2023, Number 3
The ABCs of palliative care for surgery
Full text
10.35366/112929
Language: English/Spanish [Versi?n en espa?ol]
References: 11
Page: 191-194
PDF size: 147.95 Kb.
ABSTRACT
There is a wide range of diseases that require palliative care attention, such as neoplastic, cerebrovascular, and central nervous system diseases, among other chronic-degenerative diseases. With a focus on providing relief from the symptoms, pain, and stress of severe illness, regardless of diagnosis or prognosis, the goal of palliative care is to improve the quality of life for both patients and their families or primary caregivers. The basic management of symptoms, the discussion of the prognosis, the approach to treatment objectives and decisions at the end of life, are basic elements of palliative care that any doctor should know, as well as the moment in which they should consult a palliative care team.INTRODUCTION
According to the World Health Organization (WHO), palliative care (PC) is the active and comprehensive care of patients who do not respond to curative treatments to improve the quality of life of patients and their families.1 This definition has confined the care of patients with palliative needs only to those who cannot be offered curative therapeutic options or even in the terminal stage only, leaving unaccompanied all those patients in active treatment who live their illness not only with physical symptoms but also with a tremendous psychosocial and spiritual impact.
For this reason, the Center for Advanced Palliative Care (CAPC) defines palliative care as "care that is focused on providing relief from the symptoms, pain, and stress of severe illness, regardless of diagnosis or prognosis. The goal is to improve the quality of life for both patients and their family or primary caregivers."2
There is a wide range of diseases that require palliative care. According to the second WHO Global Atlas of Palliative Care published in 2020, about 30% of the world's population between 20 and 70 years of age requires palliative care, whereas the adult population over 20 years suffer from chronic diseases such as HIV (22.2%), neoplastic conditions (28.2%), cerebrovascular disease (14.1%), dementia (12.2%), pulmonary diseases (5%), liver pathology (2.4%), among others.3 To meet these needs, a significant increase in the professional workforce trained in palliative care or at least with the basic knowledge of palliative care is required.
Palliative care consultation is less common in surgical patients than in cases with chronic diseases, postponing this care until the patient is in the agonal phase; however, palliative care reaches its highest degree of effectiveness when considered at an early stage in the course of the disease, not only improving the quality of life of the patients but also reducing unnecessary hospitalizations and the use of health services, also decreasing the economic burden that these patients represent for the health system.4,5
WHEN TO CONSIDER THE SUPPORT OF A PALLIATIVE CARE TEAM IN A HOSPITAL SETTING?
The CAPC considers that there are clinical situations that warrant consultation by a palliative care team, including:5
- 1. Prognosis of mortality in less than 12 months.
- 2. Frequent hospital admissions.
- 3. Use of health resources due to complex physical or psychological symptoms.
- 4. Need for complex care.
- 5. Decrease in function.
- 6. Stay in the Intensive Care Unit (ICU) for over seven days.
In the surgical area, the American College of Surgeons Task Force on Palliative Care has identified specific conditions that warrant the integration of palliative care specialists for the management of surgical patients, such as:5
- 1. Family or primary caregiver request.
- 2. Disagreements in decision-making and advance directives.
- 3. Diagnosis with survival of less than six months.
- 4. Carcinomatosis or unresectable malignancy.
- 5. Presence of advance care directives (in Mexico, known as the Advance Directive Law).
- 6. Glasgow Coma Scale less than 8 points for more than one week in patients older than 55.
- 7. Multiple organ failure.
ESSENTIAL SYMPTOM MANAGEMENT IN THE PATIENT WITH PALLIATIVE NEEDS
Although pain is one of the main symptoms present, not only in oncology patients but also in those with advanced disease, it is not the only symptom that patients with a severe diagnosis may experience.6
The main symptoms associated with the disease or treatments that are evaluated and treated by palliative care specialists are nausea, fatigue, anorexia, constipation, dyspnea, increased secretions, sadness, and anxiety, among others.2
To evaluate these symptoms and their impact on daily life, it is advisable, for each symptom that the patient expresses, to ask the patient to rate the symptom on a scale of 1 to 10, with 10 being the most severe expression of the symptom; in addition, it is advisable to ask how the patient rates the symptom at the time of the evaluation and how much he/she considers the symptom to be a tolerable score.2
This assessment will allow the prioritization of the symptoms that impose the greatest burden on the patient and those that must be addressed immediately, as well as the development of a care plan for future visits.
