Comparing the Need and Development of Pediatric Palliative Care in Mexico: A Geographical Analysis.

CONTEXT: The Global Atlas of Palliative Care (GAPC) ranked Mexico's palliative care services at a preliminary integration stage into mainstream healthcare services. However, this data does not reflect pediatric palliative care (PPC) development. OBJECTIVES: To analyze the current need and level of development of PPC within Mexico. METHODS: PPC need was estimated using causes of death associated with serious health-related suffering from national mortality data from the General Directorate of Health Information. The level of development was measured through six indicators involving access to PPC services and opioids, then classified using the GAPC development categories adapted to regional territories based on available data. RESULTS: In 2021, 37,444 children died in Mexico. Of those, 10,677 (28.29%) died from conditions with serious health-related suffering, averaging a need for PPC of 25/100,000 children. Out of Mexico's 32 states, two (6.2%) had no PPC activity (category 1), twenty (62.6%) were in a capacity-building phase (category 2), eight (25%) had isolated PPC provision (category 3a), while two (6.2%) had generalized PPC provision (category 3b). No state had early (category 4a) or advanced PPC integration (category 4b). Overall, Mexico was classified as category 2. CONCLUSIONS: PPC services are distributed unevenly across the country, leading to inequitable access to care and an inability to meet the needs of patients and families. There is a disparity between the level of development of adult palliative care services and the underdevelopment of PPC in Mexico. This information can help stakeholders guide the development of PPC where it is needed most.

Palliative care education in undergraduate medical and nursing programs in Colombia: a cross-sectional analysis.

BACKGROUND: The number of people suffering from chronic diseases requiring palliative care (PC) is increasing rapidly. Therefore, PC teaching in undergraduate health science programs is necessary to improve primary PC based on international recommendations and available scientific evidence. METHODS: A descriptive cross-sectional study was conducted. Active undergraduate medical and nursing programs that were approved by the Colombian Ministry of Education and integrated PC teaching into their curricula were included in the study. The total sample consisted of 48 programs: 31 nursing and 17 medical programs. RESULTS: PC competencies are distributed throughout the curriculum in 41.67% of programs, in elective courses in 31.25%, and in mandatory courses in 27.08% of the programs. The average PC teaching hours is 81 for nursing and 57.6 for medicine. PC clinical rotations are not offered in 75% of the programs. For undergraduate nursing programs, the most frequent competencies taught are the definition and history of PC and identifying common symptoms associated with advanced disease. In undergraduate medicine, the most common competencies are pharmacological and non-pharmacological pain management and identification of PC needs. CONCLUSIONS: PC teaching in undergraduate health science programs mainly addresses the conceptual and theoretical aspects of PC, which are part of the competencies present throughout the programs' curricula. Low availability of PC clinical rotations was identified. Future studies should assess whether the low availability of clinical rotations in PC limits the ability of students to develop the practical competencies necessary to provide quality PC. TRIAL REGISTRATION: Not applicable.

Accessibility to palliative care services in Colombia: an analysis of geographic disparities.

OBJECTIVES: Due to the increase in the prevalence of non-communicable diseases and the Colombian demographic transition, the necessity of palliative care has arisen. This study used accessibility and coverage indicators to measure the geographic barriers to palliative care. METHODS: Population-based observational study focused on urban areas and adult population from Colombia, which uses three measurements of geographic accessibility to services: a) density of palliative care services per 100,000 inhabitants, b) analysis of geographic distribution by territorial nodes of the country, and c) spatial analysis of palliative care services using Voronoi diagrams. ArcGIS Pro software was used to map services' locations and identify geographic disparities. RESULTS: A total of 504 palliative care services were identified, of which 77% were primary health care services. The density of palliative care services in Colombia is 1.8 primary care services per 100,000 inhabitants and 0.4 specialized services per 100,000 inhabitants. The average palliative care coverage is 41%, two regions of the country have a coverage below 30%. Twenty-eight percent of the services provide care for a population greater than 50,000 inhabitants within their coverage area, exceeding the acceptable limit by international standards. CONCLUSIONS: Palliative care services are concentrated in three main regions (Bogotá D.C., the Center, and the Caribbean) and are limited in the Orinoquia and Amazonia nodes. Density of specialized palliative care services is extremely low and there are regions without palliative services for adults with palliative needs.

Building an action plan to tackle palliative care inequality through multi-stakeholder platforms.

Background: To achieve universal care and overcome existing barriers, the most effective strategy is to devise an action plan that incorporates palliative care into primary health care (PHC), as recommended by the World Health Organization's (WHO) Astana Declaration. In Colombia, a country with an upper-middle-income status, about 128,000 individuals experience severe health-related suffering (SHS) that necessitates palliative care. Although the country's healthcare system has made steady strides in the integration and development of palliative care, there is still no national plan in place for palliative care. Objective: Build up Colombia's palliative care plan through stakeholder consensus. Method: Based on the participatory action research method and the multi-stakeholder platforms model, this study convened 142 stakeholders from different levels of the health system (patient representatives, journalists, health professionals, government entities, insurance companies, universities, and drug regulatory authorities). Results: The national plan aims to achieve its objectives through a series of strategic actions. These include integrating and diversifying palliative care services, improving access to opioids, increasing palliative care education, promoting community-based palliative care programs, securing funding, and implementing a regulatory framework for palliative care by public policymakers. Conclusions: The national palliative care is an alliance that aims to reduce palliative care inequity in Colombia by 2026 by empowering stakeholders nationwide to collaborate around specific goals and objectives.

