Measuring moral distress in health professionals using the MMD-HP-SPA scale.

BACKGROUND: Moral distress (MD) is the psychological damage caused when people are forced to witness or carry out actions which go against their fundamental moral values. The main objective was to evaluate the prevalence and predictive factors associated with MD among health professionals during the pandemic and to determine its causes. METHODS: A regional, observational and cross-sectional study in a sample of 566 professionals from the Public Health Service of Andalusia (68.7% female; 66.9% physicians) who completed the MMD-HP-SPA scale to determine the level of MD (0-432 points). Five dimensions were used: i) Health care; ii) Therapeutic obstinacy-futility, iii) Interpersonal relations of the Healthcare Team, iv) External pressure; v) Covering up of medical malpractice. RESULTS: The mean level of MD was 127.3 (SD=66.7; 95% CI 121.8-132.8), being higher in female (135 vs. 110.3; p<0.01), in nursing professionals (137.8 vs. 122; p<0.01) and in the community setting (136.2 vs. 118.3; p<0.001), with these variables showing statistical significance in the multiple linear regression model (p<0.001; r2=0.052). With similar results, the multiple logistic regression model showed being female was a higher risk factor (OR=2.27; 95% CI 1.5-3.4; p<0.001). 70% of the sources of MD belonged to the dimension "Health Care" and the cause "Having to attend to more patients than I can safely attend to" obtained the highest average value (Mean=9.8; SD=4.9). CONCLUSIONS: Female, nursing professionals, and those from the community setting presented a higher risk of MD. The healthcare model needs to implement an ethical approach to public health issues to alleviate MD among its professionals.

Study of the Psychometric Properties of the Spanish Version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA).

BACKGROUND: The early detection of moral distress requires a validated and reliable instrument. The aim of this study was to carry out an advanced analysis of the psychometric properties of the moral distress scale for health professionals (MMD-HP-SPA) by performing a validation of the construct and its internal and external reliability. METHODS: We performed a multicentre cross-sectional study in health professionals belonging to the Andalusian public health system. Construct validity was performed by exploratory (n = 300) and confirmatory (n = 275) factor analysis (EFA/CFA) in different subgroups; we also analysed the internal consistency and temporal reliability of the scale. RESULTS: 384 doctors and 191 nurses took part in the survey. The overall mean for moral distress was 128.5 (SD = 70.9), 95% CI [122.7-134.3], and it was higher in nurses at 140.5 (SD = 74.9) than in doctors at 122.5 (SD = 68.1), F = 8.37 p < 0.01. The EFA produced a model of five components which accounted for 54.8% of the variance of the model. The CFA achieved a goodness of fit of Chi2 = 972.4; AIC = 1144.3; RMSEA = 0.086; CFI = 0.844; TLI = 0.828; NFI = 0.785. CONCLUSIONS: The MMD-HP-SPA scale has solid construct validity, excellent internal consistency, optimal temporal reliability, and underlying dimensions which effectively explore the causes of moral distress in health professionals, thus guaranteeing its use in hospital and community settings.

Valoración y seguimiento de pacientes y familias por parte del equipo de psicólogos de cuidados paliativos / Assessment and control of patients and their families by the pyschological palliative care team

