Nursing students' attitude toward euthanasia following its legalization in Spain.

BACKGROUND: Euthanasia is a controversial practice in many countries. Since Spain's Euthanasia Law came into effect on March 24, 2021, healthcare providers have faced a new challenge since they must inform patients, provide care, accompany them, and implement the law. It also represents a new stumbling block at universities, which must adapt to regulatory changes and educate future professionals accordingly. Little is known about the attitude of nursing students in Spain toward euthanasia since this law was implemented. OBJECTIVE: This study aims to answer the following research questions: What is the attitude of nursing students toward euthanasia? What factors influence this attitude? RESEARCH DESIGN: A cross-sectional study was conducted using an online questionnaire. PARTICIPANTS AND RESEARCH CONTEXT: The study population comprised all nursing students at a public university in Barcelona (n = 444), Spain, during the 2022-2023 academic year. The validated Spanish version of the Euthanasia Attitude Scale was employed. A bivariate analysis was performed. ETHICAL CONSIDERATIONS: The university Ethics Committee (CEEAH 6247) approved this study. All participating students signed an informed consent form. Participation was voluntary, and data anonymity and confidentiality were guaranteed. RESULTS: Two hundred and forty-four nursing students responded to the questionnaire. The mean total score was 79.64. Participants with religious beliefs presented lower scores, indicating a more negative attitude toward euthanasia. Participants in their second, third, or fourth year of the nursing degree scored higher, demonstrating a more positive attitude. CONCLUSIONS: The attitude of nursing students toward euthanasia was remarkably positive. Working on ethical content during the degree course and clinical practice are factors that help to develop a more positive attitude. In addition, nursing education should encourage professional aspects to prevail over religious beliefs in euthanasia situations.

[The euthanasia law and professional experiences: tensions in clinical practice]. / La ley de eutanasia y experiencias profesionales: tensiones en la práctica clínica.

OBJECTIVE: To analyze the process of assisted death provision in Catalonia and identify the main tensions, difficulties, and/or sources of discomfort related to professional practice. METHOD: A qualitative study was conducted based on interviews (n=29) and focus groups (n=19) with professionals who participated in the euthanasia process. The selection of participants combined the snowball and maximization of variability procedures, taking into account the variables of professional profile, setting, gender, age and territoriality. Intentional and theoretical sampling process. RESULTS: The assisted death process is divided into four main moments: 1) reception of the request, 2) medical-bureaucratic procedure, 3) the actual procedure, and 4) closure. At each of these moments, difficulties arise that can be a source of discomfort and have to do with the limits and tensions between the legal and moral, the conception of one's own professional role, the lack of recognition of some professional roles, stress and overload, the lack of formal and informal support, and the relationship with the patient and his/her family. The bureaucratic-administrative stress derived from a protective law, with both prior and subsequent verifying control, stands out, given that it stresses the professionals immersed in a healthcare system already under high pressure after budget cuts and the COVID-19 epidemic. CONCLUSIONS: Throughout the assisted death process, the sources of distress are diverse and of a psychological, psychosocial, and structural nature. These results may lead to interventions for psychological and peer support, information, training, institutional involvement, and burden reduction.

[The provision of assisted death in the context of the desire to anticipate death]. / La prestación de ayuda a morir en el contexto del deseo de anticipar la muerte.

The entry into force of the Organic Law on the Regulation of Euthanasia in June 2021 obliges clinicians to reconsider their professional work, in the face of a new service that expands the limits of what was considered correct until then. This new service affects the entire healthcare system, but especially primary care professionals. Beyond the procedural and moral aspects, it is necessary to rethink the assessment of the patient who expresses a wish to die. In this review, we start with the relatively recent definition of the wish to hasten death (WTHD), its causes, epidemiology and differential diagnosis. Then, we examine the different mental frameworks found in the process of dying and the concept of a «good death¼. Finally, we analyse the paths that can lead to the provision of aid in dying within the framework of current legislation. The WTHD is specific to requests in case of «serious and advanced illness¼, not in other cases contemplated by the Law. When faced with a request to activate the Aid in Dying Prestation in the context of WTHD (that is, in the proximity of death), it becomes necessary to increase the patient's sense of control and begin to work on grief. Besides, in the face of an administrative process that will necessarily be long, adapting the therapeutic efforts and sedation should be considered as possible options. We understand that it is essential not to create false expectations for patients/families and not to overload healthcare professionals with administrative tasks that will be futile. It is difficult to balance these in the face of a request for a right to which the patient should always have access.

