Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Palliative care services in the community. Some experiences from Cienfuegos, Cuba.
- Alfredo A. Espinosa-Roca, Juan R. Zerquera-Rodríguez, Alfredo D. Espinosa-Brito, José L. Garriga-Valdés (23 April 2007)
-
Let's go to hospital: palliative care in A&E
- Kirsty J Boyd, Katherine Linton, Sandra McConnell (8 May 2007)
|
|
|||
|
Alfredo A. Espinosa-Roca, Coordinator Pallliative care program Municipal Health Division of Cienfuegos, Ave 56 No. 2917, Cienfuegos 55 100, Cuba, Juan R. Zerquera-Rodríguez, Alfredo D. Espinosa-Brito, José L. Garriga-Valdés
Send response to journal:
|
Editor: We agree with Munday and Dale (1) that “developing palliative care services in primary care is essential for realising the expectations of dying people”. It seems to be logical to develop these type of services in any community, in order to bridge the gap between the wishes of terminally ill patients (and their relatives) -who prefer their own homes as the place for dying- on one side, and what is taking place in different contexts nowadays, on the other part. Care in the hospital of this type of patients is very costly in all senses, and it is often not what the person or their family would ideally like if stress could be removed from the home situation. Based on the advantages of primary care services as part of our National Health System, and with the objective to offer health services so close the community as it is possible, since the last years of the past decade our group developed and have implemented a comprehensive programme of palliative care services in primary care in Cienfuegos, Cuba. (2) We carried out a survey in Cienfuegos City, and we interviewed the relatives or proxies of a randomized sample of 226 adults (>15) who had lived in the city and died in 2003. (2) Among other data, it was found that 171 -three out of four adult deaths occurred in Cienfuegos-, fulfil the criteria of terminally ill patients, (2) as a logical consequence of our main causes of death distribution, according the third stage of epidemiological transition, including a progressive ageing process of the population. (3) Although 51% of deaths occurred at hospitals, 53% of those terminally ill patients died at their domiciles, in the great majority because of their own wishes -substantially more people would prefer to die at home-, while 71% of those classified as no terminally ill, died at hospitals. Reorientation of human and material resources is a very important issue for the sustainability of palliative care services in primary care. As part of our programme in Cienfuegos, we published appropiate clinical guidelines to manage palliative care services, based on the best evidences in this field, which were locally achieved, attempered and implemented. (4) It is commonly assumed that all primary care professionals have the potential and the ability to provide good end of life care for most patients. However, not always it is so. As Godlee wrote: “medical training is about conquering disease. Death is too often seen as failure, and impending death as our signal to withdraw from the scene” (5) In another local survey, we found that almost one out three medical doctors of primary care sevices in Cienfuegos answered that they did not receive an adequate education in palliative care during their university years. In order to improve this matter, we started a continuous education programme for them since 2002, with very good results. Our framework enabled general practitioners and community nurses, social workers, pharmacists, red cross volunteers, caregivers and community leaders to optimise practice by providing guidance through workshops and locally based facilitation on how to implement processes needed for good primary palliative care. (4) As the experience reported by Munday and Dale, (1) our education programme was supported by different practical tools, guidance documents, and examples of good practice. Exploring the community satisfaction with our palliative care programme through several qualitative methods, showed that 93% of the patient relatives interviewed were satisfied with the services. This outcome has been very important to support they need of adequate investment for the sustainability of our programme. (1) Alfredo A. Espinosa-Roca, MD, coordinator, palliative care programme,
Municipal Health Division of Cienfuegos, Ave 56 No. 2917 altos, Cienfuegos 55 100, Cuba Alfredo D. Espinosa-Brito, MD, PhD, professor, Department of Internal
Medicine, Teaching Hospital “Dr. Gustavo Aldereguía Lima”, Cienfuegos, Ave 5 de Septiembre and Calle 51A, Cienfuegos 55 100, Cuba References 1. Munday D, Dale D. Palliative care in the community (editorial). BMJ 2007;334:809-810 (21 April), doi:10.1136/bmj.39174.605081.80 2. Espinosa-Roca AA, Espinosa-Brito AD, Fernández-Casteleiro E, Sabatés- Llerandi T. Where patients with cancer die in Cuba. BMJ 2006;332:668. 3. Cuba. Ministerio de Salud Pública. Anuario Estadístico de Salud. Años 1970-2005. República de Cuba. La Habana, Cuba. 4. Espinosa AA, Romero AJ, Misas M, Fresneda O. Asistencia al enfermo terminal en la atención primaria de salud. Rev Finlay 2005;10 (número especial):133-43. 5. Godlee F. Straight thinking. BMJ 2007;334(21 April), doi:10.1136/bmj.39189.594178.BD Competing interests: None declared |
|||
|
|
|||
|
Kirsty J Boyd, Consultant in Palliative Medicine Royal Infirmary of Edinburgh. Little France Crescent, EdinburghEH 16 4SA, Katherine Linton, Sandra McConnell
Send response to journal:
|
Dear Editor, Munday and Dale promote the Gold Standards Framework as a primary care based tool that could enhance community palliative care and give more people the option of dying at home, given adequate funding for nursing care and specialist palliative care advice. (1, 2) The Framework aims to improve coordination of care through establishing registers of palliative care patients, encouraging regular multidisciplinary review meetings, and ensuring good communication with out-of-hours services. We recently conducted a pilot audit of palliative care admissions presenting acutely via the accident and emergency unit of the main hospital in Lothian. In a seven day period we identified 43 palliative care patients (8%) out of the 557 people admitted. Patient records were retrieved and screened using the Prognostic Indicator Guidance from the Gold Standards Framework. It contains a range of clinical factors suggesting the patient has a limited life expectancy and is recommended as a tool for use in identifying palliative cancer patients and those with advanced non-malignant disease such as heart failure and chronic obstructive pulmonary disease. Most of the palliative care patients were elderly (33; 79% over 70), lived alone (26; 61%) and 26 were women. Multiple co-morbidities predominated with only six having a cancer diagnosis. Breathlessness was the commonest presenting complaint followed by “collapse” and falling. One cancer patient had pain as the main issue. Nearly half the patients arrived during normal working hours, almost all came by ambulance (39; (91%), and a “999” call was common (26; 61%). By seven days 44% had gone home again. Although this was a small study, the findings raise important questions. Are elderly palliative care patients presenting acutely to hospital with non-specific deterioration and without contacting their GP? Patients and carers and professionals identify a palliative cancer patient more readily than someone with an advanced non-malignant illness and the elderly population with multiple life-limiting conditions is increasing. (3) An absence of advance care planning militates against maintaining care in the community. Health care and support for people with multiple advance progressive illnesses is complex and requires new partnerships and working practices involving not just primary care professionals but a range of specialist services as well. 1. Munday D, Dale J. Palliative care in the community. BMJ 2007;334:809-810 2. National Health Service. End of life care programme. Gold Standards Framework. 2006. www.goldstandardsframework.nhs.uk. 3 Smith SM, O’Dowd T. Chronic diseases: what happens when they come in multiples? Br J Gen Pract 2007;57:268-70 Competing interests: None declared |
|||