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Limitation of therapeutic effort in departments of internal medicine
Limitación del esfuerzo terapéutico en medicina interna
I. Torrente Jiménez
, M.A. Villarino Marzo, S. Herranz Martínez
Corresponding author
Unidad de Geriatría de Agudos y Paciente Crónico Complejo, Consorcio Sanitario Parc Taulí, Sabadell, Barcelona, Spain
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Torrente Jiménez, M.A. Villarino Marzo, S. Herranz Martínez" "autores" => array:3 [ 0 => array:4 [ "nombre" => "I." "apellidos" => "Torrente Jiménez" "email" => array:1 [ 0 => "isaluna29@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M.A." "apellidos" => "Villarino Marzo" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Herranz Martínez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Geriatría de Agudos y Paciente Crónico Complejo, Consorcio Sanitario Parc Taulí, Sabadell, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Limitación del esfuerzo terapéutico en medicina interna" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with interest the study by García Caballero et al. on the “Limitation of therapeutic effort in patients hospitalized in departments of internal medicine”<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> and would like to make a few comments. Firstly, given the difficulty in accurately defining the concept of limitation of therapeutic effort, we consider it more appropriate to talk of appropriateness of the therapeutic effort (ATE), defined as the proactive therapeutic actions that include adding, modifying, not starting or removing treatments according to the therapeutic objectives for the patient's current developmental stage, when palliative sedation is considered as part of the objectives.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Secondly, the criteria of the Spanish Society of Palliative Care (SECPAL) for defining the terminal phase require changes to adapt to elderly nononcologic patients.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> When treating elderly patients, an appropriate comprehensive geriatric assessment would provide highly relevant information, emphasizing the functional status, which in elderly patients is the most reliable predictor of poor progression and mortality, regardless of the clinical diagnoses. Based on the current evidence, we propose the use of the PALIAR index<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> instead of the Charlson index, because the former has shown to be superior as a predictor of mortality in chronic nononcologic diseases.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Regarding the results, it is worth adding the patient's preferences to the planning of care and not basing the care solely only the stage of the process. We agree that expressions regarding not performing aggressive measures are not very specific. Data such as a 10.3% rate of unexpected deaths, the use of terminal sedation in only 47.6% of patients and only 51% of patients considered terminal demonstrate the difficulty in identifying palliative nononcologic patients.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We therefore support the need for promoting training in nononcologic palliative care and geriatric medicine starting at the university level.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Torrente Jiménez I, Villarino Marzo MA, Herranz Martínez S. Limitación del esfuerzo terapéutico en medicina interna. Rev Clin Esp. 2018;218:265–265.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Limitación del esfuerzo terapéutico en pacientes hospitalizados en servicios de medicina interna" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. García Caballero" 1 => "B. Herreros" 2 => "D. Real de Asúa" 3 => "S. Gámez" 4 => "G. Vega" 5 => "L. García Olmos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rce.2017.10.001" "Revista" => array:6 [ "tituloSerie" => "Rev Clin Esp" "fecha" => "2018" "volumen" => "218" "paginaInicial" => "1" "paginaFinal" => "6" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29137700" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Documento sobre adecuación del esfuerzo terapéutico" ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:2 [ "fecha" => "2017" "editorial" => "Área de Salud de León" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Criterios de selección de pacientes con enfermedades no oncológicas en programas y/o servicios de cuidados paliativos" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. 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