[Care complexity and place of death in palliative home care]. / Complejidad asistencial y lugar de muerte en atención domiciliaria paliativa.

OBJECTIVE: To examine the associations between the dimensions of the HexCom care complexity model and the place of death. METHOD: Multicenter longitudinal observational study in patients with advanced illness cared for by home care support teams in Catalonia. Age, gender, type of illness, main caregiver, external support, place of death and the sub-areas of care complexity provided by HexCom were registered. A multivariate Cox regression analysis was performed. RESULTS: Participation of 1527 patients (72% oncology), cared for a median of 35 days. 45% died at home. The probability of dying at home was greater when a greater functional impairment was detected in the initial assessment (hazard ratio [HR]: 7.67; 95% confidence interval [95%CI]: 4.93-11.92), when the patient was male (HR: 1.19; 95%CI: 1.02-1.39), was over 80 years old (HR: 1.41; 95%CI: 1.20-1.66) and when care complexity was detected in relation to being in a situation of last days (HR: 2.24; 95%CI: 1.69-2.97). It was more likely not to die at home in the case of cancer (HR: 0.76; 95%CI: 0.64-0.89), or if poor external support to the family group was detected in the first evaluation (HR: 0.79; 95%CI: 0.67-0.93), or that the patient did not feel at peace with others (HR: 0.56; 95%CI: 0.40-0.79), or lack of agreement on the planning of the place of death (HR: 0.57; 95%CI: 0.48-0.68). CONCLUSIONS: The assessment of the complexity of care through the HexCom-Clin model can help to improve advance planning of decisions by incorporating among its dimensions the feeling of peace with others, the external support to the family nucleus and the degree of agreement on the place of death.

Complejidad asistencial y lugar de muerte en atención domiciliaria paliativa / Care complexity and place of death in palliative home care

Objetivo: Examinar las asociaciones entre las dimensiones del modelo de complejidad asistencial HexCom y la ubicación de la muerte. Método: Estudio observacional longitudinal multicéntrico en pacientes con enfermedad avanzada tratados por los equipos de soporte a la atención domiciliaria en Cataluña. Se recogieron edad, sexo, estado funcional y cognitivo, tipo de enfermedad, cuidador/a principal, trabajador/a familiar, lugar de la muerte y complejidad tras la primera visita. Se realizó un análisis de regresión de Cox multivariante. Resultados: Participación de 1527 pacientes (72% oncológicos), atendidos una mediana de 35 días. El 45% fallecieron en su domicilio. La probabilidad de morir en casa era mayor cuando se detectaba un mayor deterioro funcional (hazard ratio [HR]: 7,67; intervalo de confianza del 95% [IC95%]: 4,93-11,92), cuando el sujeto era varón (HR: 1,19; IC95%: 1,02-1,39), cuando la edad era >80 años (HR: 1,41; IC95%: 1,20-1,66) y cuando se detectaba complejidad en relación a la situación de últimos días (HR: 2,24; IC95%: 1,69-2,97). Era más probable no morir en casa si se padecía cáncer (HR: 0,76; IC95%: 0,64-0,89), si se detectaba un pobre apoyo externo al grupo familiar (HR: 0,79; IC95%: 0,67-0,93), si el/la paciente no se sentía en paz con los demás (HR: 0,54; IC95%: 0,39-0,75) o si había falta de acuerdo en la planificación del lugar de la muerte (HR: 0,57; IC95%: 0,48-0,68). Conclusiones: La valoración de la complejidad asistencial a través del modelo HexCom-Clin puede contribuir a una mejor planificación anticipada de decisiones al incorporar entre sus dimensiones el sentirse en paz con los demás, el soporte externo al núcleo familiar y el grado de acuerdo sobre el lugar de muerte. (AU)

