Prevalence and characteristics of patients with heart failure needing palliative care.

BACKGROUND: Few hospitals and heart failure (HF) clinics offer concurrent palliative care (PC) together with life-prolonging therapies. To know the prevalence of patients in HF clinics needing PC and useful tools to recognize them are the first steps to extending PC in those settings. However, it is still unknown whether tools commonly used to identify patients with HF needing PC can correctly distinguish them. Two systematic reviews found that the NECesidades PALiativas (NECPAL) tool was one of the two most commonly used tools to asses PC needs in HF patients. Therefore, we assessed 1) the prevalence of PC needs in HF clinics according to the NECPAL tool, and 2) the characteristics of the patients identified as having PC; mainly, their quality of life (QoL), symptom burden, and psychosocial problems. METHODS: This cross-sectional study was conducted at two HF clinics in Colombia. We assessed the prevalence of PC in the overall sample and in subgroups according to clinical and demographic variables. We assessed QoL, symptom burden, and psychosocial problems using the 12-Item Short-Form Health Survey (SF-12), the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Edmonton Symptom Assessment System (ESAS). We compared the results of these tools between patients identified as having PC needs (+NECPAL) and patients identified as not having PC needs (-NECPAL). RESULTS: Among the 178 patients, 78 (44%) had PC needs. The prevalence of PC needs was twice as nigh in patients NYHA III/IV as in patients NYHA I/II and almost twice as high in patients older than 70 years as in patients younger than 70 years. Compared to -NECPAL patients, +NECPAL patients had worse QoL, more severe shortness of breath, tiredness, drowsiness, and pain, and more psychosocial problems. CONCLUSION: The prevalence of PC needs in outpatient HF clinics is high and is even higher in older patients and in patients at more advanced NYHA stages. Compared to patients identified as not having PC needs, patients identified as having PC needs have worse QoL, more severe symptoms, and greater psychosocial problems. Including a PC provider in the multidisciplinary team of HF clinics may help to assess and cover these needs.

The 'Surprise question' in heart failure: a prospective cohort study.

OBJECTIVE: The Surprise Question (SQ) is a prognostic screening tool used to identify patients with limited life expectancy. We assessed the SQ's performance predicting 1-year mortality among patients in ambulatory heart failure (HF) clinics. We determined that the SQ's performance changes according to sex and other demographic (age) and clinical characteristics, mainly left ventricular ejection fraction (LVEF) and the New York Heart Association (NYHA) functional classifications. METHODS: We conducted a prospective cohort study in two HF clinics. To assess the performance of the SQ in predicting 1-year mortality, we calculated the sensitivity, specificity, positive and negative likelihood ratios, and the positive and negative predictive values. To illustrate if the results of the SQ changes the probability that a patient dies within 1 year, we created Fagan's nomograms. We report the results from the overall sample and for subgroups according to sex, age, LVEF and NYHA functional class. RESULTS: We observed that the SQ showed a sensitivity of 85% identifying ambulatory patients with HF who are in the last year of life. We determined that the SQ's performance predicting 1-year mortality was similar among women and men. The SQ performed better for patients aged under 70 years, for patients with reduced or mildly reduced ejection fraction, and for patients NYHA class III/IV. CONCLUSIONS: We consider the tool an easy and fast first step to identify patients with HF who might benefit from an advance care planning discussion or a referral to palliative care due to limited life expectancy.

El Contractualismo como fundamento de implicación en cuestiones morales sobre la naturaleza y el ambiente / Contractualism as the foundation of involvement in moral issues about nature and the environment / O contratualismo como base para o envolvimento em questões morais sobre a natureza e o meio ambiente

El presente texto busca hacer un recorrido a través de una propuesta ética antropocéntrica, con el fin de establecer un tipo de vínculo moral que incluya a todos los agentes racionales, en el ejercicio de un actuar moral en pro del ambiente y los animales. Para ello, se analiza, define y propone, de manera particular, una ética contractual basada en varios aportes teóricos de diferentes autores contractualistas. Para, posteriormente, derivar las llamadas responsabilidades morales indirectas que recaen sobre los pacientes morales, que, para este caso, son los animales y el medio ambiente, de manera que se confirme la existencia de principios de acción moral, que puedan ser aceptados de manera razonable por todos los agentes contractuales.

The present text seeks to make a journey through an anthropocentric ethical proposal, in order to establish a type of moral bond that includes all rational agents, in the exercise of a moral act in favor of the environment and animals. For this purpose, a contractual ethical proposal based on several theoretical contributions of different contractarian authors is analyzed, defined and established in a particular way. To, subsequently, derive the so-called indirect moral responsibilities that fall on moral patients, which for this case are the animals and the environment, so that the existence of principles of moral action, which can be reasonably accepted by all parties, is confirmed contractual agents.

O presente texto busca fazer uma jornada através de uma proposta ética antropocêntrica, a fim de estabelecer um tipo de vínculo moral que inclua todos os agentes racionais, no exercício de um ato moral a favor do meio ambiente e dos animais. Para isso, uma proposta ética contratual baseada em diversas contribuições teóricas de diferentes autores contratuais é analisada, definida e estabelecida de maneira particular. Para, posteriormente, derivar as chamadas responsabilidades morais indiretas que se enquadram em pacientes morais, que, neste caso, são os animais e o meio ambiente, de modo que a existência de princípios de ação moral, que pode ser razoavelmente aceita por todas as partes, seja confirmada agentes contratuais.

Predictors of suffering in advanced cancer.

