Descriptive cohort trial of terminal patients in medical home care in Bogotá – 2008–2012

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"/22562087/0000004200000002/v1_201404120216/S2256208714000261/v1_201404120216/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "Scientific and Technological Research" "titulo" => "Descriptive cohort trial of terminal patients in medical home care in Bogotá – 2008–2012" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "100" "paginaFinal" => "106" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Liliana M. Támara" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Liliana M." "apellidos" => "Támara" "email" => array:1 [ 0 => "drltamara@yahoo.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "MD, Specialist in Bioethics and Palliative Care, Candidate to a Masters Degree in Social Protection, Private Physician of Home End-of-Life Care in Bogotá, Colombia" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Correspondence to: Calle 119ª No. 56 A 83 Ap 101, Bogotá, Colombia." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estudio de cohorte descriptivo de los pacientes terminales atendidos médicamente en su domicilio en Bogotá. 2008–2012" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: home care medical record, Bogotá, January 2008 through June 2012." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 600 "Ancho" => 1635 "Tamanyo" => 63974 ] ] "descripcion" => array:1 [ "en" => "General distribution according to marital status." ] ] ] "textoCompleto" => "IntroductionEnd-of-life medical care of patients involves some specific internationally defined guidelines. In 2007 the WHO established some palliative care recommendations as an urgent public policy to care for cancer patients and other chronic lethal conditions.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>There are 3 measures for developing palliative care from the public health perspective<a class="elsevierStyleCrossRef" href="#bib0010">2</a>: public policy, educational policy, and pharmaceutical policy to ensure the availability of essential medicines.Palliative home carePalliative home care requires around-the-clock availability, proper, state-of-the-art scientific and humane knowledge and adequate familiar, social and sanitary conditions to meet all the end-of-life needs of the patient. It is based on providing pain relief and alleviating other symptoms, in addition to understanding death as a normal process, as well as helping families to handle the disease of the patient and their own bereavement.A number of studies show the preference of both patients and families to be at home until the patient's demise,<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a> with home care that ensures good quality of life even in our own environment.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>According to Twycross, the art of medicine resides in deciding when vital support is basically useless and thus when to allow the patient to die with no further impediment. A physician is not legally or ethically obliged to preserve life “at all costs”. Life should be preserved as long as it is biologically sustainable.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>The physical and psychological end-of-life symptoms demand active and very close medical care. Currently, the therapeutic armamentarium provides excellent levels of analgesia, pursuant to the WHO recommendations for relieving cancer pain that date back to 1986,<a class="elsevierStyleCrossRef" href="#bib0035">7</a> and later revisions, as well as the recommendations by PAHO,<a class="elsevierStyleCrossRef" href="#bib0040">8</a> national associations<a class="elsevierStyleCrossRef" href="#bib0045">9</a> and government agencies.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> The availability of opiates in Bogotá is good; however, there are still some limitations to access the medication.While there is an increasing number of consolidated units and palliative care groups in Colombia, due in part to advances in the legislation,<a class="elsevierStyleCrossRef" href="#bib0050">10</a> there is still considerable difficulty to provide enough coverage to this population and to ensure ethical end-of-life decisions.<a class="elsevierStyleCrossRef" href="#bib0055">11</a>Palliative care sedationPalliative care sedation is valuable at different points in time, whether intermittent or continuous, in accordance with the patient's condition. The Spanish Society of Palliative Care defines sedation as the purposeful administration of drugs, at the doses and combinations required, to reduce the awareness of a patient with advanced or terminal disease, to the extent needed to adequately relief one or more refractory symptoms,<a class="elsevierStyleCrossRef" href="#bib0060">12</a> provided that the patient or legal representative has given his/her explicit consent.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>Guidelines for end-of-life sedation have been developed in various countries.<a class="elsevierStyleCrossRefs" href="#bib0070">14,15</a> In Colombia there are several case reports<a class="elsevierStyleCrossRefs" href="#bib0080">16,17</a> and a consensus was recently published for sedation administered by non-anesthesiologists.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>Use or interruption of hydration and nutrition during permanent sedation in palliative careOne of the most complex end-of-life interventions is caring for the pathophysiological mechanisms while the patient is dying. When the process is irreversible and death is imminent, starting interventions to hydrate and provide nutritional support that require hospital transfers, surgical procedures (venodisections, central venous catheters, gastrostomies) and even regular venopunctures for a patent venous access does not help in reducing the suffering of the family, the patient or the health team. Moreover, these measures fail to respond to the pathological conditions arising in most patients with a reduced osmotic pressure that translates into symptoms (edemas, rattles, fluid weight gain) that hinder the adoption of comfort measures or actions to at least avoid any further discomfort.The instructions given by the patient while still aware, informed, escorted and with certainty that his/her suffering will not be further aggravated, and who enjoys the support for a family or social network that ensures that the patient is not experiencing any physical symptoms such as thirst or hunger, shall be followed. Within this context, the ethical recommendations for decision-making based on the proportionality of the medical intervention are applicable.<a class="elsevierStyleCrossRef" href="#bib0095">19</a>There are no studies in Colombia – more specifically in Bogotá – describing the characteristics of the population that asks for palliative care. Neither the methodology nor the results of interventions such as home care sedation, hydration and nutrition management in the terminal patient are well known. Thus, the purpose of this paper is to describe a population of terminally ill patients that asked for private medical care from 2008 to 2011 in Bogotá, including the proportion of patients requiring sedation and nutritional and hydration management during this stage.Materials and methodsA cohort of 164 patients undergoing medical care were followed from January 1st through June 30, 2012. The patients were diagnosed with end-stage disease and they asked for private medical care in Bogotá, Colombia. The information was collected from the medical records of a private health care provider, using a form designed to record the information that was transferred to an Excel database. A descriptive statistical analysis was then performed on the socio-demographic variables, the place where care was provided, the primary lethal diagnoses, the management of the patients, length of care, use of terminal sedation and limitation of therapeutic efforts. This article was endorse by the Colombian Institute of Bioethical Studies (ICEB).ResultsOf the 164 patients, 54% (n=90) received care until their demise and the corresponding death certificate was issued. The rest of the patients decided to seek care elsewhere. The age range of the patients that were taken care of until their demise was 37–94 years old, with a mean of 77 and a 3.5 standard deviation. The age range of the dropout patients was 13–99 years old, with a mean of 74 and a standard deviation of 4.0. The gender distribution was similar, with 63% females (n=103) and 41% widowers (n=67). The total distribution is presented in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The general distribution in accordance with their last year of education was as shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>; most patients completed their last year of university education and high-school. The range included no education in one patient, to 6 people with a master's degree.