Política pública en cuidados paliativos y sus implicaciones sobre servicios, opioides y educación en Colombia / Public policy on palliative care and its implications for services, opioids, and education in Colombia

Introducción: El desarrollo de cuidados paliativos exige la intervención de múltiples dimensiones de salud pública, incluyendo la disponibilidad de servicios de salud, medicamentos esenciales y programas educativos. En Colombia se han realizado diversos cambios en las políticas públicas para promover la atención de personas con necesidades paliativas. Objetivo: Evaluar empíricamente las políticas públicas, existentes en cuidados paliativos y sus implicaciones sobre disponibilidad de servicios, opioides y programas educativos en los años 2010 ­ 2019 en Colombia. Materiales y métodos: Se diseñó un estudio mixto exploratorio secuencial en tres fases: identificación de indicadores empíricos de políticas nacionales, diagnostico situacional de cuidados paliativos y evaluación cualitativa de los resultados de la implementación de políticas en siete nodos territoriales de Colombia. Resultados: Se revisaron siete normas obteniendo 12 indicadores empíricos para la evaluación, seis de ellos no contaban con fuentes de información. El diagnostico nacional evidencia un aumento gradual de servicios y consumo de opioides en los años hito del desarrollo de políticas. 44 profesionales de cuidados paliativos perciben un efecto positivo de las políticas públicas en el consumo de opioides y bajos resultados para el dominio de servicios y educación Conclusiones: Existe una relación positiva entre políticas públicas y consumo de opioides, una relación cuantitativa positiva para servicios de cuidados paliativos y una relación cuanticualitativa negativa para programas educativos, lo que denota un bajo estatus operativo de las políticas construidas para mejorar el dolor y sufrimiento asociado a la enfermedad crónica avanzada.

Introduction: Palliative care development requires the intervention of multiple dimensions of public health, including the availability of health services, essential medicines, and educational programs. In Colombia, several changes have been made in public policy to promote the care of people with palliative needs. Objective: To empirically evaluate existing public policies on palliative care and their implications for the availability of services, opioids, and educational programs during the years 2010 to 2019 in Colombia. Materials and methods: A mixed sequential exploratory study was designed in three phases: identification of empirical indicators of national policies, palliative care situational diagnosis, and qualitative assessment of the results of policy implementation in seven regional nodes in Colombia. Results: Seven standards were reviewed, yielding 12 empirical indicators for assessment, six of which had no sources of information. The national diagnosis shows a gradual increase in services and opioid use during the landmark years of policy development. Forty-four palliative care professionals perceive a positive effect of public policy on opioid use and low outcomes for service and education domains. Conclusions: There is a positive relationship between public policy and opioid use, a positive quantitative relationship with palliative care services, and a negative quantitative-qualitative relationship with educational programs. This indicates a low operational status of policies designed to alleviate the pain and suffering associated with advanced chronic diseases.

Introdução: O desenvolvimento dos cuidados paliativos requer a intervenção de múltiplas dimensões da saúde pública, incluindo a disponibilidade de serviços de saúde, medicamentos essenciais e programas educativos. Na Colômbia, várias mudanças foram feitas nas políticas públicas para promover o cuidado de pessoas com necessidades paliativas. Objetivo: Avaliar empiricamente as políticas públicas existentes em cuidados paliativos e suas implicações na disponibilidade de serviços, opioides e programas educacionais nos anos 2010 - 2019 na Colômbia. Materiais e métodos: Desenhou-se um estudo misto exploratório sequencial em três fases: identificação de indicadores empíricos de políticas nacionais, diagnóstico situacional de cuidados paliativos e avaliação qualitativa dos resultados da implementação de políticas em sete nodos territoriais da Colômbia. Resultados: Sete normas foram revisadas, obtendo-se 12 indicadores empíricos para avaliação, seis delas não possuíam fontes de informação. O diagnóstico nacional mostra um aumento gradual nos serviços e consumo de opioides nos anos marcantes do desenvolvimento de políticas. 44 profissionais de cuidados paliativos percebem efeito positivo das políticas públicas sobre o consumo de opioides e resultados baixos para o domínio serviços e educação Conclusões: Existe relação positiva entre políticas públicas e consumo de opioides, relação quantitativa positiva para serviços de cuidados paliativos e negativa relação quantitativo-qualitativa para programas educativos, o que denota um baixo status operacional das políticas destinadas a melhorar a dor e o sofrimento associados à doença crônica avançada.

Effectiveness of Subcutaneous Administration of Antibiotics to Control Infections in Elder Palliative Patients: A Systematic Review.

Background: Infections are common in patients with advanced illnesses for whom the intravenous or oral route is not possible. The subcutaneous administration of antibiotics is a promising alternative, but there is not enough theoretical support for its use. This study aims to explore the effectiveness and safety of subcutaneous antibiotic therapy in the context of palliative care in elderly patients. Methods: A systematic review was conducted using PubMed and Embase, without time or language limits. Seven articles were selected on the effectiveness of subcutaneous antibiotic therapy in adult patients with chronic progressive diseases. The quality of the articles was assessed with the Newcastle Ottawa Scale and relevant data was extracted using a selection capture file. Results: Seven quasi-experimental studies evaluated 865 elderly patients with advanced diseases, comorbidities, and infections (ie, urinary tract, respiratory system, and bone joint) who received subcutaneous antibiotic therapy (ie, Ceftriaxone, Ertapenem, and Teicoplanin). The pooled success rate of subcutaneous antibiotics for the 7 studies was 71%, the therapy failure rate was 22%, its withdrawal mean was 8%, and the mean mortality rate was 7%. The studies were of low quality and were heterogeneous in the types of infections, types of antibiotics, time of follow-up, and outcomes assessed. Conclusions: Pilot studies have found a limited number of antibiotics that can be safely used to treat specific infections. Nevertheless, the data isn´t robust enough to recommend their use.