CONTEXT: Suffering is a complex experience. Identifying its predictors is useful to signal at-risk patients. OBJECTIVE: To identify suffering predictors in patients with advanced cancer in palliative care. METHODS: A total of 98 patients participated in the study. A semistructured interview examining suffering levels and physical, psychological, social, and spiritual aspects was used. Instruments included Pictorial Representation of Illness and Self Measure (PRISM), Edmonton Symptom Assessment System (ESAS), Detection of emotional distress (DED), and Structured Interview of Symptoms and Concern (SISC). Variance-based structural equation model was used for the data analysis. RESULTS: All measures were valid and reliable. The structural model explained 64% of the variance. Suffering levels were directly determined by psychological and adjustment problems and indirectly determined by physical, psychological, and spiritual aspects and coping strategies. CONCLUSION: Our study supports the proposed theoretical model and signals the important mediating effect of psychological and spiritual variables between physical symptoms and suffering.

Manejo eficiente del prurito con emolientes y gabapentina en el paciente urémico y su impacto en la calidad de vida / Treatment of the uremic patient’s pruritus with emolients and gabapentine and life quality impact

Introducción. Entre los síntomas que con mayor frecuencia presentan los pacientes con enfermedad renal crónica terminal en la terapia de reemplazo renal de tipo hemodiálisis y diálisis peritoneal, se encuentra el prurito urémico. Objetivo. Comparar la efectividad de los emolientes con la de la gabapentina en el manejo del prurito urémico y el impacto en la calidad de vida en los pacientes con enfermedad renal crónica terminal en terapia de reemplazo renal de tipo hemodiálisis y diálisis peritoneal, en el Servicio de Terapia Renal del Hospital Pablo Tobón Uribe, entre enero y abril de 2010. Metodología. Se realizó un ensayo clínico controlado de asignación aleatoria, sin cegamiento, en el que se administraron tratamientos con emolientes o gabapentina a grupos de pacientes con insuficiencia renal crónica y prurito, que acudieron al Servicio de Terapia Renal del Hospital Pablo Tobón Uribe, para recibir terapia de reemplazo renal, ya fuera hemodiálisis o diálisis peritoneal. Resultados. En ambos grupos se observó mejoría sustancial del prurito. En 15 pacientes que fueron tratados con gabapentina, se encontró una disminución de la intensidad del prurito, medido por la escala visual análoga, pasando de una media de 6,6 al inicio a una de 1,1 al final. Del mismo modo ocurrió con los 18 pacientes del grupo que recibió emolientes, pasando de una media de 5,2 al inicio a una de 1,3 al final. Con respecto a la evaluación de la calidad de vida, se observó diferencia únicamente para el dominio de la funcionalidad social en el grupo de emolientes entre la primera y segunda evaluación, sin apreciarse diferencias significantes en el grupo de gabapentina. Conclusión. Los pacientes experimentaron una mejoría estadísticamente significativa en el prurito con los dos tratamientos; sin embargo, cuando se compararon, no se observó diferencia significativa, por lo que no se puede aseverar, con el tamaño de muestra obtenido, que un tratamiento sea mejor que el otro. En cuanto a la calidad de vida, únicamente en el grupo de emolientes se apreció mejoría en el dominio de funcionalidad social.

Barriers and facilitating communication skills for breaking bad news: from the specialists’ practice perspective / Barreras y facilitadores en la comunicación de malas noticias: Perspectiva desde la práctica de médicos especialistas

Introduction: Breaking bad news is one of a physician’s most difficult duties. There are several studies related to the patient’s needs, but few reflect on the doctors’ experience. Materials and method: A descriptive, cross-sectional research was carried out to study issues related to the process of delivering bad news which might act as barriers and facilitating skills from the doctor’s point of view. These issues were identified through a self-administered survey. Results: Participant doctors use different strategies to communicate bad news to their patients. Examples of these strategies are: to be familiar with the patients’ medical history, to ensure that there is enough time, to know the patient’s caregivers and/or relatives, to determine the patient’s level of knowledge about his/her condition, to use non-technical words, to give information in small pieces, to assess the patient’s understanding, to devise a joint action plan, among others. Conclusion: The communication barriers that were identified focused on the emotional issues of the communication process, particularly those related to the recognition of own emotions, and the limited training about communication strategies available to doctors. Consequently, there is a need to implement training programs that provide doctors with tools to facilitate the bad news communication process.

Introducción: La comunicación de malas noticias es una de las tareas más difíciles que deben enfrentar los profesionales de la salud. Existen múltiples estudios acerca de las necesidades del paciente, pero pocos que tengan en cuenta la experiencia de los médicos. Materiales y método: Se realizó una investigación descriptiva, transversal para estudiar aspectos del proceso de comunicación de malas noticias que pueden actuar como barreras y facilitadores desde la percepción del médico; identificados por medio de una encuesta auto-aplicable. Resultados: Los médicos participantes utilizan distintas estrategias durante la comunicación de malas noticias a sus pacientes como: conocer los detalles de la historia clínica, asegurarse de tener tiempo suficiente, conocer a los acompañantes e identificar cuánto sabe el paciente acerca de su situación, utilizar vocabulario sencillo, dar la información por partes, comprobar que el paciente esté comprendiendo, formular en conjunto un plan que se ha de seguir, entre otros. Conclusiones: Las barreras comunicativas identificadas se centraron en los aspectos emocionales del proceso comunicativo, específicamente en lo relacionado con la identificación de emociones propias, y en la limitada formación que reciben los médicos en estrategias comunicativas, lo que genera la necesidad de implementar programas de capacitación que les brinden herramientas para facilitar el proceso de comunicación de malas noticias.