End-of-Life Care in Latin America

Number of palliative care nurse home visits and duration of palliative care associated with domains of the Good Death Inventory: A national survey of bereaved family caregivers in a middle income country

Background

In the lower-middle-income country of Kazakhstan, palliative care services are in the early stages of integration into healthcare services. No prior studies have investigated associations between palliative care service factors and a good death in lower-middle-income countries, nor explored how palliative care nurses contribute to a good death. In this paper, a good death is referred to as the control of pain and symptoms, clear decision-making, a sense of closure, being recognized and perceived as an individual, preparation for death, and still being able to contribute to others, all taken together.

Objectives

To identify new opportunities for palliative care service nurses by investigating associations between palliative care service factors and a good death, as measured by the Good Death Inventory.

Methods

Family caretakers of deceased patients from palliative care units and hospices were surveyed across six different regions of Kazakhstan. Data collected included demographics for patients and caregivers, palliative care service data, and Good Death Inventory items. Poisson regression analysis with r variance and linear regressions were conducted to identify determinants for achieving a Good Death and for the 18 Good Death Inventory domains.

Results

Two hundred and eleven family caregivers participated in the survey. Bivariate analysis revealed five statistically significant associations (p ≤ 0.05) with the outcome of a good death. In multivariate linear regression analyses, a palliative care duration of greater-than-6-months, compared to less-than-1-month, was associated with improvements in 10 out of 18 domains of the Good Death Inventory (p ≤ 0.05). More-than-once-weekly palliative care home visits by nurses, compared to no visits, were also associated with improvements in four domains (p ≤ 0.05).

Conclusion

We provide new directions for improvements in palliative care services in low-middle-income countries, giving impetus for resource allocation to palliative care home visits by nurses for achieving a good death for greater numbers of patients.

Exploring factors and trends in place of death by cancer: a population-based study in Brazil

Background

The place of death profoundly affects end-of-life care quality, particularly in cancer. Assisting individuals at home enhances support, privacy, and control, reducing healthcare costs. This study seeks to elucidate factors associated and trends in place of death by cancer in Brazil.

Methods

Using data obtained from the National Mortality Information System, this study extracted tumour topography, sociodemographic characteristics, and the place of death (outcome classified into hospital or home death) by cancer in Brazil from 2002 to 2021.

Findings

The analysis included 3,677,415 cases, with 82.3% of deaths occurring in hospitals and 17.7% at home. Most participants were male (53.1%), had gastrointestinal tumours (32.2%), and resided in the Southeastern region (48.7%). Home deaths were more frequent in the Northeastern (30.2%) and Northern (24.8%) regions compared to the Southern (17.1%) and Southeastern (12.2%) regions. A strong inverse correlation was found between home deaths and the Human Development Index of the region. Over the years, there was a reduction in home deaths, followed by a recent increase. Individuals with no formal education, indigenous individuals, and patients from the North, Northeast, and Central-West regions had higher rates of home deaths, while patients with haematological malignancies had lower rates compared to those with gastrointestinal tumours.

Interpretation

The minority of deaths by cancer in Brazil occur at home, with distinct trends over time. Home death was associated with regional, racial and educational level differences.

Funding

No funding.

Challenges in Palliative Care in Latin America: A Narrative Review

In "graying" populations with extended lifespans and survivable forms of cancer, palliative services become increasingly important but may be difficult to introduce into public discourse, public policy, and healthcare systems. Latin America (LATAM) faces many challenges as it introduces and, in some cases, develops its palliative care programs; though the challenges faced here are in many ways universal ones, LATAM approaches may be unique and based on the region's specific culture, politics, and economics. This narrative review based on a literature search identified 10 main themes that can be interpreted as challenges and opportunities for palliative care in LATAM. These challenges are integrating palliation into healthcare systems; public policy and funding; therapeutic obstinacy; changing demographics; access to services; analgesia; the role of religion, spirituality, and folk medicine; social determinants of palliative care; low health literacy; and limited clinician training. Some of the LATAM nations have palliative programs and palliative care training in place while others are developing these systems. Integrating this care into existing healthcare and reimbursement systems has been a challenge. A notable challenge in LATAM is also access to care since palliative programs tend to cluster in metropolitan areas and create hardships for rural citizens to access them. The better-defined role of familial caregivers and telehealth may be important factors in the expansion of palliative care in LATAM and beyond.