Objective: To examine the associations between the dimensions of the HexCom care complexity model and the place of death. Method: Multicenter longitudinal observational study in patients with advanced illness cared for by home care support teams in Catalonia. Age, gender, type of illness, main caregiver, external support, place of death and the sub-areas of care complexity provided by HexCom were registered. A multivariate Cox regression analysis was performed. Results: Participation of 1527 patients (72% oncology), cared for a median of 35 days. 45% died at home. The probability of dying at home was greater when a greater functional impairment was detected in the initial assessment (hazard ratio [HR]: 7.67; 95% confidence interval [95%CI]: 4.93-11.92), when the patient was male (HR: 1.19; 95%CI: 1.02-1.39), was over 80 years old (HR: 1.41; 95%CI: 1.20-1.66) and when care complexity was detected in relation to being in a situation of last days (HR: 2.24; 95%CI: 1.69-2.97). It was more likely not to die at home in the case of cancer (HR: 0.76; 95%CI: 0.64-0.89), or if poor external support to the family group was detected in the first evaluation (HR: 0.79; 95%CI: 0.67-0.93), or that the patient did not feel at peace with others (HR: 0.56; 95%CI: 0.40-0.79), or lack of agreement on the planning of the place of death (HR: 0.57; 95%CI: 0.48-0.68). Conclusions: The assessment of the complexity of care through the HexCom-Clin model can help to improve advance planning of decisions by incorporating among its dimensions the feeling of peace with others, the external support to the family nucleus and the degree of agreement on the place of death. (AU)

Intra-rater reliability and feasibility of the HexCom advanced disease complexity assessment model / Fiabilidad intraobservador y viabilidad del modelo de valoración de la complejidad en enfermedad avanzada HexCom®

Aim: To study the intra-rater reliability and feasibility of the HexCom complexity assessment model by analyzing internal consistency, intra-rater reliability and response time. Design: Test–retest study with a selection of 11 clinical situations that cover the full scope of situations assessed by the HexCom model and which are responded to individually. Location: Home care, primary care, hospital and sociosanitary care. Two specialized palliative home care teams (PADES). Participants: A total of 20 professionals comprising 10 experts in palliative home care (PADES) and 10 professionals from general palliative care (primary care, hospital and sociosanitary care). These professionals came from the fields of family medicine (5), internal medicine (2), geriatrics (2), nursing (9), psychology (1) and social work (1). Main measurements: Cronbach's alpha, weighted kappa, response time. Results: Cronbach's alpha of 0.91 for HexCom-Red and 0.87 for HexCom-Clin. Intra-rater reliability ranging from good to very good for HexCom-Red (kappa: 0.78–1) and from moderate to very good for HexCom-Clin (kappa: 0.58–0.91). Average response time of 0:57 for HexCom-Red and 3:80min for HexComClin. Conclusions: HexCom-Red and HexCom-Clin are reliable tools and feasible for use by all professionals involved in both general and specialized palliative care at different levels.(AU)

Objetivo: Estudiar la fiabilidad intraobservador y la viabilidad del modelo de valoración de la complejidad HexCom®, a través del análisis de la consistencia interna, la concordancia intraobservador y el tiempo de respuesta. Diseño: Estudio test-retest con un panel de 11 situaciones clínicas que incluyen todo el abanico de situaciones valoradas por el modelo HexCom® y que son respuestas individualmente. Emplazamiento: Atención domiciliaria, primaria, hospitalaria y sociosanitaria. Dos equipos de atención domiciliaria paliativa especializada (PADES). Participantes: Veinte profesionales, 10 expertos en atención domiciliaria paliativa (PADES) y 10 de atención paliativa generalista (atención primaria, hospitalaria y sociosanitaria). Incluye medicina de familia (5), medicina interna (2) y geriatría (2), enfermería (9), psicología (1) y trabajo social (1). Medidas principales: Alfa de Cronbach, Kappa ponderado, tiempo de respuesta. Resultados: Alfa de Cronbach de 0,91 por HexCom-Red® y de 0,87 por HexCom-Clin®. Fiabilidad intraobservador entre buena y muy buena por HexCom-Red® (Kappa: 0,78-1) y entre moderada y muy buena por HexCom-Clin® (Kappa: 0,58-0,91). Tiempo de respuesta de 0:57min de media por el HexCom-Red y de 3:80min por HexCom-Clin®. Conclusiones: Los instrumentos HexCom-Red® y HexCom-Clin® son fiables y su uso factible para todas las profesiones implicadas en la atención paliativa, tanto generalista como especializada y de los diferentes niveles asistenciales.(AU)

Intra-rater reliability and feasibility of the HexCom advanced disease complexity assessment model.

