Editorial
Internal medicine and palliative care: Science and humanism
Medicina interna y cuidados paliativos: ciencia y humanismo
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Galindo Ocaña, C. Aguilera González" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Galindo Ocaña" "email" => array:1 [ 0 => "galinx2@gmail.com" ] "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" => "C." "apellidos" => "Aguilera González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Medicina Interna, UHD/ESCP, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Hospitalización Domiciliaria/Equipo de Soporte de Cuidados Paliativos, Servicio de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Medicina interna y cuidados paliativos: ciencia y humanismo" ] ] "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" => 684 "Ancho" => 805 "Tamanyo" => 99903 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pablo Ruiz Picasso, Science and Charity, 1897.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">According to estimates by the Spanish National Institute of Statistics,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> almost 40% of the Spanish population will be older than 65 years of age by 2050. Life expectancy will be approximately 90 years, and, at the same time, the number of deaths will reach half a million annually.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This aging of the population represents a qualitative change and a challenge for healthcare systems due to the increased demand. The complex chronic diseases, those that are incurable, potentially disabling, symptomatic and that are the most common causes of death, worsen tremendously the perceived sensation of health; such that 5% of the population is responsible for 75% of the pharmaceutical expenditure in Spain.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> In addition, these diseases usually present as a group; 5% of elderly patients in primary care present 2 or more of these complex chronic diseases. In a general internal medicine ward, 25–50% of those admitted present multiple diseases.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3,4</span></a> This burden of end-of-life conditions will involve major palliative care needs in the future. In studies conducted in Spain, 1.5% of the population might require palliative care, with the most significant causes being frailty (31%), dementia (23%) and cancer (13%).<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">5</span></a> Therefore, the internal medicine specialty will have a leading role in the care of more complex chronic patients in end-of-life conditions. The Spanish Society of Internal Medicine has thus created a Palliative Care workgroup, a symptom of the reality that is occurring in Spain (<a href="http://www.fesemi.org/">www.fesemi.org</a>). Moreover, the third edition of the Integrated Healthcare Process “Care for Polypathological Patients”<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> backs the implementation of the Comprehensive Integrated Assessment (<span class="elsevierStyleItalic">Valoración Integral Exhaustiva</span>, VIE), which includes “the clinical, functional, cognitive, emotional and social-familial, prognostic assessment... of the individual's preferences and values...”. This VIE reminds us of the multidimensional assessment recommended by the palliative care societies, addressing the physical, mental, emotional, social-familial and spiritual needs (<a href="http://www.secpal.es/">www.secpal.es</a>). The main difference between VIE and the recommendations of the European Association for Palliative Care (EAPC) is the issue of spiritual needs addressed in the EAPC.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a> These needs are difficult to investigate, given that they are not measurable and differ between cultures, religions and societal circumstances. However, projects are being developed with innovative humanist and multidisciplinary viewpoints to understand the entire issue of humans at the end of life (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Examples of these projects include London's “The Art of Dying” and California's “Seeing the Difference Project”, which include the vision of artists and healthcare practitioners.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In this issue, Sancho Zamora et al. assessed a prognostic model for patients at the end-of-life. The model consists of a functional assessment using the Palliative Performance Scale (PPS) plus the presence of pain/delirium/dyspnea. Consistent with previous studies, the authors found a strong association between low scores and mortality in periods as short as 6 days (for scores of 20).<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">8–10</span></a> The authors related this prediction with better relative/caregiver satisfaction by having improved patient selection before being transferred to a medium-stay center. For a better prognosis, the EAPC specifically recommends using the subjective criteria of the healthcare practitioner responsible for the patient, added to objective scales with proven validity and reproducibility.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">11</span></a> The subjective prognosis is more reliable if the clinician has experience and has been able to determine the patient's progress more recently. The objective scales and indices are based on assessing the functional state, from the simplest Eastern Cooperative Oncology Group, Karnofsky index (KI), the modified KI or its variant PPS, which adds the presence of adynamia, signs of disease, delirium and dysphagia.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">12–15</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The most complex models contain other predictors from various clinical, demographic, social-familial and laboratory areas, such as the Palliative Prognostic Score (PaP), the Glasgow Palliative Score,<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a> the Palliative Prognostic Index (PPI),<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">16</span></a> PROFUND<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">17</span></a> and PALIAR.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">18,19</span></a> All have shown good reproducibility and correlation. PPS and PIP have been validated in complex chronic patients and in patients with cancer in terminal conditions.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">12–16</span></a> The PROFUND index<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">17</span></a> was validated for numerous diseases to predict mortality at 12 months, while the PALIAR index<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">18,19</span></a> predicts mortality at 6 months for patients with advanced disease of one or more systems. In oncological palliative care, the most widely used prognostic scale is PPS,<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">12–15</span></a> followed by the PIP and modified KI. These indices are interchangeable, and proportionality between them has been established.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">16</span></a> The PPS scale is also validated in Spanish<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">9</span></a> and for a considerable variety of clinical scenarios (e.g., chronically ill patients without cancer and not terminal, as well as numerous other conditions).<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">12–15</span></a> The validity and accuracy of the PIP, which was recalibrated in almost 2000 chronic patients without cancer in advanced conditions, have also been demonstrated.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">16</span></a> Therefore, the most reproducible prognostic factors would be those associated with the burden and consequences of disease<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a> and not so much with the type of disease, whether it is cancer or not. Furthermore, Zimmermann et al.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> stated that the subjective opinion of physicians and nurses, coupled with objective data, such as functional impairment, symptoms of severity (dyspnea, pain, asthenia, anorexia, etc.), laboratory changes and tumor aggressiveness (histopathology, tumor location and metastases) are reasonably associated with more advanced disease and poorer survival. A recent systematic review<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a> on the prognostic value of the PPS included 17 studies (9 in oncology) and showed that a score <30% predicted mortality at 5–36 days; if the scores were <10%, the patients died in only 1–3 days. In the article by Sancho et al., the satisfaction survey was not validated; however, there is currently no standard for assessing satisfaction in palliative care. Numerous factors influence satisfaction, such as the accommodations, convenience and closeness to relatives’ homes or public transportation, thereby requiring qualitative methods to assess satisfaction. In this study, the authors address the usefulness of the prognosis in the decision-making process, a relationship that in palliative care is particularly relevant.</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: Galindo Ocaña J, Aguilera González C. Medicina interna y cuidados paliativos: ciencia y humanismo. Rev Clin Esp. 2019;219:324–326.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 684 "Ancho" => 805 "Tamanyo" => 99903 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pablo Ruiz Picasso, Science and Charity, 1897.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0110" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Notas de prensa del INE. 24-10-2014. 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