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array:24 [ "pii" => "S2254887417300061" "issn" => "22548874" "doi" => "10.1016/j.rceng.2017.02.001" "estado" => "S300" "fechaPublicacion" => "2017-05-01" "aid" => "1340" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "copyrightAnyo" => "2016" "documento" => "article" "crossmark" => 1 "subdocumento" => "ssu" "cita" => "Rev Clin Esp. 2017;217:222-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 3 "PDF" => 3 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0014256516302004" "issn" => "00142565" "doi" => "10.1016/j.rce.2016.12.002" "estado" => "S300" "fechaPublicacion" => "2017-05-01" "aid" => "1340" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "crossmark" => 1 "subdocumento" => "ssu" "cita" => "Rev Clin Esp. 2017;217:222-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 57 "formatos" => array:2 [ "HTML" => 34 "PDF" => 23 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Revisión</span>" "titulo" => "Problemática actual en la implementación de la orden de no reanimar en el paciente cardiológico" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "222" "paginaFinal" => "228" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Current issues in implementing do-not-resuscitate orders for cardiac patients" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1073 "Ancho" => 1552 "Tamanyo" => 84577 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Riesgo de reingreso tras una hospitalización por insuficiencia cardíaca. Las áreas en blanco en ambos extremos representan períodos de mayor riesgo para la readmisión inmediata tras el alta y justo antes de la muerte; el área en blanco en el centro refleja la fase de meseta de menor riesgo; y el área sombreada en negro refleja la supuesta línea de base de reingresos inevitables.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Adaptada de Desai et al.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a>.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Ruiz-García, I. Canal-Fontcuberta, M. Martínez-Sellés" "autores" => array:3 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Ruiz-García" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Canal-Fontcuberta" ] 2 => array:2 [ "nombre" => "M." 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Polypathology</span>" "titulo" => "Polypathology, an emerging phenomenon and a challenge for healthcare systems" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "229" "paginaFinal" => "237" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La pluripatología, un fenómeno emergente y un reto para los sistemas sanitarios" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1351 "Ancho" => 1500 "Tamanyo" => 100128 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Number of medical errors according to the number of specialists who treated a patient. Abbreviations: AUS, Australia; CAN, Canada; FR, France; GER, Germany; NL, The Netherlands; NZ, New Zealand; UK, United Kingdom; US, United States.</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Own preparation. Modified from the 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">21</span></a></p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Román, A. Ruiz-Cantero" "autores" => array:2 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Román" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Ruiz-Cantero" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256517300486" "doi" => "10.1016/j.rce.2017.01.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256517300486?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887417300243?idApp=WRCEE" "url" => "/22548874/0000021700000004/v1_201704280917/S2254887417300243/v1_201704280917/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S225488741730036X" "issn" => "22548874" "doi" => "10.1016/j.rceng.2017.02.006" "estado" => "S300" "fechaPublicacion" => "2017-05-01" "aid" => "1376" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2017;217:212-21" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1 "PDF" => 1 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special Article</span>" "titulo" => "Commitment to quality of the Spanish scientific societies" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "212" "paginaFinal" => "221" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Compromiso por la calidad de las sociedades científicas en España" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 889 "Ancho" => 1670 "Tamanyo" => 170289 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Methodology for the preliminary selection of “do not do” recommendations.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. García-Alegría, S. Vázquez-Fernández del Pozo, F. Salcedo-Fernández, J.M. García-Lechuz Moya, G. Andrés Zaragoza-Gaynor, M. López-Orive, S. García-San Jose, P. Casado-Durández" "autores" => array:8 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "García-Alegría" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Vázquez-Fernández del Pozo" ] 2 => array:2 [ "nombre" => "F." "apellidos" => "Salcedo-Fernández" ] 3 => array:2 [ "nombre" => "J.M." "apellidos" => "García-Lechuz Moya" ] 4 => array:2 [ "nombre" => "G." "apellidos" => "Andrés Zaragoza-Gaynor" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "López-Orive" ] 6 => array:2 [ "nombre" => "S." "apellidos" => "García-San Jose" ] 7 => array:2 [ "nombre" => "P." "apellidos" => "Casado-Durández" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256517300656" "doi" => "10.1016/j.rce.2017.02.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256517300656?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S225488741730036X?idApp=WRCEE" "url" => "/22548874/0000021700000004/v1_201704280917/S225488741730036X/v1_201704280917/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Current issues in implementing do-not-resuscitate orders for cardiac patients" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "222" "paginaFinal" => "228" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. Ruiz-García, I. Canal-Fontcuberta, M. Martínez-Sellés" "autores" => array:3 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Ruiz-García" "email" => array:1 [ 0 => "j.ruizgarcia@hotmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "I." "apellidos" => "Canal-Fontcuberta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Martínez-Sellés" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Servicio de Cardiología, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Facultad de Ciencias Biosanitarias, Universidad Francisco de Vitoria, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Universidad Europea, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Universidad Complutense de Madrid, Madrid, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Problemática actual en la implementación de la orden de no reanimar en el paciente cardiológico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:9 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Adapted from Desai et al.