Conspiracy of Silence in Oncological Palliative Care: Perspectives and Strategies of the Healthcare Team

Introduction: Silence about dismal news is common in palliative care, involving patients, family and the healthcare team. This phenomenon of hiding the truth ­ conspiracy of silence ­ has negative consequences and deserves attention from professionals. Objective: This study investigates and explores the strategies used by healthcare professionals to prevent and intervene in the conspiracy of silence in the context of oncological palliative care. Method: Cross-sectional qualitative study using the Interpretative Phenomenological Analysis approach. The participants were nurses, doctors and a psychologist who work in the palliative care unit of a cancer center. A semi-structured interview was applied to a sample of 12 healthcare professionals. Results: The age of the participants varied between 31 and 64 years old, mostly females, ten nurses, one physician and one psychologist. From the analysis of the interviews, the following themes emerged: perception of the phenomenon of the conspiracy of silence; difficulties and challenges in dealing with the conspiracy of silence in palliative care; professionals' feelings about the conspiracy of silence; strategies to intervene and prevent the conspiracy of silence. Important strategies were reported such as honest communication without impositions, listening to the motivations that led to the silence.

O silêncio sobre notícias difíceis é comum em cuidados paliativos, envolvendo pacientes, familiares e equipe de saúde. Esse fenômeno de ocultação da verdade ­ conspiração do silêncio ­ tem consequências negativas e merece atenção dos profissionais. Objetivo: Investigar e explorar as estratégias utilizadas pelos profissionais de saúde para prevenir e intervir na conspiração do silêncio no contexto dos cuidados paliativos oncológicos. Método: Estudo qualitativo transversal utilizando a abordagem da Análise Fenomenológica Interpretativa. Os participantes foram enfermeiros, médico e uma psicóloga que atuam na unidade de cuidados paliativos de um centro oncológico. Aplicou-se entrevista semiestruturada a uma amostra de 12 profissionais de saúde. Resultados: A idade dos participantes variou entre 31 e 64 anos, a maior parte da amostra é do sexo feminino. Quanto à profissão, dez são enfermeiros, um médico e um psicólogo. Da análise das entrevistas, emergiram os seguintes temas: percepção do fenômeno da conspiração do silêncio; Dificuldades e desafios para lidar com a conspiração do silêncio nos cuidados paliativos; Sentimentos dos profissionais sobre a conspiração do silêncio; Estratégias para intervir na conspiração do silêncio; Estratégias para evitar a conspiração do silêncio. Foram relatadas estratégias importantes como a comunicação honesta e sem imposições, ouvindo as motivações que levaram ao silêncio.

El silencio ante noticias difíciles es común en los cuidados paliativos, involucrando a pacientes, familiares y equipo de salud. Estas características de ocultar la verdad ­ conspiración de silencio ­ tienen consecuencias negativas y merecen la atención de los profesionales. Objetivo: Investigar y explorar las estrategias utilizadas por los profesionales de la salud para prevenir e intervenir en la conspiración del silencio en el contexto de los cuidados paliativos oncológicos. Método: Estudio cualitativo transversal utilizando el enfoque de Análisis Fenomenológico Interpretativo. Los participantes fueron enfermeras, médico y un psicólogo que trabajan en la unidad de cuidados paliativos de un centro oncológico. Se aplicó una entrevista semiestructurada a una muestra de 12 profesionales de la salud. Resultados: La edad de los participantes varía entre 31 y 64 años, la mayoría de la muestra es femenina. En cuanto a su profesión, diez son enfermeros, un médico y un psicólogo. Del análisis de las entrevistas surgieron los siguientes temas: percepción de las especificidades de la conspiración del silencio; Dificultades y desafíos para afrontar la conspiración del silencio en los cuidados paliativos; Sentimientos de los profesionales sobre la conspiración del silencio; Estrategias para intervenir en la conspiración del silencio; Estrategias para evitar la conspiración del silencio. Se reportaron estrategias importantes, como la comunicación honesta y no impuesta, escuchando las motivaciones que llevaron al silencio

Temporal distribution of deaths in cancer patients during the day in different settings.

