Editorial article
To palliate or not to palliate, it should never be the question
Paliar o no paliar, nunca debería ser la cuestión
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"Alfredo Zamora Mur" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Alfredo" "apellidos" => "Zamora Mur" "email" => array:1 [ 0 => "azamora@usj.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Geriatría, Hospital Sagrado Corazón de Jesús, Huesca, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Vicepresidente de la Sociedad Aragonesa de Cuidados Paliativos (CUSIRAR), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Paliar o no paliar, nunca debería ser la cuestión" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Traditionally, palliative care has been defined as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and accurate assessment and treatment of pain and other problems, physical, psychosocial and spiritual”.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> Also traditionally, this approach has often been reserved for oncological processes, especially in the context of terminal illness or even in cases of extreme pain, and are ignored during the advanced stages of incurable diseases. Again traditionally, both patients and their relatives, as well as health professionals, have been intensely concerned with establishing prognosis, based fundamentally on the variable ‘time’, which is so often not modifiable, prioritising quantity to the detriment of quality, and relatively frequently erring in the time given in their prognosis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">According to the National Health Survey 2011–2012<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a> conducted by the Spanish National Institute of Statistics (INE), the first analysing health-related quality of life, through the EuroQol questionnaire, the issue most frequently affecting the population is pain, followed by anxiety-depression, and third, problems with walking. The fourth and fifth issues reducing quality of life are problems related to basic activities of daily living. Coinciding exactly with what was reflected in this survey, Dr. Iribarren refers to an editorial<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> that should be obligatory reading regarding the deterioration of quality of life as a consequence of a decrease in mobility, self-care, habitual activities and a greater prevalence of pain, anxiety or depression. The article is based on a study published in 2015 regarding an already classic concept, that is still popular today, fragility. Reading this editorial evoked the time I first heard about ‘limitation of therapeutic efforts’ (correctly modified to ‘appropriate therapeutic effort’): the prioritisation of treatment of symptoms and palliative care over medical treatment, through a colleague who was a specialist in intensive care. And this did not happen during my university training period, which started the same year the SUPPORT study was published, but much later. Too much later according to my approach and my subsequent professional career.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We currently have multiple classifications of patients, from the chronically dependent to the pluripathological, through to the chronically complex, and even the chronically advanced; the Spanish Society for Palliative Care (SECPAL) having recently published an article regarding advanced chronicity. All these classifications are added to the aforementioned concepts: terminal illnesses and advanced incurable diseases. We have a wide variety of tools to try to predict their future, each applicable to its specific context, such as the Acute Physiology And Chronic Health Evaluation (APACHE), Mortality Prediction Models (MPM), Simplified Acute Physiology Score (SAPS), Short Form-36 Health Survey (SF-36), Palliative Prognostic Index (PPI), Body mass index, airflow Obstruction, Dysnea and Exercise capacity index (BODE), Comorbidity, Obstruction, Dyspnea and previous severe EXacerbations (CODEX) index, Charlson comorbidity index, Sequential Organ Failure Assessment score (SOFA score), Walter index, Seattle Heart Failure Model (SHFM), Older People's Mortality Index (OPMI) and the Chinese Prognostic Scale (ChPS), to name only a few.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We also have several prognostic markers, some widely studied, such as hypoalbuminaemia, hypocholesterolaemia, activities of daily living dependence and alpha-1-acid glycoprotein,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> and other novel ones, such as the recently described proadrenomedulin,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> as well as fragility, the number of geriatric syndromes and the concentration of plasma hemoglobin.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> A wonderful thesis<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> that I discovered while writing this editorial, not only describes numerous prognostic factors of mortality in the elderly population (sociodemographic, medical and related to geriatric assessment), but its author also demonstrates a clear relationship between various forms of functional deterioration with higher mortality, reminding us that determining to what extent a patient has declined is much more significant than a single moment profile picture. I could verify this a couple of years before, with that found by Dr. Gallego, only this time in the field of oncology, where the geriatric patient was attended to at home; Dr. Gallego associated the degree of functional decline, through a decrease in the Barthel index with an earlier mortality and the appearance of certain symptoms. Similarly, a very interesting review,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> reminds us that functional deterioration is the most reliable predictor of a poor evolution and mortality, regardless of the elderly patient's clinical diagnoses.