Sedación paliativa en un Hospital Universitario: experiencia tras la puesta en marcha de un protocolo específico / Palliative sedation in a University Hospital: experience after introducing a specific protocol

Pacientes y métodos. Estudio descriptivo prospectivo del registro de sedación paliativa (SP) durante un año tras la puesta en marcha del protocolo de SP. Criterios de inclusión. Pacientes incluidos en el protocolo de SP del Hospital Universitario Virgen Macarena y para los que se había completado la «Hoja de registro de datos». Fuentes de información. Hojas de registro incluidas en el protocolo de SP como anexo n.° 5, incluidas como anexo 1 en este trabajo. Variables. Datos de filiación, datos relativos a la enfermedad de base, pronóstico, nivel de información. Síntoma refractario: tipo, tiempo de evolución y tratamientos aplicados. Participación del enfermo y/o sus representantes en la toma de decisiones. Tipo de sedación, continuidad, profundidad, fármacos utilizados, duración y resultados y reajuste del resto de medidas terapéuticas. Análisis estadístico. Se analizaron las variables mediante SPSS 14.0: para variables cualitativas se estudiaron frecuencias absolutas y proporciones. Para cuantitativas con distribución normal, medias y desviaciones típicas, y con distribución no normal, medianas y rangos. Resultados. En el periodo del estudio constatamos 90 casos de SP. Ello representa el 27,6% de los pacientes atendidos por el equipo de soporte de cuidados paliativos (ESCP) hospitalario, y el 7,03% de los enfermos fallecidos en el hospital. La edad media de los pacientes tratados con SP fue de 59,22 años y rango entre 40,86 y 77,58 años. Un 68,1% fueron hombres. Todos se encontraban en fase avanzada o terminal de su enfermedad, y el 49,5% en fase agónica. En el 90,4% de los casos la patología fundamental fue oncológica. Respecto a la indicación de SP, esta fue realizada de manera conjunta por el médico del ESCP y su médico responsable en 60 casos (66,6%); Los síntomas que motivaron la sedación fueron mayoritariamente: disnea, delirium y dolor. En 5 casos se consultó al Comité de Ética Asistencial. La duración media de la sedación fue de 134,02 h (5,5 días). En el 90% de los casos, la duración osciló entre 50 y 218,04 h (2-9 días). La profundidad de la SP, tras inducción, quedó registrada en el 88,8% de los casos. El consentimiento informado (CI) fue explícito en el 11,2%, otorgado antes de presentar síntomas refractarios y/o fase agónica. En el 88,8% de las sedaciones el CI fue por representación. Respecto a los fármacos empleados como opción inicial, fue midazolam en el 87,8%, y levomepromacina en el 10,2%. Hasta un 15% de sedaciones precisaron cambio o asociación de fármacos. Conclusión. 1) La aplicación de un protocolo de SP y la disponibilidad del ESCP hospitalario y el Comité de Ética asistencial favorecieron el uso seguro (correcto) de la SP en un hospital sin unidad de cuidados paliativos (UCP), y el registro homogéneo de datos para su análisis, con criterios de calidad similares a los que ofrece una UCP. 2) Hemos detectado áreas de mejora que se aplicarán en la segunda versión de nuestro protocolo(AU)

Patients and methods. A descriptive prospective study of palliative sedation (PS) records during a one year period after starting the PS protocol. Inclusion criteria. Patients included in the PS protocol and those who had completed the «data registry form». Data sources. Registry forms included in the PS protocol as Annex 5 (included as Annex 1 in this study). Variables. Personal data, data regarding basal disease, prognosis, level of information. Refractory symptoms: type, time of evolution and treatments employed. Involvement of the patient and/or representatives in decision making. Type of sedation, continuity, depth, employed, duration and results, and readjustment of other therapeutic measures. Statistical analysis. The SPSS 14.0 was used. For qualitative variables we studied absolute frequencies and proportions. For quantitative variables with normal distribution, we used means and standard deviations, and for non-normal distribution, medians and ranges. Results. In the study period 90 cases of PS were counted. This represented 27.6% of the patients treated in the hospital palliative care support team (PCST), and 7.03% of the total deceased patients in our hospital. Mean age of patients undergoing PS was 59.22 years old, range between 40.86 and 77.58 years, and 68.1% were men. All patients were in an advanced or terminal stage of their condition, and 49.5% in an agonal phase. In 90.4% of the cases, the main pathology was oncological. Regarding PS indication, this was jointly made between the PCST physician and the patient's usual doctor in 60 cases (66.6%). Symptoms leading to sedation were mainly dyspnea, delirium and pain. The Ethics committee was consulted in five cases. Mean time under sedation was 134.02 hours (5.5 days). In 90% of the cases, duration ranged from 50 to 218.04 hours (2-9 days). Depth of PS after induction was registered in 88.8% of the cases. Informed consent (IC) was explicit in 11.2% of the cases,and given prior to the appearance of refractory symptoms and/or agonal phase. In 88.8% of sedation cases, the IC was given by a representative. Midazolam was the most used drug of choice in 87.8% of the cases, and levomepromazine in 10.2%. Up to 15% of sedations required drug changes or combinations. Conclusion. 1) The application of a PS Protocol and the availability of a hospital PCST and an Ethical Care Committee favored a safe (correct) use of PS in a hospital lacking a palliative care unit (PCU), and a homogeneous data registry for their analysis, with quality criteria similar to those offered by a PCU. 2) We have detected areas of improvement that will be applied in the second version of our protocol(AU)