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>According to the medical record, 138 patients were Catholics (84%), and 20 medical charts fail to specify the religion; 3 patients said they did not practice any religion, while 3 of them were: Jew, Adventists and Menonits.Most patients were affiliated to the Social Security System: 49.4% (n=81) were in the obligatory prepaid medicine system; 7.9% (n=13) belonged to special regimes (military, professors, Ecopetrol) and 1% to the subsidized regime 1% (n=2). Additionally, 25% (n=41) had national or international insurance, complementary insurance plans or HMOs. Only 8 patients did not have any type of insurance and were paying for their care from their own pockets.Diagnoses52% (n=86) of the patients cared for had some form of cancer and 25% (n=41) had neurological conditions; the rest included heart disease, pulmonology, renal and other conditions as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Among the group of oncology patients, the most frequent tumors were prostate tumors (n=11; 6.7%), breast (n=9, 5.48%) and brain (n=9, 5.48%).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Of the patients that were taken care of until their demise, the main causes of death were emaciation, sepsis and respiratory failure. <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> illustrates the various lethal diagnoses.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Medical care characteristics91% (n=150) of the cases received medical home care, 11 (7%) were admitted at geriatric units and 3 (2%) went to private 3rd level health care institutions. The number of visits ranged between 1 and 9 visits, though most of them – 52% (n=86) only had one visit. <a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a> illustrates the distribution of the number of visits.<elsevierMultimedia ident="fig0020"></elsevierMultimedia>The length of care of patients who stayed until the end varied from 1 to 361 days, with a mean of 45.6 days, with a standard deviation of 16.06.The preferred route of administration of the drugs was the oral route and the second choice was subcutaneous; the intramuscular route was only used in 10 (11%) of the sepsis patients. Inhaled administration was used in all patients with respiratory failure (n=18, 20%) and in 10 (11%) patients with death rattles. No IV or subcutaneous catheters were used.MedicinesThe most frequently used drug was tramadol in 74 patients (82%). Only ten (11%) patients did not require painkillers. Hydromorphone was used in 2 (2.2%) patients, while morphine was used in 4 (4.44%). The tramadol doses used ranged between 50mg/day and 1800mg/day, with an average of 177mg/day.The second most frequent drug used was subcutaneous ranitidine in 70 patients (77%) at doses ranging from 50 to 100mg/day.The proportion of midazolam was similar and it was administered to 70 patients (77%). 5 of these patients only received 2mg rescue doses as needed. The rest of them used a dose range between 2.5mg/day and up to 90mg/day. The only patient who received a 90mg/day dose had a considerable body surface area, had used opiates on an on going basis for over 2 years and was in persistent vegetative state. The average dose used was 15mg/day.The common antiemetic agent used was metoclopramide in 73% (n=66) and alizapride in 16% (n=15). 10% (n=9) of the patients did not require any antiemetics.Other less frequently used drugs were furosemide (n=3; 3.3%), vitamin K (n=5; 5.5%), ipratropium bromide solution inhaler (n=25; 27.7%), prednisolone (n=6; 6.6%) and atropine (n=6; 6.6%). Some patients however used more than one medicine.Palliative sedation66 patients, 73% of the total number of patients that received end-of-life care until their demise, were treated with medicines to maintain a superficial sedation. The sedation lasted from 1 to 35 days, with an average of 4.1 days; the standard deviation was 1.12. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the sedation time range distribution; 85% (n=56) stayed sedated for less than one week, while 7 patients were sedated for just one day.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Artificial hydration and nutritionA gastrostomy tube was used for feeding 3 patients, either at the request of the patient or the family. In one patient a nasogastric tube provided hydration, upon consent of the patient and family after being informed about its metabolic effects during the end-of-life phase. Nasogastric or gastrostomy nutritional support was interrupted in 8 patients (n=6 and n=2, respectively).DiscussionThe population forecast for 2010 based on the 2005 census was 7,363,782 inhabitants.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> The estimated implicit mortality rate for 2005–2010 was around 4.4/thousand inhabitants,<a class="elsevierStyleCrossRef" href="#bib0105">21</a> taking into consideration other causes of mortality besides violence, neonatal and maternal mortality. The percentage of home care patients studied who paid from their own pockets from 2008 to 2012 was 0.19%, by just one private health care practitioner.Most of the terminally ill patients receiving care were beyond the life expectancy age for the Colombian population; i.e., 73 years.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> However, patients range from adolescents to ninety year olds.No studies have been made about the reasons why patients or their families ask for private home care or for patients wanting to receive this type of care until their demise. The results presented in this study show that most patients were females. On the other hand, the fact that the wife died meant that most of the patients were widowers. Another characteristic of the population was the level of education, mostly university graduates or at least high-school education. Most patients were Catholics, which is a critical aspect in the end-of-life approach. Knowing the religious or spiritual affiliation of patients and families helps for improved decision-making.<a class="elsevierStyleCrossRef" href="#bib0115">23</a>Most of the patients in this cohort still need end-of-life care due to cancer illnesses; the broad range and the scope of cancer-related symptoms demand aggressive medical interventions for adequate management, in addition to the “relative” ease for an objective and subjective acknowledgment of the fact that every possible therapeutic resource available has been exhausted to move to a purely palliative approach, within the framework of a society that mostly refuses to accept euthanasia or assisted suicide as an option. This distribution by diagnoses is similar to the hospice care offered in the United States.<a class="elsevierStyleCrossRef" href="#bib0120">24</a>Secondly, there are some neurological pathologies with evident additional difficulties, since these patients are no longer self-sufficient, including their sound judgment for decision-making, so it is up to the family to decide if the patient has not previously expressed his/her will. The patient representative finds it hard to decide what their loved one would have liked, and he/she is even influenced by his/her own interests (taking advantage of the patient's pension or housing and even getting the attention of the rest of the family).Care was mostly given at patient homes to avoid the ER or hospital admission, responding to the constantly changing needs of terminally ill patients for prompt relief. Such approach provides the proper environment and facilitates family decision-making in accordance with their realities and with adequate medical and professional information. It most be noted however that while most patients prefer to die at home, there is a group of patients and/or families who do not, and these differences shall be assertively managed.<a class="elsevierStyleCrossRef" href="#bib0125">25</a>Hence it is desirable and recommendations have been made on the characteristics of palliative care programs where medical management should be the core, with nursing support, therapies and mental health, among other components.