Rural Palliative Care Telemedicine for Advanced Cancer Patients: A Systematic Review.

Context: Telemedicine offers the opportunity to provide remote palliative care for patients to control symptoms and improve quality of life, even for patients with advanced diseases. Objectives: Establish a telemedicine model of rural palliative care for advanced cancer patients with difficulties in accessing standard care. Methods: This review comports with the minimum standards described in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and uses the palliative care literature review iterative method (PALETTE) proposed by Zwakman et al in 2018. Results: Three hundred, ninety-two articles were identified in PubMed and EMBASE databases and alternative search engines such as Google Scholar and OpenGrey. A telemedicine delivery model was developed for patients with limited access to standard care, which consists of identifying the candidate population, establishing the most convenient telemedicine modality, agreeing with patients and caregivers on palliative care needs, and evaluating the interventions effectiveness. Conclusion: Telemedicine is a revolutionary tool to provide palliative care to advanced cancer patients whose clinical condition or location prevent them from accessing conventional care.

Barriers to Access to Palliative Care in Colombia: A Social Mapping Approach Involving Stakeholder Participation.

This study aimed to identify barriers to access to palliative care through a social mapping approach. In Colombia, the barriers to access to palliative care denote an enormous geographic disparity of resources and health needs, making it necessary to conduct community-based participatory research using an approach such as social mapping. A qualitative research design was used. Stakeholders from health insurance companies, regulatory authorities, regional health secretariats, health care professionals, patient and caregiver organizations, scientific societies, and medical journalists from 7 Colombian regions participated. It involved 3 stages. Stage 1: Semi-structured, audio-recorded interviews were conducted with 36 stakeholders and were subsequently transcribed and analyzed. Stage 2: An electronic survey was conducted to obtain feedback on the first outline of the map and the categories that emerged from stage 1. Stage 3: The nominal group technique was used to analyze and validate the barriers to access to palliative care included in the final map. The COREQ checklist was used. Twenty-seven barriers to access to palliative care related to limited availability of medications, stakeholders' poor knowledge of regulations, limited formal education in palliative care, few patients' support networks, patient care fragmentation, few specialized programs of palliative care, and mistaken beliefs about palliative care were identified. Stakeholders' diverse perspectives and opinions were crucial to understanding the development of palliative care in Colombia and its challenges. Better knowledge about palliative care can open opportunities to overcome the barriers identified in this study, directly impacting access to palliative care.

Availability and accessibility of opioids for pain and palliative care in Colombia: a survey study / Disponibilidad y accesibilidad de los opioides para manejo del dolor y cuidado paliativo en Colombia: estudio tipo encuesta

Abstract Introduction: Access to essential medicines, including opioids, is a component of the right to health. Objective: To identify barriers to opioid availability and accessibility for pain and palliative care. Methods: Online survey with Colombian prescribers. Availability barriers were analyzed for each facility (distribution and/or dispensing). Accessibility barriers were analyzed by type. Descriptive analyses were conducted using relative frequencies. Significance within categories and regions was measured using Fisher's exact test. Results: Out of 1,208 prescribers invited, 806 (66.7%) completed the survey. Availability: 76.43% reported barriers. The most cited barrier was "Pharmacies authorized by health insurance companies", where opioids are frequently unavailable. Accessibility: 74.6% reported barriers. Most frequently cited was "Difficulty securing payment authorization for medication from health insurance companies". Significant differences were observed in terms of regions and "Cost" (p=0.02). Lack of coordination among procuring and distributing agencies affects availability. Limited awareness and bureaucratic procedures affect accessibility. Conclusions: There are barriers to opioid availability and access in Colombia, related to the existing structure for guaranteeing equitable supply. From the perspective of healthcare providers, problems related to pharmacy availability, prescription and cost of medicines hinder pain treatment.

Resumen Introducción: El acceso a medicamentos esenciales, incluidos los opioides, es un componente del derecho a la salud. Objetivo: Identificar las barreras de disponibilidad y acceso a los opioides para dolor y cuidados paliativos. Métodos: Encuesta virtual a prescriptores colombianos. Las barreras de disponibilidad se analizaron para cada centro (distribución y/o dispensación) y las barreras de acceso se analizaron por tipo. Los análisis descriptivos se realizaron utilizando frecuencias relativas. La significancia dentro de categorías y regiones se midió utilizando la prueba exacta de Fischer. Resultados: De los 1208 prescriptores invitados, 806 (66.7%) respondieron la encuesta. Disponibilidad: el 76,43% reportó barreras. La barrera más citada fue la relacionada con las "farmacias autorizadas por las aseguradoras de salud", donde los opioides con frecuencia no están disponibles. Acceso: el 74,6% reportó barreras. Se citó con mayor frecuencia la "Dificultad para obtener la autorización de pago de medicamentos por parte de las aseguradoras". Se observaron diferencias significativas entre regiones y "costos" (p=0,02). La falta de coordinación entre las entidades de adquisición y distribución afecta la disponibilidad. La limitada conciencia y los procedimientos burocráticos afectan la accesibilidad. Conclusiones: Existen barreras de disponibilidad y acceso a los opioides en Colombia, las cuales están relacionadas con la estructura disponible para garantizar un suministro equitativo. Desde el punto de vista de los prescriptores, los problemas relacionados con la disponibilidad de las farmacias, la prescripción y el costo de los medicamentos, obstaculizan el tratamiento adecuado del dolor.