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patients we see every day in our practice, at the hospital or at their home, are hardly represented by randomised clinical trials or meta-analyses, since they are rarely young, healthy or suffering from a single morbid process. Similarly, in patients with multiple pathologies or pathologies associated with various advanced chronic diseases, evidence-based medicine will not be able to answer the question of what to do in certain circumstances, and in the absence of specific indexes for this increasingly prevalent population, establishing prognosis that will help us make those decisions will be very difficult.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In addition to other indices developed or adapted to the multi-pathological patient, such as the PPI<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> and the CRONIGAL<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> index, in the current issue of <span class="elsevierStyleSmallCaps">Medicina Clínica</span>, Díez-Manglano et al., presents a study comparing two indices designed by working groups with various points in common, the PROFUND index and the PALIAR index.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> The work focuses on multi-pathological patients with chronic, non-oncological disease in an advanced stage, unifying in some way all those concepts that we previously named, and thus classifying our patients in different ways. These are indices that can be very useful for establishing prognosis in daily practice and the consequent appropriateness of our efforts with our patient. Congratulations for the work carried out and I wish you all the best in your advancements with these projects, as there is much to discover, move forward and improve by sharpening prognosis, without forgetting the patient who may need relief from their pain, dyspnea, anxiety, insomnia or anguish more than another diagnostic test or a futile prolongation of an already set time-frame.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The figures resulting from this study and other similar ones<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> are alarming in terms of this population's polypharmacy. The use of multiple medications by a patient is not associated with greater survival rates and often exposes the group to more adverse effects, such as weight loss, falls, functional and cognitive deterioration and hospitalisations, in addition to a worse adherence.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> Although there are studies that promulgate an attempt to improve adherence to treatments,<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> I would advocate an adequate de-prescription in subsidiary cases, prioritising palliative care over curative and especially preventive treatment, in cases of a lack of benefits according to medicine-based evidence. The withdrawal of certain measures (and non-initiation of them), is equivalent to the aforementioned appropriate therapeutic effort, such that our objectives prioritise the aspects that cause a loss in patients’ quality of life, exactly as they have asked us to do themselves, which we know through INE surveys and by listening to them directly in our every-day practice. Furthermore, indices such as the ones compared in the aforementioned study, confirm that we should worry more about how rather than how much.</p><p id="par0040" class="elsevierStylePara elsevierViewall">We are morally obliged to profoundly reflect on the current dynamics of the management of patients who have multiple pathologies, one or several advanced chronic diseases, especially in the hospital context – so frequently invasive, aggressive, dehumanising, loaded with fear and demands and denial of death, as these facts often translate into defensive medicine, therapeutic obstinacy and avoidance of relief measures. We must abandon our reluctance to associate appropriateness with aspects that go beyond orders of do not resuscitate or non-specific ‘avoidance of aggressive measures’.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> We must know that it is often better for the patient that we “not do”<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> and instead seek clinical and environmental well-being, prioritise the patient's functional status, encourage advance care planning from the diseases’ early stages as soon as possible without aetiological treatment, and address the patient and their family's needs, by respecting their wishes,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> which we should know in advance. And all this is actually ‘doing a lot’.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The negative effect of hospitalisation on functional capacity is well documented and has shown that up to 70% of hospitalised elderly people experience deterioration during their hospital stay<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a>; to this we must add the repercussions that impact on the patient and their family. Considering all this, and as reported in other publications,<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> we should “adopt a health care model based on the so-called ‘Comprehensive Healthcare Model’, characterised by the following points: (1) focused on the person and not on the disease, (2) based on primary care and not on hospital care, (3) focused on the population's needs and not those of the individual patient, (4) organised for proactive and planned care, not reactive in the face of symptoms and (5) focused on promotion and prevention, not treatment”.</p><p id="par0050" class="elsevierStylePara elsevierViewall">I end by declaring my distance from concepts such as therapeutic nihilism and those who confuse it with the appropriate therapeutic effort, feeling as though I am approaching the debate of euthanasia, erroneously understood as a process that aims to provoke or accelerate death and not etymologically as a legitimate death without suffering, and declaring myself totally in favour of adequate palliative sedation, as an indispensable option,<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> carried out at the right time, with an appropriate intensity, with the indicated drugs and within the medical, ethical and legal assumptions established by the patient and/or their relatives’ – in the case the patient is unable to do so – needs and wishes, and article 36 of Spain's 2011 deontological code, and legislation.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Zamora Mur A. 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