Percepción sobre la formación en cuidados paliativos de los estudiantes de las especializaciones de Cirugía general en Colombia / Perception of palliative care training among students of General Surgery specializations in Colombia

Introducción. Los cuidados paliativos responden al sufrimiento de pacientes terminales y requieren personal entrenado para la intervención. Forman parte de la actividad en cirugía, sin embargo, no encontramos información sobre la educación de postgrado en cirugía en Colombia. El objetivo de este estudio fue evaluar el nivel de conocimientos en cuidados paliativos, la calidad de la formación y las estrategias pedagógicas en los residentes. Métodos. Estudio observacional con recolección de la información autodiligenciada por medio electrónico. Resultados. Participaron 228 residentes, 7,8 % mencionaron asistir a rotación en cuidado paliativo y 66,6 % tener contacto con especialistas en cuidados paliativos. El 30,7 % no identificó una estrategia pedagógica clara. El 29,3 % tuvo alto nivel de conocimiento y 21,1 % adecuada calidad de formación. El 83,8 % tuvo un alto nivel en el manejo de obstrucción intestinal. No hubo asociación entre el nivel de conocimiento y las variables evaluadas (p>0,05). Conclusiones. Ni el aprendizaje recibido, ni el año de entrenamiento tuvieron efecto en el nivel percibido de conocimiento. Las competencias en cuidados paliativos, sus métodos y la calidad del aprendizaje son deficientes a nivel de postgrado en cirugía en Colombia. Probablemente está en un currículo oculto. Es necesario implementar estrategias pedagógicas en los currículos de estudios de los programas de formación de cirujanos.

Introduction. Palliative care responds to the suffering of terminal patients and requires trained personnel for intervention. They are part of the activity in surgery; however, we did not find information about postgraduate education in surgery in Colombia. The objective of this study was to evaluate the level of knowledge in palliative care, the quality of training and pedagogical strategies in residents. Methods. Observational study with self-completed information collection by electronic means. Results. A total of 228 residents participated, 7.8% mentioned a palliative care rotation and 66.6% mentioned having contact with palliative care specialists; 30.7% did not identify a clear pedagogical strategy; 29.3% had a high level of knowledge and 21.1% had adequate quality of training; 83.8% had a high level in the management of intestinal obstruction. There was no association between the level of knowledge and the variables evaluated (p>0.05). Conclusions. Neither the learning received nor the year of training had an effect on the perceived level of knowledge. Competencies in palliative care, its methods and the quality of learning are deficient at the postgraduate level in surgery in Colombia. It is probably on a hidden resume. It is necessary to implement pedagogical strategies in the study curricula of surgeon training programs.

Testamento vital: conhecimento docente e acadêmico de uma escola médica / Living will: academic and faculty knowledge at a medical school / Testamento vital: conocimiento docente y académico de una escuela de medicina

Resumo Esta pesquisa busca avaliar o nível de conhecimento de acadêmicos e docentes do curso de medicina quanto à aplicabilidade do testamento vital, às decisões sobre finitude de vida e ao conceito de morte digna. Foi realizada pesquisa qualitativa, por meio de entrevista semiestruturada, com dez acadêmicos e cinco docentes de uma universidade do Sul do Brasil. Os dados foram obtidos por meio de análise do discurso e classificados nas seguintes categorias: conhecimento e aplicabilidade do testamento vital; visão do processo de finitude e morte digna; e o limiar entre a visão do médico e a autonomia do paciente. As conclusões reforçam a necessidade de difusão desse conhecimento para benefício do paciente e atitudes éticas amparadas legalmente por parte dos médicos.

Abstract This qualitative study evaluates the level of academic and faculty knowledge in a medicine program regarding the living will and its applicability, end-of-life decision making, and the concept of dignified death. Semistructured interviews were conducted with ten scholars and five professors from a university in southern Brazil. Data were obtained by discourse analysis and classified in the following categories: knowledge and applicability of living wills; view of the end-of-life process and dignified death; and the limits between the physician's duty and patient autonomy. In conclusion, this knowledge required greater dissemination to benefit patients and legally supported ethical attitudes.

Resumen Esta investigación pretende evaluar el nivel de conocimiento de los académicos y docentes de medicina con respecto a la aplicabilidad del testamento vital, a las decisiones sobre el fin de la vida y al concepto de muerte digna. La investigación cualitativa se realizó mediante entrevistas semiestructuradas con diez académicos y cinco docentes de una universidad en el Sur de Brasil. Los datos se obtuvieron del análisis del discurso y se clasificaron en las siguientes categorías: conocimiento y aplicabilidad del testamento vital; visión del proceso de fin de la vida y muerte digna; y umbral entre la visión del médico y la autonomía del paciente. Las conclusiones refuerzan la necesidad de difundir este conocimiento en beneficio del paciente y las actitudes éticas legalmente apoyadas por los médicos.

