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Older patients with advanced and multiple diseases&#44; who are highly dependent and commonly readmitted&#44; die in internal medicine departments of hospitals for the acutely ill&#46; Due to their characteristics&#44; internal medicine departments are primarily in charge of providing end-of-life care to many of these patients&#46; The question is whether they are doing it properly&#46;</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&#39;s health systems&#46; Beyond the policies&#44; we as internists should concern ourselves as to how we really treat our patients in this short but crucial period&#46; The multicenter study by D&#237;ez-Manglano et al&#46; shows that&#44; of all patients who died while hospitalized in internal medicine departments&#44; death is expected in almost 63&#37; of cases&#44; 51&#46;9&#37; of the patients were considered in their final stage of life&#44; and 32&#37; died solely due to cancer&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We know that patients on average spend too long in hospital at the end of life &#40;median&#44; 8&#8211;20 days&#41; and that in many cases this last hospitalization provides no improvement in the patient&#39;s quality of life &#40;or death&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;4</span></a> In standard clinical practice&#44; internists conduct highly effective clinical activities&#59; however&#44; they also routinely conduct interventions &#40;diagnostic or therapeutic&#41; that do not always provide benefits and can become counterproductive&#46; This is the problem with healthcare complexity&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">D&#237;ez-Manglano et al&#46; indicated that most patients and their families are unaware or do not assume that the patient is at the end of life&#44; and this topic is not directly discussed with them&#46; Few are asked about the care they wish to receive&#46; In our opinion&#44; when a patient reaches their end of life&#44; the clinical judgment should not matter so much&#46; Responding to a set of needs &#40;some of them clinical&#44; no doubt&#41; that emerge at this moment should take priority&#46; As physicians&#44; we are trained to diagnose and heal&#44; and sometimes we fail to recognize that we are incapable of saving complex chronic and polypathological patients or patients with terminal cancer&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6</span></a> We ignore the fact that the patient will soon be dead and employ the typical hospital resources&#44; treating the patient as just another patient&#44; treating the disease and not the individual&#46; It is easy to fall into the trap of therapeutic cruelty if we do not adapt our care to the patient&#39;s actual situation&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">On other occasions&#44; the closeness of death is so apparent that we place ourselves at the other end&#44; abandoning the patient and their family because &#8220;there is nothing left to do&#8221;&#46; In these circumstances&#44; however&#44; dyspnea&#44; pain&#44; confusion and respiratory secretions are very common signs and symptoms that require expert care&#46; A set of measures are therefore needed for the comprehensive care of patients and their families in this situation&#46; It is precisely this activity that is considered &#8220;palliative care&#8221;&#46; This care should be gradual&#44; with a systematic assessment of the individual&#39;s needs&#44; not only as the patient&#39;s death draws near but also in earlier phases of the disease progression&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7&#44;8</span></a> The objective is focused on adapting to each patient&#39;s condition and improving their quality of life rather than focusing on a specific period of expected survival&#46; The process should be progressive and based on the patient&#39;s values&#44; beliefs and preferences&#44; without forgetting that relieving the suffering should be coupled with psychological&#44; social and spiritual support&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A surprising finding in the study by D&#237;ez-Manglano et al&#46; is that there is no mention as to whether the patients had been assessed by a palliative care hospital team&#44; and yet more than 57&#37; of the patients who died were administered palliative sedation&#46; 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 &#8220;palliative sedation&#8221;&#46; Figures above 50&#37; are not usually seen even in the setting of palliative care&#46; The rate of palliative sedation in hospital palliative care units&#44; medium to long-stay hospital centers and homes is 45&#37;&#44; 25&#37; and 15&#37;&#44; respectively&#46; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Many of these patients&#44; theoretically on &#8220;palliative sedation&#8221;&#44; were also prescribed drugs such as statins&#44; antibiotics&#44; anticoagulants and antiplatelets&#44; regardless of whether they had do-not-resuscitate orders&#46; There is also a surprising multitude of nursing care indications for the repeated measurement of vital signs and capillary blood glucose&#44; which bother the patient and their family near the end of the patient&#39;s life&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">We welcome articles such as the one by D&#237;ez-Manglano et al&#46; to the pages of the society&#39;s journal&#44; thanking them for informing us of our patients&#8217; end-of-life period and providing a view of the actions we as internists perform in these moments&#46; This type of management undoubtedly needs improvement if we are to become better managers of this important moment in our patients&#8217; lives and that of their families&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">It is therefore a priority that we prepare protocols and clinical guidelines for end-of-life care&#46; We need to acquire and promote our training and that of our residents in palliative care&#44; communication and care at the end-of-life&#46;</p></span>"
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Editorial
Internists and death in the hospital
Los internistas y la muerte en el hospital
S. Plaza Cantelia,
Corresponding author
susana.plaza@salud.madrid.org

Corresponding author.
, J. Marco Martínezb
a Unidad de Cuidados Paliativos, Servicio de Medicina Interna, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
b Sección de Medicina Interna, Hospital Universitario Clínico San Carlos, Madrid, Spain
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