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> It is not recommended to require time-consuming formalities to include patients in the program, but rather to have programs that are more flexible and suitable for terminally ill patients instead of simply enrolling them in programs for patients with chronic conditions. It is cumbersome to transfer terminally ill patients to and from doctor offices to deal with each of their multiple symptoms, or to repeat the medical record to each specialist visiting the patient at home, with no continuity of the process, which in itself is quite complex and difficult.The number of visits is an indicator of various factors; first, doing an intervention at the first visit is a sign of the urgency of end-of-life care. A second observation refers to a 24×7 hotline, for anticipating any events and keeping in mind a subcutaneous route as a rapid and effective approach for relieving symptoms. Thirdly, the presence of severe pain or any other symptoms as a source of direct stimulus, requires the use of analgesic doses to calm down the agonic patient so that the demise may occur a few hours or days later with no additional interventions required. Finally, when the patient expresses his/her final wishes to the family in a calm and friendly environment that moment becomes cathartic to relief tensions and reduce the anxiety of the final process.In terms of medicines used, the generalized availability of a moderately strong parenteral opiate at an affordable price such as tramadol that acts on the three types of pain makes it a convenient painkiller to relief pain, including cancer pain. Moreover, the tolerance to tramadol is excellent if antiemetic and laxative agents are anticipated, avoiding the very frequent psychotropic effects of non-synthetic opiates in bed-ridden patients.The use of subcutaneous anti-ulcer agents such as a prophylactic measure in erosive GI tract diseases is key and prevents the occurrence of alarming symptoms such as GI tract bleeding.Superficial sedation was used in almost three fourths of the patients cared for until their demise. This is a decision made by those patients with a strong family and social support network that favor pain relief rather than being fully aware till the end; they have been properly informed about what they should expect, they have sufficient economic and social resources to pay for the sedative that is expensive and some times difficult to find.Certain considerations are involved in the decision to maintain or remove hydration or nutritional support when the oral rout is compromised. Just as nobody made the decision to change the route for accomplishing the same purpose, it was not as easy to decide the removal of the gastrostomy tube, the catheter or the intravenous line. These decisions are extremely sensitive and nothing should be imposed; however, make sure that all the relevant information is shared. This approach gives both patients and family some options to decide in an extremely difficult situation.<a class="elsevierStyleCrossRef" href="#bib0135">27</a>Lastly, a few general observations: presently, medicine provides us with powerful therapeutic tools for managing physical symptoms. End-of-life myths and preconceptions for using drugs that may have side effects – shorten the life span – should be put aside. We must continue to make headway in encouraging the availability of essential medicines for managing terminally ill patients,<a class="elsevierStyleCrossRef" href="#bib0140">28</a> and keep in mind that ultra-short acting benzodiazepines are safe and effective for superficial sedation of these patients.Absolutely it is better to avoid treating end-of-life patients in a cruel, inhuman or degrading manner at all times, but mostly when death is imminent. Scientific compassion, avoiding forcing the nature of human existence of the patients we assist, is fundamental to guide palliative therapeutic processes.<a class="elsevierStyleCrossRef" href="#bib0145">29</a>There is then a humanistic and scientific approach to the management of end-of-life care; it is however necessary to develop a legislative framework to protect our patients against any actions that are not consistent with such an approach and be able to legally demand proper care.FundingNone.Conflicts of interestThe author has no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:18 [ 0 => array:2 [ "identificador" => "xres329735" "titulo" => array:4 [ 0 => "Abstract" 1 => "Methodology" 2 => "Results" 3 => "Analysis" ] ] 1 => array:2 [ "identificador" => "xpalclavsec311614" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres329734" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Metodología" 3 => "Resultados" 4 => "Análisis" ] ] 3 => array:2 [ "identificador" => "xpalclavsec311613" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Palliative home care" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Palliative care sedation" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Use or interruption of hydration and nutrition during permanent sedation in palliative care" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Materials and methods" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 10 => array:3 [ "identificador" => "sec0035" "titulo" => "Diagnoses" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Medical care characteristics" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Medicines" ] ] ] 11 => array:2 [ "identificador" => "sec0050" "titulo" => "Palliative sedation" ] 12 => array:2 [ "identificador" => "sec0055" "titulo" => "Artificial hydration and nutrition" ] 13 => array:2 [ "identificador" => "sec0060" "titulo" => "Discussion" ] 14 => array:2 [ "identificador" => "sec0065" "titulo" => "Funding" ] 15 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflicts of interest" ] 16 => array:2 [ "identificador" => "xack78515" "titulo" => "Acknowledgement" ] 17 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-01-05" "fechaAceptado" => "2014-01-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec311614" "palabras" => array:5 [ 0 => "Palliative Care" 1 => "Ambulatory Care" 2 => "Ethics, Clinical" 3 => "Aged" 4 => "Analgesia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec311613" "palabras" => array:5 [ 0 => "Cuidados paliativos" 1 => "Atención ambulatoria" 2 => "Ética clínica" 3 => "Anciano" 4 => "Analgesia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Palliative care for end-of-life patients in Bogotá is still in the process of consolidation. This type of care demands high technical and scientific standards, in addition to supporting the patient and family in making end-of-life ethical decisions, particularly with respect to sedation, hydration and feeding. MethodologyStatistical descriptive analysis of a cohort comprised of 164 terminally ill patients treated in private practice in Bogotá between 2008 and 2012. ResultsOut of the 90 patients who received care until their demise, the average age was 77 years old, including 63% women, 30%, university students, 41% widowers, and 84% Catholics. 8 patients had no medical insurance. 52% of the patients were cancer patients, 91% received home care, the average number of care days was 45 and the usual route of administration of medicines was subcutaneous. The most commonly used drugs were tramadol, ranitidine and midazolam. 73% of the patients required superficial sedation. In some cases, feeding and hydration were administered through alternate routes and in others were discontinued. AnalysisThere is a need to study the conditioning factors for private medical home care and for maintaining this type of care until the end of life. Characterizing this population enables the identification of some useful information for the administration of end-of-life care in the country." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "IntroducciónEl cuidado médico paliativo en Bogotá para pacientes terminales sigue en proceso de consolidación. Esta atención exige altos estándares técnicos y científicos, así como el apoyo a las decisiones éticas al final de la vida del paciente y sus allegados, especialmente en cuanto a la sedación y al uso de hidratación y alimentación. MetodologíaSe realizó un análisis estadístico descriptivo de una cohorte de 164 pacientes terminales atendidos en práctica médica privada en Bogotá entre 2008 y 2012. ResultadosDe los 90 pacientes atendidos hasta su fallecimiento se encontró un promedio de edad de 77 años; el 63% mujeres, el 30% universitarios/as, el 41% viudos/as, el 84% cató-licos/as, y 8 pacientes sin afiliación al sistema de seguridad social. El 52% de los pacientes fueron oncológicos, y el 91% se atendieron en sus casas. El promedio de atención fue de45 días, y la vía más utilizada para la administración de medicamentos fue la vía subcutánea. Los medicamentos más usados fueron el tramadol, la ranitidina y el midazolam. El73% de los pacientes requirieron sedación superficial. En algunos casos se continuaron y en otros se interrumpieron la alimentación y la hidratación por vías alternas. AnálisisSe requieren estudios que den cuenta de los factores que condicionan la solicitud de atención médica privada domiciliaria, o para mantenerse en este tipo de atención hasta el final de la vida. La caracterización de esta población permite identificar algunos elementos útiles para la práctica del cuidado paliativo en el país." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Támara LM. Estudio de cohorte descriptivo de los pacientes terminales atendidos médicamente en su domicilio en Bogotá. 2008–2012. Rev Colomb Anestesiol. 2014;42:100–106." ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: home care medical record, Bogotá, January 2008 through June 2012." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 600 "Ancho" => 1635 "Tamanyo" => 63974 ] ] "descripcion" => array:1 [ "en" => "General distribution according to marital status." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Home care medical charts, Bogotá, January 2008 to June 2012." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 729 "Ancho" => 1317 "Tamanyo" => 53846 ] ] "descripcion" => array:1 [ "en" => "General patient distribution according to schooling." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Home care medical records, Bogotá, January 2008 to June 2012." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1142 "Ancho" => 1498 "Tamanyo" => 108271 ] ] "descripcion" => array:1 [ "en" => "Distribution of diagnosis that led to death." ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Home care medical records, Bogotá, January 2008 to June 2012." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 726 "Ancho" => 1555 "Tamanyo" => 57023 ] ] "descripcion" => array:1 [ "en" => "Number of medical visits." ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Home care medical records, Bogotá, January through June 2008 to June 2012." "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Diagnostic group \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Cared for \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Withdrawn \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cancer pathology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">86 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Degenerative encephalopathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Persistent vegetative state \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Miscellaneous neurological \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Heart failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">COPD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CRF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Senility \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rheumatoid arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HIV AIDS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">164 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab483744.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Non-oncological diagnostic characteristics leading to the end-of-life phase." ] ] 5 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Home care medical records, Bogotá, January 2008 to June 2012." "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Range of duration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No. of patients \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1–6 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7–13 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>14 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab483743.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Distribution according to the duration of care in days." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cancer control: knowledge into action: WHO guide for effective programmes; module 5" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "WHO Palliative Care" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2007" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cancer pain relief with a guide to opioid availability" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "WHO" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:4 [ "edicion" => "2nd ed." 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Scientific and Technological Research

Estudio de cohorte descriptivo de los pacientes terminales atendidos médicamente en su domicilio en Bogotá. 2008–2012

Liliana M. Támara

Corresponding author

drltamara@yahoo.com

Correspondence to: Calle 119ª No. 56 A 83 Ap 101, Bogotá, Colombia.

MD, Specialist in Bioethics and Palliative Care, Candidate to a Masters Degree in Social Protection, Private Physician of Home End-of-Life Care in Bogotá, Colombia

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">End-of-life medical care of patients involves some specific internationally defined guidelines&#46; In 2007 the WHO established some palliative care recommendations as an urgent public policy to care for cancer patients and other chronic lethal conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">There are 3 measures for developing palliative care from the public health perspective<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#58; public policy&#44; educational policy&#44; and pharmaceutical policy to ensure the availability of essential medicines&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Palliative home care</span><p id="par0015" class="elsevierStylePara elsevierViewall">Palliative home care requires around-the-clock availability&#44; proper&#44; state-of-the-art scientific and humane knowledge and adequate familiar&#44; social and sanitary conditions to meet all the end-of-life needs of the patient&#46; It is based on providing pain relief and alleviating other symptoms&#44; in addition to understanding death as a normal process&#44; as well as helping families to handle the disease of the patient and their own bereavement&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A number of studies show the preference of both patients and families to be at home until the patient&#39;s demise&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> with home care that ensures good quality of life even in our own environment&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">According to Twycross&#44; the art of medicine resides in deciding when vital support is basically useless and thus when to allow the patient to die with no further impediment&#46; A physician is not legally or ethically obliged to preserve life &#8220;at all costs&#8221;&#46; Life should be preserved as long as it is biologically sustainable&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The physical and psychological end-of-life symptoms demand active and very close medical care&#46; Currently&#44; the therapeutic armamentarium provides excellent levels of analgesia&#44; pursuant to the WHO recommendations for relieving cancer pain that date back to 1986&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and later revisions&#44; as well as the recommendations by PAHO&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> national associations<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and government agencies&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The availability of opiates in Bogot&#225; is good&#59; however&#44; there are still some limitations to access the medication&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">While there is an increasing number of consolidated units and palliative care groups in Colombia&#44; due in part to advances in the legislation&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> there is still considerable difficulty to provide enough coverage to this population and to ensure ethical end-of-life decisions&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Palliative care sedation</span><p id="par0040" class="elsevierStylePara elsevierViewall">Palliative care sedation is valuable at different points in time&#44; whether intermittent or continuous&#44; in accordance with the patient&#39;s condition&#46; The Spanish Society of Palliative Care defines sedation as the purposeful administration of drugs&#44; at the doses and combinations required&#44; to reduce the awareness of a patient with advanced or terminal disease&#44; to the extent needed to adequately relief one or more refractory symptoms&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> provided that the patient or legal representative has given his&#47;her explicit consent&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Guidelines for end-of-life sedation have been developed in various countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> In Colombia there are several case reports<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> and a consensus was recently published for sedation administered by non-anesthesiologists&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Use or interruption of hydration and nutrition during permanent sedation in palliative care</span><p id="par0050" class="elsevierStylePara elsevierViewall">One of the most complex end-of-life interventions is caring for the pathophysiological mechanisms while the patient is dying&#46; When the process is irreversible and death is imminent&#44; starting interventions to hydrate and provide nutritional support that require hospital transfers&#44; surgical procedures &#40;venodisections&#44; central venous catheters&#44; gastrostomies&#41; and even regular venopunctures for a patent venous access does not help in reducing the suffering of the family&#44; the patient or the health team&#46; Moreover&#44; these measures