AIM: To study the intra-rater reliability and feasibility of the HexCom complexity assessment model by analyzing internal consistency, intra-rater reliability and response time. DESIGN: Test-retest study with a selection of 11 clinical situations that cover the full scope of situations assessed by the HexCom model and which are responded to individually. LOCATION: Home care, primary care, hospital and sociosanitary care. Two specialized palliative home care teams (PADES). PARTICIPANTS: A total of 20 professionals comprising 10 experts in palliative home care (PADES) and 10 professionals from general palliative care (primary care, hospital and sociosanitary care). These professionals came from the fields of family medicine (5), internal medicine (2), geriatrics (2), nursing (9), psychology (1) and social work (1). MAIN MEASUREMENTS: Cronbach's alpha, weighted kappa, response time. RESULTS: Cronbach's alpha of 0.91 for HexCom-Red and 0.87 for HexCom-Clin. Intra-rater reliability ranging from good to very good for HexCom-Red (kappa: 0.78-1) and from moderate to very good for HexCom-Clin (kappa: 0.58-0.91). Average response time of 0:57 for HexCom-Red and 3:80min for HexComClin. CONCLUSIONS: HexCom-Red and HexCom-Clin are reliable tools and feasible for use by all professionals involved in both general and specialized palliative care at different levels.

Gender and Observed Complexity in Palliative Home Care: A Prospective Multicentre Study Using the HexCom Model.

This study analyses gender differences in the complexity observed in palliative home care through a multicentre longitudinal observational study of patients with advanced disease treated by palliative home care teams in Catalonia (Spain). We used the HexCom model, which includes six dimensions and measures three levels of complexity: high (non-modifiable situation), medium (difficult) and low. Results: N = 1677 people, 44% women. In contrast with men, in women, cancer was less prevalent (64.4% vs. 73.9%) (p < 0.001), cognitive impairment was more prevalent (34.1% vs. 26.6%; p = 0.001) and professional caregivers were much more common (40.3% vs. 24.3%; p < 0.001). Women over 80 showed less complexity in the following subareas: symptom management (41.7% vs. 51,1%; p = 0.011), emotional distress (24.5% vs. 32.8%; p = 0.015), spiritual distress (16.4% vs. 26.4%; p = 0.001), socio-familial distress (62.7% vs. 70.1%; p = 0.036) and location of death (36.0% vs. 49.6%; p < 0.000). Men were more complex in the subareas of "practice" OR = 1.544 (1.25-1.90 p = 0.000) and "transcendence" OR = 1.52 (1.16-1.98 p = 0.002). Observed complexity is related to male gender in people over 80 years of age. Women over the age of 80 are remarkably different from their male counterparts, showing less complexity regarding care for their physical, psycho-emotional, spiritual and socio-familial needs.

[Wish to hasten death in home palliative care. Look for your seven percent.] / El deseo de adelantar la muerte en cuidados paliativos domiciliarios. Busca tu siete por ciento.

OBJECTIVE: The wish to hasten death has been little researched in the area of Mediterranean countries and we are not aware of specific studies on its particularities in home care in our setting. The aim of this work was to investigate the prevalence and evolution of wish to hasten death in home care, analysing its relationship with physical, emotional, spiritual, ethical and social-family unrest. METHODS: Longitudinal observational study in palliative home care in Catalonia. 43 teams agreed on the level of complexity after the first visit and after the discharge of the patient with the HexCom model, which classifies the desire to anticipate death into Low complexity (no or sporadic manifestation); Medium (persistent desire that requires specific treatment); or High (persistent desire that is considered potentially refractory). For the comparison of proportions, Pearson's Chi-squared test was used and a multivariate logistic regression analysis was performed, in which the dependent variable corresponded to the desire to hasten initial death. The level of significance was p≤0.05. RESULTS: The total number of patients included in this study was 1,677, of whom 1,169 (69.7%) were oncologic. The prevalence of desire to hasten death was 6.67%. It was related to spiritual distress, especially lack of meaning (OR 3.25) and lack of connection (OR 3.81), to psychoemotional distress (OR 2.34) and to ethical distress. Protective factors were spiritual distress in relation to transcendence (OR 0.50), the caregiver being a partner (OR 0.50) and being cared for by a team that included psychology and social work (OR 0.34). The desire to anticipate death is stable in 71.6% of patients. CONCLUSIONS: The desire to anticipate death is a changing and complex phenomenon that can emerge at any time. The presence of psycho-emotional, spiritual-existential and ethical discomfort, especially in patients without a partner, should make us take a proactive attitude to identify it early.