Expressão da espiritualidade nos cuidados paliativos: revisão narrativa / Expressing spirituality in palliative care: a narrative review / Expresión de la espiritualidad en los cuidados paliativos: una revisión narrativa

Resumo A terminalidade da vida requer uma abordagem ampla, com o alívio das dores física, emocional, familiar e social. Ademais, questões espirituais devem ser abordadas como forma de garantir ao paciente todas as fontes de conforto. Em vista disso, esta revisão narrativa da literatura tem o intuito de discutir os efeitos da espiritualidade/religiosidade nos cuidados paliativos. A partir de uma busca manual de trabalhos nas bases PubMed e Biblioteca Virtual em Saúde, foram selecionados 11 trabalhos para a revisão. As discussões foram divididas em três eixos: espiritualidade dos pacientes terminais, espiritualidade dos profissionais da saúde e espiritualidade dos familiares. Conclui-se que as práticas espirituais durante o fim da vida e no enfrentamento das angústias são cruciais tanto para pacientes e familiares quanto para os profissionais.

Abstract End of life requires a comprehensive approach to relief physical, emotional, family and social pain, addressing spiritual issues as a way to ensure patients all sources of comfort. Given this scenario, this narrative literature review discusses the effects of spirituality/religiosity in palliative care. Based on a manual search for papers in the PubMed and Virtual Health Library databases, 11 articles were selected for the review. The discussions were divided into three axes: spirituality of terminally ill patients, spirituality of health professionals and spirituality of family members. In conclusion, spiritual practices during the end of life and in coping with anguish are crucial both for patients and their families and for professionals.

Resumen El final de la vida requiere un enfoque amplio, con alivio del dolor físico, emocional, familiar y social. Además, las cuestiones espirituales deben abordarse como forma de ofrecer confort al paciente. En este contexto, esta revisión narrativa de la literatura tiene como objetivo discutir los efectos de la espiritualidad/religiosidad en los cuidados paliativos. A partir de una búsqueda de artículos en PubMed y en la Biblioteca Virtual de Salud, se seleccionaron 11 artículos para la revisión. Los debates se dividieron en tres ejes: espiritualidad de los pacientes terminales, espiritualidad de los profesionales sanitarios y espiritualidad de los familiares. Se concluye que las prácticas espirituales durante el final de la vida y en el afrontamiento de la angustia son cruciales tanto para los pacientes y sus familias como para los profesionales de la salud.

Knowledge and preference of Filipino COPD patients on advance care planning: A cross-sectional survey

Objectives@#To explore the current experiences and perspectives of patients with chronic obstructive pulmonary disease (COPD) with advance care planning (ACP).@*Methods@#A cross-sectional survey was conducted among patients diagnosed with COPD in the Philippine General Hospital. Results were illustrated using descriptive statistics.@*Results@#A total of 90 patients were interviewed and included in the analysis. Nearly all patients were unfamiliar with the terms ACP (95.55%), end-of-life care (99.89%), and do-not-resuscitate order (100%). The majority expressed a desire to have ACP discussions (94.44%) which were not viewed as distressing and were deemed beneficial (96.67%). Patients who were employed were more likely to express readiness to sign legal papers. Patients living with their nuclear family or living alone, and those with higher COPD assessment test (CAT) scores were more likely to relegate health care decisions to their doctors.@*Conclusion@#Most patients with COPD in our cohort are unfamiliar with ACP and have not received ACP discussions. Most think that it will improve healthcare and quality of life. Some demographic and clinical factors may make patients more likely to engage in ACP-related activities.

Perfil do médico que atua em cuidados paliativos no Brasil / Profile of the palliative care physician in Brazil / Perfil del médico que actúa en cuidados paliativos en Brasil

Resumo Cuidado paliativo é um modelo assistencial multidisciplinar de atenção à saúde que busca proporcionar conforto a paciente com doença ameaçadora da vida ou com doença grave e terminal. A medicina paliativa é reconhecida no Brasil há pouco tempo, sendo fundamental que o médico que trabalha nessa uma área desenvolva seu conhecimento. Desse modo, é relevante para o aprimoramento dos modelos de formação na área e na educação médica no Brasil compreender as caraterísticas desse profissional, identificando perfil sociodemográfico, formação profissional e atividade de trabalho. Este estudo tem recorte transversal, descritivo e exploratório, apresentando abordagem quantitativa. Os resultados são fruto de pesquisa nacional, realizada por meio de questionários aplicados a médicos que atuam em cuidados paliativos no Brasil.

Abstract Palliative care is a multidisciplinary health care model that seeks to provide comfort to patients with life-threatening or severe and terminal illness. Palliative medicine has only recently been recognized in Brazil, and it is essential that physicians working in this area develop their knowledge. Thus, to improve training models in palliative care and in medical education in Brazil, we must understand the characteristics of this professional, identifying sociodemographic profile, professional training, and work activity. This is a cross-sectional, descriptive, and exploratory study, with a quantitative approach. Data were collected from a national survey conducted by means of questionnaires applied to palliative care physicians in Brazil.