[Palliative sedation in a university hospital: experience after introducing a specific protocol]. / Sedación paliativa en un Hospital Universitario: experiencia tras la puesta en marcha de un protocolo específico.

PATIENTS AND METHODS: A descriptive prospective study of palliative sedation (PS) records during a one year period after starting the PS protocol. INCLUSION CRITERIA: Patients included in the PS protocol and those who had completed the "data registry form". DATA SOURCES: Registry forms included in the PS protocol as Annex 5 (included as Annex 1 in this study). VARIABLES: Personal data, data regarding basal disease, prognosis, level of information. Refractory symptoms: type, time of evolution and treatments employed. Involvement of the patient and/or representatives in decision making. Type of sedation, continuity, depth, employed, duration and results, and readjustment of other therapeutic measures. STATISTICAL ANALYSIS: The SPSS 14.0 was used. For qualitative variables we studied absolute frequencies and proportions. For quantitative variables with normal distribution, we used means and standard deviations, and for non-normal distribution, medians and ranges. RESULTS: In the study period 90 cases of PS were counted. This represented 27.6% of the patients treated in the hospital palliative care support team (PCST), and 7.03% of the total deceased patients in our hospital. Mean age of patients undergoing PS was 59.22 years old, range between 40.86 and 77.58 years, and 68.1% were men. All patients were in an advanced or terminal stage of their condition, and 49.5% in an agonal phase. In 90.4% of the cases, the main pathology was oncological. Regarding PS indication, this was jointly made between the PCST physician and the patient's usual doctor in 60 cases (66.6%). Symptoms leading to sedation were mainly dyspnea, delirium and pain. The Ethics committee was consulted in five cases. Mean time under sedation was 134.02 hours (5.5 days). In 90% of the cases, duration ranged from 50 to 218.04 hours (2-9 days). Depth of PS after induction was registered in 88.8% of the cases. Informed consent (IC) was explicit in 11.2% of the cases,and given prior to the appearance of refractory symptoms and/or agonal phase. In 88.8% of sedation cases, the IC was given by a representative. Midazolam was the most used drug of choice in 87.8% of the cases, and levomepromazine in 10.2%. Up to 15% of sedations required drug changes or combinations. CONCLUSION: 1) The application of a PS Protocol and the availability of a hospital PCST and an Ethical Care Committee favored a safe (correct) use of PS in a hospital lacking a palliative care unit (PCU), and a homogeneous data registry for their analysis, with quality criteria similar to those offered by a PCU. 2) We have detected areas of improvement that will be applied in the second version of our protocol.

[Assessment of chronic pain coping strategies]. / Evaluación de las estrategias de afrontamiento del dolor crónico.

INTRODUCTION: We made an adaptation of the Coping Strategies Questionnaire (CSQ) to the Spanish population. This measure, the most used in its scope, was developed by Rosenstiel and Keefe in 1983. METHOD: 205 participants coming from Primary Health Care and pain clinics made up the sample. More than half suffered migraine and chronic tension-type headache; the rest, fibromyalgia, low back pain, arthrosis or arthritis. RESULTS: Factor analyses explained 59 % of the total variance, on an 8-factor structure that converged into a 2-factor structure. In the 8-factor solution the novelty was the diversification of mental-non-mental distraction strategies, and religious-non-religious hope strategies. In the 2-factor solution the novelty was the grouping according to the efficacy of the coping. All the CSQ factors showed inner consistency and construct validity. Thus, unadaptive coping strategies were related to negative, anxious and depressed self-talk, related to lack of control and perceived self-efficacy, and related to many pain behaviors. On the contrary it happened with adaptive coping strategies. In addition, the diagnosis of pain was related to the utilization and effectiveness of coping strategies. CONCLUSIONS: CSQ is shown to be a reliable and valid measure of coping strategies in chronic pain in the Spanish population, showing the difference between theoretical and empirical factor structures again.