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a>" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1105 "Ancho" => 1520 "Tamanyo" => 83982 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Risk of readmission after a hospitalization for heart failure. The areas in white at both ends represent periods of greater risk for immediate readmission after discharge and just before death. The area in white in the center reflects the plateau phase of lower risk. The shaded area in black reflects the supposed baseline of inevitable readmissions.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiology is directly involved in the diagnosis and treatment of the main causes of mortality.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">1</span></a> Heart failure (HF), the common final pathway of a considerable number of heart diseases and the most common cause of hospitalization in patients older than 65 years,<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a> results in numerous readmissions, which are more frequent the closer the patient is to death (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a> However, the attention by cardiologists to end-of-life care and reflected in the clinical practice guidelines (CPGs) is scarce and can clearly be improved.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">4,5</span></a> Most clinicians are open to acquiring skills on this issue.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The “do-not-resuscitate” (DNR) order offers properly informed patients the possibility of rejecting cardiopulmonary resuscitation (CPR) in the event of a cardiopulmonary arrest (CPA).<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a> In Cardiology, the use of the DNR order is less widespread than in other specialties. This order is registered later, in a smaller percentage of patients<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">8</span></a> and is recommended with lesser conviction.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">9</span></a> This fact can have unfortunate consequences: (1) It deprives cardiac patients of the opportunity of making informed decisions on their resuscitation, and (2) CPR is performed on patients who would not have wanted it or on those for whom it would only extend their suffering.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">End-of-life care should respect the patient's wishes and preferences. Open and repeated communication concerning their needs and expectations, as well as on the prognosis and treatment of heart disease, is therefore essential.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">5,10</span></a> Cardiac patients’ perception of their disease prognosis<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11–13</span></a> and the CPR maneuvers<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a> is far from realistic. There is a tendency toward optimism that can overestimate their expectations of survival, modifying their wishes and preferences regarding the treatment plan.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">15</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">It is very likely that increasing the training and participation of physicians in the end-of-life care could contribute to improving the correlation between the wishes and the final experiences of a considerable number of patients. With this in mind, we performed a literature analysis of the most recently published studies in the Medline database that approached the problems of implementing DNR orders for cardiac patients, enabling us to suggest a number of solutions for improving their implementation.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Problems in the implementation of do-not-resuscitate orders for cardiac patients</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Infrequent conversations with patients and disregarded patient preferences</span><p id="par0025" class="elsevierStylePara elsevierViewall">The immense majority of patients with HF acknowledge not having had a conversation with their physicians about the end of life,<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11,13</span></a> or about their preferences for resuscitation.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">7,16</span></a> Patients also manifest highly diverse attitudes toward these preferences. Some patients want to choose and are eager to obtain information on the progress and prognosis of their disease, while others directly reject making such a choice or are reluctant to receive information that could cause them uncertainty or worry.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Only 12% of physicians involved in treating patients with HF acknowledge having periodic discussions about the end of life as recommended in the CPGs.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a> The reasons for avoiding conversations with patients include a lack of experience and training in conducting the conversation, a lack of communication skills in this field that impedes finding the appropriate vocabulary to explain the condition and prognosis in an understandable manner, the uncertainty concerning the outcome (variable) of HF compared with other diseases, a fear of causing unnecessary worry or hopelessness in early stages of the disease and a lack of time.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">6,10,11,13</span></a> This situation often results in avoiding our responsibility to start this conversation and shifting it to other physicians.