fail to respond to the pathological conditions arising in most patients with a reduced osmotic pressure that translates into symptoms &#40;edemas&#44; rattles&#44; fluid weight gain&#41; that hinder the adoption of comfort measures or actions to at least avoid any further discomfort&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The instructions given by the patient while still aware&#44; informed&#44; escorted and with certainty that his&#47;her suffering will not be further aggravated&#44; and who enjoys the support for a family or social network that ensures that the patient is not experiencing any physical symptoms such as thirst or hunger&#44; shall be followed&#46; Within this context&#44; the ethical recommendations for decision-making based on the proportionality of the medical intervention are applicable&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">There are no studies in Colombia &#8211; more specifically in Bogot&#225; &#8211; describing the characteristics of the population that asks for palliative care&#46; Neither the methodology nor the results of interventions such as home care sedation&#44; hydration and nutrition management in the terminal patient are well known&#46; Thus&#44; the purpose of this paper is to describe a population of terminally ill patients that asked for private medical care from 2008 to 2011 in Bogot&#225;&#44; including the proportion of patients requiring sedation and nutritional and hydration management during this stage&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Materials and methods</span><p id="par0065" class="elsevierStylePara elsevierViewall">A cohort of 164 patients undergoing medical care were followed from January 1st through June 30&#44; 2012&#46; The patients were diagnosed with end-stage disease and they asked for private medical care in Bogot&#225;&#44; Colombia&#46; The information was collected from the medical records of a private health care provider&#44; using a form designed to record the information that was transferred to an Excel database&#46; A descriptive statistical analysis was then performed on the socio-demographic variables&#44; the place where care was provided&#44; the primary lethal diagnoses&#44; the management of the patients&#44; length of care&#44; use of terminal sedation and limitation of therapeutic efforts&#46; This article was endorse by the Colombian Institute of Bioethical Studies &#40;ICEB&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">Of the 164 patients&#44; 54&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>90&#41; received care until their demise and the corresponding death certificate was issued&#46; The rest of the patients decided to seek care elsewhere&#46; The age range of the patients that were taken care of until their demise was 37&#8211;94 years old&#44; with a mean of 77 and a 3&#46;5 standard deviation&#46; The age range of the dropout patients was 13&#8211;99 years old&#44; with a mean of 74 and a standard deviation of 4&#46;0&#46; The gender distribution was similar&#44; with 63&#37; females &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>103&#41; and 41&#37; widowers &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>67&#41;&#46; The total distribution is presented in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The general distribution in accordance with their last year of education was as shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#59; most patients completed their last year of university education and high-school&#46; The range included no education in one patient&#44; to 6 people with a master&#39;s degree&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">According to the medical record&#44; 138 patients were Catholics &#40;84&#37;&#41;&#44; and 20 medical charts fail to specify the religion&#59; 3 patients said they did not practice any religion&#44; while 3 of them were&#58; Jew&#44; Adventists and Menonits&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Most patients were affiliated to the Social Security System&#58; 49&#46;4&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>81&#41; were in the obligatory prepaid medicine system&#59; 7&#46;9&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#41; belonged to special regimes &#40;military&#44; professors&#44; Ecopetrol&#41; and 1&#37; to the subsidized regime 1&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#46; Additionally&#44; 25&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>41&#41; had national or international insurance&#44; complementary insurance plans or HMOs&#46; Only 8 patients did not have any type of insurance and were paying for their care from their own pockets&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Diagnoses</span><p id="par0090" class="elsevierStylePara elsevierViewall">52&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>86&#41; of the patients cared for had some form of cancer and 25&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>41&#41; had neurological conditions&#59; the rest included heart disease&#44; pulmonology&#44; renal and other conditions as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Among the group of oncology patients&#44; the most frequent tumors were prostate tumors &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#59; 6&#46;7&#37;&#41;&#44; breast &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#44; 5&#46;48&#37;&#41; and brain &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#44; 5&#46;48&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Of the patients that were taken care of until their demise&#44; the main causes of death were emaciation&#44; sepsis and respiratory failure&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> illustrates the various lethal diagnoses&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Medical care characteristics</span><p id="par0100" class="elsevierStylePara elsevierViewall">91&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>150&#41; of the cases received medical home care&#44; 11 &#40;7&#37;&#41; were admitted at geriatric units and 3 &#40;2&#37;&#41; went to private 3rd level health care institutions&#46; The number of visits ranged between 1 and 9 visits&#44; though most of them &#8211; 52&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>86&#41; only had one visit&#46; <a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a> illustrates the distribution of the number of visits&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The length of care of patients who stayed until the end varied from 1 to 361 days&#44; with a mean of 45&#46;6 days&#44; with a standard deviation of 16&#46;06&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The preferred route of administration of the drugs was the oral route and the second choice was subcutaneous&#59; the intramuscular route was only used in 10 &#40;11&#37;&#41; of the sepsis patients&#46; Inhaled administration was used in all patients with respiratory failure &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>18&#44; 20&#37;&#41; and in 10 &#40;11&#37;&#41; patients with death rattles&#46; No IV or subcutaneous catheters were used&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Medicines</span><p id="par0115" class="elsevierStylePara elsevierViewall">The most frequently used drug was tramadol in 74 patients &#40;82&#37;&#41;&#46; Only ten &#40;11&#37;&#41; patients did not require painkillers&#46; Hydromorphone was used in 2 &#40;2&#46;2&#37;&#41; patients&#44; while morphine was used in 4 &#40;4&#46;44&#37;&#41;&#46; The tramadol doses used ranged between 50<span class="elsevierStyleHsp" style=""></span>mg&#47;day and 1800<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; with an average of 177<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The second most frequent drug used was subcutaneous ranitidine in 70 patients &#40;77&#37;&#41; at doses ranging from 50 to 100<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The proportion of midazolam was similar and it was administered to 70 patients &#40;77&#37;&#41;&#46; 5 of these patients only received 2<span class="elsevierStyleHsp" style=""></span>mg rescue doses as needed&#46; The rest of them used a dose range between 2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;day and up to 90<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#46; The only patient who received a 90<span class="elsevierStyleHsp" style=""></span>mg&#47;day dose had a considerable body surface area&#44; had used opiates on an on going basis for over 2 years and was in persistent vegetative state&#46; The average dose used was 15<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The common antiemetic agent used was metoclopramide in 73&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>66&#41; and alizapride in 16&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41;&#46; 10&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#41; of