Identifying patients with advanced chronic conditions for a progressive palliative care approach: a cross-sectional study of prognostic indicators related to end-of-life trajectories.

OBJECTIVES: 2 innovative concepts have lately been developed to radically improve the care of patients with advanced chronic conditions (PACC): early identification of palliative care (PC) needs and the 3 end-of-life trajectories in chronic illnesses (acute, intermittent and gradual dwindling). It is not clear (1) what indicators work best for this early identification and (2) if specific clinical indicators exist for each of these trajectories. The objectives of this study are to explore these 2 issues. SETTING: 3 primary care services, an acute care hospital, an intermediate care centre and 4 nursing homes in a mixed urban-rural district in Barcelona, Spain. PARTICIPANTS: 782 patients (61.5% women) with a positive NECPAL CCOMS-ICO test, indicating they might benefit from a PC approach. OUTCOME MEASURES: The characteristics and distribution of the indicators of the NECPAL CCOMS-ICO tool are analysed with respect to the 3 trajectories and have been arranged by domain (functional, nutritional and cognitive status, emotional problems, geriatric syndromes, social vulnerability and others) and according to their static (severity) and dynamic (progression) properties. RESULTS: The common indicators associated with early end-of-life identification are functional (44.3%) and nutritional (30.7%) progression, emotional distress (21.9%) and geriatric syndromes (15.7% delirium, 11.2% falls). The rest of the indicators showed differences in the associations per illness trajectories (p<0.05). 48.2% of the total cohort was identified as advanced frailty patients with no advanced disease criteria. CONCLUSIONS: Dynamic indicators are present in the 3 trajectories and are especially useful to identify PACC for a progressive PC approach purpose. Most of the other indicators are typically associated with a specific trajectory. These findings can help clinicians improve the identification of patients for a palliative approach.

Plan de formación y docencia en un centro integral de cáncer: estrategia e implementación / Continuing education and teaching plans in a comprehensive cancer centre: strategy and implementation

Introducción. El Institut Català d’Oncologia (ICO) puso en marcha la Unidad de Formación y Docencia (UFiD), en el año2006, con el objetivo de potenciar el desarrollo profesional, la difusión del conocimiento y la calidad de la atención oncológica. En el presente artículo se describe el proceso de puesta en marcha de la UFiD, los resultados del estudio de las necesidades formativas realizada por los profesionales y colectivos de la institución, las acciones formativas organizadas, y en el área de docencia, los resultados de la reorganización de las trayectorias docentes de los diferentes servicios, así como el apoyo de nuevas iniciativas. Materiales y métodos. Durante el periodo 2008-2009, se implantaron acciones formativas y docentes en concordancia con los resultados del estudio de necesidades y con las líneas estratégicas de la institución. Se realizaron un total de 71actividades formativas, con 898 participantes de todas las categorías profesionales, con una tasa de satisfacción de los participantes de 7,8 sobre 10. En el apartado de docencia, durante el mismo periodo se realizaron 3 másteres, 3 posgrados,59 cursos de actualización con metodología semipresencial y 19 cursos con metodología online, todos ellos con acreditación académica. La satisfacción media fue de 8 sobre 10.Resultados y conclusiones. La actividad llevada a cabo por la UFiD ha permitido, por una parte, articular la formación continuada en base al estudio de las necesidades de los profesionales, lo que ha contribuido a promover el desarrollo profesional y la calidad asistencial de éstos, y por otra parte, dar soporte a las actividades docentes ya existentes y promover nuevas iniciativas para favorecer la difusión de conocimientos en el área oncológica, lo que ha posicionado al ICO como un centro absolutamente comprometido con la formación oncológica (AU)

Introduction. The Oncology Catalonian Institute (ICO) launched the training and education unit (UFiD) in 2006, in order to enhance professional development, dissemination of knowledge and quality of the oncology care. Here are described the tune-up of this process and the results of the training needs survey carried out among the professionals and collectives of the centre. Materials and methods. Training and educational actions deployed during 2008 and 2009 and its evaluation results are presented. A total of 60 training activities were carried out in which 719 students of all professional categories participated, and with a score of participant’s satisfaction of 7.8 out of 10. In the area of education, the paths of the different services were reorganized and new initiatives were supported. A total of 3 masters, 3 post-graduate degrees, 59 update courses with semi-presential (blended learning) methodology and 19 on-line methodology courses, all of them with academicaccreditation were imparted with a satisfaction average score of 8 out of 10.Results and conclusions. The activity carried out by the UFiD during this period, has made possible to articulate the continuing training based on the study of the professionals needs. This has allowed promoting the professional development and the quality of the care. Supporting existing training activities and promoting new initiatives encourage the dissemination of knowledge in the area of oncology and has positioned us as a centre committed to oncology training (AU)

