Nuevas estrategias de atención y cuidado en el contexto de una pandemia: desarrollo de un sistema de monitorización de síntomas telemático en pacientes con enfermedades avanzadas (AvanzaT) / New attention and care strategies in the context of a pandemic: development of a telematic symptom monitoring system in patients with advanced diseases (AvanzaT)

Antecedentes: Las iniciativas de telemedicina involucran a los pacientes en sus cuidados, favorecen la adherencia a los tratamientos y ayudan a centrar las valoraciones presenciales en los problemas más importantes, mejorando en general la atención.Objetivo: Diseño y evaluación de la factibilidad de una app dirigida a monitorizar la situación clínica en pacientes con enfermedades avanzadas.Material y métodos: Tipo de estudio: cualitativo (Diseño app) - cuantitativo (Evaluación en pacientes). Ubicación: Unidades de Cuidados Paliativos del Complejo Hospital Universitario Ntra. Sra. de Candelaria (CHUNSC) en Tenerife y Complejo Hospital Universitario de Ferrol (CHUF). Intervención: diseño app entre profesionales expertos en enfermedades avanzadas y un equipo de desarrollo de app sanitarias. Evaluación: análisis del uso de app por parte de pacientes y profesionales, aportación al seguimiento diario, y satisfacción con su uso. (AU)

Background: Telemedicine initiatives involve patients in their care, promote adherence to treatment, and help focus face-to-face assessments on the most important problems, improving care in general.Objective: Design and evaluation of the feasibility of an app aimed at monitoring clinical status in patients with advanced diseases.Material and methods: Type of study: qualitative (app design)-quantitative (evaluation in patients). Location: Palliative Care Units at the Ntra. Sra. de Candelaria University Hospital Complex (CHUNSC) in Tenerife, and Ferrol University Hospital Complex (CHUF). Intervention: app development by experts in advanced diseases and a health app development team. Evaluation: analysis of the use of the app by patients and professionals, contribution to daily monitoring, and satisfaction with its use. (AU)

Palliative sedation: beliefs and decision-making among Spanish palliative care physicians.

PURPOSE: To describe physician attitudes to deep palliative sedation. METHODS: A nationwide e-survey of Spanish palliative care specialists was performed using vignettes which described patients close to death with intractable symptoms. Sedation levels were defined according to the Richmond Agitation-Sedation Scale. Multivariate analyses were performed to assess the explanatory factors involved in decision-making. RESULTS: Responses of 292 palliative care specialists were analyzed (response rate 40%). Ninety-four percent, 87%, and 81% of the respondents supported the use of palliative sedation in cases of irreversible refractory symptoms as hyperactive delirium and dyspnea at rest secondary to lung cancer and GOLD stage IV COPD; 60% agreed with the use of palliative sedation in cases of existential suffering. Logistic regression analysis found as the explanatory factor in not performing palliative sedation the physicians' belief that sedation therapy constitutes undercover euthanasia (OR = 12, p < 0.01). Around 80% of physicians who decided on palliative sedation chose deep/complete sedation for every vignette; there were no common explanatory factors for decision-making for every vignette. The belief that sedation therapy equates to undercover euthanasia justifies not performing deep sedation in cases of irreversible refractory agitated delirium (OR = 7) and irreversible intractable dyspnea (OR = 6). Physician background in palliative care and sedation were associated with the selection of deep/complete sedation in cases of refractory delirium and cancer-associated dyspnea. CONCLUSIONS: Spanish palliative physicians generally agree with the use of deep sedation as a proportionate treatment in dying patients with refractory symptoms. Decision-making is associated with physician beliefs regarding euthanasia and with the physician's background in palliative care and sedation.

Fentanyl treatment for end-of-life dyspnoea relief in advanced cancer patients.