the patients did not require any antiemetics&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Other less frequently used drugs were furosemide &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#59; 3&#46;3&#37;&#41;&#44; vitamin K &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#59; 5&#46;5&#37;&#41;&#44; ipratropium bromide solution inhaler &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>25&#59; 27&#46;7&#37;&#41;&#44; prednisolone &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#59; 6&#46;6&#37;&#41; and atropine &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#59; 6&#46;6&#37;&#41;&#46; Some patients however used more than one medicine&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Palliative sedation</span><p id="par0140" class="elsevierStylePara elsevierViewall">66 patients&#44; 73&#37; of the total number of patients that received end-of-life care until their demise&#44; were treated with medicines to maintain a superficial sedation&#46; The sedation lasted from 1 to 35 days&#44; with an average of 4&#46;1 days&#59; the standard deviation was 1&#46;12&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the sedation time range distribution&#59; 85&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>56&#41; stayed sedated for less than one week&#44; while 7 patients were sedated for just one day&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Artificial hydration and nutrition</span><p id="par0145" class="elsevierStylePara elsevierViewall">A gastrostomy tube was used for feeding 3 patients&#44; either at the request of the patient or the family&#46; In one patient a nasogastric tube provided hydration&#44; upon consent of the patient and family after being informed about its metabolic effects during the end-of-life phase&#46; Nasogastric or gastrostomy nutritional support was interrupted in 8 patients &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6 and <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#44; respectively&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0150" class="elsevierStylePara elsevierViewall">The population forecast for 2010 based on the 2005 census was 7&#44;363&#44;782 inhabitants&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The estimated implicit mortality rate for 2005&#8211;2010 was around 4&#46;4&#47;thousand inhabitants&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> taking into consideration other causes of mortality besides violence&#44; neonatal and maternal mortality&#46; The percentage of home care patients studied who paid from their own pockets from 2008 to 2012 was 0&#46;19&#37;&#44; by just one private health care practitioner&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Most of the terminally ill patients receiving care were beyond the life expectancy age for the Colombian population&#59; i&#46;e&#46;&#44; 73 years&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> However&#44; patients range from adolescents to ninety year olds&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">No studies have been made about the reasons why patients or their families ask for private home care or for patients wanting to receive this type of care until their demise&#46; The results presented in this study show that most patients were females&#46; On the other hand&#44; the fact that the wife died meant that most of the patients were widowers&#46; Another characteristic of the population was the level of education&#44; mostly university graduates or at least high-school education&#46; Most patients were Catholics&#44; which is a critical aspect in the end-of-life approach&#46; Knowing the religious or spiritual affiliation of patients and families helps for improved decision-making&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Most of the patients in this cohort still need end-of-life care due to cancer illnesses&#59; the broad range and the scope of cancer-related symptoms demand aggressive medical interventions for adequate management&#44; in addition to the &#8220;relative&#8221; ease for an objective and subjective acknowledgment of the fact that every possible therapeutic resource available has been exhausted to move to a purely palliative approach&#44; within the framework of a society that mostly refuses to accept euthanasia or assisted suicide as an option&#46; This distribution by diagnoses is similar to the hospice care offered in the United States&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Secondly&#44; there are some neurological pathologies with evident additional difficulties&#44; since these patients are no longer self-sufficient&#44; including their sound judgment for decision-making&#44; so it is up to the family to decide if the patient has not previously expressed his&#47;her will&#46; The patient representative finds it hard to decide what their loved one would have liked&#44; and he&#47;she is even influenced by his&#47;her own interests &#40;taking advantage of the patient&#39;s pension or housing and even getting the attention of the rest of the family&#41;&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Care was mostly given at patient homes to avoid the ER or hospital admission&#44; responding to the constantly changing needs of terminally ill patients for prompt relief&#46; Such approach provides the proper environment and facilitates family decision-making in accordance with their realities and with adequate medical and professional information&#46; It most be noted however that while most patients prefer to die at home&#44; there is a group of patients and&#47;or families who do not&#44; and these differences shall be assertively managed&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Hence it is desirable and recommendations have been made on the characteristics of palliative care programs where medical management should be the core&#44; with nursing support&#44; therapies and mental health&#44; among other components&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> It is not recommended to require time-consuming formalities to include patients in the program&#44; but rather to have programs that are more flexible and suitable for terminally ill patients instead of simply enrolling them in programs for patients with chronic conditions&#46; It is cumbersome to transfer terminally ill patients to and from doctor offices to deal with each of their multiple symptoms&#44; or to repeat the medical record to each specialist visiting the patient at home&#44; with no continuity of the process&#44; which in itself is quite complex and difficult&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The number of visits is an indicator of various factors&#59; first&#44; doing an intervention at the first visit is a sign of the urgency of end-of-life care&#46; A second observation refers to a 24<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>7 hotline&#44; for anticipating any events and keeping in mind a subcutaneous route as a rapid and effective approach for relieving symptoms&#46; Thirdly&#44; the presence of severe pain or any other symptoms as a source of direct stimulus&#44; requires the use of analgesic doses to calm down the agonic patient so that the demise may occur a few hours or days later with no additional interventions required&#46; Finally&#44; when the patient expresses his&#47;her final wishes to the family in a calm and friendly environment that moment becomes cathartic to relief tensions and reduce the anxiety of the final process&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">In terms of medicines used&#44; the generalized availability of a moderately strong parenteral opiate at an affordable price such as tramadol that acts on the three types of pain makes it a convenient painkiller to relief pain&#44; including cancer pain&#46; Moreover&#44; the tolerance to tramadol is excellent if antiemetic and laxative agents are anticipated&#44; avoiding the very frequent psychotropic effects of non-synthetic opiates in bed-ridden patients&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The use of subcutaneous anti-ulcer agents such as a prophylactic measure in erosive GI tract diseases is key and prevents the occurrence of alarming symptoms such as GI tract bleeding&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Superficial sedation was used in almost three fourths of the patients cared for until their demise&#46; This is a decision made by those patients with a strong family and social support network that favor pain relief rather than being fully aware till the end&#59; they have been properly informed about what they should expect&#44; they have sufficient economic and social resources to pay for the sedative that is expensive and some times difficult to find&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Certain considerations are involved in the decision to maintain or remove