Ensuring quality of life in palliative care physiotherapy in developing countries

Palliative care (PC) focuses on the body, mind, and spirit and can also provide pain and symptom relief, clarifying and focusing the provision of care on the patient's desires and goals, and helping them understand their disease and its treatment plans. Although PC is widely recognized for its applicability near the end of life or during terminal illness, it is also applicable and beneficial for patients with diseases in their earlier stages. Near the end of life, palliative care often focuses on providing continual symptom management and supportive care. Although palliative care has been noted to improve some life expectancy, its primary aim is to improve quality of life via focusing on the comfort of the patient, maintaining dignity, reducing intensive care utilization, and avoidance of expensive hospitalizations. One major challenge to quality of life for patients in PC is the physical and functional decline that occurs with disease progression. These issues can be addressed by specialized PC physiotherapy. Uniform provision of high-quality PC services (and physiotherapy in palliative care) faces substantial challenges in resource-challenged settings, including low- and middle-income countries. When properly integrated into PC teams and adequately supported, physiotherapy within PC can address common symptoms (pain, breathlessness, weakness) and assist patients to remain in an adapted home setting to optimize their quality of life, safety, and dignity.

Disparities in Cancer Control in Central America and the Caribbean

Central America and the Caribbean is a highly heterogeneous region comprising more than 30 countries and territories with more than 200 million inhabitants. Although recent advances in the region have improved access to cancer care, there are still many disparities and barriers for obtaining high-quality cancer treatments, particularly for those from disadvantaged populations, immigrants, and rural areas. In this article, we provide an overview of cancer care in Central America and the Caribbean, with selected examples of issues related to disparities in access to care and suggest solutions and strategies to move forward.

Hospital care for the dying patient with cancer: does an advance care planning invitation influence bereaved relatives' experiences? A two country survey

OBJECTIVES

Advance care planning (ACP) is not systematically performed in Argentina or Norway. We used the post-bereavement survey of the ERANet-LAC International Care Of the Dying Evaluation (CODE) project (2017-2020) to examine the proportion of relatives who were offered an ACP conversation, the proportion of those not offered it who would have wanted it and whether the outcomes differed between those offered a conversation and those not.

METHODS

Relatives after cancer deaths in hospitals answered the CODE questionnaire 6-8 weeks post bereavement, by post (Norway) or interview (Argentina). Two additional questions asked if the relative and patient had been invited to a conversation about wishes for the patient's remaining lifetime, and, if not invited, whether they would have wanted such a conversation. The data were analysed using mixed-effects ordinal regression models.

RESULTS

276 participants (Argentina 98 and Norway 178) responded (56% spouses, 31% children, 68% women, age 18-80+). Fifty-six per cent had been invited, and they had significantly more positive perceptions about care and support than those not invited. Sixty-eight per cent of the participants not invited would have wanted an invitation, and they had less favourable perceptions about the care, especially concerning emotional and spiritual support.

CONCLUSIONS

Relatives who had been invited to a conversation about wishes for the patient's remaining lifetime had more positive perceptions about patient care and support for the relatives in the patient's final days of life. A majority of the relatives who had not been invited to an ACP conversation would have wanted it.

Validation of the Mexican version of the Schedule of Attitudes Toward Hastened Death in patients undergoing palliative care in Mexico

OBJECTIVES

The Schedule of Attitudes Toward Hastened Death (SAHD) has emerged as a valid and reliable tool to assess the wish to hasten death (WTHD) among patients diagnosed with advanced cancer; however, the instrument has never been culturally adapted and validated for patients in Mexico. This study sought to validate and abbreviate the SAHD tool for use among patients attending the Palliative Care Service of the Instituto Nacional de Cancerología in Mexico.

METHODS

The SAHD was culturally adapted from a previously published validation in patients from Spain. Eligible patients included Spanish literate subjects treated as outpatients in the Palliative Care Service, with an Eastern Cooperative Oncology Group (ECOG) performance status of 0-3. Patients were asked to answer the Mexican version of SAHD (SAHD-Mx) instrument and the Brief Edinburgh Depression Scale (BEDS).

RESULTS

A total of 225 patients were included in the study. Median positive response in the SAHD-Mx was 2 (range 0-18). Positive correlation was identified between the SAHD-Mx scale and ECOG performance status (r = 0.188, p = 0.005), as well as BEDS (r = 0.567, p < 0.001). SAHD-Mx displayed strong internal consistency (alpha = 0.85) and adequate reliability from test-retest phone interviews (r = 0.567, p < 0.001). Using the confirmatory factor analysis model, a factor was identified and the number of items was reduced to 6, including items 4, 5, 9, 10, 13, and 18.