Resumen Los cuidados paliativos son una modalidad de asistencia multidisciplinaria que busca brindar comodidad al paciente con enfermedad potencialmente mortal o con enfermedad grave y terminal. Hace poco tiempo que se ofrece la medicina paliativa en Brasil, por lo que es fundamental la capacitación de los médicos que actúan en esta área. Ante lo anterior, para la mejora de los modelos de formación en el área y en la educación médica en Brasil es importante comprender las características de este profesional al identificar el perfil sociodemográfico, la formación profesional y la actividad laboral. Este estudio es transversal, descriptivo y exploratorio, con enfoque cuantitativo. Los resultados utilizan datos de una encuesta nacional, con la realización de cuestionarios aplicados a médicos que actúan en cuidados paliativos en Brasil.

Perfil clínico-epidemiológico dos pacientes em cuidados paliativos atendidos em um serviço de urgência geral / The clinical-epidemiological profile of patients in palliative care treated in an general emergency service

Os pacientes em cuidados paliativos procuram o pronto-socorro para alívio imediato da dor ou de outros sintomas físicos. Os profissionais que atuam em serviços de urgência são treinados para prestar cuidados focados no tratamento direcionado a doenças agudas, mas podem fornecer intervenções paliativas para gerenciar as exacerbações de doenças crônicas ou os cuidados próximos ao fim da vida. Conhecer o perfil dos pacientes em cuidados paliativos atendidos em serviço de urgência e emergência é imprescindível para implementação de medidas que melhorem a qualidade do atendimento deste grupo de pacientes e otimizem o serviço prestado. O objetivo do estudo é descrever o perfil clínico-epidemiológico dos pacientes em cuidados paliativos atendidos no pronto-socorro. Foi realizado um estudo transversal, observacional e retrospectivo, de pacientes adultos de ambos os sexos, em cuidados paliativos atendidos em uma unidade de pronto atendimento ­ UPA, num período de dez meses. O estudo teve aprovação do Comitê de Ética e Pesquisa. Foram analisados 83 pacientes com média de idade de 78,5 (±14,3) anos. Houve predominância do sexo feminino (61,4%). A maioria era procedente do domicílio (87,9%). Havia a presença de cuidador em 91.57% dos casos, predominando o cuidador familiar não-remunerado (76,3%). Sobre atendimento prévio, 44,58% haviam procurado o pronto-socorro no último mês. Quanto à doença de base, 31,3% era oncológica e 68,6% não-oncológica. O câncer de próstata representou a principal causa oncológica (30,7%), seguido de neoplasia hepática e das vias biliares (15,4%). Nos casos não-oncológicos, foi mais frequente a síndrome de fragilidade (42,10%) e sequela grave de acidente vascular cerebral (17,5%). O principal sintoma foi a dispneia em 38 pacientes (45,7%). A dor e a dispneia foram mais frequentes nos casos oncológicos (34,6% e 23,0%, respectivamente), seguidos de dispneia e delirium nos casos não-oncológicos (56,1% e 28,0%, respectivamente). No presente estudo, predominou a faixa etária idosa em cuidados paliativos com cuidador presente com maior frequência de doença de base não-oncológica, dispneia, dor e delirium (AU)

Patients seek emergency rooms for immediate relief from pain or other physical symptoms. Professionals in emergency rooms are trained to render focused care in the targeted treatment of acute diseases and provide palliative interventions to manage exacerbations of chronic illnesses or end-of-life care to patients under palliative care. Knowing the patient's profile for palliative care in the emergency room can be helpful for implementing targeted measures to provide better patient care. This study aims to describe the clinical-epidemiological profile on patients in palliative care treated in an emergency room. A transversal, observational, and retrospective study was carried out of adult patients of both sexes in palliative care treated at Unidade de Pronto Atendimento -UPA over ten months. Data were collected about admission, type of caregiver, pathology, and outcomes. The study was approved by the Research and Ethics Committee. In total, 83 patients with a mean age of 78.5 (±14.3) were analyzed. There was a predominance of female patients (61.4%), and most came from a residence (87.9%). Further, 91.57% had caregivers, predominantly unpaid family caregivers (76.3%). Regarding previous care, 44.58% had sought palliative care less than one month ago. As the base disease, 68.6% were oncological and 31.3% non-oncological. Prostate cancer constituted the primary oncological cause (30.7%), followed by hepatic neoplasia and bile ducts (15.4%). Fragility syndrome (42.10%) and severe complications after a stroke (17.5%) were more frequent in non-oncological base cases. The main symptom was dyspnea noted in 38 patients (45.7%). Pain and dyspnea were more frequent in oncological cases (34.6% and 23.0%, respectively), followed by dyspnea and delirium in non-oncological cases (56.1% and 28.0%, respectively). In the present study, predominantly older patients with a caregiver demonstrated a more significant frequency of non-oncological base disease, dyspnea, pain, and delirium (AU)

Medicina paliativa hospitalaria: modelo de atención implementado en un hospital universitario / Hospital palliative medicine. Revision of a care model implemented at a university hospital