Introducción: Los cuidados paliativos (CP) tienen como finalidad la mejora en la atención a los pacientes con enfermedades avanzadas, resguardando la capacidad de los individuos para hacer frente al proceso de enfermedad terminal. Una de las principales áreas de intervención de los psicólogos se realiza en estas unidades especializadas.Objetivo: Analizar las actividades de valoración, intervención y seguimiento de pacientes y familias por los psicólogos de CP y poner en evidencia el valor añadido de estos profesionales en los equipos de CP.Material y método: Estudio descriptivo retrospectivo de pacientes y familiares atendidos por los psicólogos del equipo de CP durante un periodo de 3 meses, en visitas de valoración y segui- miento en el área hospitalaria del Hospital Virgen Macarena de Sevilla.Resultados: Se incluyeron 310 sujetos en este estudio, de los cuales el 39,68 % eran pacientes y el 60,32 % familiares. La mayoría (89,68 %) pertenecía al grupo oncológico y el 84 % estaban en estadio terminal. Un 69 % de los sujetos evaluados padecía malestar emocional, así como un 32,9 % ansiedad y un 63,9 % depresión. Se encontró asociación entre estos 2 síntomas, de tal forma que los pacientes con sintomatología depresiva tenían mayor riesgo de presentar también ansiedad (OR: 3,48). Conforme se establecía una mayor relación entre los sujetos del estudio y los psicólogos, se observaron mejoras significativas en los síntomas psicológicos evaluados, así como en el malestar emocional, la información percibida y el grado de vinculación con los psicólogos.Conclusión: La intervención por parte de profesionales expertos influye en la evolución de los síntomas psicológicos en CP y en el sufrimiento en las etapas finales de la vida. (AU)

Background: Palliative Care (PC) teams aim to improve care for patients with advanced diseases, safeguarding the ability of individuals to cope with the process of terminal illness. One of the main areas of intervention of psychologists is performed in these specialized units.Objective: A study that aims to analyze the assessment, intervention and follow-up of patients and families by the palliative care psychological team, highlighting the added value of these teams.Material and methods: A retrospective descriptive study of patients and family members treated by CP team’s psychologists during a period of 3 months in assessment and follow-up visits in Virgen Macarena Hospital (Seville).Results: A total of 310 subjects were included in this study (39.68 % patients; 60.32 % family members), a large majority (89.68 %) belonged to the oncological group and 84 % were in the terminal stage; 69 % of the subjects tested suffered from emotional distress, 32.9 % had anxi- ety and 63.9 % had depression. A link was found between these 2 symptoms, so that patients with depressive symptomatology were at higher risk to develop anxiety (OR: 3.48). Significant improvements were observed in the psychological symptoms evaluated, as well as in the emo- tional discomfort, degree of information perceived, and degree of linkage with psychologists as a greater relationship was established with them.Conclusion: Psychological interventions by well trained professionals do influence on psychologi- cal symptoms (depression and anxiety) in palliative care, as well as in emotional discomfort in end-of-life stages. (AU)

Reflexiones éticas desde la experiencia práctica de la crisis COVID-19 / Ethical reflections from the practical experience of the COVID-19 crisis

El objetivo de este artículo es realizar una reflexión ética en base a documentos generados durante la pandemia por COVID-19, aportando conclusiones sobre lo aprendido y lo que nos falta por aprender. Se desarrollarán seis áreas de acción: priorización de los recursos, consulta presencial y telemedicina, la (des)protección de los profesionales, la atención en los centros de mayores, la respuesta social y la atención en los últimos días. Ante la falta de recursos, la autoridad pública puede establecer criterios que limiten, sin suprimirlo, el derecho a la protección de la salud de algunos. Se puede justificar la asignación según la capacidad de recuperación del paciente, sin discriminar por edad o discapacidad. Las consultas telemáticas ayudan a mantener la relación clínica, pero requieren de tiempo y entrenamiento. La relación clínica tiene exigencias deontológicas, y requiere mejorar la tecnología y las habilidades de relación telemática. La metáfora bélica y del heroísmo genera presión y confusión sobre el alcance del deber, ante la grave desprotección sufrida por los profesionales. Se debe realzar el valor de la interdependencia y la responsabilidad, no "romantizar" el riesgo, y compensar a los profesionales y sus familias. En las residencias de mayores predominan grandes centros, organizados por tareas, con poca autonomía y privacidad. Debemos decidir qué modelos queremos, y podemos pagar, y qué riesgos compartidos asumimos desde valores comunes. La sociedad civil puede responder a las crisis (democracia es "gobierno del pueblo", que debe protagonizar la vida pública, no los políticos). El acompañamiento al morir son derechos reconocidos. Su limitación excepcional no puede ser una privación total. La planificación anticipada requiere hablar de los miedos y los valores con los pacientes y sus familias. Es un proceso deliberativo que debemos recuperar en la era de la COVID-19

