[Care complexity and place of death in palliative home care]. / Complejidad asistencial y lugar de muerte en atención domiciliaria paliativa.

OBJECTIVE: To examine the associations between the dimensions of the HexCom care complexity model and the place of death. METHOD: Multicenter longitudinal observational study in patients with advanced illness cared for by home care support teams in Catalonia. Age, gender, type of illness, main caregiver, external support, place of death and the sub-areas of care complexity provided by HexCom were registered. A multivariate Cox regression analysis was performed. RESULTS: Participation of 1527 patients (72% oncology), cared for a median of 35 days. 45% died at home. The probability of dying at home was greater when a greater functional impairment was detected in the initial assessment (hazard ratio [HR]: 7.67; 95% confidence interval [95%CI]: 4.93-11.92), when the patient was male (HR: 1.19; 95%CI: 1.02-1.39), was over 80 years old (HR: 1.41; 95%CI: 1.20-1.66) and when care complexity was detected in relation to being in a situation of last days (HR: 2.24; 95%CI: 1.69-2.97). It was more likely not to die at home in the case of cancer (HR: 0.76; 95%CI: 0.64-0.89), or if poor external support to the family group was detected in the first evaluation (HR: 0.79; 95%CI: 0.67-0.93), or that the patient did not feel at peace with others (HR: 0.56; 95%CI: 0.40-0.79), or lack of agreement on the planning of the place of death (HR: 0.57; 95%CI: 0.48-0.68). CONCLUSIONS: The assessment of the complexity of care through the HexCom-Clin model can help to improve advance planning of decisions by incorporating among its dimensions the feeling of peace with others, the external support to the family nucleus and the degree of agreement on the place of death.

Complejidad asistencial y lugar de muerte en atención domiciliaria paliativa / Care complexity and place of death in palliative home care

Objetivo: Examinar las asociaciones entre las dimensiones del modelo de complejidad asistencial HexCom y la ubicación de la muerte. Método: Estudio observacional longitudinal multicéntrico en pacientes con enfermedad avanzada tratados por los equipos de soporte a la atención domiciliaria en Cataluña. Se recogieron edad, sexo, estado funcional y cognitivo, tipo de enfermedad, cuidador/a principal, trabajador/a familiar, lugar de la muerte y complejidad tras la primera visita. Se realizó un análisis de regresión de Cox multivariante. Resultados: Participación de 1527 pacientes (72% oncológicos), atendidos una mediana de 35 días. El 45% fallecieron en su domicilio. La probabilidad de morir en casa era mayor cuando se detectaba un mayor deterioro funcional (hazard ratio [HR]: 7,67; intervalo de confianza del 95% [IC95%]: 4,93-11,92), cuando el sujeto era varón (HR: 1,19; IC95%: 1,02-1,39), cuando la edad era >80 años (HR: 1,41; IC95%: 1,20-1,66) y cuando se detectaba complejidad en relación a la situación de últimos días (HR: 2,24; IC95%: 1,69-2,97). Era más probable no morir en casa si se padecía cáncer (HR: 0,76; IC95%: 0,64-0,89), si se detectaba un pobre apoyo externo al grupo familiar (HR: 0,79; IC95%: 0,67-0,93), si el/la paciente no se sentía en paz con los demás (HR: 0,54; IC95%: 0,39-0,75) o si había falta de acuerdo en la planificación del lugar de la muerte (HR: 0,57; IC95%: 0,48-0,68). Conclusiones: La valoración de la complejidad asistencial a través del modelo HexCom-Clin puede contribuir a una mejor planificación anticipada de decisiones al incorporar entre sus dimensiones el sentirse en paz con los demás, el soporte externo al núcleo familiar y el grado de acuerdo sobre el lugar de muerte. (AU)

Objective: To examine the associations between the dimensions of the HexCom care complexity model and the place of death. Method: Multicenter longitudinal observational study in patients with advanced illness cared for by home care support teams in Catalonia. Age, gender, type of illness, main caregiver, external support, place of death and the sub-areas of care complexity provided by HexCom were registered. A multivariate Cox regression analysis was performed. Results: Participation of 1527 patients (72% oncology), cared for a median of 35 days. 45% died at home. The probability of dying at home was greater when a greater functional impairment was detected in the initial assessment (hazard ratio [HR]: 7.67; 95% confidence interval [95%CI]: 4.93-11.92), when the patient was male (HR: 1.19; 95%CI: 1.02-1.39), was over 80 years old (HR: 1.41; 95%CI: 1.20-1.66) and when care complexity was detected in relation to being in a situation of last days (HR: 2.24; 95%CI: 1.69-2.97). It was more likely not to die at home in the case of cancer (HR: 0.76; 95%CI: 0.64-0.89), or if poor external support to the family group was detected in the first evaluation (HR: 0.79; 95%CI: 0.67-0.93), or that the patient did not feel at peace with others (HR: 0.56; 95%CI: 0.40-0.79), or lack of agreement on the planning of the place of death (HR: 0.57; 95%CI: 0.48-0.68). Conclusions: The assessment of the complexity of care through the HexCom-Clin model can help to improve advance planning of decisions by incorporating among its dimensions the feeling of peace with others, the external support to the family nucleus and the degree of agreement on the place of death. (AU)

Gender and Observed Complexity in Palliative Home Care: A Prospective Multicentre Study Using the HexCom Model.