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The provision of end-of-life care should coincide with the patient's preferences. To meet these preferences, they must first be understood by the attending physicians. The patients’ preferences depend in considerable measure on their assessment of the burden of treatment regarding their expectations of results and the probability of adverse events. The presence of cognitive or functional impairment is particularly important in terms of the patients’ preferences and therefore deserves to be explicitly detailed during the conversation.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">15</span></a> A complete discussion on the prognosis of heart disease and associated comorbidities should include the vital prognosis, the potential burdens of worsening symptoms, the loss of functional and cognitive capacity, the loss of independence, the loss of quality of life and the workload for relatives and caregivers.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Inability to predict patient's preferences</span><p id="par0040" class="elsevierStylePara elsevierViewall">Given the above, one could surmise that patients affected by symptomatic chronic heart disease would prefer a better quality of life over prolonged survival.</p><p id="par0045" class="elsevierStylePara elsevierViewall">A subanalysis of the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness assessed how the preferences between survival and quality of life of patients with decompensated HF could change during hospitalization and 6 months after starting decongestive therapy.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">18</span></a> The subanalysis employed the time trade-off “negotiation” tool that, through personal questions, sought to determine how many years of life the patient was willing to exchange for time at full health. During the hospitalization of 404 patients (mean age of 56 years), 49% stated virtually no desire to negotiate with their time (they did not want to give up more than 1 month of life to feel better), while 28% were willing to give up almost all of their remaining time to feel better in the time that was left. A striking fact was the absence of differences among the demographic characteristics (age, sex, race, left ventricular ejection fraction) and the clinical parameters (presence and degree of systemic and pulmonary congestion) at rest of these patients with such differing wishes, which once again shows the inability to correlate common clinical parameters with the patient's wishes.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">18</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The data found were not due to the cohort's age, which could lead to overestimating their life expectancy. This finding was confirmed by another very similar study<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">19</span></a> but conducted with patients 60 years or older (mean, 77<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>8 years; 74% in New York Heart Association functional class<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>III), which used the same time “negotiation” tools. Of the 555 patients who answered at the start, 74% were not willing to negotiate any loss of survival for an optimal health condition. During the 12 and 18-month follow-up, there was even a decrease in the number of patients who were willing to accept this offer. We sought to identify the factors that could be related to a greater willingness to negotiate time alive for time free of symptoms. However, after the multivariate analysis was performed and even by combining several of these factors, a reliable predictive model could not be established.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">19</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Regardless of age, most patients prefer survival, even in advanced phases of their HF or during decompensations, which questions the idea that quality of life is more important than longevity for these patients. The study also confirmed that preferences could be different for patients with similar characteristics and symptoms. Lastly, the changes in preference over time require not only talking with patients but also periodically addressing the problem.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In both studies,<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">18,19</span></a> most of the patients were willing to respond to end-of-life issues, which should motivate us to lose the fear of starting these conversations. In Spain, we have also recently been able to determine that cardiac patients are very cooperative in studies that address this subject.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Lack of correlation with the patient's preferences</span><p id="par0065" class="elsevierStylePara elsevierViewall">A subanalysis of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment assessed the correlation between the CPR preferences of patients hospitalized for HF decompensation and the perception of those preferences by the responsible physicians.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">20</span></a> The physician's opinion did not coincide with the patient's preference in 24% of cases, both when patients wanted resuscitation and when they did not. However, a greater tendency toward correlation was observed in the latter case. These discrepancies were strongly associated with the patient's age, going from 17% for patients 40–64 years of age to 29% for those 75 years or older (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001).<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">20</span></a> Of all of the patients who responded to the question about their desire for resuscitation, 23% explicitly rejected CPR. However, as an example of the lack of attention to these very wishes and demands, only 27% of these patients had a DNR order at hospital discharge, while 7% who had not expressed a rejection of CPR had this stated in the discharge report. As an example of the importance of reflecting in writing the transmission of the DNR order, 11 of the patients who had expressed their rejection of resuscitation presented cardiac arrest during hospitalization. Five of them had a written DNR order and were not resuscitated; unfortunately, the other 6 patients without a written DNR order underwent a resuscitation attempt, although only 1 survived to the hospital discharge.