Evaluación cualitativa del desarrollo del Proyecto Demostrativo OMS de Cuidados Paliativos de Cataluña a los 15 años de su implementación y propuestas de mejora del programa / No disponible

Introducción: la consideración sistemática de elementos cualitativos en la evaluación de programas públicos de cuidados paliativos debe ser igualmente relevante y complementaria de los aspectos cuantitativos habitualmente descritos. Objetivos: describir los resultados del análisis cualitativo del proyecto demostrativo OMS de Cuidados Paliativos de Cataluña a los 15 años, así como las propuestas de mejora. Material y método: el análisis cualitativo se realizó empleando elementos de la metodología EFQM a través de 2 revisiones sistemáticas llevadas acabo por grupos de líderes organizativos y expertos. Se evaluaron 8 dimensiones(Cobertura, Acceso y Equidad, Calidad de servicios, Sistemas y conexión sectorizada, Profesionales, Formación, Investigación, y Financiación). Resultados: los resultados cualitativos muestran como puntos fuertes:la buena cobertura geográfica para los pacientes que sufren cáncer y algo menor para enfermos de otras patologías; la experiencia, diversidad y compromiso de los profesionales; la generación de evidencia científica en temas como efectividad y eficiencia; una percepción de alta satisfacción de enfermos y familias. Las principales áreas de mejora identificadas son: la cobertura para enfermos no oncológicos, la atención continuada, la equidad entre sectores, la variabilidad en la implantación de medidas generales en servicios convencionales, escaso desarrollo de aspectos psicosociales y de políticas de calidad, escasos mecanismos de soporte y reconocimiento profesional y académico y un modelo de financiación y compra poco adaptado a complejidad, entre los principales. Conclusiones: el programa de CP de Cataluña, a los 15 años de su inicio ha demostrado que da respuesta a las necesidades de la población aunque debe ser dinámico e introducir mejoras que se adapten a la realidad cambiante de su entorno y a la madurez de los equipos y profesionales (AU)

Introduction: quality assessment should be considered equally relevant and a complement of the quantitative aspects usually described in the evaluation of public palliative care programmes. Objectives: a) to describe the results of the qualitative evaluation of the WHO Palliative Care Demonstration Programme in Catalonia at 15 years after its implementation; b) to describe quality improvement strategies for public palliative care programmes. Material and method: elements of the EFQM methodology were applied. Palliative care leaders and experts on service organization got together to review and qualitatively assess eight dimensions, including coverage, access and equity, quality of services, links amongst health sectors, professionals, training, research, and funding. Results: the following strengths were identified: good coverage for cancer patients, although less developed for patients affected with other diseases; professional expertise, diverse backgrounds and commitment; the generation of scientific evidence in effectiveness and efficacy; high satisfaction perceived in patients and families. There were several areas for improvement, such as coverage for non-cancer patients; on-call duties; equity amongst health sectors; variability on the implementation of general measures in conventional services; poor development of psychosocial care and quality improvement policies; poor support mechanisms; poor professional and academic recognition, and mechanisms of funding poorly adapted to the complexity of services. Conclusions: the Catalan palliative care programme has demonstrated its capacity to respond well to the needs of the population at 15 years after its implementation. It should, however, be dynamic and able to accept changes in response to the growth and maturity of its professionals (AU)

Epidemiología del dolor oncológico: revisión / No disponible

Objetivo: ofrecer información del estado actual de la epidemiología del dolor oncológico, en base a los trabajos publicados y adecuados para este objetivo. Material y método: revisión sistemática MEDLINE hasta el 1 de octubre de 2007. Así mismo, se identificaron posibles fuentes bibliográficas suministradas en las referencias de los artículos obtenidos e información específica reciente conocida por los autores. Se excluyeron trabajos en que la epidemiología era marginal. Resultados: se obtuvieron 18 trabajos relevantes sobre dolor oncológico en general y pacientes adultos. Cinco para la edad pediátrica y 6 en pacientes geriátricos. Conclusiones: la prevalencia del dolor en cáncer depende de su estadio evolutivo; en estadios iniciales es de un 50%, mientras que en las fases avanzadas puede llegar hasta el 80%. No todos los tumores se relacionan por igual con la presencia de dolor; los que afectan al hueso se asocian con más dolor. La intensidad se afecta por factores tales como el significado que el paciente le otorga, siendo mayor si el paciente lo atribuye a la progresión del cáncer. Puntuaciones superiores a 4 en la escala numérico verbal se relacionan con una mayor interferencia en la vida del paciente. El síndrome doloroso y sus características son independientes del origen de la neoplasia. El dolor habitualmente se relaciona con la progresión tumoral pero se considera que un 20% de los dolores son secundarios al tratamiento oncológico, en la población pediátrica esta cifra alcanza el 66%. Los pacientes ancianos con déficits funcionales y cognitivos son el grupo con mayor riesgo de obtener un mal control del dolor (AU)

