be rewarding and this satisfaction relates to higher work engagement and resiliency, formal caregivers of palliative care patients may develop compassion fatigue due to the nature of their work. This fatigue affects caregivers, their interpersonal relationships, and the quality of care they provide. Supporting formal caregivers and improving communication plays a vital role. Considering the efficacy of the existential interventions in other populations, and the lack of testing of these interventions on formal caregivers of palliative care teams, this article aims to describe the design and development of an eight-session cognitive-existential group-based psychoeducational intervention to reduce compassion fatigue and to promote self-care and satisfaction of formal caregivers of palliative care patients in a Latin American context. The intervention used Frankl's Logotherapy and Ellis' rational emotive therapy as the theoretical framework and included the necessities of formal caregivers in this specific setting. As a result, this article presents the theoretical development of the intervention and its structure, as well as the objectives and specific content of each session. Empirical research, reported elsewhere, has proven its long-term effectiveness in reducing the compassion fatigue of this population. This makes it a replicable intervention with promising results. Future studies need to continue its evaluation and include professionals in other settings outside palliative care.

Resumen Los cuidados paliativos buscan mejorar la calidad de vida de las personas con enfermedades crónicas y avanzadas, y la de sus familiares. Este tipo de cuidados requiere un enfoque multidisciplinario desde un equipo de cuidadores formales, trabajadores o voluntarios asociados a un sistema de servicios estructurado que brindan cuidados y atención. Este equipo puede incluir voluntarios y especialistas en medicina, enfermería, trabajo social, psicología, cuidado espiritual, nutrición, entre otros. Todos los involucrados deben tener entrenamiento específico y una actitud humanizada para lidiar no solo con los síntomas físicos de las enfermedades sino con las necesidades psicológicas y espirituales que los pacientes y sus familias puedan tener. Por esto, trabajar en cuidados paliativos demanda conocimiento, autocuidado y fortaleza emocional y psicológica. A pesar de que cuidar de otras personas puede ser gratificante y esta satisfacción se relaciona con el compromiso laboral (engagement) y la resiliencia, los cuidadores formales de personas con necesidades paliativas también pueden desarrollar fatiga por compasión debido a la naturaleza de su labor. Esta fatiga afecta a sus relaciones interpersonales y a la calidad del cuidado que brindan. Desde una perspectiva organizacional, el apoyar a los cuidadores formales es vital. Investigaciones muestran que el respeto, el sentido y el perdón pueden influir en la satisfacción laboral y en el desempeño. La literatura contiene algunas intervenciones que procuran promover estas y otras características para aliviar la posible carga del cuidador; sin embargo, es difícil analizar y replicar dichas intervenciones debido a una falta de rigurosidad en el reporte de sus procedimientos, su desarrollo y su efectividad. Las intervenciones centradas en el sentido se han mostrado efectivas en promover la satisfacción en pacientes y familiares de personas con necesidades paliativas. No obstante, a la fecha de realización de este estudio, solo una intervención reportaba el uso del enfoque existencial con cuidadores formales (enfermeras de cuidados paliativos). Considerando la efectividad de las intervenciones de base existencial en otras poblaciones y la ausencia de investigación sobre estas en cuidadores formales de equipos de cuidados paliativos, este artículo tiene como objetivo describir el diseño y desarrollo de una intervención psicoeducativa grupal de tipo cognitivo-existencial de ocho sesiones creada para reducir la fatiga por compasión y promover el autocuidado y la satisfacción de los cuidadores formales de pacientes en cuidados paliativos en un contexto latinoamericano. Primero, considerando la literatura existente y las situaciones específicas con las que lidian los cuidadores, inicialmente utilizamos la logoterapia de Viktor Frankl como la base teórica de la intervención. De esta manera buscamos abordar los problemas existenciales y las situaciones que los cuidadores enfrentan diariamente. Después de este desarrollo teórico, dos expertos en terapia existencial revisaron la intervención propuesta. Como resultado, se incorporaron técnicas de la terapia racional emotiva de Albert Ellis. Además, también se tuvo en cuenta un estudio cualitativo que informaba sobre las necesidades de los cuidadores formales en este contexto específico con respecto a su fatiga y satisfacción en el trabajo. De esta manera, se adaptó la versión final de la intervención para satisfacer las necesidades específicas de la población objetivo. Como resultado, este artículo presenta el desarrollo teórico de la intervención y la construcción de su estructura, así como los objetivos y el contenido de cada una de las sesiones. Tanto el material para los participantes como el manual del facilitador están disponibles mediante el contacto con el autor responsable de la correspondencia. Investigación empírica, publicada en otro lugar, ha demostrado la eficacia a largo plazo de esta intervención para reducir la fatiga por compasión. Esto la convierte en una intervención replicable con resultados prometedores. Futuros estudios podrían continuar su evaluación con cuidadores en entornos fuera de los cuidados paliativos.