BACKGROUND: All living organisms perform their functions normally according to circadian rhythms. Certain diseases, such as ischemic heart disease and asthma, produce symptoms that are distributed during the day in a nonrandom fashion. Chronomodulated therapy with some regimens of chemotherapy and other drugs produce better results than traditional schedules. Even death is not evenly distributed during the day. Significant differences in the time of death through the day could influence the work planning and care activities. OBJECTIVE: To determine whether timing of death from a population of cancer patients admitted at our Oncology Institute varied during the day and according to different settings: at home (H), at the palliative care unit (PCU), and at other services (OS) of the hospital. Comparing the timing of deaths from different settings can give some clues about the possible existence of a circadian rhythm and the influence of external circumstances in the time of death of cancer patients. DESIGN: We conducted a retrospective study of the records of time of death at the different settings. RESULTS: The study involved 772 patients from the PCU and 997 from OS who died between May 25, 1996, and May 24, 2000, and 347 patients who died at H between April 1, 1999, and December 31, 2001. A statistically significant difference was found in the distribution of time of death in patients at the PCU (p <.001), but not at OS or at H. There were two peaks between 08:00 and 10:00 and between 00:00 and 02:00, and one trough between 04:00 and 08:00. This suggests that a temporal variation occurs in the time of death of cancer patients dying in the PCU, but not in other settings. CONCLUSIONS: The clinical relevance of the results obtained in this study would depend on the amplitude of the eventual variation detected in the number of deaths during the day. Therefore, although there was a statistically significant variation at the time of death during the day, its amplitude is not high enough to make it clinically significant. The differences observed among the various settings suggest that, even if circadian rhythms exist at the time of death in cancer patients, external factors can overcome these rhythms.

Pesticide intoxications in the Centre of Portugal: three years analysis.

Pesticides are used in most countries around the world to protect agricultural and horticultural crops against damage. Poisoning by these toxicant agents occurs as a result of misuse or accidental exposure, and also by oral ingestion (voluntary or not). In Portugal, pesticide intoxications are still a cause of death, found in a considerable number of cases. The authors retrospectively examined the cases of pesticide poisoning in the Centre of Portugal, from autopsies performed in the Forensic Pathology Service of Coimbra's Delegation of the National Institute of Legal Medicine (NILM) and from other autopsies carried out in the Centre of Portugal, as well as some samples taken in hospitals in cases of suspected intoxication. In this study, the positive cases have been especially studied, in order to identify the pesticide used, as well as the etiology. The frequency of intoxications and its distribution by sex and age were also analyzed. Between January 2000 and December 2002, the Forensic Toxicology Laboratory received 639 pesticide analysis requests. In 2000, in a total of 149 analysis requests, 30 cases were positive, 63.3% from male individuals and 36.7% from female. In 2001, the analysis requests increased to 240 as well as the positive cases (43), 74.4% from male individuals and 25.6% from female and in 2002, the total cases analyzed also increased to 250, with 38 positive (73.6% from male individuals and 26.4% from female). Among the pesticides, organophosphorus insecticides still constitute the most important class detected in forensic intoxications, representing 63% of the total positive cases, followed by herbicides, with 33% of the positive results. Quinalphos is the most important organophosphorus insecticide, present in 32 of the 111 positive cases, followed by the herbicide paraquat, detected in 31 cases. The study emphasizes the increasing number of pesticide analyses, particularly relevant for the organophosphorus compounds and herbicides. Intoxication suspicion, accidental or voluntary, seems to be the most common cause of the incidents, for which analyses are requested, but it is also evident that the putative cause is unknown in a large number of cases. Therefore, more stringent legislation and enforcement regarding the sale and distribution of these toxic substances are needed.

The last forty-eight hours of life in a Portuguese palliative care unit: does it differ from elsewhere?

The last few days of life have received significant attention in the literature. Reports have shown similarities and differences between programs. As a palliative care service in a cultural context that has not been reported on, we thought that an audit of our own experience in the care of patients in the last 48 hours of life and a comparison with other programs would be important. A prospective audit was designed to record data for four general domains: general demographic information, symptom prevalence, patient performance status, and perceived level of comfort. The inclusion criteria of patients were: older than 15 years of age (an admission criterion for patients of the unit), diagnosis of cancer, no active cancer-direct treatments, and patients who were on the unit for longer than 48 hours. The audit was completed when the 300th eligible patient died in the unit. Twenty-nine of 300 patients (9.6%) required sedation and the most common cause was delirium. Morphine was the most widely prescribed medication (85% of patients). The subcutaneous route was utilized extensively. Only 12% of the patients received parenteral fluids, usually via hypodermoclisis. Death was considered by staff to have been peaceful in 86% of cases. Our practice appears to mirror that of other palliative care groups.