OBJETIVO: El deseo de adelantar la muerte ha sido poco investigado en el área de los países mediterráneos y no conocemos estudios específicos sobre sus particularidades en atención domiciliaria en nuestro entorno. El objetivo de este trabajo fue investigar la prevalencia y la evolución del deseo de anticipar la muerte en atención domiciliaria, analizando su relación con el malestar físico, emocional, espiritual, ético y sociofamiliar. METODOS: Estudio observacional longitudinal en el ámbito de la atención domiciliaria paliativa en Catalunya. 43 equipos acordaron el nivel de complejidad tras la primera visita y tras el alta del paciente con el modelo HexCom, el cual clasifica el deseo de anticipar la muerte en complejidad Baja (manifestación nula o esporádica); Media (Deseo persistente que requiere tratamiento específico); o Alta (Deseo persistente que se considera potencialmente refractario). Para la comparación de proporciones se utilizó la prueba de Ji cuadrado de Pearson y se realizó un análisis de regresión logística multivariante, en el que la variable dependiente correspondía con el deseo de adelantar la muerte inicial. El nivel de significación fue p≤0,05. RESULTADOS: El número total de pacientes incluidos en este estudio fue de 1.677, de los cuales 1.169 (69,7%) eran oncológicos. La prevalencia de deseo de anticipar la muerte fue del 6,67%. Se relacionó con el malestar espiritual, ante todo con la falta de sentido (OR 3,25) y de conexión (OR 3,81), con el malestar psicoemocional (OR 2,34) y con el malestar ético. Fueron factores protectores el malestar espiritual en relación con la transcendencia (OR 0,50), que el cuidador fuese la pareja (OR 0,50) y ser atendido por un equipo en el que se incluyese psicología y trabajo social (OR 0,34). El deseo de anticipar la muerte fue estable en el 71,6% de los pacientes. CONCLUSIONES: El deseo de anticipar la muerte es un fenómeno cambiante y complejo que puede emerger en cualquier momento. La presencia de malestar psicoemocional, espiritual-existencial y ético, sobre todo en pacientes sin pareja, nos han de hacer tomar una actitud proactiva para identificarlo precozmente.

Trayectorias de complejidad en el final de la vida: un estudio multicéntrico prospectivo observacional longitudinal / End-of-life complexity trajectories: a prospective, longitudinal observational multicenter study

Antecedentes: La complejidad se ha convertido en un tema central en cuidados paliativos. Se describe la evolución de la complejidad en atención domiciliaria y su relación con la ubicación de la muerte. Métodos: Estudio observacional de una cohorte prospectiva en el ámbito de la atención provista por los equipos de soporte a la atención domiciliaria en Cataluña. Los equipos evaluaron y acordaron el nivel de complejidad tras la primera visita y al exitus. El modelo HexCom incluye seis áreas de necesidades (clínicas, psicológicas, espirituales, sociofamiliares, éticas y relacionadas con la muerte), con tres niveles de complejidad: alto, moderado y bajo. Resultados: n = 648 pacientes: oncológicos 426 (65,7 %). Murieron en casa 364 (56,2 %), aumentando hasta el 86,4 % en los enfermos con demencia y al 81 % en los enfermos con fragilidad (p < 0,001). La puntuación de complejidad aumentó de 42 a 114 (p < 0,001), y este aumento fue más acusado en el grupo neurológico (de 32 a 213, p < 0,001). Se halló una asociación lineal entre complejidad y ubicación de la muerte (p < 0,001). La complejidad clínica y la sociofamiliar se asociaron a la ubicación de la muerte fuera del domicilio (p < 0,000). Conclusiones: La complejidad aumenta a medida que nos acercamos a la muerte, y esto se cumple en los grupos de pacientes oncológicos, con fallo de órgano y en los pacientes neurológicos, pero no en la demencia y la fragilidad/multimorbilidad. La complejidad se asocia con la ubicación de la muerte, principalmente en las áreas clínica y sociofamiliar. (AU)