Feasibility of using death certificates for studying place of death in Latin America

[ABSTRACT]. Objective. This paper assesses the availability and quality of death certificate data in Latin America and the feasibility of using these data to study place of death and associated factors. Methods. In this comparative study, we collected examples of current official death certificates and digital data files containing information about all deaths that occurred during 1 year in 19 Latin American countries. Data were collected from June 2019 to May 2020. The records for place of death and associated variables were studied. The criteria for data quality were completeness, number of ill-defined causes of death and timeliness. Results. All 19 countries provided copies of current official death certificates and 18 of these registered the place of death. Distinguishing among hospital or other health care institution, home and other was possible for all countries. Digital data files with death certificate data were available from 12 countries and 1 region. Three countries had data considered to be of high quality and seven had data considered to be of medium quality. Categories for place of death and most of the predetermined factors possibly associated with place of death were included in the data files. Conclusions. The quality of data sets was rated medium to high in 10 countries. Hence, death certificate data make it feasible to conduct an international comparative study on place of death and the associated factors in Latin America.

[RESUMEN]. Objetivo. En este artículo se evalúa la disponibilidad y la calidad de los datos del certificado de defunción en América Latina y la factibilidad de emplear estos datos para estudiar el lugar de defunción y factores asociados. Métodos. En este estudio comparativo, se recogieron ejemplos de certificados oficiales de defunción actuales y archivos digitales de datos que contenían información acerca de todas las defunciones que ocurrieron durante un año en 19 países latinoamericanos. Se recopilaron datos desde junio del 2019 hasta mayo del 2020. Se estudiaron los registros del lugar de la muerte y las variables asociadas. Los criterios para determinar la calidad de los datos fueron la exhaustividad, el número de causas de muerte mal definidas y la presentación oportuna de la información. Resultados. Los 19 países proporcionaron copias de los certificados oficiales de defunción actuales; en 18 de estos se registraba el lugar de la muerte. En todos los países fue posible distinguir entre hospital u otra institución de atención de salud, el hogar y otros. Se obtuvieron los archivos de datos digitales con los datos del certificado de defunción de 12 países y una región. Tres países tenían datos considerados de buena calidad y siete tenían datos considerados de calidad media. En los archivos de datos se incluyeron categorías para lugar de defunción y la mayoría de los factores predeterminados posiblemente asociados con el lugar de defunción. Conclusiones. La calidad de los conjuntos de datos se calificó de media a buena en 10 países. En consecuencia, es factible realizar un estudio internacional comparativo sobre el lugar de defunción y los factores asociados en América Latina con los datos del certificado de defunción.

[RESUMO]. Objetivo. Este estudo avalia a disponibilidade e a qualidade dos dados das declarações de óbito na América Latina e a viabilidade de usar esses dados para estudar o local do óbito e fatores associados. Métodos. Neste estudo comparativo, coletamos exemplos de declarações de óbito oficiais atuais e arquivos de dados digitais contendo informações sobre todos os óbitos que ocorreram durante 1 ano em 19 países latinoamericanos. Os dados foram coletados no período de junho de 2019 a maio de 2020. Foram estudados os registros do local do óbito e variáveis associadas. Os critérios de qualidade dos dados foram preenchimento completo, número de causas mal definidas de morte e oportunidade. Resultados. Todos os 19 países forneceram cópias das declarações de óbito oficiais atuais, e 18 deles registraram o local do óbito . Foi possível distinguir em todos os países entre hospital ou outra instituição de saúde, lar ou outro local. Arquivos de dados digitais com os dados das declarações de óbito foram disponibilizados por 12 países e 1 região. Três países tiveram dados considerados de alta qualidade, e sete tiveram dados considerados de qualidade média. As categorias de local do óbito e a maioria dos fatores predeterminados possivelmente associados ao local do óbito foram incluídos nos arquivos de dados. Conclusões. A qualidade dos conjuntos de dados foi classificada como média a alta em 10 países. Portanto, os dados de declarações de óbito possibilitam a realização de um estudo comparativo internacional sobre local do óbito e fatores associados na América Latina.

The Development of Palliative Care in Colombia: An Analysis of Geographical Inequalities Through the Application of International Indicators.

CONTEXT: The national evaluation of an individual country is a tool used to improve the universal provision of palliative care. The evaluation of a country's internal situation, by means of an analysis of the development of palliative care by region, may also be an instrument for improvement. OBJECTIVES: The aim of this study was to understand the regional development of palliative care in Colombia, through the application of international indicators. METHODS: Regional development was analyzed for Colombia, with a country-specific adaptation of the evaluation method used in the latest edition of the Palliative Care World Map (Clark D, 2020), the need for palliative care per death with serious health-related suffering (Knaul FN, 2019), and the coverage of specialized services, following European standards (Centeno, 2016). A total of 33 of the country's regions were classified. RESULTS: Some 41% of the people who die in Colombia need palliative care. The average figure for specialized services is 0.5/100,000 inhabitants, with a maximum coverage of 51%. In Colombia, there are 12 regions with a generalized level of provision; six regions with isolated provision, nine regions developing their capacity, four with no known activity, and two at an advanced level of palliative care integration. The regions with the highest level of palliative care development coincide with higher demand and coverage of specialized services. CONCLUSION: Regional palliative care development is unequal and unbalanced. Applying international indicators to levels of regional development allows for the identification of geographical inequalities and highlights low palliative care development, especially in the rural areas of the country.