PURPOSE: We assessed the effects of subcutaneous-endovenous fentanyl on dyspnoea in a cohort of advanced cancer patients. METHODS: We performed a retrospective study in a cohort of advanced cancer patients with dyspnoea at rest who received subcutaneous or intravenous fentanyl. Patients with no shortness of breath at rest or at minimal exertion, no rescue doses per 24 h, were deemed to be responders to fentanyl. The period of assessment was 6 days from the beginning of fentanyl treatment. RESULTS: Seventy-two patients were evaluated: 65% males, 50% ≥ 75 years, Palliative Performance Scale (PPS) median of 30%. Seventy-six percent of the patients were responders to fentanyl. Fentanyl efficacy was not statistically related to age, gender, cancer type, previous opioid treatment, steroid and midazolam doses and PPS. The median fentanyl dose in responders was 25 mcg/h (interquartile range 12-70). It was significantly related to age (37 vs 12 mcg/h, for ≤ 75 vs > 75 years, respectively; p = 0.02). There was not a significant difference between fentanyl doses of responders and non-responder patients. Thirty-six, 23 and 15 patients had sustained improvements in dyspnoea over 48, 72 and 96 h. Fentanyl had no significant toxicity. The length of inclusion in the study and exclusion were related to low performance status (hazard ratio 0.961; 95%CI 0.927-0.996; Cox-regression) but not to fentanyl doses (hazard ratio 0.875; 95%CI 0.620-1.234; Cox-regression). CONCLUSION: Our preliminary data suggest that subcutaneous-endovenous fentanyl may be associated with dyspnoea relief in dying patients. Further research is needed to confirm these findings.

Spanish Validation of the Care Evaluation Scale for Measuring the Quality of Structure and Process of Palliative Care From the Family Perspective.

CONTEXT: A reliable and valid measure of the structure and process of end-of-life care is important for improving the outcomes of care. OBJECTIVES: This study evaluated the validity and reliability of the Spanish adaptation of a satisfaction tool of the Care Evaluation Scale (CES), which was developed in Japan to evaluate palliative care structure and process from the perspective of family members. METHODS: Standard forward-backward translation and a pilot test were conducted. A multicenter survey was conducted with the relatives of patients admitted to palliative care units for symptom control. The dimensional structure was assessed using confirmatory factor analyses. Concurrent and discriminant validity were tested by correlation with the SERQVHOS, a Spanish hospital care satisfaction scale and with an 11-point rating scale on satisfaction with care. The reliability of the CES was tested by Cronbach α and by test-retest correlation. RESULTS: A total of 284 primary caregivers completed the CES, with low missing response rates. The results of the factor analysis suggested a six-factor solution explaining 69% of the total variance. The CES moderately correlated with the SERQVHOS and with the overall satisfaction scale (intraclass correlation coefficients of 0.66 and 0.44, respectively; P = 0.001). Cronbach α was 0.90 overall and ranged from 0.85 to 0.89 for subdomains. Intraclass correlation coefficient was 0.88 (P = 0.001) for test-retest analysis. CONCLUSION: The Spanish CES was found to be a reliable and valid measure of the satisfaction with end-of-life care structure and process from family members' perspectives.

Fentanyl for episodic dyspnoea in cancer patients.

Two different patterns of breathlessness have been identified: chronic or continuous breathlessness and breathlessness crisis (acute, incident, episodic, breakthrough breathlessness). Meta-analysis and systematic reviews prove that opioids are beneficial in either opioid-naïve or -tolerant patients. However, data from two recent randomised controlled trials were not able to show the effectiveness of fentanyl for the relief of exertion-induced dyspnoea.

Appropriateness and reliability testing of the modified Richmond Agitation-Sedation Scale in Spanish patients with advanced cancer.

CONTEXT: A tool to quantify agitation severity and sedation level in patients with advanced cancer is needed. OBJECTIVES: To test the appropriateness and reliability of the Richmond Agitation-Sedation Scale (RASS) in Spanish patients with advanced cancer. METHODS: The original RASS was translated into Spanish according to the standard guidelines. Face validity was assessed by members of the palliative care team, and interrater reliability was assessed, using a weighted kappa, from observations of patients admitted to the palliative care unit. The association between scores of the RASS, Ramsay Sedation Scale, and Glasgow Coma Scale was evaluated using Spearman's ρ. RESULTS: Three hundred twenty-two observations were performed in 156 patients: 116 observations were performed for delirious patients, 76 observations for sedated patients, and 130 observations for patients admitted for other symptom control. The weighted kappa values were practically equal to or greater than 0.90 between nurses and nurses and physicians. The agreement level between observers for each RASS score was roughly 90%. The correlation between the RASS and the Ramsay and Glasgow Scale values was analyzed for 196 observations recorded in 80 patients. The sedation scale of the RASS had a strong correlation with both the Ramsay (Spearman's ρ, -0.89; P < 0.001) and the Glasgow Coma Scales (Spearman's ρ, 0.85; P < 0.001). CONCLUSION: These data support the use of the RASS in Spanish patients with advanced cancer.