The aim of this article was to conduct an ethical reflection based on documents generated during the COVID-19 pandemic, providing conclusions about what has been learned and what we still have to learn. Six areas of action will be developed: prioritization of resources, face-to-face consultation and telemedicine, (un)protection of professionals, care in nursing homes, social response, and last days care. Facing lack of resources, public authority can establish criteria that limit the right to health protection. The allocation can be justified according to the patient's ability to recover, without discriminating by age or disability. Telematic consultation can keep patient-clinician relationship, but requires time and training. The clinical relationship has deontological requirements, and requires improving technology and telematic communication skills. The war metaphor generates pressure and confusion over the scope of duty in the face of the serious lack of protection suffered by professionals. The value of interdependence and responsibility must be enhanced, not "romanticizing" the risk, and compensating professionals and their families. Nursing homes in our country are predominantly large centers, organized by tasks, with little autonomy and privacy. We must decide which models we want and can afford, and which shared risks we assume from common values. Civil society can respond to crises (democracy is the "government of the people", which must begin in public life, not in politicians. Accompaniment at death is a recognized right). Exceptional limitation of resources cannot be total deprivation. Advanced care planning requires talking about fears and values with patients and their families. It is a deliberative process we must recover in the COVID-19 era

All with You: a new method for developing compassionate communities-experiences in Spain and Latin-America.

BACKGROUND: In recent years, compassion has motivated the development of programs oriented to create communities and societies involved in the relief of suffering. The development of compassionate communities and cities begins in each one of us, though it relies on organizations, providers and societies as a whole who need tools and methodologies as a part of a set of actions to help compassionate communities and cities to become a reality rooted widely in social values. In order to describe the "All with You®" methodology and its components: a method designed to develop compassionate communities and cities at the end of life that can be extended to organizations, communities, municipalities, cities or countries. In addition, this article tries to describe several experiences from applying the method in different cities and contexts. METHODS: A search of models for the development of compassionate communities was carried out initially to guide the elements and phases that could help to create a systematized method that will help organizations to create compassionate communities. After analysing the results, alliances were established with some of the main promoters at the time in the development of compassionate communities to validate the designed method. The city of Seville (Spain) was selected to validate the phases of the method and analyse the results based on a series of indicators. Finally, the methodology is being spread throughout cities in various countries, and the experiences are being evaluated with common indicators. RESULTS: The "All with You®" method (Todos Contigo® in Spanish) has been developed as a systematic approach that enables anyone interested in building compassionate communities or cities to include all of the elements outlined in the Compassionate City Charter. All with You® is a method that includes eight phases that allows organizations to be guided in the development of compassionate communities and cities towards a certification process that is evaluated through a series of structures, process and results indicators. The main actions of this method are based on social awareness, training, and the implementation of networks of care using innovative elements like Community Promoters and the RedCuida protocol to provide support, backing and care for those who face advanced chronic disease and end of life situations. Several cities in Spain and Latin America have already joined the movement of compassionate cities using this method, including four in Spain (Seville, Badajoz, Getxo and Pamplona), four in Colombia (Cali, Medellin, Fusagasugá and Bogotá) and one in Argentina (Buenos Aires). CONCLUSIONS: The All with You® method has made the development of compassionate communities and cities possible, aligning organizations and cities to promote compassionate acts, and to start creating networks involved in a global community united by a vocation for caring.

Endoscopic ultrasound-guided placement of plastic pigtail stents for the drainage of refractory malignant ascites.

Endoscopic ultrasound (EUS)-guided drainage is now the treatment of choice in cases of pancreatic pseudocysts and walled-off necrosis, especially in the absence of luminal bulging and in patients with portal hypertension. Malignant refractory ascites usually heralds a poor prognosis and substantially impairs the quality of life of patients because of the symptoms experienced and the need for repeated paracentesis. EUS-guided placement of lumen-apposing, fully covered, self-expandable metal stents (FCSEMS) has been reported for the drainage of malignant ascites. Herein, we present the results of EUS-guided placement of plastic pigtails stents for the drainage of refractory malignant ascites in three patients. The aim was to improve symptoms and minimize the possible drawbacks of large-caliber FCSEMS. In this preliminary experience, EUS-guided placement of plastic stents was feasible and avoided further paracentesis.