Evaluación de las estrategias de afrontamiento del dolor crónico / Assessment of chronic pain coping strategies

Introducción. Se realizó una adaptación a la población española del Cuestionario de Estrategias de Afrontamiento del Dolor (CSQ). El instrumento, el más utilizado en su ámbito, fue desarrollado por Rosentiel y Keefe en 1983.Método. Compusieron la muestra 20,5 pacientes procedentes de centros públicos de Atención Primaria y unidades de dolor. Más de la mitad padecía migraña y cefalea tensional crónica; el resto fundamentalmente fibromialgia, lumbalgia, artrosis y artritis. Resultados. Los diversos análisis factoriales explicaron el 59 por ciento de la varianza total sobre una estructura de ocho factores de primer orden que convergieron en dos de segundo orden. En los de primer orden la novedad fue la diversificación de la distracción mental y no mental y de la esperanza con y sin matices religiosos. En los de segundo orden lo novedoso fue la agrupación según la eficacia del afrontamiento. Todos los factores obtenidos mostraron su consistencia interna y validez de constructo. Así, las estrategias de afrontamiento desadaptativas se asociaron a un lenguaje interno negativo, ansiógeno y depresógeno, a una deficiente percepción de control y autoeficacia percibida y a la proliferación de conductas de dolor de diversa naturaleza. Al contrario ocurrió con las estrategias de afrontamiento en función del diagnóstico. Conclusiones. El CSQ se muestra como un instrumento válido y fiable para evaluar las estrategias de afrontamiento del dolor crónico en población española, volviéndose a demostrar la discrepancia entre su estructura teórica y la obtenida empíricamente (AU)

[Reactions of the family after one of their members' death: bereavement, grief, and mourning]. / Reacciones de la familia después de la muerte de un ser querido: duelo, aflicción y luto.

A brief review is presented concerning effects produced in closely related by the lose of a relative. It could be see, even thought people know in a "notional level" that death is the last and unavoidably part of our life-cycle, when this even happen in the near ambience it take totally different connotations. The situation appear with a special characteristic and it is a normal thing to find in closely related very different reaction both emotional and behaviour state.

[Suicide and euthanasia as attitudes of desire facing death]. / El suicidio y la eutanasia como actitudes de deseo frente a la muerte.

Death can come by different ways and in a many circumstances, some naturally and other accidentally. This research will analyse two death's manner with special characteristics: those that people cause themselves conscious and deliberately: Suicide and Euthanasia. It describe different types of this two manners of death, and some of the principal theories about this matter, analysing attitudes propers and impropers face these different death's manners.

Psychological problems in the family members of gravely traumatised patients admitted into an intensive care unit.

The aim of these studies was the analysis of the psychological repercussions on the closest members of families of 76 gravely traumatised patients admitted into the Intensive Care Unit (ICU) of the Hospital Universitario de Rehabilitación y Traumatología "Virgen del Rocio", Sevilla (Spain). An investigation based on social information and the Clinical Analysis Questionnaire was used. The sample of family members was composed of 42 women and 34 men, with an average age of 41.3 years (SD +/- 12.8). Results showed that (a) more than 50% of the family members of gravely traumatised patients admitted into an ICU showed symptoms of depression, (b) the women scored more points in hypochondria, suicidal depression, anxious depression, low-energy depression, guilt-resentment, apathy-withdrawal, paranoia, schizophrenia, psychasthenia and psychological disadjustment, and (c) in general terms, the psychological characteristics of the families were far from the norm of the control group.

[Adolescence and disease]. / Adolescencia y enfermedad.

The difficulties of the combined analysis of two factors, as illness behaviour and adolescence are studying in our work. Most authors support the subjectivity and impression of this field of investigation. We consider some relevant aspects in adolescence and the effects of the illness situation on it. We concluded it's necessary to realize particular and individual analysis of this problem, because it's not possible to report a general conclusion. However, it's possible to realize some predictions about some conflict global areas of behaviour and personality. We analyze the trends of behaviour, adaptative or not, and the differential effects of the illness (chronic and acute). We review the effects of the life-events and the social support on the behaviour, and the relevancy of some particular and transitory aspects of the people on his behaviour.