Background: Complexity has become a central issue in palliative care. The evolution of complexity in home care and its relationship to place of death are described. Methods: An observational, prospective cohort study in the context of the care provided by home care supporting teams in Catalonia. Teams evaluated and agreed upon a complexity level after their first visit and after patient demise. The HexCom model includes six need areas (clinical, psychological, spiritual, family environment, ethical, and related to death) with three levels of complexity: high, moderate, and low. Results: n = 648 patients, of which 426 (65.7 %) were cancer patients. A total of 364 (56,2 %) subjects died at home, this figure reaching up to 86.4 % for patients with dementia, and to 81 % for fragile patients (p < 0.001). The Complexity Score increased from 42 to 114 (p < 0.001), an increase that was most pronounced in the neurological group (from 32 to 213, p < 0.001). A linear relationship was found between complexity and place of death (p < 0.001). Clinical and family environment complexity was associated with places of death outside the place of residence (p < 0.000). Conclusions: Complexity increases as death is approached, a relationship that holds for cancer patients, patients with organ failure, and neurological patients, but not for those with dementia or fragility/multimorbidity. Complexity is associated to place of death, mainly in the clinical and family environment areas. (AU)

Assessing Face Validity of the HexCom Model for Capturing Complexity in Clinical Practice: A Delphi Study.

Capturing complexity is both a conceptual and a practical challenge in palliative care. The HexCom model has proved to be an instrument with strong reliability and to be valid for describing the needs and strengths of patients in home care. In order to explore whether it is also perceived to be helpful in enhancing coordinated and patient-centred care at a practical level, a methodological study was carried out to assess the face validity of the model. In particular, a Delphi method involving a group of 14 experts representing the full spectrum of healthcare professionals involved in palliative care was carried out. The results show that there is a high level of agreement, with a content validity index-item greater than 0.92 both with regard to the complexity model and the HexCom-Red, HexCom-Basic, and the HexCom-Clin instruments, and higher than 0.85 regarding the HexCom-Figure and the HexCom-Patient instruments. This consensus confirms that the HexCom model and the different instruments that are derived from it are valued as useful tools for a broad range of healthcare professional in coordinately capturing complexity in healthcare practice.

Describing Complexity in Palliative Home Care Through HexCom: A Cross-Sectional, Multicenter Study.

BACKGROUND: Complexity has become a core issue in caring for patients with advanced disease and/or at the end-of-life. The Hexagon of Complexity (HexCom) is a complexity assessment model in the process of validation in health-care settings. Our objective is to use the instrument to describe differences in complexity across disease groups in specific home care for advanced disease and/or at the end-of-life patients, both in general and as relates to each domain and subdomain. METHODS: Cross-sectional study of home care was conducted in Catalonia. The instrument includes 6 domains of needs (clinical, psychological/emotional, social/family, spiritual, ethical, and death-related), 4 domains of resources (intrapersonal, interpersonal, transpersonal, and practical), and 3 levels of complexity (High (H), Moderate (M), and Low (L)). Interdisciplinary home care teams assessed and agreed on the level of complexity for each patient. RESULTS: Forty-three teams participated (74.1% of those invited). A total of 832 patients were assessed, 61.4% of which were cancer patients. Moderate complexity was observed in 385 (47.0%) cases and high complexity in 347 (42.4%). The median complexity score was 51 for cancer patients and 23 for patients with dementia (p<0.001). We observed the highest level of complexity in the social/family domain. Patients/families most frequently used interpersonal resources (80.5%). CONCLUSIONS: This study sheds light on the high-intensity work of support teams, the importance of the social/family domain and planning the place of death, substantial differences in needs and resources across disease groups, and the importance of relationship wellbeing at the end-of-life.