Feasibility of using death certificates for studying place of death in Latin America

Objective: this paper assesses the availability and quality of death certificate data in Latin America and the feasibility of using these data to study place of death and associated factors. Methods: in this comparative study, we collected examples of current official death certificates and digital data files containing information about all deaths that occurred during 1 year in 19 Latin American countries. Data were collected from June 2019 to May 2020. The records for place of death and associated variables were studied. The criteria for data quality were completeness, number of ill-defined causes of death and timeliness. Results: all 19 countries provided copies of current official death certificates and 18 of these registered the place of death. Distinguishing among hospital or other health care institution, home and other was possible for all countries. Digital data files with death certificate data were available from 12 countries and 1 region. Three countries had data considered to be of high quality and seven had data considered to be of medium quality. Categories for place of death and most of the predetermined factors possibly associated with place of death were included in the data files. Conclusions: the quality of data sets was rated medium to high in 10 countries. Hence, death certificate data make it feasible to conduct an international comparative study on place of death and the associated factors in Latin America.

Cuidados paliativos: una apuesta por la salud y la calidad de vida / Palliative care: A commitment to health and quality of life / Cuidados paliativos: uma aposta para a saúde e para a qualidade de vida

cuidados paliativos se referem ao cuidado ativo e total dos pacientes, cuja doença não responde ao tratamento curativo, especialmente se estiver em uma fase avançada e progressiva. Nesta etapa, os obje-tivos principais passam a ser o alívio e a prevenção do sofrimento, a identificação precoce e o tratamento impecável tanto da dor como de outros problemas físicos, psicossociais e espirituais, assim como a cola-boração para que o paciente e a família aceitem a realidade e procurem conseguir a melhor qualidade de vida para o doente, evitando o uso de medidas desesperadas como obstinação terapêutica. (1). Na Colômbia, os cuidados paliativos são os cuidados apropriados para o paciente com uma doença terminal, crônica degenerativa e irreversível, na qual o controle da dor e outros sintomas requer, além do suporte clínico, social e espiritual, apoio psicológico e familiar durante a doença e o luto. O objetivo dos cuidados paliativos é proporcionar a melhor qualidade de vida possível para o paciente e sua família (2)

Palliative care refers to the active and total care of the patients whose disease does not respond to curative treatment, especially if it is in an advanced and progressive phase. At this stage, the main goals become relief and prevention of suffering, early identification and impeccable treatment of both pain and other physical, psychosocial and spiritual problems, as well as collaboration so that the patient and the family accept the reality and seek to achieve the highest quality of life for the sick, avoiding the use of desperate measures such as cruel therapies (1). In Colombia, palliative care is the appropriate care for a patient with a terminal, chronic, degenerative and irreversible disease in which the control of pain and other symp-toms require, in addition to clinical, social and spiritual support, psychological and family support during the illness and mourning. The goal of palliative care is to achieve the best possible quality of life for the patient and his family (2)

Los cuidados paliativos hacen referencia al cuidado activo y total de los pacientes cuya enfermedad no responde al tratamiento curativo, más aún si esta se halla en fase avanzada y progresiva. En esta etapa las metas principales pasan a ser el alivio y la prevención del sufrimiento, la identificación precoz y el tratamiento impecable tanto del dolor como de otros problemas físicos, psicosociales y espirituales, así como la colaboración para que el paciente y la familia acepten la realidad y procuren conseguir la mayor calidad de vida para los enfermos, evitando el uso de medidas desesperadas como el encarnizamiento tera-péutico (1). En Colombia, los cuidados paliativos son los cuidados apropiados para el paciente con una enfermedad terminal, crónica, degenerativa e irreversible en la cual el control del dolor y otros síntomas requieren, además del soporte clínico, social y espiritual, apoyo psicológico y familiar durante la enfer-medad y el duelo. El objetivo de los cuidados paliativos es lograr la mejor calidad de vida posible para el paciente y su familia (2).

Abordaje de los síntomas neurológicos desde la perspectiva de los cuidados paliativos / Neurological symptoms approach from the perspective of palliative care

Resumen Objetivo: Abordar los síntomas neurológicos desde la perspectiva de los cuidados paliativos a través de la revisión de literatura científica disponible teniendo en cuenta los componentes teóricos del Modelo Revisado del Manejo de Síntomas de Marylin J. Dodd. Metodología: Siguiendo los pasos propuestos por la declaración Prisma, se realizó revisión sistemática de las publicaciones realizadas entre el año 2002 y 2017 de artículos relacionados que abordaban los síntomas neurológicos desde la perspectiva del cuidado paliativo aplicando los componentes del Modelo Revisado del Manejo de Síntomas de Marylin J. Dodd, los cuales incluyen la experiencia del síntoma, los componentes de las estrategias para el manejo de síntomas y el resultado en términos del estado y el impacto del síntoma. Resultados: De los 60 articulos identificados inicalmente, 50 cumplieron con los criterios de selección y se clasificaron según las categorias de la Teoría Manejo de síntomas. Conclusiones: El aporte multidisciplinario optimiza el control de síntomas y la calidad de vida, pero son las enfermeras las responsables de detectar las respuestas humanas y distinguir entre el dolor y la agitación, equilibrar los riesgos de sub y sobremedicación y la posibilidad de acelerar la muerte. Se necesitan enfoques innovadores para alinear los comportamientos profesionales de la salud con el mejor cuidado donde se incluya una atención integral que mejore significativamente la atención al paciente.