BACKGROUND: Palliative Medicine (PM) is a specialty whose objective is to prevent and alleviate suffering associated with advanced diseases. Hospital palliative medicine has benefits in symptom control, quality of life and cost containment. Hospital PM support teams that serve as referral specialists are in charge of a PM care model. AIM: To describe the clinical experience of a PM support team in a tertiary hospital in Chile. MATERIAL AND METHODS: Review of clinical records of patients referred to a hospital PM support team between March 2015 and July 2018. Administrative data of referrals, sociodemographic and clinical characteristics of patients, their investigated problems and the interventions proposed by the PM team were described. RESULTS: During the study period, 790 referrals were registered, most of them from the internal medicine department (31%) or critical care (24%). During the study period, the number of annual referrals increased from 177 to 237 and the time lapse after hospital admission decreased from five to three days. The mean age of patients was 65.8 years and their main diagnosis was an oncological disease in 81%. The most frequently identified symptoms were fatigue in 71% of patients, depression in 68% and pain in 60%. The main interventions proposed by the PM team were communication support in 64% of patients, analgesia in 62% and education for family caregivers in 49%. Conclusions: The hospital PM team proposes a care model that allows the evaluation and a therapeutic approach for patients suffering from advanced diseases, using a multidimensional perspective including their families.

Cuidados paliativos para profissionais de saúde: avanços e dificuldades / Palliative care for health professionals: advances and difficulties / Cuidados paliativos para profesionales de salud: avances y dificultades

Esta pesquisa exploratória e qualitativa analisou os discursos sobre cuidados paliativos de 23 profissionais de saúde atuantes num hospital especializado no tratamento em oncologia. Os dados coletados por um questionário e uma entrevista semiestruturada foram analisados mediante a técnica de enunciação. Os resultados descrevem os sentidos de cuidados paliativos para os profissionais de saúde; as ações desenvolvidas; as dificuldades da assistência ao doente oncológico em cuidados paliativos; e as limitações da formação profissional para a atuação profissional neste campo. As conclusões mostram uma evolução no conhecimento do tema pelos profissionais, apontam a fragilidade na formação profissional para atuação em cuidados paliativos e a necessidade de mais investimentos para capacitar os profissionais que assistem doentes em paliação. Em relação à terminalidade e qualidade da morte, os profissionais foram unânimes quanto à carência de discussão durante a formação. Os profissionais reivindicam a criação de uma equipe especializada para o exercício desses cuidados e capacitação para os demais profissionais de apoio, aqueles que dão suporte ao trabalho dos profissionais de saúde, como condição essencial para a prestação de um cuidado de qualidade e humanizado.(AU)

This exploratory and qualitative research analyzed the discourses on palliative care of 23 health professionals working in a hospital specialized in oncology treatment. Data collected by a questionnaire and a semi-structured interview were analyzed by using the enunciation technique. The results describe the meanings of palliative care for health professionals; the actions developed; the difficulties in the assistance to cancer patients in palliative care; and the limitations of the professional training to work in this field. The conclusions demonstrate an evolution in the professionals' knowledge of the subject, the fragility of the professional training to work in this area, and the need for more investments to qualify professionals who assist patients in palliation. Regarding the terminality and quality of death, all professionals reported the lack of discussion during academic training. The professionals call for the creation of a palliative care specialized team for offering this care and training other support professionals, as an essential condition for quality and humanized care.(AU)

Este estudio exploratorio y cualitativo analizó los discursos sobre cuidados paliativos de 23 profesionales de salud actuantes en un hospital especializado en oncología. Los datos tomados por un cuestionario y una encuesta semiestructurada fueron analizados mediante la técnica de la enunciación. Los resultados describen los sentidos de cuidados paliativos para profesionales de salud; las acciones desarrolladas; las dificultades de la asistencia al enfermo oncológico en cuidados paliativos; y las limitaciones de la formación profesional para la actuación en este campo. Las conclusiones muestran una evolución en el conocimiento del tema por los profesionales, apuntan una fragilidad en la formación profesional para actuación en cuidados paliativos, y la necesidad de otras inversiones para capacitar los profesionales que asisten a pacientes en cuidados paliativos. En cuanto a la terminalidad y calidad de la muerte los profesionales fueron unánimes en cuanto a la falta de discusión durante la formación académica. Los profesionales reivindican la creación de un equipo especializado en cuidados paliativos y entrenamiento para los profesionales de apoyo, que son aquellos que apoyan el trabajo de los profesionales de salud, como condición esencial para una asistencia de calidad y humanizada.(AU)