Factores sociodemográficos que influyen en la ansiedad ante la muerte en estudiantes de medicina / Sociodemographic factors that influence death anxiety in Medical Students

FUNDAMENTO Y OBJETIVO: Conocer el grado de ansiedad ante la muerte de los estudiantes de medicina analizando la posible influencia de factores sociodemográficos. MATERIAL Y MÉTODO: Diseño observacional, descriptivo y transversal. Participaron 175 estudiantes, que respondieron a un cuestionario con variables sociodemográficas y a la escala de miedo a la muerte de Collet-Lester. Se calculan medias y desviaciones típicas, prueba «t» de Student, ANOVA y coeficiente de correlación de Pearson. RESULTADOS: El nivel medio de ansiedad ante la muerte es moderado. Las mujeres puntúan más alto en las 4 subescalas, alcanzando significación estadística en la escala de miedo al propio proceso de morir y miedo a la muerte de otros. Quienes se manifiestan creyentes en una religión puntúan más alto que los no creyentes en las 4 subescalas, alcanzando significación en 3 de ellas. No existen diferencias significativas en cuanto a la experiencia directa de la muerte en otros, según la práctica de creencias, ni respecto a la creencia en la vida eterna. Acerca de la preferencia por trabajar en cuidados paliativos no se observan diferencias significativas. No se observa correlación estadística entre el grado o la importancia otorgada a la religiosidad, así como el grado de importancia otorgado a la espiritualidad y las subescalas de Collet-Lester. CONCLUSIONES: El sexo y la creencia en una religión influyen en la ansiedad ante la muerte. El afrontamiento de la ansiedad ante la muerte ha de ser contemplado específicamente en los programas de formación de pregrado en medicina

BACKGROUND AND OBJECTIVE: To determine the degree of death anxiety in Medicine students and analyze the possible influence of sociodemographic factors. MATERIAL AND METHOD: Design observational, descriptive and transversal. 175 students participated responding to a sociodemographic variables questionnaire and the scale Collet-Lester of fear of death. Means and standard deviations, Student t test, ANOVA and Pearson correlation coefficient was calculated. RESULTS: The mean level of death anxiety is moderate. Women score higher in the 4 subscales, reaching statistical significance in the scale of fear to the process of dying and fear of death of others. The believers in a religion score higher than non-believers in the four subscales reaching significance in three of them. No significant differences were found, in the direct experience of death in others, according to the practice of beliefs, or concerning the belief in eternal life. About the preference for working in palliative care, was no significant differences. No statistical correlation between the degree or importance given to religiosity, and the importance given to spirituality and subscales Collet-Lester were observed. CONCLUSIONS: Sex and the belief in a religion influence over death anxiety. Coping with anxiety before death must be specifically addressed in undergraduate training programs in Medicine

Dolor irruptivo y calidad de vida: estudio comparativo de la percepción por parte de los médicos y los pacientes oncológicos / Breakthrough pain and quality of life: A comparative study of the perception by physicians and cancer patients