Abstract Objective: To address neurological symptoms from the perspective of palliative care through the review of available scientific literature taking into account the theoretical components of the Revised Symptom Management Model of Marylin J. Dodd. Methodology: Following the steps proposed by the PRISMA statement, a systematic review was made of the publications made between 2002 and 2017, of related articles that addressed neurological symptoms from the perspective of palliative care applying any of the components of the Revised Symptom Management Model of Marylin J. Dodd, which include the experience of the symptom, the components of symptoms management strategies and the result in terms of the state and impact of the symptom. Results: According to the search limits defined within the inclusion criteria, 51 articles were selected to be analyzed from the perspective of palliative care applying the components of the Revised Symptom Management Model. It is evident that there is a significant amount of research that addresses delirium as a neurological symptom. Discussion: The multidisciplinary contribution often optimizes the control of neurological symptoms and the quality of life of patients and their families. In the same way, it is important to learn the use of scales and the early recognition of the impact of the symptom on the patient and his family to significantly improve the adaptation process. Conclusions: Although there are not sufficient innovative approaches to improve the management of symptoms as a whole and not as individual manifestations, education and training in the use of non-pharmacological interventions help to provide quality palliative care that complements to the traditional managements.

Clasificación Oxford para la validación de un protocolo de antibioticoterapia subcutánea paliativa / Oxford classification for the validation of a protocol of palliative subcutaneous antibiotic therapy / Classificação Oxford para a validação de um protocolo de aplicação paliativa de antibióticos por via subcutânea

Introducción: los casos de pacientes con procesos infecciosos al final de la vida muestran la necesidad de contar con alternativas que garanticen el cuidado y el manejo terapéutico instaurado. Las vías clásicas intravenosa, intramuscular y oral se ven limitadas, mientras que la vía subcutánea demuestra ser una alternativa prometedora; sin embargo, la escasa evidencia científica reflejada en el bajo número de investigaciones, devela la necesidad de explorar y generar productos científicos que respalden esta práctica. Metodología: estudio documental, con base en un proceso de revisión sistemática, en el cual se realiza la búsqueda de 10 acciones descritas en un protocolo. Fueron seleccionados 34 artículos en idioma inglés y español, excluyendo 17. Los artículos fueron clasificados a partir de la escala del Centre for Evidence-Based Medicine, Oxford, consultando las bases: Nursing Skills, Clinicalkey, Pubmed, Springerlink, Science Direct, ProQuest y Cochrane. Se utilizaron como descriptores: antibacterianos, cuidados paliativos, protocolos, catéter, subcutáneo, signos, tiempo, antibiótico, enfermería, registros, consentimiento informado, valoración. Resultados: el 60% de las acciones propuestas en el protocolo no tuvo artículos que respaldaran su práctica, solamente el 40% fue clasificado. Conclusión: el protocolo no se recomienda, puesto que más del 50% de las actividades no cuentan con evidencia científica que las respalde.

Introduction: the cases of patients with infectious processes at the end of life show the necessity to count with alternatives that guarantee the care and the established therapeutic management. The classic intravenous, intramuscular and oral routes are limited, while the subcutaneous route demonstrates to be a promising alternative; however, the scarce scientific evidence reflected in the low number of research, unveils the necessity to explore and generate scientific products to endorse this practice. Methodology: a documental study, based on a systematic review process, in which the search of 10 actions described in a protocol is performed. 34 articles in English and Spanish were selected, excluding 17. The articles were classified based on the scale from Centre for Evidence-Based Medicine, Oxford, consulting the databases: Nursing Skills, Clinicalkey, Pubmed, Springerlink, ScienceDirect, ProQuest and Cochrane. The used descriptors: antibacterials, palliative care, protocols, subcutaneous catheter, signs, time, antibiotic, nursing, records, informed consent, and valuation. Results: 60% of the actions proposed in the protocol did not have articles to endorse their practice, only 40% was classified. Conclusion: the protocol is not recommended, since more than 50% of the activities do not have scientific evidence to endorse them.

Introdução: os casos de pacientes com processos infecciosos ao final da vida mostram a necessidade de contar com alternativas que garantam o cuidado e o manejo terapêutico estabelecido. As vias clássicas intravenosa, intramuscular e oral estão limitadas, enquanto que a via subcutânea demostra ser uma alternativa prometedora; porém, a escassa evidencia científica refletida no baixo número de pesquisas, revela a necessidade de explorar e gerar produtos científicos que respaldem esta prática. Metodologia: estudo documental, baseado num processo de revisão sistemática, no qual se realizou a busca de 10 ações descritas num protocolo. Foram selecionados 34 artigos em idioma inglês e espanhol, excluindo 17. Os artigos foram classificados a partir da escala do Centre for Evidence-Based Medicine, Oxford, consultando as bases: Nursing Skills, Clinicalkey, Pubmed, Springerlink, Science Direct, ProQuest e Cochrane. Utilizaram-se como descritores: antibacterianos, cuidados paliativos, protocolos, cateter, subcutâneo, signos, tempo, antibiótico, enfermagem, registros, consentimento informado, valoração. Resultados: o 60% das ações propostas no protocolo não teve artigos que respaldaram sua prática, somente o 40% foi classificado. Conclusão: o protocolo não se recomenda, já que mais do 50% das atividades não têm evidencia científica para apoiá-lo.