This study analyses gender differences in the complexity observed in palliative home care through a multicentre longitudinal observational study of patients with advanced disease treated by palliative home care teams in Catalonia (Spain). We used the HexCom model, which includes six dimensions and measures three levels of complexity: high (non-modifiable situation), medium (difficult) and low. Results: N = 1677 people, 44% women. In contrast with men, in women, cancer was less prevalent (64.4% vs. 73.9%) (p < 0.001), cognitive impairment was more prevalent (34.1% vs. 26.6%; p = 0.001) and professional caregivers were much more common (40.3% vs. 24.3%; p < 0.001). Women over 80 showed less complexity in the following subareas: symptom management (41.7% vs. 51,1%; p = 0.011), emotional distress (24.5% vs. 32.8%; p = 0.015), spiritual distress (16.4% vs. 26.4%; p = 0.001), socio-familial distress (62.7% vs. 70.1%; p = 0.036) and location of death (36.0% vs. 49.6%; p < 0.000). Men were more complex in the subareas of "practice" OR = 1.544 (1.25-1.90 p = 0.000) and "transcendence" OR = 1.52 (1.16-1.98 p = 0.002). Observed complexity is related to male gender in people over 80 years of age. Women over the age of 80 are remarkably different from their male counterparts, showing less complexity regarding care for their physical, psycho-emotional, spiritual and socio-familial needs.

[Wish to hasten death in home palliative care. Look for your seven percent.] / El deseo de adelantar la muerte en cuidados paliativos domiciliarios. Busca tu siete por ciento.

OBJECTIVE: The wish to hasten death has been little researched in the area of Mediterranean countries and we are not aware of specific studies on its particularities in home care in our setting. The aim of this work was to investigate the prevalence and evolution of wish to hasten death in home care, analysing its relationship with physical, emotional, spiritual, ethical and social-family unrest. METHODS: Longitudinal observational study in palliative home care in Catalonia. 43 teams agreed on the level of complexity after the first visit and after the discharge of the patient with the HexCom model, which classifies the desire to anticipate death into Low complexity (no or sporadic manifestation); Medium (persistent desire that requires specific treatment); or High (persistent desire that is considered potentially refractory). For the comparison of proportions, Pearson's Chi-squared test was used and a multivariate logistic regression analysis was performed, in which the dependent variable corresponded to the desire to hasten initial death. The level of significance was p≤0.05. RESULTS: The total number of patients included in this study was 1,677, of whom 1,169 (69.7%) were oncologic. The prevalence of desire to hasten death was 6.67%. It was related to spiritual distress, especially lack of meaning (OR 3.25) and lack of connection (OR 3.81), to psychoemotional distress (OR 2.34) and to ethical distress. Protective factors were spiritual distress in relation to transcendence (OR 0.50), the caregiver being a partner (OR 0.50) and being cared for by a team that included psychology and social work (OR 0.34). The desire to anticipate death is stable in 71.6% of patients. CONCLUSIONS: The desire to anticipate death is a changing and complex phenomenon that can emerge at any time. The presence of psycho-emotional, spiritual-existential and ethical discomfort, especially in patients without a partner, should make us take a proactive attitude to identify it early.

OBJETIVO: El deseo de adelantar la muerte ha sido poco investigado en el área de los países mediterráneos y no conocemos estudios específicos sobre sus particularidades en atención domiciliaria en nuestro entorno. El objetivo de este trabajo fue investigar la prevalencia y la evolución del deseo de anticipar la muerte en atención domiciliaria, analizando su relación con el malestar físico, emocional, espiritual, ético y sociofamiliar. METODOS: Estudio observacional longitudinal en el ámbito de la atención domiciliaria paliativa en Catalunya. 43 equipos acordaron el nivel de complejidad tras la primera visita y tras el alta del paciente con el modelo HexCom, el cual clasifica el deseo de anticipar la muerte en complejidad Baja (manifestación nula o esporádica); Media (Deseo persistente que requiere tratamiento específico); o Alta (Deseo persistente que se considera potencialmente refractario). Para la comparación de proporciones se utilizó la prueba de Ji cuadrado de Pearson y se realizó un análisis de regresión logística multivariante, en el que la variable dependiente correspondía con el deseo de adelantar la muerte inicial. El nivel de significación fue p≤0,05. RESULTADOS: El número total de pacientes incluidos en este estudio fue de 1.677, de los cuales 1.169 (69,7%) eran oncológicos. La prevalencia de deseo de anticipar la muerte fue del 6,67%. Se relacionó con el malestar espiritual, ante todo con la falta de sentido (OR 3,25) y de conexión (OR 3,81), con el malestar psicoemocional (OR 2,34) y con el malestar ético. Fueron factores protectores el malestar espiritual en relación con la transcendencia (OR 0,50), que el cuidador fuese la pareja (OR 0,50) y ser atendido por un equipo en el que se incluyese psicología y trabajo social (OR 0,34). El deseo de anticipar la muerte fue estable en el 71,6% de los pacientes. CONCLUSIONES: El deseo de anticipar la muerte es un fenómeno cambiante y complejo que puede emerger en cualquier momento. La presencia de malestar psicoemocional, espiritual-existencial y ético, sobre todo en pacientes sin pareja, nos han de hacer tomar una actitud proactiva para identificarlo precozmente.

