Palliative sedation in clinical scenarios: results of a modified Delphi study.

PURPOSE: To explore the consistency in international expert opinions about palliative sedation. METHODS: A modified electronic-Delphi procedure was carried out in two rounds. On hundred nine eligible experts were identified from their publications in MEDLINE related with terminal delirium, dyspnea and palliative sedation in the last 3 years. Delphi study included three vignettes of cancer patients and two non-cancer patients, with an estimated survival of days and severe suffering secondary to refractory complications. Experts were asked about whether they would perform continuous sedation and sedation level (described as Richmond Agitation Sedation Scale or defined as patient/family report of symptom relief). Consensus was considered when 70% or more of the experts agreed on a certain topic. RESULTS: Thirty-four and 27 panellists completed the 2 Delphi rounds, respectively. Participants were from the USA, Canada, Europe, Australia and Asia. One hundred per cent, 97% and 88% of the respondent agreed use of sedatives, continuously or temporary, in cases of refractory delirium, dyspnea secondary to lung cancer and GOLD IV-EPOC. There were discrepancies for cases of dementia and psycho-existential suffering. Expert selection of continuous palliative sedation was 93% for delirium, 41% for cancer dyspnea, 66% for EPOC dyspnea, 22% for agitation/pain in dementia and 19% for existential suffering. Responses about types and levels of sedation did not achieve consensus in any cases. CONCLUSIONS: The Delphi study failed to reach consensus in continuous palliative sedation and sedation levels for patients with refractory symptoms described in hypothetical clinical scenarios.

A systematic review of specialised palliative care for terminal patients: which model is better?

There is evidence of improved effectiveness of specialised palliative care for terminally ill patients in comparison to conventional care. However, there is uncertainty about which model is better. The objective of this systematic review was to identify studies that compare specialised palliative care models between them assessing their effectiveness or cost-effectiveness. We searched studies published between 2003 and 2006 in several electronic databases and updated the search in MEDLINE up to 2008. Papers published before 2003 were identified by means of previous systematic reviews and manual search. Studies with broad designs comparing two or more specialised palliative care programmes in adults with terminal illness were selected. Six systematic reviews, three studies on effectiveness and one cost study were included. All systematic reviews drew the conclusion that specialised palliative care is more effective than conventional care. The methodological limitations of the original studies and the heterogeneity of programmes did not allow to draw conclusions about whether a specific model of specialised palliative care is more or less effective or cost-effective than other.

A veces, ser cuidador puede ser saludable / At times it may be healthy to be a carer

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Diagnóstico y tratamiento de la ascitis en pacientes con cáncer en fase terminal / No disponible

Introducción: no hay muchos datos disponibles que permitan establecer una guía clínica contrastada sobre el diagnóstico y tratamiento de la ascitis maligna. Es preciso para ello extrapolar la información disponible del diagnóstico y tratamiento de la ascitis no maligna. Objetivo: establecer unas recomendaciones en relación a la evidencia disponible sobre el diagnóstico y tratamiento de la ascitis maligna. Emplazamiento: unidad de cuidados paliativos de tercer nivel, Tenerife. Diseño: revisión de la evidencia empírica disponible. Búsqueda de la información en MEDLINE, 1990-2004, mediante las palabras «peritoneal efusión», «malignant ascites», «ascites diagnoses» y «ascites treatment» cruzadas con «palliative care» y «terminal cancer». Criterios de selección: todos los trabajos publicados en inglés y castellano sin criterios de exclusión. Se incluyeron estudios de cohortes, casos control, series de casos, revisiones sistemáticas, guías clínicas y guías generales. Variables valoradas: eficacia de los métodos diagnósticos y de los tratamientos. Resultados: el diagnóstico de la ascitis es fundamentalmente clínico. La ecografía abdominal sólo mejora el diagnóstico clínico en situaciones de ascitis tabicada, o semiología compatible con escasa extracción de líquido por paracentesis. El tratamiento descansa en el uso reiterado de paracentesis. Estas se realizarán si tratamiento concomitante con albúmina o expansores del plasma cuando no coexista una hipertensión portal. Los diuréticos sólo son eficaces cuando coexiste una hipertensión portal. Conclusiones: el grado de evidencia disponible sobre el diagnóstico y tratamiento de la ascitis maligna sólo alcanza el nivel IV de recomendación de expertos. En relación a él, pueden establecerse unas recomendaciones generales, sobre el uso de la paracentesis y de los diuréticos (AU)

Introduction: data available are not enough to establish clinical guidelines for the diagnosis and treatment of malignant ascites. It is necessary therefore to extrapolate the information available on the diagnosis and treatment of non-malignant ascites. Objective: to establish recommendations related to the available evidence regarding the diagnosis and treatment of malignant ascites. Location: a third-level palliative care unit in Santa Cruz de Tenerife. Design: a review of the available empiric evidence. Information search in MEDLINE for 1990-2004 by means of the following key words: «peritoneal effusion», «malignant ascites», «ascites diagnosis», «ascites treatment», «palliative care», «terminal cancer». Selection criteria: All reviews published in English and Spanish, with no criteria being excluded. They included cohort studies, case-control studies, case series, systematic reviews, clinical guidelines, and general guidelines. Variable rates: efficacy of diagnosis methods and treatments. Results: the diagnosis of ascites is essentially clinical. Abdominal ultrasounds only improve clinical diagnosis for «walled-up» ascites or cases of limited extraction by paracenthesis. Treatment is supported by a repeated use of paracenthesis. This will be achieved with no concomitant albumin or plasma expanders whenever there is no coexisting portal hypertension. The efficacy of diuretics is only demonstrated in cases of comorbid portal hypertension. Conclusions: the available evidence on the diagnosis and treatment of malignant ascites only reaches level IV in expert recommendations. Because of this, general recommendations about the use of paracenthesis and diuretics may be established (AU)

Impacto del estado funcional y cognitivo en la mortalidad de las personas mayores que viven en la comunidad / Impact of functional and cognitive status on elderly people living in the community

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[The exhaustive geriatric evaluation in primary care: an assessment of its utility]. / Evaluación geriátrica exhaustiva en atención primaria: valoración de su utilidad.

OBJECTIVE: To describe the preliminary results from evaluating the application of an exhaustive geriatric evaluation procedure within primary care. DESIGN: A descriptive crossover study of a non-random sample. SETTING: This was carried out in primary care at an out-station clinic serving a suburban population. PATIENTS AND OTHER PARTICIPANTS: Those people aged 70 and over who requested health-care at the clinic. All the 131 people who attended between February and December 1992 were included in the procedure. MEASUREMENTS AND MAIN RESULTS: The Exhaustive Geriatric Evaluation was applied as an instrument to diagnose hidden health problems. The instrument is composed of functional classification (Katz and Lawton-Brody scales), detection of risk factors which might lead to institutionalisation and an exhaustive clinical assessment (biomedical, psychological and socio-family). The diagnostic usefulness of the procedure is 2.4 +/- 0.21 new diagnoses per patient, for 98% of those to whom the complete new procedure was applied (62.6% of the patients included). Problems of hypoacusis (33.3%), senile memory lapses (41.6%) and urinary incontinence (26.2%) were found to a significant degree (p < 0.05) compared with the previously diagnosed morbidity. On the Katz and Lawton-Brody scales, 74% and 41.9% of patients, respectively, were independent. 55.7% of patients presented at least one risk factor leading to institutionalisation, with loneliness being the most common (35.8% of cases). CONCLUSIONS: The exhaustive geriatric evaluation is valid in primary care in looking after the elderly population, as it leads to the detection of functional and hidden bio-psychosocial problems.