hydration or nutritional support when the oral rout is compromised&#46; Just as nobody made the decision to change the route for accomplishing the same purpose&#44; it was not as easy to decide the removal of the gastrostomy tube&#44; the catheter or the intravenous line&#46; These decisions are extremely sensitive and nothing should be imposed&#59; however&#44; make sure that all the relevant information is shared&#46; This approach gives both patients and family some options to decide in an extremely difficult situation&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Lastly&#44; a few general observations&#58; presently&#44; medicine provides us with powerful therapeutic tools for managing physical symptoms&#46; End-of-life myths and preconceptions for using drugs that may have side effects &#8211; shorten the life span &#8211; should be put aside&#46; We must continue to make headway in encouraging the availability of essential medicines for managing terminally ill patients&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> and keep in mind that ultra-short acting benzodiazepines are safe and effective for superficial sedation of these patients&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Absolutely it is better to avoid treating end-of-life patients in a cruel&#44; inhuman or degrading manner at all times&#44; but mostly when death is imminent&#46; Scientific compassion&#44; avoiding forcing the nature of human existence of the patients we assist&#44; is fundamental to guide palliative therapeutic processes&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">There is then a humanistic and scientific approach to the management of end-of-life care&#59; it is however necessary to develop a legislative framework to protect our patients against any actions that are not consistent with such an approach and be able to legally demand proper care&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Funding</span><p id="par0225" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of interest</span><p id="par0230" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "References"
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    "fechaRecibido" => "2013-01-05"
    "fechaAceptado" => "2014-01-24"
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          "titulo" => "Keywords"
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            2 => "Ethics&#44; Clinical"
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            1 => "Atenci&#243;n ambulatoria"
            2 => "&#201;tica cl&#237;nica"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Palliative care for end-of-life patients in Bogot&#225; is still in the process of consolidation&#46; This type of care demands high technical and scientific standards&#44; in addition to supporting the patient and family in making end-of-life ethical decisions&#44; particularly with respect to sedation&#44; hydration and feeding&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0010">Methodology</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Statistical descriptive analysis of a cohort comprised of 164 terminally ill patients treated in private practice in Bogot&#225; between 2008 and 2012&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Out of the 90 patients who received care until their demise&#44; the average age was 77 years old&#44; including 63&#37; women&#44; 30&#37;&#44; university students&#44; 41&#37; widowers&#44; and 84&#37; Catholics&#46; 8 patients had no medical insurance&#46; 52&#37; of the patients were cancer patients&#44; 91&#37; received home care&#44; the average number of care days was 45 and the usual route of administration of medicines was subcutaneous&#46; The most commonly used drugs were tramadol&#44; ranitidine and midazolam&#46; 73&#37; of the patients required superficial sedation&#46; In some cases&#44; feeding and hydration were administered through alternate routes and in others were discontinued&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Analysis</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">There is a need to study the conditioning factors for private medical home care and for maintaining this type of care until the end of life&#46; Characterizing this population enables the identification of some useful information for the administration of end-of-life care in the country&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0030">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El cuidado m&#233;dico paliativo en Bogot&#225; para pacientes terminales sigue en proceso de consolidaci&#243;n&#46; Esta atenci&#243;n exige altos est&#225;ndares t&#233;cnicos y cient&#237;ficos&#44; as&#237; como el apoyo a las decisiones &#233;ticas al final de la vida del paciente y sus allegados&#44; especialmente en cuanto a la sedaci&#243;n y al uso de hidrataci&#243;n y alimentaci&#243;n&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0035">Metodolog&#237;a</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un an&#225;lisis estad&#237;stico descriptivo de una cohorte de 164 pacientes terminales atendidos en pr&#225;ctica m&#233;dica privada en Bogot&#225; entre 2008 y 2012&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">De los 90 pacientes atendidos hasta su fallecimiento se encontr&#243; un promedio de edad de 77 a&#241;os&#59; el 63&#37; mujeres&#44; el 30&#37; universitarios&#47;as&#44; el 41&#37; viudos&#47;as&#44; el 84&#37; cat&#243;-licos&#47;as&#44; y 8 pacientes sin afiliaci&#243;n al sistema de seguridad social&#46; El 52&#37; de los pacientes fueron oncol&#243;gicos&#44; y el 91&#37; se atendieron en sus casas&#46; El promedio de atenci&#243;n fue de45 d&#237;as&#44; y la v&#237;a m&#225;s utilizada para la administraci&#243;n de medicamentos fue la v&#237;a subcut&#225;nea&#46; Los medicamentos m&#225;s usados fueron el tramadol&#44; la ranitidina y el midazolam&#46; El73&#37; de los pacientes requirieron sedaci&#243;n superficial&#46; En algunos casos se continuaron y en otros se interrumpieron la alimentaci&#243;n y la hidrataci&#243;n por v&#237;as alternas&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">An&#225;lisis</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se requieren estudios que den cuenta de los factores que condicionan la solicitud de atenci&#243;n m&#233;dica privada domiciliaria&#44; o para mantenerse en este tipo de atenci&#243;n hasta el final de la vida&#46; La caracterizaci&#243;n de esta poblaci&#243;n permite identificar algunos elementos &#250;tiles para la pr&#225;ctica del cuidado paliativo en el pa&#237;s&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; T&#225;mara LM&#46; Estudio de cohorte descriptivo de los pacientes terminales atendidos m&#233;dicamente en su domicilio en Bogot&#225;&#46; 2008&#8211;2012&#46; Rev Colomb Anestesiol&#46; 2014&#59;42&#58;100&#8211;106&#46;</p>"
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                  \t\t\t\t">48&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CRF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Senility&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rheumatoid arthritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HIV AIDS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Total</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">90</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">74</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">164</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab483744.png"
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          ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Non-oncological diagnostic characteristics leading to the end-of-life phase&#46;</p>"
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      ]
      5 => array:8 [
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "Source&#58; Home care medical records&#44; Bogot&#225;&#44; January 2008 to June 2012&#46;"
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          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Range of duration&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">No&#46; of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#8211;6 days&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#8211;13 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;14 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Total</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">66</span>&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Distribution according to the duration of care in days&#46;</p>"
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        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:29 [
            0 => array:3 [
              "identificador" => "bib0005"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cancer control&#58; knowledge into action&#58; WHO guide for effective programmes&#59; module 5"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "WHO Palliative Care"