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">20</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Occasionally, the advance directives document is insufficient to improve the degree of agreement between the physician's opinion and the patient's wishes. Sometimes, even a conversation between them fails to improve the agreement. Desharnasis et al. assessed the results of a conversation about end-of-life care between physicians and patients with an estimated life expectancy of less than 6 months due to terminal cancer or HF. After the conversation, only 14% of the physicians knew the patient's preferences concerning the approach to pain or the location of death.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">21</span></a> This alarming disconnect between the physician's perception and the patient's preferences brings into question the efficacy of the training in skills necessary for understanding the patient's preferences regarding the end of their life.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Delayed conversations</span><p id="par0075" class="elsevierStylePara elsevierViewall">One of the reasons for the scarce participation of patients in developing DNR orders is that the physician–patient discussion is delayed so much that the patient cannot participate in it.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment</span> documented the presence of a resuscitation discussion in the history of 2644 patients, only 39% of the 6802 patients included in that study.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">8</span></a> In addition to the low frequency of DNR orders is the fact that they are written much later than the patients want. Between the patients who died in the hospital, the median time between their DNR orders and death was 3 days (range of 1–7 days).<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">8</span></a> Given the antiquity of this study, we might conclude that after the dissemination of the advance directives documents, these delays could be corrected. In fact, there are indirect data that indicate a greater precocity in the use of DNR orders. For example, in the analysis of 4182 patients hospitalized for an acute myocardial infarction between 2001 and 2007, DNR orders were found in 25% of the cases. There were no significant variations in the rate of DNR orders over the course of the study period, but a significant increase was observed in the DNR orders written before hospitalization (9% in 2001 vs. 55% in 2007). Strikingly, the patients with DNR orders prior to admission had a lower probability of dying during hospitalization and during the month following their hospitalization than the patients whose DNR orders were written during the hospitalization. Those patients whose orders were written later during hospitalization had a significantly greater probability of dying in the 3 following days than patients with earlier DNR orders.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">22</span></a> The question arises as to whether many of these later DNR orders were no more than a response to their rapid and unexpected clinical deterioration and thereby a simple marker of severity and death, rather than the result of a true planned conversation. Moreover, the increase in the proportion of patients with DNR orders prior to admission for an acute myocardial infarction, although promising, could also be attributed to the greater age of these patients and to the growing proportion of prior infarctions and other comorbidities among hospitalized patients.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Insufficient information to decide</span><p id="par0085" class="elsevierStylePara elsevierViewall">The current survival rate at discharge after a hospital CRP is <25%, and approximately 30% of the survivors have significant neurological sequela.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">23</span></a> However, we have recently verified in a consecutive series of Spanish cardiac outpatients that both mean survival at discharge (76%) and mean survival free of significant neurological impairment (65%) were significantly far from these readings.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Nevertheless, to freely exercise their rights, cardiac patients need to be aware of the actual prognosis of their underlying disease, in addition to knowing the actual result of the CPR. Despite advances in therapy, the prognosis for HF is still poor.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a> The mortality of patients with HF at 5 years of the diagnosis varies between 50% for men and 46% for women,<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">24</span></a> observing over the last few decades a slight improvement in the prognosis for older patients.<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">24,25</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Not only survival is important for the patient's decision-making process but also the issues regarding the clinical and societal consequences of the disease (direct and indirect medical costs, loss of opportunities, caregiver burden, etc.).<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">15</span></a> The patient should be aware of the symptoms associated with chronic HF because the disease entails highly varied symptoms in a very similar proportion to that of patients with advanced cancer, chronic obstructive pulmonary disease and terminal kidney disease (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">26</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The natural history of HF is characterized by its decompensations, many of which will require hospitalization. This is especially common in the last 30–60 days of life, reaching up to 50% of the patient's readmissions in this period.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a> In the last 6 months of their life, 80% of patients with HF will be hospitalized at least once, including stays in intensive care units, which become increasingly longer.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">27</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Despite this reality, patients with HF have a poor understanding of their prognosis and are less involved in the decision-making process than patients with other chronic diseases, such as cancer.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">11</span></a> The reasons for this are numerous, but it is often the physicians themselves who are reluctant to discuss the prognosis, in part because it is risky to determine the prognosis given the variable clinical course of HF.