Objective: to offer current information about the epidemiology of cancer pain. Material y method: a systematic review using MEDLINE, and searching since October 1, 2007. From references obtained other bibliographic sources were looked for. Any other new information known by the authors was also used. Papers with marginal epidemiological data were excluded from analysis. Results: eighteen general papers on adult populations were reviewed. Five related to pediatric and 6 to geriatric populations. Conclusions: the prevalence of cancer pain is related to stage; in early stages it is around 50%, in advanced stages it is 80%. Bone tumours, primary or secondary, have the highest frequency. Severity as reported by patients was linked to pain significance -it is higher when patients suspect a relation to tumour progression. Using a numerical rating scale, a score above 4 is related to a higher interference with daily activities. Pain syndromes and characteristics are independent of primary tumours. Usually, pain is related to disease progression, but in 20% of cases pain is due to cancer treatment, with this figure reaching 66% in the pediatric population. Elderly patients with functional and cognitive deficits make up the group with the highest risk for inadequate pain relief (AU)

Intervención psicológica en Cuidados Paliativos. Análisis de los servicios prestados en España / No disponible

Introducción: el hecho de morir es uno de los acontecimientos con mayor impacto psicológico. Provoca un intenso flujo de emociones en el enfermo y en la familia, que puede desencadenar en estrés psicológico, destructuración emocional y un gran sufrimiento. Esta posible complejidad es la que plantea la necesidad del psicólogo en los Equipos de Cuidados Paliativos (ECP). Objetivo: establecer las funciones del psicólogo en los Equipos de Cuidados Paliativos que disponen de esta figura. Método: estudio observacional, descriptivo, mediante encuesta remitida por correo electrónico a todos los ECP de España. Resultados: de los 262 equipos respondieron 201 equipos (tasa de respuesta del 77%). 102 equipos (51%) disponían de psicólogo y 99 no (49%). 71 psicólogos cumplimentaron la encuesta. La mayor parte desarrollaban su actividad en equipos domiciliarios. El 46% de los psicólogos se dedicaba la jornada completa al ECP. La función principal (100%) era la atención psicológica a enfermos y familiares. El 80% referían asesorar a su equipo y el 45% prestaba apoyo psicológico para prevenir el burnout. El 62% realizaban actividades docentes, y el 37% colaboraba en investigación. Los ECP son el origen del 51,44% de los casos atendidos por el psicólogo, éstos atienden habitualmente situaciones complejas. Conclusiones: los datos obtenidos muestran que el psicólogo tiene un papel específico y unas actividades e intervenciones concretas a realizar en los ECP (AU)

Introduction: dying is, in fact, a most difficult event to confront, and has a psychological impact, releasing an intense flow of emotions both in the patient and his or her family that may cause psychological stress, emotional destructuration, and lots of suffering. This complexity is the reason underlying the need for psychologists in palliative care teams (PCTs). Objective: to identify PCTs including psychologists in their staff, the roles that these professionals play, and cases susceptible of specific psychological interventions. Method: an observational, descriptive study was carried out using a survey that included all PCTs in Spain. Results: 201 of all 262 PCTs surveyed completed the questionnaire (77%); 102 PCTs (51%) included psychologists and 99 lacked them (49%); 71 psychologists completed the survey. Most of them developed their activity in home-oriented PCTs; 46% on a full-time basis. Their main function (100%) was to psychologically care for patients and their relatives. Eighty percent reported advisory activities to their team, and 45% also provided psychological support to prevent burnout. Sixty-two percent performed educational activities too, and 37% used some of their time in research activities. PCTs are the source of 51.44% of cases followed by psychologists, usually regarding complex situations. Conclusions: data collected show that psychologists play a specific role in PCTs (AU)

Prevalencia, características y efectividad del tratamiento del dolor en pacientes con cáncer avanzado tratados en Servicios de Cuidados Paliativos en España. Estudio ALGOPAL / No disponible