Quality of care in palliative sedation: audit and compliance monitoring of a clinical protocol.

CONTEXT: The European Association for Palliative Care and the U.S. National Hospice and Palliative Care Organization have published statements that recommend an audit of palliative sedation practices. OBJECTIVES: The aim was to assess the feasibility of a quality care project in palliative sedation. METHODS: We carried out an audit of adherence to a guideline regarding palliative sedation, undertaken as a yearly assessment during two years, of a sample of patient charts. With an audit tool, the charts were evaluated as to the presence of the ethical sedation checklist, information that justified palliative sedation, patient and/or family agreement, and the appropriateness of treatment in concordance with the clinical protocol. An educational program and result feedback meetings were used as the implementation strategy. RESULTS: Roughly 25% of the medical charts of patients who died in the palliative care unit were evaluated, 94 in 2007 and 110 in 2008. In 2007 and 2008, 63% and 57% of the patients, respectively, whose median age was 65 years, were sedated, with a median length of two days. The main reason for sedation was agitation concomitant with respiratory failure in roughly 60% and 75% of the cases in 2007 and 2008, respectively. Agreement of the patient/family about sedation was collected from 100% of the cases. The concordance of procedures with the sedation guideline was 100% in both years. CONCLUSION: Our quality-of-care strategy was shown to obtain a higher level of compliance with the palliative sedation guideline for at least two years.

A strategy for conversion from subcutaneous to oral ketamine in cancer pain patients: effect of a 1:1 ratio.

CONTEXT: No consensus exists about the most appropriate dose ratio for conversion from parenteral to oral ketamine. OBJECTIVES: To confirm that a 1:1 dose ratio is suitable for converting subcutaneous (s.c.) to oral ketamine in cancer patients. METHODS: Patients with opioid poorly responsive cancer pain, who responded to 0.4, 0.6, or 0.8 mg s.c. ketamine bolus, were treated with 0.1, 0.15, or 0.2mg/kg/h ketamine infusion, respectively. Switching to the oral route, by applying a 1:1 dose ratio, was carried out in patients who experienced adequate pain relief and continued to need ketamine as a coanalgesic. Pain, somnolence, feelings of insobriety, confusion, and cardiovascular parameters were assessed throughout the process. RESULTS: Twenty-nine patients were enrolled in the study. Ketamine infusion decreased pain intensity from severe to no pain or slight pain in 23 of 29 and six of 29 patients, respectively. The median of s.c. ketamine doses was 0.2mg/kg/h (range 0.1-0.5). After oral switching, 27 of 29 patients remained as successfully controlled as when receiving s.c. ketamine. The other two patients needed a slight dose ratio readjustment, to 1:1.3 and 1:1.5, to maintain pain control. The median of oral ketamine doses was 300 mg/day (interquartile range 240-382.5). Seven of 29 patients receiving s.c. ketamine developed moderate and transitory side effects, such as feelings of insobriety and somnolence. No side effects were present while receiving oral ketamine. No significant changes were observed in cardiovascular parameters. CONCLUSION: A 1:1 dose ratio for conversion from s.c. to oral ketamine is safe and effective in cancer pain patients.

Morphine-methadone opioid rotation in cancer patients: analysis of dose ratio predicting factors.

The dose ratio that is effective when switching opioid therapy from morphine to methadone in cancer patients varies widely. There are no conclusive data explaining the source of this variability. We analyzed 54 cancer patients undergoing opioid rotation to clarify those factors that influenced the morphine/methadone dose ratio (MMEDR) at Day 10 after the switch. Reasons for switching were uncontrolled pain (10 patients) or side effects (with or without pain, 44 patients). Initial MMEDR was 5:1 or 10:1 (82% or 18% of patients, respectively). Multivariate regression analysis was used to identify the demographic, cancer-related, and treatment-related variables that were potential predictors of MMEDR. Median previous morphine dose for the entire sample was 220 mg/day (range: 30-1000 mg/day). The stable MMEDR median was 5:1 (range: 2:1-15:1). In the univariate analysis, reasons for opioid rotation, age, and previous morphine doses were associated with MMEDR. Multiple linear regression analysis showed that only the reason for switching (pain vs. side effects; P<0.001) and previous morphine doses (lower vs. upper to 300 mg/day; P<0.001) were associated with MMEDR. From this analysis, the MMEDRs for patients rotated for side effects at 300 mg/day or more or less than 300 mg/day of morphine were 9.1:1 or 5.6:1, respectively, and the MMEDRs for those switched for pain at 300 mg/day or more or less than 300 mg/day of morphine were 4.9:1 or 3:1, respectively. Both the reasons for opioid rotation and previous morphine doses are predictive factors and should be used to select the MMEDR more accurately.