Preventing Violence by Teachers in Primary Schools: Study Protocol for a Cluster Randomized Controlled Trial in Haiti.

CONTEXT: Although teacher violence at schools is a serious problem in Haiti, there is a lack of systematic evidence on the effectiveness of school-based interventions in reducing teacher violence in this low-income country. OBJECTIVE: To test the effectiveness of the preventative intervention Interaction Competencies with Children for Teachers (ICC-T) aiming to reduce teachers' use of violent disciplinary strategies and to improve their interaction competences with children in the Haitian context. DESIGN SETTING PARTICIPANTS: The study is designed as a two-arm matched cluster randomized controlled trial. The sample consists of 468 teachers and 1,008 children from 36 (community and public) primary schools around Cap-Haïtien (Département du Nord) in Haiti. Data will be collected in three phases, before the intervention, and 6 and 18 months after. INTERVENTION: In the group of intervention schools, ICC-T will be delivered as a 5-day training workshop. Workshop sessions are divided into five modules: 1) improving teacher-student interactions, 2) maltreatment prevention, 3) effective discipline strategies, 4) identifying and supporting burdened students, and 5) implementation in everyday school life. MAIN OUTCOME MEASURE: The main outcome measure is teacher violence assessed in two ways: (i) teachers' self-reported use of violence, and (ii) children's self-reported experiences of violence by teachers. CONCLUSIONS: Prior evaluations of ICC-T had been conducted in sub-Saharan Africa with promising results. This study will test for the first time the effectiveness of this intervention outside the context of sub-Saharan Africa.

Describing Complexity in Palliative Home Care Through HexCom: A Cross-Sectional, Multicenter Study.

BACKGROUND: Complexity has become a core issue in caring for patients with advanced disease and/or at the end-of-life. The Hexagon of Complexity (HexCom) is a complexity assessment model in the process of validation in health-care settings. Our objective is to use the instrument to describe differences in complexity across disease groups in specific home care for advanced disease and/or at the end-of-life patients, both in general and as relates to each domain and subdomain. METHODS: Cross-sectional study of home care was conducted in Catalonia. The instrument includes 6 domains of needs (clinical, psychological/emotional, social/family, spiritual, ethical, and death-related), 4 domains of resources (intrapersonal, interpersonal, transpersonal, and practical), and 3 levels of complexity (High (H), Moderate (M), and Low (L)). Interdisciplinary home care teams assessed and agreed on the level of complexity for each patient. RESULTS: Forty-three teams participated (74.1% of those invited). A total of 832 patients were assessed, 61.4% of which were cancer patients. Moderate complexity was observed in 385 (47.0%) cases and high complexity in 347 (42.4%). The median complexity score was 51 for cancer patients and 23 for patients with dementia (p<0.001). We observed the highest level of complexity in the social/family domain. Patients/families most frequently used interpersonal resources (80.5%). CONCLUSIONS: This study sheds light on the high-intensity work of support teams, the importance of the social/family domain and planning the place of death, substantial differences in needs and resources across disease groups, and the importance of relationship wellbeing at the end-of-life.

International remittances, cash transfer assistance and voter turnout in Mexico.

Most research on the political consequences of international migration conceptualizes financial remittances as being a substitute for state-provided assistance. This paper tests the actual validity of this assumption. Using data from the 2012-2016 Americas Barometer, the analysis confirms previous findings on the negative impact of financial remittances on electoral turnout intentions. However it reveals that this effect does not vary according to an individual's beneficiary status of Conditional Cash Transfer (CCT) assistance. This finding is corroborated using data aggregated at the municipal level within Mexico. Accordingly, voter turnout rates in a given municipality for the 2012 presidential election are negatively associated with the percentage of households receiving remittances in that municipality. However, this association does not vary with the spending on CCT assistance within a given municipality. The evidence thus suggests that financial remittances undermine electoral participation through mechanisms other than the substitution of state-sponsored assistance, and as such further research is needed for us to discover what is really going on here.