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a> The clinical deterioration and loss of autonomy can occur gradually, in the form of slow worsening with episodes of exacerbation, without complete recovery, following a similar course to that of other organ insufficiencies. The deterioration can also occur much more abruptly, such as in the case of ischemic events and acute arrhythmia. This highly variable progression is responsible, at least in part, for the relative optimism on the prognosis of HF shared by the patient, their relatives and the physicians who handle their care. All of this facilitates the situation where many patients in terminal stages of HF receive numerous invasive therapies (CPR, intubations, balloon counterpulsation, implantable cardioverter defibrillator discharges, etc.) a few days before their death. These therapies would not be indicated for terminal patients if the therapies were not expected to produce significant improvement.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">4</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">It is known that clinicians overestimate the life expectancy of terminal patients and that non-oncological specialists do so to an even greater degree.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">28</span></a> Given the inaccuracy of our predictions, we need to search for indices and scales that increase the reliability of the prognosis to avoid as much as possible the use of invasive therapeutic measures at the end of life.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">29</span></a> We need accurate and easy-to-use prognostic models that can be applied in the clinical setting and that create information that can easily be communicated to patients.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a> If this were possible, we would have a good basis for discussing end-of-life preferences. It is very likely that if patients perceived that their survival was limited, the decision-making process would change and include end-of-life preferences. As an example of this lack of understanding and failure to communicate the prognosis to patients, we highlight the results obtained by Allen et al.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">12</span></a> in the analysis of 122 outpatients with HF, for whom survival was overestimated by 3 years compared with that estimated by one of these prognostic models (Seattle Heart Failure Model). In the multivariate analysis, the predictors of a greater optimism in this population were a younger age, the ischemic etiology, a lower degree of depression and, curiously, both a lower left ventricular ejection fraction and a poorer New York Heart Association functional class. In fact, the patients’ functional class seemed to have no relationship with their own expectations concerning their remaining life. The patients in functional class I had similar estimates as to their life expectancy as those in functional class IV.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Misinterpreted do-not-resuscitate orders</span><p id="par0115" class="elsevierStylePara elsevierViewall">A DNR order only has meaning at the moment of the CPA, either for not starting CPR or for discontinuing it, but in no case should it affect other aspects of the medical care. In the city of Worcester (Massachusetts, USA), a study observed over the last few years that patients with DNR orders had fewer chances of undergoing drug treatments of proven efficacy during hospitalization for an acute myocardial infarction (e.g. acetylsalicylic acid and beta-blockers) and that they underwent fewer coronary revascularization therapies (percutaneous or surgical) than patients without DNR orders.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">30</span></a> Recently, in the same region, another study continues to observe striking differences in terms of treatment of acute myocardial infarction (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">22</span></a> It is possible, however, that the differences found in the use of invasive therapies reflect the agreed-upon preferences between the patient and the physician. However, this possibility does not justify the lower use of some drug products such as acetylsalicylic acid in patients with DNR orders.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">For patients hospitalized for HF, the same researchers found not only a lower use of drug treatments but also a lower use of diagnostic strategies and nondrug therapies for patients with DNR orders compared with those patients who had no orders (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">31</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">The creation of DNR orders should occupy a fundamental section in the planning of end-of-life care for patients with advanced heart disease. DNR orders only specify the patient's desires concerning their CPR and is therefore different from advance directives, which are created to include the patient's preferences regarding other therapeutic options and their end-of-life care. Therefore, the theoretical effect of DNR orders should be limited to CPR measures. However, as we have shown, having DNR orders can lead to approaches that limit access to certain therapies when faced with situations that have nothing to do with CPA, which can lead to inadequate or late treatments of potentially curable acute diseases.</p><p id="par0130" class="elsevierStylePara elsevierViewall">If cardiac patients were aware of these data, it is likely that their confidence in us would be seriously deteriorated. This interpretation of the DNR orders also puts the development of conversations on CPR in serious jeopardy; firstly, because physicians can further delay the start of DNR orders due to fear that patients will not receive appropriate treatment and, secondly, because patients and their families could also be reluctant to reject CPR for fear that they could create a situation where treatment of other diseases could be compromised after recording the DNR orders in their medical history. In these circumstances, the preferences manifested by patients about their end-of-life care could be contrary to their true wishes for resuscitation.