Cuidados paliativos

Estamos em 2021, ainda na vivência da Pandemia de COVID-19. Muitos foram os desafios inerentes à doença que ceifou vidas, assustadoramente, desafiando a acessibilidade e a equidade no cuidado em saúde das pessoas. Hoje, já vislumbramos seu controle por força da ciência e das vacinas. Diante da pandemia, o nosso sistema de saúde mostrou sua sobrecarga e suas inúmeras fragilidades. Uma delas relaciona-se com a Campanha de 2021 promovida pela Worldwide Hospice Palliative Care Alliance (WHPCA), organização internacional não governamental, que faz alusão neste editorial “Não deixe ninguém para trás: equidade no acesso aos Cuidados Paliativos”.

Medical assistance in dying legislation: Hospice palliative care providers’ perspectives

Background: After over 4 years since medical assistance in dying legalization in Canada, there is still much uncertainty about how this ruling has affected Canadian society. Objective: To describe the positive aspects of medical assistance in dying legalization from the perspectives of hospice palliative care providers engaging in medical assistance in dying. Design: In this qualitative descriptive study, we conducted an inductive thematic analysis of semi-structured interviews with hospice palliative care providers. Participants and setting: Multi-disciplinary hospice palliative care providers in acute, community, residential, and hospice care in Vancouver and Toronto, Canada, who have engaged in end-of-life care planning with patients who have inquired about and/or requested medical assistance in dying. Ethical considerations: The research proposal was approved by University of British Columbia Research Ethics Board in Vancouver and University Health Network in Toronto. Participants were informed regarding the research goals, signed a written consent, and were assigned pseudonyms. Results: The 48 participants included hospice palliative care physicians (n = 22), nurses (n = 15), social workers (n = 7), and allied health providers (n = 4). The average interview length was 50 min. Positive aspects of medical assistance in dying legalization were identified at (1) the individual level: (a) a new end-of-life option, (b) patients’ last chance to express control over their lives, (c) patient and family comfort and relief, and (d) a unique learning experience for hospice palliative care providers; (2) the team level: (a) supportive collegial relationships, (b) broadened discussions about end-of-life and palliative care, and (c) team debriefs provide opportunities for education and support; and (3) the institutional level: (a) improved processes to facilitate the implementation logistics. Conclusion: While being involved in the medical assistance in dying process is complex and challenging, this study sheds light on the positive aspects of medical assistance in dying legalization from the hospice palliative care provider’s perspectives. Medical Assistance in Dying legalization has resulted in improved end-of-life conversations between hospice palliative care providers, patients, and their families. Improved communication leads to a better understanding of patients’ end-of-life care plans and bridges some of the existing gaps between hospice palliative care and medical assistance in dying.

Inpatient Hospice Palliative Care Unit and Palliative Consultation Service Enhance Comprehensive Quality of Life Outcomes in Terminally Ill Cancer Patients: A Prospective Longitudinal Study

This study aimed to explore the effectiveness of an inpatient hospice palliative care unit (PCU) and palliative consultation service (PCS) on comprehensive quality of life outcome (CoQoLo) among terminally ill cancer patients. This was a prospective longitudinal study. Terminally ill cancer patients who met the inclusion criteria and received PCU or PCS in a northern Taiwanese medical center were recruited. The CoQoLo Inventory was used to measure CoQoLo level pre- and seven days following hospice care between August 2018 and October 2019. A total of 90 patients completed the study. No significant differences were found in CoQoLo levels between the PCU and PCS groups pre- and seven days following care. However, the CoQoLo level of patients significantly improved seven days following care in both PCU and PCS groups, compared with pre-hospice care. Patients’ age, religious belief, marital status, closeness with family, palliative prognostic index (PPI), and symptom severity were significant concerning CoQoLo levels after adjusting for patients’ baseline characteristics. PCU and PCS showed no difference in CoQoLo levels, but both of them can improve CoQoLo among terminally ill cancer patients. These patients could receive PCU or PCS to achieve a good CoQoLo at the end-of-life stage.

Effects of hospice palliative care on medical service utilisation by patients on prolonged mechanical ventilation: A nationwide cohort study

Background: Several studies have shown that hospice palliative care interventions for cancer patients can reduce medical utilisation. In Taiwan, 20–25% of mechanical ventilation patients have been on prolonged mechanical ventilation (PMV), but only a few studies have discussed the effectiveness of hospice palliative care on these patients. This study aimed to explore the effectiveness of medical utilisation on patients undergoing PMV in hospice palliative care.Methods: From the Health Insurance database of a nationwide population-based study, we identified patients who had been on mechanical ventilation for over 21 days, were 18 years or older between 2009 to 2017, and had undergone hospice palliative care. The control group was obtained by 1:1 matching using propensity scoring after excluding patients who had participated in palliative care for less than 15 or more than 181 days. Furthermore, we used conditional logistic regression analysis to explore intensive care unit readmission, emergency department presentation, and cardiopulmonary resuscitation incidents, 14 days prior to death.Results: A total of 186,533 new PMV patients aged ≥ 18 years with terminal diseases were admitted between 2009 and 2017. Additionally, the number of patients receiving palliative care increased annually, from 0.6% in 2009 to 41.33% in 2017. The number of prolonged mechanical ventilation during emergency visits (odds ratio [OR]=0.68, 95%CI: 0.63-0.74), intensive care unit hospitalisation (OR=0.59, 95%CI: 0.53-0.46), cardiopulmonary resuscitation (OR=0.40, 95%CI: 0.35-0.46), and total hospitalisation cost (USD 1319.9.57 ± 1821.67 vs. 1544.37 ± 2309.27) was lower in the palliative care group.Conclusion: Patients undergoing PMV whilst in hospice palliative care can significantly reduce total hospitalisation cost, intensive care unit admittance, cardiopulmonary resuscitation utilisation, and medical expenses at ≤14 days prior to death.

Analysis of Types And Costs of Drugs Used For 7 Days Before Death of Terminal Cancer Patients Hospitalized In Hospice And General Wards.

1) PurposeThe need for hospice palliative care continues to grow as the number of deaths from cancer increases with increasing interest in and need for the management of end stage cancer patients. We conducted this study to determine differences in quantity and cost of drugs used by end-stage cancer patients who were hospitalized in general wards or hospice wards for 7 days before death.2) MethodsAmong patients who died in the hospice ward or the general ward of a university hospital in a metropolitan city (Seoul) from January 2016 to September 2019, patients aged over 18 years with a hospital stay of 8 days or more were selected. A total of 526 patients were selected, including 290 from hospice wards and 236 from general wards.3) ResultsNumbers of PO, injections, and fluid, but not opioids, used in the hospice ward were significantly lower than those in the general ward. Cost of PO, injections, fluid, and total costs were significantly lower in the hospice ward than in the general ward. In the case of opioids, the cost was higher for the hospice ward. Total costs including all drug costs in the hospice ward were significantly lower than those in the general ward. 4) ConclusionCaring for people with terminal cancer in a hospice can lower costs and increase satisfaction for dying patients. Reducing the proportion of patients caring for terminal cancer in general wards and increasing access to hospice services can address health insurance deficits and exhaustion.