OBJETIVO: El propósito de este estudio fue investigar el grado de concordancia entre pacientes que sufren dolor irruptivo oncológico y los médicos que los tratan en la percepción del dolor y la calidad de vida (CdV). MÉTODO: Se llevó a cabo un estudio multicéntrico, transversal y observacional. La información sobre el dolor y la CdV se recogió mediante las herramientas Brief Pain Inventory (BPI) y EuroQoL five-dimensional questionnaire (EQ-5D), ambas completadas por los médicos y los pacientes. También se recogieron los datos sociodemográficos y clínicos, incluyendo la puntuación de la capacidad funcional ECOG. Para el análisis de la concordancia en las percepciones de la CdV y el dolor entre médicos y pacientes se calcularon los coeficientes de correlación intraclase y el estadístico κ ponderado. Resultado: Un total de 129 médicos y 472 pacientes participaron en el estudio. Casi todos los doctores (98,4%) tenían experiencia previa en el manejo de pacientes con dolor irruptivo oncológico. Con relación a la intensidad de dolor y al impacto de este en la vida cotidiana, los coeficientes de correlación intraclase (todos por encima de 0,84) indicaron que había un alto grado de acuerdo entre las valoraciones de los médicos y la de los pacientes. Para la CdV, se observó una buena concordancia entre médicos y pacientes, con estadísticos κ desde 0,61 (ítem de ansiedad/depresión) a 0,75 (ítem de actividades de la vida diaria). La declaración del dolor experimentado por los pacientes fue de 8 para la intensidad máxima y de 5 para la intensidad media. CONCLUSIONES: En este estudio de práctica clínica habitual, los médicos participantes eran razonablemente conocedores del nivel de funcionalidad y bienestar de sus pacientes, siendo la percepción del componente psicológico (ansiedad/depresión) de la CdV la menos concordante. Estos hallazgos ayudan a conocer mejor la prevalencia e intensidad del dolor, su interferencia con las actividades de la vida diaria y la CdV en pacientes oncológicos con dolor irruptivo oncológico, un paso esencial para mejorar el manejo del dolor asociado a cáncer

OBJECTIVE: To analyse the agreement on perceptions of pain and quality of life (QoL) between patients with cancer-related breakthrough pain and their treating physicians. METHOD: A multicentre, cross-sectional, observational study was performed. Pain and QoL information was collected using the Brief Pain Inventory and the EuroQoL five-dimensional questionnaire completed by physicians and PATIENTS: Agreement between patient- and physician-perceived QoL and pain scores was evaluated using intraclass correlation coefficients and weighted κ statistics. RESULTS: A total of 129 physicians and 472 patients participated in the study. Almost all doctors (98.4%) had previous experience in managing patients with cancer breakthrough pain. For pain intensity and impact of pain on daily life, intraclass correlation coefficients (all exceeding 0.84) indicated that there was strong agreement between physician and patient assessments. For QoL, good concordance was found between patients and physicians, with weighted κ statistic ranging from 0.61 (anxiety/depression item) to 0.75 (daily activities item). Patient pain reports were 8.0 for the worst pain, and 5.0 for mean pain. CONCLUSIONS: In this setting, physicians were reasonably aware of their patients' level of functioning and well-being, with gaps only in the psychological dimension (anxiety/depression) of QoL. These findings contribute to a better understanding of pain prevalence and intensity, interference of pain with daily activities, and QoL in cancer patients with breakthrough pain, and are an essential step towards improving cancer pain management

Grupo de trabajo SECPAL sobre formación médica en medicina paliativa en la universidad española / SECPAL working group on medical training in palliative medicine in the Spanish university

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Control de los síntomas neuropsicológicos / Control of neuropsychological symptoms

Los trastornos psiquiátricos son extremadamente frecuentes en el paciente con cáncer avanzado. Por lo general son infradiagnosticados e infratratados y generan un sufrimiento importante tanto al enfermo como a sus familiares. Optimizar las estrategias diagnósticas y terapéuticas de los síntomas psiquiátricos más prevalentes permitirá mejorar sustancialmente su calidad de vida. Revisaremos los conocimientos actuales sobre los trastornos más frecuentes: depresión, ansiedad, insomnio y delirium (AU)

Psychiatric disorders are highly frequent in patients with advanced cancer. These disorders are usually under-diagnosed and under-treated, causing significant distress in both patients and their families. Optimizing the diagnostic and therapeutic strategies for the most prevalent psychiatric symptoms would substantially improve the quality of life of these patients. We review current knowledge of the most frequent psychiatric disorders: depression, anxiety, insomnia, and delirium (AU)