</p><p id="par0135" class="elsevierStylePara elsevierViewall">If DNR orders are discussed at an early stage of the disease and cease to be simple markers of clinical deterioration or of imminent death, it is likely that we will no longer see these differences in treatments for patients with DNR orders. It should be noted that there are hopeful signs, as evidenced by the results of the analysis by Dunlay et al.,<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">32</span></a> who, after adjusting for age, comorbidities and the patient's self-perception of health, found no independent increase in the risk of death due to the presence of DNR orders in 608 patients with HF followed-up for a period of 4 years (HR, 0.97; 95% CI 0.74–1.30; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.83). At the start of the study, 73.4% of the patients considered reanimation, but by the time of death most (78.5%) had DNR orders. In this case, the median elapsed time from the decision to refuse CPR and death was 37 (IQR, 7.70) days,<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">32</span></a> a period that, although still short, was longer than those described above.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">33</span></a></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">DNR orders continue to be misinterpreted and underused by cardiac patients. Most of these patients seem unaware of the prognosis of their disease or that of CPR and usually do not have the opportunity to hold the necessary talks with their physician about their resuscitation preferences.</p><p id="par0145" class="elsevierStylePara elsevierViewall">We lack reliable predictive models for guiding patient preferences. The fact that the use of DNR orders continue to limit the use of therapies not included in the CPR maneuvers can further hinder the implementation of these DNR orders.</p><p id="par0150" class="elsevierStylePara elsevierViewall">The promotion of medical training in end-of-life communication and care, the appropriate and individual assessment of each patient, the explanation of the prognosis of HF and CPR and active listening during repeated conversations from the initial phases of heart disease could likely achieve a better development of DNR orders and contribute to improving the correlation between the patients’ wishes and their final experiences.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interests</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres834093" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec830139" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres834092" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec830140" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Problems in the implementation of do-not-resuscitate orders for cardiac patients" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Infrequent conversations with patients and disregarded patient preferences" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Inability to predict patient's preferences" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Lack of correlation with the patient's preferences" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Delayed conversations" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Insufficient information to decide" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Misinterpreted do-not-resuscitate orders" ] ] ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusions" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interests" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-09-01" "fechaAceptado" => "2016-12-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec830139" "palabras" => array:5 [ 0 => "Cardiology" 1 => "Cardiopulmonary resuscitation" 2 => "Cardiopulmonary arrest" 3 => "End-of-life care" 4 => "Clinical ethics" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec830140" "palabras" => array:5 [ 0 => "Cardiología" 1 => "Reanimación cardiopulmonar" 2 => "Parada cardiorrespiratoria" 3 => "Cuidados al final de la vida" 4 => "Ética clínica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cardiovascular diseases are still the most common cause of death, and heart failure is the most common reason for hospitalization of patients older than 65 years. However, Cardiology attributes low importance to end-of-life care. Cardiac patients’ perception of their disease's prognosis and the results of cardiopulmonary resuscitation differ greatly from reality. The “do-not-resuscitate” order allows patients to pre-emptively express their rejection for cardiopulmonary resuscitation, thereby avoiding its potentially negative consequences. However, these orders are still underused and misinterpreted in cardiac patients. Most of these patients usually have no opportunity to have the necessary conversations with their attending physician on their resuscitation preferences. In this review, we performed an analysis of the causes that could explain this situation.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las enfermedades cardiovasculares continúan siendo la causa más frecuente de muerte, y la insuficiencia cardíaca la causa más frecuente de ingreso hospitalario en pacientes mayores de 65 años. Pese a ello, la importancia otorgada por la cardiología a los cuidados al final de la vida es escasa. Además, la percepción que tienen los pacientes cardiológicos del pronóstico de su enfermedad y del resultado de una reanimación cardiopulmonar dista mucho de la realidad. La orden de no reanimar permite al paciente expresar anticipadamente su rechazo a una reanimación cardiopulmonar, evitando así sus posibles consecuencias negativas. Sin embargo, estas órdenes continúan siendo infrautilizadas y malinterpretadas en los pacientes cardiológicos. La mayoría no suele tener la oportunidad de mantener las necesarias conversaciones con su médico responsable sobre sus preferencias de reanimación. En la presente revisión hemos realizado un análisis de las causas que podrían justificar esta situación.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ruiz-García J, Canal-Fontcuberta I, Martínez-Sellés M. Problemática actual en la implementación de la orden de no reanimar en el paciente cardiológico. Rev Clin Esp. 2017;217:222–228.<span class="elsevierStyleInterRef" id="intr0005" href="doi:10.1016/j.rce.2016.12.002">http://dx.doi.org/10.1016/j.rce.2016.12.002</span></p>" ] ] "multimedia" => array:4 [ 0 => array:9 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Adapted from Desai et al.