Complejidad asistencial en la atención al final de la vida: criterios y niveles de intervención en atención comunitaria de salud / Complexity of end-of-life care: criteria and levels of intervention in community health care

OBJETIVO: Definir la complejidad en la atención al final de la vida y los criterios relacionados y proponer, en función de su agrupación por niveles de complejidad, un modelo marco de intervención de los profesionales de la atención primaria de salud y de los recursos paliativos específicos. MATERIAL Y MÉTODOS: Estructura: grupo técnico interdisciplinario de consenso formado por 10 profesionales expertos en la atención al final de la vida (áreas contempladas: atención primaria de salud, paliativa específica, geriátrica, oncológica, trabajo social, bioética y espiritualidad) y la colaboración externa de 2 profesionales expertos en psicooncología y medicina interna. METODOLOGÍA: consenso de los profesionales mediante un procedimiento cualitativo tipo Delphi. Las etapas de consenso corresponden a los apartados de los RESULTADOS: El trabajo se realiza bajo la coordinación de la Sociedad Catalano-Balear de Cuidados Paliativos, la colaboración de la Sociedad Catalana de Medicina Familiar y Comunitaria (CAMFIC) y la dirección del Plan Director Sociosanitario del Departamento de Salud de la Generalitat de Catalunya. RESULTADOS: Definición: la complejidad resulta de la emergencia de procesos que interactúan cumpliendo las propiedades de los sistemas complejos. Modelo de referencia: se parte del modelo de necesidades de pacientes y familias, obteniendo 6 áreas de complejidad: necesidades físicas, psicoemocionales, sociofamiliares, espirituales, relacionadas con la muerte (situación de últimos días y duelo) y aspectos éticos. Áreas y criterios de complejidad: en cada área se describen: conceptos, situaciones habitualmente complejas y criterios de complejidad agrupados en 3 niveles de complejidad (baja, media y alta). Modelo de intervención: la propuesta es baja complejidad, intervención del equipo de referencia y puntualmente del equipo paliativo específico; complejidad media: atención compartida de intensidad pactada; alta complejidad: intervención prioritaria del equipo específico. Ingreso hospitalario. CONCLUSIONES: Resulta necesario diferenciar entre situaciones habitualmente complejas y criterios de complejidad. Aquellas se comportan frecuentemente como proceso emergente, mientras que los criterios corresponderían a la propia emergencia o su resultado. El modelo de intervención propuesto puede resultar útil para facilitar la colaboración asistencial entre los equipos referentes y paliativos específicos, ya que se trata de un modelo corresponsable y dinámico que no parcela la intervención

OBJECTIVE: To define the complexity in end-of-life care and the criteria of complexity, and depending on their grouping within these levels of complexity, to propose a model of intervention that will allow different levels of care to be established, and the framework within which the professionals of primary health care and the palliative team should work. MATERIAL AND METHODS: Structure: a technical and interdisciplinary group of consensus formed by ten professional experts in end of life care in the areas of: community health care, palliative care, geriatric care, oncology, social work, bioethics and spirituality; with external collaboration from two professionals of psycho-oncology and internal medicine. METHODOLOGY: we established a Delphi type qualitative method to obtain a consensus of all the professionals. The different stages of consensus correspond to the points described in the results. The work took place under the coordination of the Catalan-Balearic Society of Palliative Care, with the collaboration of the Catalan Society of Family and Community Medicine (CAMFIC), and the Directorate of the Social-Health Master Plan of the Health Department of the Generalitat of Catalonia. RESULTS: Definition: the complexity is caused by the emerging of processes that, when they interact, fulfil the criteria to be defined complex systems. Reference model: our base model is modelled on the needs of patients and families, thus obtaining six areas of complexity: physical needs, psycho-emotional, socio-family, spiritual, an area related directly with death (situation in the last days, grief), and an area of ethical aspects. Areas and criteria of complexity: in each area the following are obtained: base definitions, situations usually creating complexity, and criteria of complexity grouped in three levels: low medium and high. Model of intervention: the proposal is: low complexity: intervention of the community health care team with occasional intervention by the palliative care team. Medium complexity: shared caring decided between the community health care team and the palliative team. High complexity: main intervention by the palliative team. Hospital admission. CONCLUSIONS: It is necessary to differentiate between situations that are usually complex and the criteria of complexity. The first are those situations that often behave as an emerging process, whereas the criteria of complexity correspond to the actual emergence or its results. The intervention model proposed should improve the collaboration between community care and the palliative care team, as this is a co-responsibility and dynamic model that does not divide the intervention

Bioética y atención domiciliaria / Bioethics and home care

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