Sobre el concepto de dolor total / On the concept of total pain

RESUMEN El dolor de los pacientes de cáncer ha sido descrito como dolor total. Tanto en la literatura científica, los libros de texto, así como en informes y directrices de la Organización Mundial de la Salud, el concepto de dolor total ha servido de trasfondo para promover la atención multidisciplinaria de pacientes cuyo dolor involucra también aspectos psicológicos, emocionales, espirituales y sociales. El objetivo de este artículo es proponer una caracterización del concepto de dolor total de manera tal que continúe jugando un papel central en la promoción de la atención multidisciplinaria propia de los cuidados paliativos. Primero, se presenta un bosquejo del concepto y de los diferentes usos en la literatura. Segundo, se hace un contraste con la definición del dolor de la Asociación Internacional para el Estudio del Dolor (IASP) para establecer la naturaleza y referente del concepto de dolor total. Tercero, se muestra cómo esta caracterización del concepto disuelve algunas tensiones en la literatura respecto a su uso adecuado. Se plantea que el concepto de dolor total hace referencia a aquellas relaciones causales entre el dolor y los estados psicológicos, emocionales, espirituales y sociales que han sido Identificadas como susceptibles de ser intervenidas por el modelo de atención paliativa multidisciplinar. Como conclusión, se recomienda no vincular el concepto de dolor total con el padecimiento de una enfermedad en particular, ni con qué tan limitante para la vida es la enfermedad; tampoco para referirse a la "experiencia global" del paciente, ni como un punto muy alto de una escala.(AU)

ABSTRACT The pain suffering in cancer patients has been described as "total pain". The concept of "total pain" plays a key role in the promotion of the multidisciplinary nature of palliative care. In palliative attention, suffering is conceptualized as an addition of physical, psychological, emotional, spiritual and social aspects. In this paper, I offer a characterization of the concept of "total pain", one which preserves its key role in palliative care promotion. First, I sketch the concept and some different usages found in the literature. Second, I establish the nature and referent of the "total pain" concept by means of showing the contrast between it and the pain definition provided by the International Association for the Study of Pain (IASP). Third, I propose that the concept of "total pain" refers to the relevant causal chains identified by the palliative care research as elements susceptible of intervention for the purpose of alleviating patient's suffering. These causal chains feature and link physical, psychological, emotional, spiritual and social aspects of the patient's suffering. As conclusion, I add the recommendation to not associate the concept of "total pain" with any particular diagnostic or disease or any particular prognosis, neither to the global experience of the patient, nor treat it as a high point on a scale.(AU)

Atuação do psicólogo nos cuidados paliativos em cardiologia / The work f the psychologist in palliative care in cardiology

Trata-se de um artigo de reflexão que visa contextualizar, a partir da literatura e da prática, a atuação do psicólogo nos cuidados paliativos, especificamente em cardiologia. A abordagem dos cuidados paliativos em cardiologia está ainda sendo desenvolvida; teve origem com pacientes terminais de câncer. O psicólogo paliativista que atua junto à equipe multidisciplinar abrange várias áreas, como a biológica, psicológica, religiosa, espiritual, social e familiar. A atuação visa o atendimento aos pacientes, familiares e equipe, oferecendo suporte para a melhor qualidade de vida naquele momento. O psicólogo participa das conferências familiares, abre espaços para a discussão de casos, promove encontros multidisciplinares, cuida do burnout da equipe, lida com os conflitos e implementa as habilidades de comunicação. O instrumento fundamental para o trabalho é a melhora constante da comunicação, que visa agregar e harmonizar a equipe, diminuir os conflitos e impactos nas relações com o paciente, a família e os membros, esclarecendo, orientando e diminuindo a dor como um todo. Desse modo, cria uma rede de continência e um projeto terapêutico para as necessidades de cada paciente e família

This is a reflection article that aims to contextualize, based on the literature and practice, the work of the psychologist in palliative care, specifically in cardiology. The palliative care approach in cardiology is still being developed; it originated with terminal cancer patients. The palliative psychologist who works alongside the multidisciplinary team covers various areas such as biological, psychological, religious, spiritual, social and family-related. Their work aims to provide care to patients, families and staff, offering support for the best quality of life at that time. The psychologist participates in family meetings, opens spaces for discussion of cases, promotes multidisciplinary meetings, takes care of team burnout, deals with conflicts, and implements communication skills. The essential tool for the work is the constant improvement of communication, which aims to bring together and fine-tune the team, reduce conflicts and impacts in the relations with the patient, the family and the members, clarifying, guiding and reducing the overall pain. Thus, the psychologist creates a network of moderation and a therapeutic project for the needs of each patient and family

Prognostic value of a modified surprise question designed for use in the emergency department setting

OBJECTIVE: Few reliable and valid prognostic tools are available to help emergency physicians identify patients who might benefit from early palliative approaches. We sought to determine if responses to a modified version of the surprise question, “Would you be surprised if this patient died in the next 30 days” could predict in-hospital mortality and resource utilization for hospitalized emergency department patients.METHODS: For this observational study, emergency physicians responded to the modified surprise question with each admission over a five-month study period. Logistic regression analyses were completed and standard test characteristics evaluated.RESULTS: 6,122 visits were evaluated. Emergency physicians responded negatively to the modified surprise question in 918 (15.1%). Test characteristics for in-hospital mortality were: sensitivity 32%, specificity 85%, positive predictive value 6%, negative predictive value 98%. The risk of intensive care unit use (relative risk [RR], 1.87; 95% confidence interval [CI], 1.45 to 2.40), use of ‘comfort measures’ orders (RR, 3.43; 95% CI, 2.81 to 4.18), palliative-care consultation (RR, 3.06; 95% CI, 2.62 to 3.56), and in-hospital mortality (RR, 2.18; 95% CI, 1.72 to 2.76) were greater for patients with negative responses.CONCLUSION: The modified surprise question is a simple trigger for palliative care needs, accurately identifying those at greater risk for in-hospital mortality and resource utilization. With a negative predictive value of 98%, affirmative responses to the modified surprise question provide reassurance that in-hospital death is unlikely.