Objetivo: describir las características, tratamiento, efectos secundarios y grado de control de dolor en enfermos con cáncer avanzado. Método: estudio multicéntrico observacional realizado en pacientes con cáncer avanzado que presentan dolor crónico. Participan 19 centros hospitalarios con Servicios de Cuidados Paliativos incluyendo pacientes ingresados y de consultas externas. Se realiza un único cuestionario un día determinado. Resultados: se realizan 440 cuestionarios, la mitad de ellos a pacientes hospitalizados y la otra mitad de consultas externas. El 55% de los pacientes son mayores de 65 años, 63% varones, con una mediana en el índice de Karnofsky de 50%. Los tumores más frecuentes son gastrointestinales, genitourinarios y pulmonares. El tiempo medio con dolor de los pacientes es de 9meses y la intensidad media del dolor es de 5,11/10. Presentan dolor controlado (ENV < 3) el 26% de los enfermos. Existen factores de mal pronóstico en cuanto al alivio del dolor en el 45%. El 81% de los pacientes está en tratamiento con opioides potentes, siendo los opioides más utilizados el fentanilo transdérmico (48%) y la morfina (37%). El 51% de los enfermos presenta algún tipo de toxicidad secundaria a los opioides. Conclusiones: los pacientes presentan una elevada prevalencia e historia prolongada de dolor. La mayoría de los pacientes está en tratamiento con opioides potentes. Fentanilo transdérmico y morfina son los fármacos más utilizados. A la vista de los resultados obtenidos, consideramos que se puede optimizar el alivio del dolor en nuestras unidades (AU)

Objective: to describe the features, treatment, side effects, and relief of pain in advanced cancer patients. Method: an observational multicenter study was carried out with advanced cancer patients who had chronic pain. Nineteen hospitals with palliative care units (either with inpatients or outpatients) were included. Only one questionnaire is administered. Results: 440 questionnaires were completed, half of them by inpatients, half of them by outpatients. All of them were interviewed on a selected day. 55% patients are over 65 years, 63% are male, and Karnofsky index is 50% of median value. The most frequent tumours are gastrointestinal, genitourinary, and pulmonary growths. Patients had pain for an average 9 months, and pain severity had a mean value of 5.11/10. The study showed that 26% of patients had good pain relief (ENV < 3); 45% of patients had poor prognosis factors for pain relief. 81% of patients received potent opioids. Most commonly used opioids included transdermal fentanyl (48%) and morphine (37%); 51% of patients had opioid-related toxicity. Conclusions: patients had a high prevalence of pain for long periods of time. Most patients received potent opioids. Transdermal fentanyl and morphine are the most commonly used medicines. According to results obtained, we considerer that pain relief could be optimized in our units (AU)

El psicólogo en los equipos de Cuidados Paliativos / No disponible

No disponible

Atención médica al final de la vida / Medical care at the end of life

No disponible

Predicting place of death of elderly cancer patients followed by a palliative care unit.

To determine the predictors of death outside the palliative care system for elderly cancer patients who were followed by a palliative care unit (PCU), a retrospective review of 199 charts was performed. Comorbidities, current neoplastic disease (location of tumor, months since diagnosis, number of days of PCU follow-up), symptoms, drug use, and social support were recorded. Place of death was not significantly different among sexes. Factors predicting death in the general hospital for men were digestive comorbidities, vomiting, and weakness. For women, disease of the senses was predictive. Although there were no significant differences with respect to place of death between sexes in an older cancer population followed by a PCU, the factors that predicted which patients will die in the hospital for men were generally related to their medical condition, whereas the predictive factors for women were mainly related to functional dependency and social support. Social support had a trend towards predicting the place of death in women.

Catalonia WHO Demonstration Project on Palliative Care Implementation 1990-1995: results in 1995.

A global, comprehensive, publicly planned and financed program to implement palliative care was designed by the Department of Health of Catalonia (6 million inhabitants. Planned in collaboration with the cancer unit of the WHO in 1989, the program was implemented in 1990-1995. It included specific services, measures general resources, education and training, organizational and educational standards, opioid availability, legislation and evaluation. The aims included coverage for cancer, AIDS, geriatric and other conditions, equity, quality, reference, and satisfaction for patients, families, and professionals. The results in 1995 include the implementation of 18 hospital support teams and 19 Units, with a total of 350 beds, 42 home-care teams. The coverage for cancer and AIDS is around 40%, and 44/55 (80%) districts have a specific team. Palliative care implementation has been completely publicly financed, with a total yearly investment of 2,200 million ptas. Eighty percent of this has been saved through radical changes in costs and the pattern of the use of resources. Palliative care implementation has demonstrated efficacy in the care of the patients and families, efficiency in the provision of care, and cost-benefit in the regional global approach. It adds qualitative and organizational values to the health-care system. Its implementation must be prioritized and planned by the health administration, not only to improve the quality of care for advanced and terminal patients, but also to improve the global efficiency and appropriate use of resources in the public health system.

Randomized trial of tamoxifen versus aminoglutethimide and versus combined tamoxifen and aminoglutethimide in advanced postmenopausal breast cancer.

In a randomized trial, 105 postmenopausal women with advanced carcinoma of the breast received tamoxifen or aminoglutethimide or combined tamoxifen and aminoglutethimide. No differences were found in the rate of responses and duration of responses between the treatment groups. Toxicity was significantly greater (p less than 0.01) in patients who received aminoglutethimide.