Determinantes del cuidado domiciliario ideal: experiencia de cuidadores familiares de pacientes con secuelas de enfermedad cerebrovascular / Ideal home care determinants: experience of family caregivers of patients with cerebrovascular disease sequelae / Determinantes do cuidado domiciliar ideal: experiência dos cuidadores familiares de paciente com sequelas de doenças cerebrovasculares

La presente investigación es de tipo cualitativo, con orientación descriptiva fenomenológica. Por medio de una encuesta socioe\r\n-\r\nconómica y entrevistas semiestructuradas en las que se identificaron cinco categorías, se buscó comprender los determinantes \r\ndel cuidado domiciliario ideal desde el significado de las experiencias vividas por doce cuidadores de pacientes con secuelas de \r\nenfermedad cerebrovascular (ECV) en Bogotá D.C. Se concluyó que el cuidado domiciliario ideal debe brindar las condiciones \r\nnecesarias para ofrecer una atención integral que satisfaga las expectativas de los pacientes y sus cuidadores, a fin de disminuir los \r\nfactores de riesgo derivados de las intervenciones realizadas y las barreras de acceso a los servicios de salud

A qualitative research paper with descriptive phenomeno\r\n-\r\nlogical orientation is presented. A survey was given to twelve \r\ncaregivers of patients with stroke sequelae in Bogotá D.C. to \r\ngather socio-economic data and conduct semi-structured \r\ninterviews; five domains were identified, in order to understand \r\nthe determinants of the ideal home care from the accounts of \r\ntheir experiences. It was concluded that home care should \r\nprovide the necessary conditions to achieve comprehensive \r\ncare that meets the expectations of patients and their care\r\n-\r\ngivers, reducing the risk factors derived from interventions and \r\nbarriers to health services.

A presente investigação é qualitativa, com orientação descri\r\n-\r\ntiva fenomenológica. Por meio de uma pesquisa para levantar \r\ninformações socioeconômicas e entrevistas semiestruturadas, \r\nnas quais foram identificadas cinco categorias, buscou-se \r\ncompreender os determinantes de cuidado domiciliar ideal, a \r\npartir do significado das experiências vividas por 12 cuidadores \r\nde pacientes com sequelas de doença cerebrovascular, em \r\nBogotá D.C. Concluiu-se que, o cuidado domiciliar ideal deve \r\nprover as condições necessárias para oferecer uma atenção \r\nintegral que satisfaça as expectativas dos pacientes e seus \r\ncuidadores, diminuindo os fatores de risco derivados das inter\r\n-\r\nvenções realizadas e das barreiras de acesso aos serviços de \r\nsaúde.

Medición científica: la ruta crítica de la investigación en Colombia / Scientific measurement: the critical path of research in Colombia / Medição científica: o caminho crítico da pesquisa na Colômbia

El conocimiento científico en la modernidad ha evolucionado a tal ritmo que en la actualidad la deno\r\n-\r\nminada "sociedad del conocimiento" representa un estadio que implica el uso social y económico de la \r\ninformación para la construcción de las comunidades científicas (1). El aumento de la información en \r\nformato digital operado por ordenadores es un hecho sin precedentes que avanza como una ola imparable \r\na la cual se deben unir las comunidades científicas que deseen perdurar y demostrar capacidades en la \r\ncreación e innovación del conocimiento científico (1). Las tecnologías de la información y comunicación \r\nhan trasformado en los últimos veinte años los modos de organización de la comunidad científica, permi\r\n-\r\ntiendo percibir nuevos escenarios, dando paso a las redes virtuales de investigadores y a los consorcios de \r\ninvestigación que rompen barreras de tiempo y espacio para configurarse como redes globales de genera\r\n-\r\nción y uso del conocimiento (2).\r\nEl impacto social de la ciencia es posible analizarlo desde la población a la cual se dirige la actividad \r\ncientífica, así como desde la población que genera la investigación, la comunidad de investigadores, la \r\ncual tiene la necesidad de dar a conocer al mundo científico los resultados de sus avances. El desarrollo \r\ncientífico y tecnológico de los países se ha convertido en uno de los indicadores de mayor importancia \r\npara la evaluación del desarrollo mundial. De acuerdo con el Banco Mundial la innovación tecnológica, \r\nnormalmente estimulada por los gobiernos, promueve el crecimiento industrial y ayuda a mejorar los \r\nniveles de vida de la población, por lo que es importante invertir e incentivar en su desarrollo y establecer \r\nestrategias de gestión y evaluación (3).\r\nAmérica Latina invierte el 0,84% del producto interno bruto en comparación a los países miembros de \r\nla Organización para la Cooperación y el Desarrollo Económico (OCDE), de los cuales se destinan el \r\n2,4% para ciencia y tecnología (3). La evaluación de la actividad científica es un elemento imprescindible \r\npara todos los programas de investigación, tecnología y desarrollo que se implementan en una sociedad. \r\nLa cienciometría ha contribuido al desarrollo de indicadores que constituyen una herramienta clave en \r\nla gestión de la política científica y tecnológica, y en los procesos de toma de decisiones estratégicas (4), \r\nsiendo la piedra angular de los gobiernos para la gestión de la investigación, la tecnología y la innovación.\r\nLos procesos de evaluación científica de los países se expresan a nivel internacional a través del Programa \r\npara la Evaluación Internacional de Estudiantes (PISA), puesto en marcha desde 1997, y de la evaluación \r\nde las capacidades nacionales de ciencia y tecnología, en la cual se tienen en cuenta factores relacionados \r\ncon inversión, formación científica y tecnológica, recurso humano calificado y producción científica y \r\ntecnológica del país.