Changes in Perceptions and Attitudes of Medical Students toward End-of-Life Care after Hospice and Palliative Medicine Education / 한국호스피스완화의료학회지

PURPOSE: High-quality hospice and palliative medicine curricula are necessary in Korean medical schools. This study evaluated changes in students' knowledge and attitudes toward both hospice and palliative care following the completion of a course on these topics, as well as the course's overall role in the basic medical education curriculum.METHODS: Questionnaires measuring knowledge and attitudes were collected before and after the course from 76 fourth-year medical students, who had received instructions integrating both hospice and palliative care in 2016.RESULTS: The questionnaire item “Select the correct answer on the use of opioid pain control in hospice and palliative care” changed the most in terms of number of correct answers pre- and post-course (3.50 and 5.32, respectively; P<0.001). Pre- and post-course, the numbers of students who answered “Strongly Agree” and “Agree” to questions concerning their attitudes toward hospice and palliative care (“I know the purposes and roles of hospice and palliative care”) were 17 (22.4%) and 65 (85.6%), respectively (P≤0.001). Affirmative responses also increased for “As a pre-physician, I know when to describe and advise hospice and palliative care to patients”, from 22 (28.9%) to 65 (85.6%; P≤0.001).CONCLUSION: This study showed that comprehensive hospice education in the form of an integrated educational course might promote changes in medical students' knowledge and attitudes toward hospice and palliative medicine.

Matriz de competências de medicina paliativa para o geriatra / Competency framework of palliative medicine for geriatricians

INTRODUÇÃO E OBJETIVO: Apesar da grande interface entre cuidados paliativos (CPs) e geriatria, ainda não há propostas de currículos de competências de medicina paliativa (MP) para geriatra no Brasil. Diante disso, objetivou-se desenvolver uma matriz de competências de medicina paliativa para o geriatra (MCMPG), especialmente para aquele em formação. MÉTODO: A primeirafase consistiu na elaboração da matriz piloto. Para se determinar o consenso, um grupo de geriatras com certificação de área de atuação em MP de todas as regiões do país foi convidado a opinar sobre as competências elencadas na matriz piloto. Foram duas etapas (2ª e 3ª fases) de metodologia Delphi modificada para se obter o consenso (nível de concordância maior que 50 e 80%, respectivamente, na 2ª e 3ª fases). E, por fim, realizada a fase de consulta pública no XXI Congresso Brasileiro de Geriatria e Gerontologia e via site da Academia Nacional de Cuidados Paliativos. RESULTADOS: Dezenove experts em MP e Geriatria avaliaram a MCMPG. O nível de concordância de todas as áreas temáticas foi maior que o determinado, exceto a sedação paliativa (20% discordância). A MCMPG finalizou com 13 áreas temáticas, 105 competências, sendo 11 de pré­requisitos, 52 essenciais, 24 desejáveis e 18 avançadas. CONCLUSÃO: Definiu-se uma matriz de competências de CPs que pode ser integrada à educação médica, especificamente à pós-graduação em Geriatria. Propõe-se que os serviços de residência em Geriatria ofereçam, pelo menos, o treinamento das competências "essenciais", nas áreas temáticas propostas fortalecendo a educação em CPs de forma homogênea em todo o país.

INTRODUCTION AND OBJECTIVE: Despite a great interface between palliative care (PC) and geriatrics, there are currently no curriculum proposals of palliative medicine (PM) competencies for geriatricians in Brazil. Thus, the aim was to develop a competency framework of palliative medicine for geriatricians (CFPMG), especially for those under training. METHOD: The first phase consisted of preparing a pilot framework. To reach a consensus, geriatricians with expertise in the field of PM from all Brazilian regions were invited to express their opinions on the competencies listed in the pilot framework. A modified Delphi method was used in the 2nd and 3rd phases to obtain a consensus (level of agreement greater than 50% and 80%, respectively). Finally, a public consultation phase was conducted in the 21st Brazilian Congress on Geriatrics and Gerontology, and via Brazilian National Academy of Palliative Care website. RESULTS: Nineteen experts in PM and geriatrics evaluated the CFPMG. The level of agreement in all thematic areas was greater than that required, except for palliative sedation (20% of disagreement). The CFPMG concluded with 13 thematic areas and 105 competencies, including 11 prerequisite, 52 core, 24 desirable, and 18 advanced competencies. CONCLUSION: The defined competency framework of PC may be integrated into medical education, specifically into geriatric medicine training. Our suggestion is that residency programs in geriatrics provide training at least in the core competencies from the proposed thematic areas, thereby strengthening PC education homogeneously across the country.