PAIN MANAGEMENT
More than half of cancer patients experience pain related to the neoplastic process and the treatment; on the other hand, almost 90% of patients with advanced disease experience pain at any point of the disease, so it is essential to know basic pain management.6
It is recommended that, after maximizing non-opioid analgesics, treatment of severe chronic pain should include the use of weak opioid medications.2 If adequate pain control cannot be achieved, the palliative care specialist should be consulted, as they are physicians trained in the management of different pain syndromes and have experience with the management of opioids, adjuvants, and non-pharmacologic therapies for pain control.6
In addition, because of the complexity of the psychosocial and spiritual aspects surrounding the severely ill patient, the palliative care specialist can address "total pain", a term coined by Ciceley Saunders, the founder of modern palliative care; "total pain" is defined as the physical, social, psychological, and spiritual suffering experienced by a patient.6
Therefore, the surgical team must collaborate with palliative care teams to improve patients' clinical conditions.
COMMUNICATION AND DECISION-
Understanding how the disease affects the patient's life mentally and psychologically is extremely important. This understanding promotes better communication and doctor-patient relationships.
The use of natural language for the communication of a severe diagnosis, therapeutic options, prognosis, need for palliative care, goals of care, and advanced directives allows for better information processing and conscious decision-making.7
Although communication has been recognized as an essential part of medical training from the classroom to the clinical areas, addressing "bad news", prognosis, and end-of-life continue to present a significant challenge for healthcare professionals, both because of personal barriers and those present in their clinical environment, so it will be challenging to find a single way to improve communication.8
In general, communication skills involve eye contact, the use of appropriate body language such as an open posture, sitting close to the patient, performing active listening such as nodding or making noises of affirmation or encouragement to indicate understanding, reflecting empathy, and showing compassion using a warm, caring, and respectful attitude.9
For decision-making and advanced care guidelines, health professionals in our country must know the Law of Advance Directives, which, in its first article, indicates that "its purpose is to establish the rules to regulate the granting of the will of a person with capacity to exercise, to express their decision to be subjected or not to medical means, treatments, or procedures intended to prolong their life when they are in the terminal stage and, for medical reasons, it is impossible to maintain it naturally, protecting at all times the dignity of the person".10
The Advance Directive Law encompasses five main guidelines: cardiopulmonary resuscitation, mechanical respiration, specialized nutritional support, medication for pain and other physical symptoms, and palliative sedation. This law is valid in Mexico City, Coahuila, Aguascalientes, San Luis Potosí, Michoacán, Hidalgo, Guanajuato, Guerrero, Nayarit, Estado de México, Colima, Oaxaca, Yucatán, and Tlaxcala. Through the Advance Directive Law, the patient's autonomy is protected and provides a care guide for the treating medical team.10
SPIRITUAL SPHERE
Spirituality is a multidimensional concept encompassing the meaning of life and transcendence. It is closely related to the patient's life history, personal satisfaction with life events, and beliefs in a higher power or God.11 Addressing and understanding the spiritual sphere of the seriously ill patient helps the patient cope with suffering and mortality.
Key points that can be assessed during the consultation by the treating physician are faith, sense of belonging, and community, which can be done through the following questions:2
- 1. Do you practice any religion?
- 2. What are the components of your life that give it meaning?
- 3. Are your beliefs important in making decisions about your health?
- 4. Do you belong to any religious or spiritual community?
Spiritual symptoms are closely related to psychosomatic expressions in terminal illness, such as chronic pain, so offering spiritual assistance improves the quality of life, serenity, and the dying process.11
CONCLUSIONS
Palliative care is expressly recognized in the context of the human right to health. It should be provided through integrated, person-centered health services, with particular attention to the individual's needs and preferences. Considering that surgical inpatients and outpatients are less likely to be referred to palliative care for symptom management and end-of-life decision-making and that the number of palliative care specialists does not meet the demand for palliative needs in the population, surgical teams must be aware of the basic principles of palliative care, as well as the areas in which they can be supported to improve patient care.
REFERENCES
Clayton JM, Hancock KM, Butow PN, et al. Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers. Med J Aust. 2007; 186: S77-S105. Available in: https://doi.org/10.5694/j.1326-5377.2007.tb01100.x
AFFILIATIONS
1 Specialist in Palliative Care. Mexican School of Medicine, Universidad La Salle, Mexico. https://orcid.org/0009-0000-6327-4701
2 Head of the Center for Educational Innovation in Medicine and Clinical Simulation of La Salle. Mexican School of Medicine, Universidad La Salle, Mexico. https://orcid.org/0000-0002-0451-5285
CORRESPONDENCE
Sara Concepción Ortega-Espino. E-mail: dra.saraoe@gmail.comReceived: 06/26/2023. Accepted: 07/31/2023.