The clinician and their patient at the end of life

Conthe, P.

doi:10.1016/j.rceng.2017.10.008

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Conthe" "autores" => array:1 [ 0 => array:3 [ "nombre" => "P." "apellidos" => "Conthe" "email" => array:1 [ 0 => "pedro.conthe@salud.madrid.org" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Sección de Medicina Interna, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El médico clínico ante el paciente en el final de sus días" ] ] "textoCompleto" => "End-of-life medical care is a significant challenge for health departments in developed societies. The decision to limit therapeutic efforts (LTE) is one of the medical acts that requires greater experience, understanding, sensitivity and compassion to prevent needless suffering by the patient and those close to them. All clinicians need to address this fact when faced with a patient at the end of their life. The care of patients at the end of life has become a routine and growing situation in acute care hospitals.<a class="elsevierStyleCrossRefs" href="#bib0050">1–5</a> Each day, more deaths occur in the hospital setting, specifically in internal medicine departments where the mortality rate varies between 8% and 22%.<a class="elsevierStyleCrossRef" href="#bib0055">2</a> Death and the acceptance of its reality as a phenomenon tied to the essence of life is a complex topic. Over the past century, numerous philosophers, humanists and bioethicists have stated that we are witnessing the so-called “denial of death”.<a class="elsevierStyleCrossRefs" href="#bib0075">6,7</a> Death is one of the few taboos that the family, the medical class, the healthcare system and society as a whole turns their back on, as if it were not a fact of nature. The inexperienced physician, even with a high degree of technical expertise, often lacks training in addressing these situations.In this edition of Revista Clínica Española, a study was published that addressed this important topic.<a class="elsevierStyleCrossRef" href="#bib0085">8</a> It is a study with merit, despite its numerous limitations. As indicated by the authors, the study is essentially a simple description of the basic clinical characteristics of a small group of patients who died during hospitalization, with the typical biases of a retrospective study. The study described how some type of LTE was reflected in these cases. As expected, the patients had advanced age and comorbidity, were mostly considered terminal and had sedation prescribed hours before their death. It is noteworthy that the main causes of death were varied (less than 10% due to cancer), and there was a long period from admission to the LTE decision. The study's limitations included the lack of knowledge as to the specific reason why the clinicians adopted LTE measures. The study also makes no reference to the presence or absence of strategies or availability of precise protocols, drugs or doses. The study also lacks data on the information provided to the patient and community (main caregivers and other relatives), the strategy for transmitting the information, the patient's wishes and the degree of perceived satisfaction in their final medical care. All of these aspects can comprise areas for future research. The results reflect that the implementation of terminal care in hospital internal medicine departments is not efficient.However, we can highlight some relevant data from the study: (1) The prescription of LTE measures is very common among patients who die in internal medicine departments; (2) most terminal patients who are admitted to internal medicine department are admitted for nononcologic diseases, which can lead to a delay in identifying the process as terminal; and (3) it seems plausible that there is a delay in starting palliative treatment; improving our competence in identifying terminal nononcologic patients is therefore essential.Clinicians who treat patients in the final phase of life require, in addition to a realistic and inclusive vision, a considerable capacity for communication with the patient and their caregivers. Internists are therefore in a privileged position to perform this function, without compromising other practitioners and specialists. In this field, situations arise in which physicians must make decisions according to the “lex artis”, without absolute certainty but with conviction and the humility that their mission should be limited to caring and consoling. When talking about the end of life, we need to refer to and consider the living will. In Spain, the autonomous communities have taken a step towards legally regulating this type of document. However, the knowledge and use of these documents in actual medical practice is still not sufficiently consolidated.In the European Union, there is considerable variability in the organizational aspects in terms of facilitating a dignified death in the family setting, with the technical and emotional assistance needed. In the United Kingdom, the Royal College of Physicians since 2013 has led a project called Future Hospital/Hospital Without Walls, which seeks to implement periodic Care of Dying Evaluations (CODE), providing recent publications that raise awareness about the importance of end-of-life care demanded by society.<a class="elsevierStyleCrossRef" href="#bib0050">1</a> In any case, all terminal patients should have access to an appropriate degree of care in all healthcare settings. Healthcare organizations should promote the training and competence of its practitioners in the treatment of pain and end-of-life anxiety, regardless of the care setting, ensuring the continuity of care.<a class="elsevierStyleCrossRefs" href="#bib0055">2,3,8,9</a> The promotion of multidisciplinary study should be considered a key factor for supporting home palliative care and avoiding as much as possible that this difficult end occurs in the hospital." 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Revista Clínica Española (English Edition)

ISSN: 2254-8874

Revista Clínica Española published its first issue in 1940 and is the body of expression of the Spanish Society of Internal Medicine (SEMI).
The journal fully endorses the goals of updating knowledge and facilitating the acquisition of key developments in internal medicine applied to clinical practice. Revista Clínica Española is subject to a thorough double blind review of the received articles written in Spanish or English. Ten issues are published each year, including mostly originals, reviews and consensus documents.

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Vol. 218. Issue 1.

Pages 15-16 (January - February 2018)

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