Palliative care: A proposal for undergraduate education in Medicine / Cuidados paliativos: Uma proposta para o ensino da graduação em Medicina

Objective: to propose essential competencies for the teaching of palliative care on undergraduate Medicine courses. Method: a documentary analysis of the literature on general competencies in palliative care was initially carried out, to construct a framework with suggestions of essential competencies for undergraduate education in Brazil. The elaborated material was then presented individually to eight professionals from a range of areas for analysis. All the professionals had specialized training in palliative care, and the material was accompanied by an interview with three open questions. The categorical thematic content analysis proposed by Bardin was used in the documentary analysis and the interviews with the professionals. Results: the initial documentary analysis resulted in five categories, eight subcategories and 96 units of analysis, based on which the researcher was able to construct the suggestions for competences, which were distributed with their respective contents in a framework with five modules. Six categories, 12 subcategories and 168 analysis units emerged from the interviews with the professionals following a reading of the material. From the discourse contained in the subcategories and units of analysis, suggestions emerged for a better distribution of the modules, resulting in the renaming of the same (Basic principles of palliative care, Symptom management, Teamwork, Ethical and legal issues, Care in the last moments of life). Conclusion: the discussion and improvement of the palliative care competencies suggested in this study will be essential at medical education forums, providing clarity about what is really required in general practitioner training.

Objetivo: Propor competências essenciais para o ensino de Cuidados Paliativos nos cursos de graduação em Medicina. Método: Inicialmente, foi feita uma análise documental na literatura sobre competências gerais em Cuidados Paliativos, no sentido de construir um quadro com sugestões de competências essenciais para o ensino de graduação no Brasil. A seguir, o material elaborado foi apresentado individualmente a oito profissionais com formação especializada em cuidados paliativos de diferentes áreas para análise, acompanhado de uma entrevista com três questões abertas. Na análise documental e nas entrevistas com os profissionais, foi utilizada a análise de conteúdo temática categorial proposta por Bardin. Resultados: A análise documental inicial resultou em cinco categorias, oito subcategorias e 96 unidades de análise que deram subsídio ao pesquisador para construção das sugestões de competências, distribuídas num quadro em cinco módulos, com seus respectivos conteúdos. Das entrevistas com os profissionais, após leitura do material que lhes foi entregue, emergiram seis categorias, 12 subcategorias e 168 unidades de análise. Das falas contidas nas subcategorias e unidades de análise, emergiram sugestões para melhor distribuição dos módulos, resultando na renomeação destes (Princípios básicos dos Cuidados Paliativos, Manejo de sintomas, Trabalho em Equipe, Questões Éticas e Legais, Assistência nos Últimos Momentos de Vida). Conclusão: A discussão e aprimoramento das competências em Cuidados Paliativos sugeridas nesse estudo serão essenciais durante os fóruns de educação médica, para que possamos ter mais clareza do que realmente é necessário para a formação do médico generalista.

EXPERIENCES IN CLINICAL ETHICS: A PROJECT FOR MEETINGS ON CLINICAL ETHICS IN PALLIATIVE MEDICINE / EXPERIENCIAS EN ÉTICA CLÍNICA: EL PROYECTO DE "ENCUENTROS SOBRE ÉTICA CLÍNICA EN LA MEDICINA PALIATIVA" / EXPERIENCIAS NA ÉTICA CLÍNICA: O PROJETO DE "ENCONTROS SOBRE ÉTICA CLÍNICA NA MEDICINA PALIATIVA"

"Meetings on Clinical Ethics in Palliative Medicine," as outlined in this article, is a project on ethical and clinical training in the area of palliative care. The project is part of a clinical program and broader research pertaining to recovery of the anthropological and ethical roots in the clinical practice of palliative care. It is aimed at professionals and researchers in palliative care and consists of informal meetings where the human and professional values involved in actual clinical cases are analyzed. Anthropology, general ethics, medical epistemology and philosophy of medicine are considered essential in this program of ethical and clinical training, as are the valuable insights provided by the humanities. The specific objective is not only to provide a list of ethical principles, but also to promote an ethical disposition on the part of the person who acts.

"Encuentros sobre ética clínica en la medicina paliativa" es un proyecto de formación ética y clínica en el ámbito de los cuidados paliativos. Hace parte de un programa clínico y de investigación más amplio que pertenece a la línea de recuperación de las raíces antropológicas y éticas en la práctica clínica de los cuidados paliativos. Está dirigido a profesionales e investigadores en cuidados paliativos, y contempla el desarrollo de reuniones informales, donde se analizan los valores humanos y profesionales involucrados en casos clínicos reales. En este programa de formación ética y clínica, se consideran esenciales la antropología, la ética general, la epistemología médica y la filosofía de la medicina, además es valiosa la información proporcionada por las humanidades. El objetivo específico no es solo proporcionar una lista de principios éticos, sino también promover una disposición ética de parte de la persona que actúa.