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                    0 => array:1 [
                      "Libro" => array:1 [
                        "fecha" => "2007"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cancer pain relief with a guide to opioid availability"
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                          "etal" => false
                          "autores" => array:1 [
                            0 => "WHO"
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                    0 => array:1 [
                      "Libro" => array:4 [
                        "edicion" => "2nd ed&#46;"
                        "fecha" => "1996"
                        "editorial" => "World Health Organization"
                        "editorialLocalizacion" => "Geneva"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Terminal cancer care and patients preference for place of death&#58; a prospective study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Townsend"
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                            2 => "D&#46; Fermont"
                            3 => "S&#46; Dyer"
                            4 => "O&#46; Karran"
                            5 => "A&#46; Walgrove"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Br Med J&#46;"
                        "fecha" => "1990"
                        "volumen" => "301"
                        "paginaInicial" => "415"
                        "paginaFinal" => "417"
                      ]
                    ]
                  ]
                ]
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            3 => array:3 [
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              "etiqueta" => "4"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Domiciliary care&#58; a comparison of views of terminally ill patients and their family caregivers"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
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                          ]
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Palliat Med"
                        "fecha" => "1993"
                        "volumen" => "7"
                        "paginaInicial" => "109"
                        "paginaFinal" => "115"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7505170"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Medici&#243;n de la calidad de vida de un grupo de pacientes terminales en una unidad de cuidado paliativo domiciliario en Santaf&#233; de"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "L&#46; T&#225;mara"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2000"
                        "editorial" => "Bio&#233;tica y Calidad de Vida&#46; Colecci&#243;n Bios y Ethos&#46; Ediciones El Bosque"
                        "editorialLocalizacion" => "Bogot&#225;&#46; Colombia"
                      ]
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                ]
              ]
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            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Medicina paliativa&#58; filosof&#237;a y consideraciones &#233;ticas"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "R&#46; Twycross"
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Acta Bioeth"
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                        "volumen" => "6"
                        "paginaInicial" => "29"
                        "paginaFinal" => "46"
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                ]
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            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "El uso de medicamentos opioides en al alivio del dolor por c&#225;ncer en Latinoam&#233;rica"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "L&#46; De Lima"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rev Colomb Anestesiol"
                        "fecha" => "2000"
                        "volumen" => "28"
                        "paginaInicial" => "227"
                        "paginaFinal" => "230"
                      ]
                    ]
                  ]
                ]
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            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Disponibilidad de medicamentos opioides en Latinoam&#233;rica y Colombia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Z&#46; Acu&#241;a"
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:5 [
                        "titulo" => "ACED"
                        "fecha" => "2009"
                        "paginaInicial" => "251"
                        "paginaFinal" => "256"
                        "editorial" => "Dolor y c&#225;ncer"
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              ]
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            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Analg&#233;sicos opioides en Latinoam&#233;rica&#58; la barrera de&#46; accesibilidad supera la de disponibilidad"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "R&#46; Wenk"
                            1 => "M&#46; Bertolino"
                            2 => "L&#46; De Lima"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Pal &#40;Madrid&#41;"
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            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Rep&#250;blica de Colombia&#46; Ley 1384&#47;2010&#46;"
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            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cuidado paliativo una aproximaci&#243;n a los aspectos &#233;ticos del paciente con c&#225;ncer"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Persona y Bio&#233;tica"
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                        "paginaFinal" => "45"
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            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "Sociedad Espa&#241;ola de Cuidados Paliativos&#46; Organizaci&#243;n m&#233;dica colegial de Espa&#241;a"
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                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:4 [
                        "fecha" => "2011"
                        "paginaInicial" => "11"
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Article information

ISSN: 22562087
Original language: English

DOI:10.1016/j.rcae.2014.02.002

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Year/Month	Html	Pdf	Total

2024 November	2	1	3
2024 October	10	10	20
2024 September	5	1	6
2024 August	9	8	17
2024 July	5	5	10
2024 June	15	5	20
2024 May	10	2	12
2024 April	7	17	24
2024 March	48	6	54
2024 February	13	7	20
2024 January	10	3	13
2023 December	28	6	34
2023 November	8	8	16
2023 October	14	6	20
2023 September	9	5	14
2023 August	5	4	9
2023 July	4	5	9
2023 June	2	3	5
2023 May	6	3	9
2023 April	4	1	5
2023 March	3	2	5
2023 February	10	3	13
2023 January	11	12	23
2022 December	15	6	21
2022 November	8	5	13
2022 October	5	4	9
2022 September	8	9	17
2022 August	9	7	16
2022 July	11	9	20
2022 June	4	5	9
2022 May	9	7	16
2022 April	4	9	13
2022 March	9	6	15
2022 February	8	7	15
2022 January	15	9	24
2021 December	9	6	15
2021 November	6	9	15
2021 October	16	10	26
2021 September	7	7	14
2021 August	29	3	32
2021 July	8	5	13
2021 June	6	6	12
2021 May	9	5	14
2021 April	22	5	27
2021 March	5	6	11
2021 February	5	5	10
2021 January	7	11	18
2020 December	5	4	9
2020 November	3	2	5
2020 October	4	5	9
2020 September	10	9	19
2020 August	5	9	14
2020 July	12	4	16
2020 June	2	2	4
2020 May	5	5	10
2020 April	3	6	9
2020 March	4	2	6
2020 February	4	2	6
2020 January	5	3	8
2019 December	3	4	7
2019 November	1	3	4
2019 October	1	2	3
2019 September	3	2	5
2019 August	1	1	2
2019 July	1	6	7
2019 June	0	1	1
2019 May	1	13	14
2018 December	1	0	1
2018 September	1	0	1
2018 June	3	1	4
2018 May	37	6	43
2018 April	40	10	50
2018 March	24	7	31
2018 February	37	9	46
2018 January	42	7	49
2017 December	38	10	48
2017 November	28	10	38
2017 October	33	10	43
2017 September	45	12	57
2017 August	64	9	73
2017 July	57	10	67
2017 June	65	15	80
2017 May	50	5	55
2017 April	54	13	67
2017 March	28	7	35
2017 February	19	6	25
2017 January	19	6	25
2016 December	48	9	57
2016 November	23	8	31
2016 October	36	12	48
2016 September	40	13	53
2016 August	32	9	41
2016 July	19	5	24
2016 June	0	12	12
2016 May	2	22	24
2016 April	0	22	22
2016 March	3	29	32
2016 January	1	8	9
2015 December	6	15	21
2015 November	37	7	44
2015 October	37	18	55
2015 September	27	5	32
2015 August	38	8	46
2015 July	36	8	44
2015 June	41	4	45
2015 May	47	6	53
2015 April	28	9	37
2015 March	19	9	28
2015 February	24	6	30
2015 January	50	7	57
2014 December	35	13	48
2014 November	39	9	48
2014 October	42	10	52
2014 September	29	12	41
2014 August	31	10	41
2014 July	57	19	76
2014 June	63	15	78
2014 May	94	18	112
2014 April	44	9	53

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