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a>" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1105 "Ancho" => 1520 "Tamanyo" => 83982 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Risk of readmission after a hospitalization for heart failure. The areas in white at both ends represent periods of greater risk for immediate readmission after discharge and just before death. The area in white in the center reflects the plateau phase of lower risk. The shaded area in black reflects the supposed baseline of inevitable readmissions.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Adapted from Saczynski et al.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">22</span></a>" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1538 "Ancho" => 1540 "Tamanyo" => 116033 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Drugs administered and procedures performed on patients hospitalized for an acute myocardial infarction according to a “do-not-resuscitate” order. <span class="elsevierStyleItalic">p</span> Value <0.001 for all comparisons between patients with a present or absent DNR order. <span class="elsevierStyleItalic">Abbreviations</span>: ACEI, angiotensin-converting enzyme inhibitor; DNR, do-not-resuscitate; PCI, percutaneous coronary intervention.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Adapted from Chen et al.<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">31</span></a>" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1264 "Ancho" => 1576 "Tamanyo" => 108088 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Treatments and measures applied and counseling provided to patients hospitalized for heart failure according to the presence or absence of a DNR order. <span class="elsevierStyleItalic">p</span> Value <0.05 for all comparisons between patients with present and absent DNR orders, except for the reduction in alcohol consumption. <span class="elsevierStyleItalic">Abbreviations</span>: ARB, angiotensin II receptor blocker<span class="elsevierStyleSmallCaps">;</span> LVEF, left ventricular ejection fraction; ACEI, angiotensin-converting enzyme inhibitor; DNR, do-not-resuscitate orders. In the multivariate analysis, the differences remained statistically significant.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Adapted from Moens et al.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">26</span></a>" "tabla" => array:2 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The intervals shown in the table reference the minimum–maximum prevalence of each problem detected in a systematic review of the original studies of patients with advanced cancer in palliative care (57 studies, 34,866 patients), COPD (10 studies, 2045 patients), terminal KD (47 studies, 11,140 patients), and chronic HF (8 studies, 1310 patients).</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: COPD, chronic obstructive pulmonary disease; HF, heart failure; KD, kidney disease.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cancer \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">COPD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Terminal KD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Chronic HF \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fatigue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23–100% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32–96% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13–100% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42–82% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30–94% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21–77% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11–83% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14–78% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nausea/vomiting \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2–78% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8–52% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2–48% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dyspnea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16–77% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56–98% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11–82% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18–88% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Insomnia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3–67% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15–77% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1–83% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36–48% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Confusion/delirium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2–68% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14–33% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35–70% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15–48% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Constipation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4–64% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12–44% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8–65% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12–42% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diarrhea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1–25% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8–36% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Depression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4–80% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17–77% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2–61% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6–59% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anxiety \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3–74% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23–53% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7–52% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2–49% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1406604.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Prevalence of symptoms in advanced phases of various diseases compared with chronic heart failure.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:33 [ 0 => array:3 [ "identificador" => "bib0170" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Instituto Nacional de Estadística. 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