"Encontros sobre ética clínica na medicina paliativa", apresentado neste artigo, é um projeto de formação ética e clínica no âmbito dos cuidados paliativos. O projeto faz parte de um programa clínico e de pesquisa mais amplo que pertence à linha de recuperação das raízes antropológicas e éticas na prática clínica dos cuidados paliativos. Está dirigido a profissionais e pesquisadores em cuidados paliativos e leva em consideração o desenvolvimento de reuniões informais, em que se analisam os valores humanos e profissionais envolvidos em casos clínicos reais. Nesse programa de formação ética e clínica, consideram-se essenciais a antropologia, a ética geral, a epistemología médica e a filosofia da medicina, além da valiosa informação proporcionada pelas humanas. O objetivo específico não é só oferecer uma lista de princípios éticos, mas também promover uma disposição ética de parte da pessoa que atua.

Enteral stent construction: Current principles

The insertion of self-expanding stents into malignant strictures of the small and large bowel has become a routine procedure around the world. However, stent development has happened very much on a "trial & error" approach, based mostly on bright ideas of enthusiastic individuals or marketing decisions by the manufacturer. A large variety of stents are commercially available, covered to a variable degree by a membrane to reduce tissue ingrowth. However, in vitro characteristics and in vivo behavior vary significantly between stents and few operators are aware of the differences. While the ideal stent still remains to be defined, it is important that interventionists understand the variations, in order to make the best possible choice for the individual patient. This article illustrates current principles of stent construction.

Advances of Hospice Palliative Care in Taiwan / 한국호스피스완화의료학회지

Hospice and palliative care in Taiwan has been growing continuously. The 2015 Quality of Death index, as rated by the Economist Intelligence Unit, ranked Taiwan first among Asian countries and sixth in the world. In this review article, we highlight three particular areas that might have contributed to this success; the laws and regulations, spiritual care and research network. Finally, we discuss the future challenges and prospects for Taiwanese encounters. A systemic review was conducted with the keywords “hospice palliative care Taiwan” using PubMed. The passing of the “Natural Death Act” in 2000 set the example and established a landmark for patient autonomy in Asia; it guarantees the patient's right to request that medical staff do not resuscitate (DNR) them and to reject other futile medical treatments at the end of their life, thus reflecting the importance of palliative care from the policy perspective. In 2015, Taiwan passed another pioneering law entitled the “Patient Autonomy Act”. This law states that a patient may decline medical treatment according to his/her own will. Taiwanese indigenous spiritual care was launched in 2000. It requires a Buddhist Chaplain to successfully complete a training program consisting of lectures, as well as bedside practicum before applying Buddhist practices to end-of-life care. The Japan-Korea-Taiwan research network was established for the purpose of enabling collaborative research for the East-Asian collaborative cross-cultural Study to Elucidate the Dying process (EASED) cohort. With consensus from the government and society to make it a priority, hospice and palliative medicine in Taiwan has been growing steadily.

A criança frente à doença e à morte: aspectos psiquiátricos / The child acing sickness and death: psychiatric aspects

O atendimento da criança com doença grave ou terminal é uma situação bastante delicada e complexa, que envolve questões psicológicas importantes do paciente, de sua família e de todos os envolvidos no seu cuidado. A partir da revisão das etapas evolutivas das crianças, este artigo tem o objetivo de auxiliar a identificar as reações que elas apresentam diante da sua própria doença e/ou morte, ilustrando com alguns exemplos clínicos. Destaca-se a importância da participação da consultoria psiquiátrica na internação hospitalar em pediatria, que pode ser requisitada para avaliar e/ou atender, do ponto de vista psiquiátrico, a criança portadora de doença grave ou terminal e, também, a família do paciente. Cabe ainda ao consultor psiquiátrico o desafio de proporcionar atenção à equipe assistente, visto que o estresse a que são submetidos os "profissionais da linha de frente" é de tamanha intensidade, que alguns autores o compararam ao vivido no campo de batalha. A busca de um conhecimento profundo sobre si mesmos e sobre os aspectos relacionados à doença e à natureza do paciente sob seus cuidados pode permitir que os profissionais de saúde se posicionem com tranquilidade diante de uma criança gravemente doente e sua família. Quaisquer decisões que venham a ser tomadas precisam estar de acordo com os princípios éticos que cada indivíduo adota, mas também de acordo com os princípios éticos vigentes na contemporaneidade.(AU)

The treatment of a severely or terminally ill child is a very complicated situation that involves psychological issues of great significance to the patient, the family and all those involved in their care. From the review of the child's developmental stages, this study aims to help identify their reactions in front of their illness or death, illustrating with some clinical examples. We highlight the importance of the participation of the psychiatric consultation service during pediatric hospitalization, since the terminally ill child, the family, or both, frequently need psychiatric assessment or attention. The psychiatrist also has the challenge of providing attention to the "front-line" healthcare team, since the stress they experience is such that some authors compare it to the stress experienced in the battle field. The search for a profound knowledge about themselves and aspects related to the disease and the nature of the patient under their care, may allow healthcare professionals to acquire a calm stance when facing severely ill children and their families. Any decisions taken should be in agreement with ethical principles, both those held by each individual and those prevailing in contemporary times.(AU)