Diagnóstico y tratamiento del dolor oncológico / Diagnosis and treatment of cancer pain

El dolor oncológico es muy frecuente en los pacientes con cáncer terminal. El tratamiento del dolor oncológico somático y visceral se basa en el uso de la escala analgésica de la OMS, en la que los antiinflamatorios no esteroideos se utilizan para los dolores leves; los opiáceos menores, para los dolores moderados, y los opiáceos mayores, para los intensos. La disponibilidad de opiáceos mayores es amplia. La selección entre morfina oral, oxicodona oral y fentanilo transdérmico depende de las condiciones del paciente, el cumplimiento terapéutico y el coste. No está bien definido el papel de la buprenorfina transdérmica. El tratamiento de base debe combinarse con el uso de dosis de rescate de opiáceos para el control del dolor irruptivo; la morfina oral y el citrato de fentanilo transmucosa oral son alternativas adecuadas. La gabapentina y los antidepresivos tricíclicos son los fármacos de elección, junto con los opiáceos, en el dolor neuropático (AU)

Cancer pain is highly frequent in patients with terminal cancer. The treatment of somatic and visceral cancer pain is based on the use of the World Health Organization's analgesic scale, in which nonsteroidal anti-inflammatory drugs are used for mild pain, minor opiates for moderate pain, and major opiates for severe pain. Major opiates are widely available. Selecting between oral morphine, oral oxycodone and transdermal fentanyl depends on the patient's status, therapeutic compliance, and cost. The role of transdermal buprenorphine has not been well defined. Background treatment should be combined with the use of rescue opiate doses to control breakthrough pain; oral morphine and oral transmucosal fentanyl citrate are appropriate alternatives. Gabapentin and tricyclic antidepressants, together with opioids, are the drugs of choice in neuropathic pain (AU)

Opioid switching from transdermal fentanyl to oral methadone in patients with cancer pain.

BACKGROUND: Patients with cancer often are rotated from other opioids to methadone to improve the balance between analgesia and side effects. To the authors' knowledge, no clear guidelines currently exist for the safe and effective rotation from transdermal fentanyl to methadone. METHODS: The authors evaluated a protocol for switching opioid from transdermal fentanyl to oral methadone in 17 patients with cancer. Reasons for switching were uncontrolled pain (41.1% of patients) and neurotoxic side effects (58.9% of patients). Methadone was initiated 8-24 hours after fentanyl withdrawal, depending on the patient's previous opioid doses (from < 100 microg per hour to > 300 microg per hour). The starting methadone dose was calculated according to a 2-step conversion between transdermal fentanyl:oral morphine (1:100 ratio) and oral morphine:oral methadone (5:1 ratio or 10:1 ratio). The correlation between previous fentanyl dose and the final methadone dose or the fentanyl:methadone dose ratio was assessed by means of Pearson and Spearman correlation coefficients (r), respectively. A Friedman test was used to compare pain intensity before and after the switch and the use of daily rescue doses. RESULTS: Opioid rotation was fully or partially effective in 80% and 20%, respectively, of patients with somatic pain. Neuropathic pain was not affected by opioid switching. Delirium and myoclonus were reverted in 80% and 100% of patients, respectively, after opioid switching. A positive linear correlation was obtained between the fentanyl and methadone doses (Pearson r, 0.851). Previous fentanyl doses were not correlated with the final fentanyl:methadone dose ratios (Spearman r, - 0.327). CONCLUSIONS: The protocol studied provided a safe approach for switching from transdermal fentanyl to oral methadone, improving the balance between analgesia and side effects in patients with cancer.

Cuidados paliativos en pacientes no oncológicos / Palliative care in non-oncologic patients

No disponible