Scientific knowledge in modern times has evolved at such a rate that currently the so-called "society \r\nof knowledge" represents a stage, which involves the social and economic use of information for the \r\nconstruction of scientific communities (1). The increase of information in a digital format operated by \r\ncomputers is an unprecedented occurrence that advances like an unstoppable wave that scientific commu\r\n-\r\nnity who wish to endure and demonstrate capacities in the creation and innovation of scientific knowledge \r\nmust join (1). Communication and information technologies in the last twenty years have transformed the \r\norganizational modes of the scientific community, allowing perception of new scenarios, giving way to \r\nthe virtual networks of researchers and investigational consortia who break barriers of time and space in \r\norder to configure themselves as worldwide network of generation and use of knowledge (2).\r\nIt is possible to analyze the social impact of science from the population to which scientific activity is \r\ndirected, as well as from the general research population, the community of researchers, which has the \r\nneed to give the scientific world knowledge of the results of their advances. The scientific and techno\r\n-\r\nlogical development of countries has become one of the most important indicators for the evaluation of \r\nglobal development. According to the World Bank, technological innovation, normally stimulated by \r\ngovernments, promotes industrial growth and helps to improve the living standards of the population, for \r\nwhich it is important to invest and incentivize its development and establish strategies for management \r\nand evaluation (3).\r\nLatin America invests 0.84% of the gross domestic product in comparison to the member countries of the \r\nOrganization for Economic Cooperation and Development (OECD), of which 2.4% is spent for science \r\nand technology (3). The evaluation of scientific activity is an indispensible element for all research, tech\r\n-\r\nnological, and developmental programs that are implemented in a society. Scientometrics has contributed \r\nto the development of indicators that constitute a key tool in the management of political and technolo\r\n-\r\ngical policy, and in the processes of decision making strategies (4), being the cornerstone of governments \r\nfor the management of research, technology, and innovations.\r\nCountries' scientific assessment processes are expressed internationally through the Program for Interna\r\n-\r\ntional Student Assessment (PISA), launched in 1997, and concerning the evaluation of national scientific \r\nand technological capacities, in which factors related to investment, scientific and technological educa\r\n-\r\ntion, qualified human resources, and scientific and technological production of the country are taken into \r\naccount.

O conhecimento científico na modernidade evoluiu a tal ponto que, atualmente, a denominada "socie\r\n-\r\ndade do conhecimento" representa um estágio que implica o uso social e econômico da informação para \r\na construção das comunidades científicas (1). O aumento da informação em formato digital, operada por \r\ncomputadores, é um feito sem precedentes que avança como uma onda inevitável, à qual se devem unir as \r\ncomunidades científicas que desejem perdurar e demonstrar capacidades na criação e inovação do conhe\r\n-\r\ncimento científico (1). As tecnologias da informação e comunicação transformaram, nos últimos vinte \r\nanos, os modos de organização da comunidade científica, permitindo perceber novos cenários, dando \r\nlugar às redes virtuais de pesquisadores e aos consórcios de pesquisa, que rompem barreiras de tempo e \r\nespaço para configurar-se como redes globais de geração e uso do conhecimento (2).\r\nÉ possível analisar o impacto social da ciência a partir da população para a qual se dirige a atividade cien\r\n-\r\ntífica, assim como a partir da população que gera a pesquisa, a comunidade de pesquisadores, a qual tem \r\na necessidade de apresentar ao mundo científico os resultados de seus avanços. O desenvolvimento cientí\r\n-\r\nfico e tecnológico dos países se converteu em um dos indicadores de maior importância para a avaliação \r\ndo desenvolvimento mundial. De acordo com o Banco Mundial, a inovação tecnológica, normalmente \r\nestimulada pelos governos, promove o crescimento industrial e ajuda a melhorar os níveis de vida da \r\npopulação, pelo qual é importante investir e incentivar seu desenvolvimento e estabelecer estratégias de \r\ngestão e avaliação (3).\r\nA América Latina investe 0,84% do produto interno bruto em comparação com os países membros da \r\nOrganização para a Cooperação e Desenvolvimento Econômico (OCDE), dos quais se destinam 2,4% \r\npara ciência e tecnologia (3). A avaliação da atividade científica é um elemento imprescindível para todos \r\nos programas de pesquisa, tecnologia e desenvolvimento a se implementar em uma sociedade. A ciencio\r\n-\r\nmetria contribuiu para o desenvolvimento de indicadores que constituem uma ferramenta-chave na gestão \r\nda política científica e tecnológica, e nos processos de tomada de decisões estratégicas (4), sendo a pedra \r\nangular dos governos para a gestão da pesquisa, tecnologia e inovação.\r\nOs processos de avaliação científica dos países são expressos, em nível internacional, através do Programa \r\nInternacional de Avaliação de Alunos (PISA), lançado em 1997, e da avaliação das capacidades nacionais \r\nde ciência e tecnologia, na qual são levados em conta fatores relacionados com investimento, formação \r\ncientífica e tecnológica, recursos humanos qualificados e produção científica e tecnológica do país.