Editorial
Internists and death in the hospital
Los internistas y la muerte en el hospital
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Díez-Manglano, S. Isasi de Isasmendi Pérez, M. Rubio Gómez, F. Formiga, L.Á. Sánchez Muñoz, J. Castiella Herrero, E. Casariego Vales, O.H. Torres Bonafonte" "autores" => array:9 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Díez-Manglano" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Isasi de Isasmendi Pérez" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Rubio Gómez" ] 3 => array:2 [ "nombre" => "F." "apellidos" => "Formiga" ] 4 => array:2 [ "nombre" => "L.Á." "apellidos" => "Sánchez Muñoz" ] 5 => array:2 [ "nombre" => "J." "apellidos" => "Castiella Herrero" ] 6 => array:2 [ "nombre" => "E." "apellidos" => "Casariego Vales" ] 7 => array:2 [ "nombre" => "O.H." "apellidos" => "Torres Bonafonte" ] 8 => array:1 [ "colaborador" => "the researchers of the UDVIMI study, researchers of the Pluripathologic and Advanced Age Group of the Spanish Society of Internal Medicine" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S001425651830198X" "doi" => "10.1016/j.rce.2018.06.010" "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/S001425651830198X?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887418301346?idApp=WRCEE" "url" => "/22548874/0000021900000003/v1_201903280618/S2254887418301346/v1_201903280618/en/main.assets" ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Internists and death in the hospital" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "145" "paginaFinal" => "146" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "S. Plaza Canteli, J. Marco Martínez" "autores" => array:2 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Plaza Canteli" "email" => array:1 [ 0 => "susana.plaza@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Marco Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Cuidados Paliativos, Servicio de Medicina Interna, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Sección de Medicina Interna, Hospital Universitario Clínico San Carlos, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Los internistas y la muerte en el hospital" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Technological developments and the aging of the population due to reduced fertility rates and reduced mortality rates are transforming our clinical activities. We are witnessing a demographic transition that social scientists call the “demographic winter”, which will be accompanied by an epidemiological transition: chronic noncontagious diseases will become the main causes of death. Through increasing age, a greater prevalence of chronic diseases and an increased use of healthcare facilities, in-hospital mortality will reach a rate of 57%.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The article by Díez-Manglano et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> demonstrates situations that have been intuited or recognized. Older patients with advanced and multiple diseases, who are highly dependent and commonly readmitted, die in internal medicine departments of hospitals for the acutely ill. Due to their characteristics, internal medicine departments are primarily in charge of providing end-of-life care to many of these patients. The question is whether they are doing it properly.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The quality of care in agonizing situations or during the last days of life is covered within all humanization programs currently implemented in Spain's health systems. Beyond the policies, we as internists should concern ourselves as to how we really treat our patients in this short but crucial period. The multicenter study by Díez-Manglano et al. shows that, of all patients who died while hospitalized in internal medicine departments, death is expected in almost 63% of cases, 51.9% of the patients were considered in their final stage of life, and 32% died solely due to cancer.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We know that patients on average spend too long in hospital at the end of life (median, 8–20 days) and that in many cases this last hospitalization provides no improvement in the patient's quality of life (or death).<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3,4</span></a> In standard clinical practice, internists conduct highly effective clinical activities; however, they also routinely conduct interventions (diagnostic or therapeutic) that do not always provide benefits and can become counterproductive. This is the problem with healthcare complexity.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Díez-Manglano et al. indicated that most patients and their families are unaware or do not assume that the patient is at the end of life, and this topic is not directly discussed with them. Few are asked about the care they wish to receive. In our opinion, when a patient reaches their end of life, the clinical judgment should not matter so much. Responding to a set of needs (some of them clinical, no doubt) that emerge at this moment should take priority. As physicians, we are trained to diagnose and heal, and sometimes we fail to recognize that we are incapable of saving complex chronic and polypathological patients or patients with terminal cancer.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5,6</span></a> We ignore the fact that the patient will soon be dead and employ the typical hospital resources, treating the patient as just another patient, treating the disease and not the individual. It is easy to fall into the trap of therapeutic cruelty if we do not adapt our care to the patient's actual situation.</p><p id="par0030" class="elsevierStylePara elsevierViewall">On other occasions, the closeness of death is so apparent that we place ourselves at the other end, abandoning the patient and their family because “there is nothing left to do”. In these circumstances, however, dyspnea, pain, confusion and respiratory secretions are very common signs and symptoms that require expert care. A set of measures are therefore needed for the comprehensive care of patients and their families in this situation. It is precisely this activity that is considered “palliative care”. This care should be gradual, with a systematic assessment of the individual's needs, not only as the patient's death draws near but also in earlier phases of the disease progression.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7,8</span></a> The objective is focused on adapting to each patient's condition and improving their quality of life rather than focusing on a specific period of expected survival. The process should be progressive and based on the patient's values, beliefs and preferences, without forgetting that relieving the suffering should be coupled with psychological, social and spiritual support.</p><p id="par0035" class="elsevierStylePara elsevierViewall">A surprising finding in the study by Díez-Manglano et al. is that there is no mention as to whether the patients had been assessed by a palliative care hospital team, and yet more than 57% of the patients who died were administered palliative sedation. This finding could lead to the conclusion that some internists might have considered the mere administration of morphine in the last moments of life as “palliative sedation”. Figures above 50% are not usually seen even in the setting of palliative care. The rate of palliative sedation in hospital palliative care units, medium to long-stay hospital centers and homes is 45%, 25% and 15%, respectively. Palliative sedation is a treatment maneuver indicated for controlling refractory symptoms that cause the patient considerable suffering and that cannot be controlled within a reasonable period by expert personnel.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Many of these patients, theoretically on “palliative sedation”, were also prescribed drugs such as statins, antibiotics, anticoagulants and antiplatelets, regardless of whether they had do-not-resuscitate orders. There is also a surprising multitude of nursing care indications for the repeated measurement of vital signs and capillary blood glucose, which bother the patient and their family near the end of the patient's life.</p><p id="par0045" class="elsevierStylePara elsevierViewall">We welcome articles such as the one by Díez-Manglano et al. to the pages of the society's journal, thanking them for informing us of our patients’ end-of-life period and providing a view of the actions we as internists perform in these moments. This type of management undoubtedly needs improvement if we are to become better managers of this important moment in our patients’ lives and that of their families.</p><p id="par0050" class="elsevierStylePara elsevierViewall">It is therefore a priority that we prepare protocols and clinical guidelines for end-of-life care. We need to acquire and promote our training and that of our residents in palliative care, communication and care at the end-of-life.</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: Plaza Canteli S, Marco Martínez J. Los internistas y la muerte en el hospital. Rev Clin Esp. 2019;219:145–146.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Distribución geográfica y evolución de las muertes en hospitales en España, 1996–2015" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Jiménez-Puente" 1 => "J. 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