SIGNIFICANCE OF RESULTS

The SAHD-Mx emerges as an adequate tool, with appropriate psychometric characteristics, for assessing WTHD among patients diagnosed with cancer undergoing palliative care in Mexico. .

Advance Care Planning for Spanish-Language Speakers: Patient, Family, and Interpreter Perspectives

Language access barriers for individuals with limited-English proficiency are a challenge to advance care planning (ACP). Whether Spanish-language translations of ACP resources are broadly acceptable by US Spanish-language speakers from diverse countries is unclear. This ethnographic qualitative study ascertained challenges and facilitators to ACP with respect to Spanish-language translation of ACP resources. We conducted focus groups with a heterogeneous sample of 29 Spanish-speaking persons who had experience with ACP as a patient, family member, and/or medical interpreter. We conducted thematic analysis with axial coding. Themes include: (1). ACP translations are confusing; (2). ACP understanding is affected by country of origin; (3). ACP understanding is affected by local healthcare provider culture and practice; and (4). ACP needs to be normalized into local communities. ACP is both a cultural and clinical practice. Recommendations for increasing ACP uptake extend beyond language translation to acknowledging users' culture of origin and local healthcare culture.

End of Life in Patients With Advanced Non-curable Cancer: Patient Considerations Around the Moment of Death

There is limited knowledge regarding Colombian patients with advanced cancer preferences regarding their final moments, place of death, and post-death wishes. To better understand these preferences, we conducted 23 in-depth interviews with patients between the ages of 28 and 78 receiving treatment at two academic hospitals and the National Cancer Institute. While many participants desired a peaceful death, few were comfortable discussing the topic of death directly. Some younger participants expressed an interest in euthanasia but had not received any guidance or support. While several participants preferred a home death, some expressed a desire to die in a hospital due to better symptom control. Additionally, when discussing post-death wishes, some participants expressed frustration about being unable to have these conversations with their loved ones and their preferences for funeral arrangements. Socioeconomic and geographical factors significantly impacted the wishes and preferences expressed, with many individuals hesitant to initiate difficult conversations.

End-of-Life Care and Advanced Directives in Hispanic/Latinx Patients: Challenges and Solutions for the Practicing Oncologist

Advanced end-of-life care (EOL) comprises a group of strategies to provide comfort to patients at the end of life. These are associated with better quality of life, better satisfaction, and a lower rate of hospitalizations and aggressive medical treatment. Advanced EOL care, including advanced directives completion and hospice enrollment, is suboptimal among Hispanic/Latinx patients with cancer due to personal, socio-cultural, financial, and health system-related barriers, as well as due to a lack of studies specifically designed for this population. In addition, the extrapolation of programs that increase participation in EOL for non-white Hispanics may not work appropriately for Hispanic/Latinx patients and lead to overall lower satisfaction and enrollment in EOL care. This review will provide the practicing oncologist with the tools to address EOL in the Hispanic/Latinx population. Some promising strategies to address the EOL care disparities in Latinx/Hispanic patients have been culturally tailored patient navigation programs, geriatric assessment-guided multidisciplinary interventions, counseling sessions, and educational interventions. Through these strategies, we encourage oncologists to take advantage of every clinical setting to discuss EOL care. Treating physicians can engage family members in caring for their loved ones while practicing cultural humility and respecting cultural preferences, incorporating policies to foster treatment for the underserved migrant population, and providing patients with validated Spanish language tools.

Place of death and associated factors in 12 Latin American countries: A total population study using death certificate data

Background

Little is known about place of death in Latin America, although this data are crucial for health system planning. This study aims to describe place of death and associated factors in Latin America and to identify factors that contribute to inter-country differences in place of death.

Methods

We conducted a total population observational study using death certificates of the total annual decedent populations in 12 countries (Argentina, Brazil, Chile, Colombia, Costa Rica, El Salvador, Guatemala, Ecuador, Mexico, Paraguay, Peru, and Uruguay) for the most recent available year (2016, 2017, or 2018). Data were analysed regarding place of death and multivariable logistic regression with place of death as the dependent variable was used to examine associated clinical and sociodemographic factors (independent variables) in each of the countries.

Results

The total study sample was 2 994 685 deaths; 31.3% of deaths occurred at home, and 57.6% in hospitals. A strong variation was found among the countries with home deaths ranging from 20% (Brazil) to 67.9% (Guatemala) and hospital deaths from 22.3% (Guatemala) to 69.5% (Argentina). These differences between countries remained largely unchanged after controlling for sociodemographic factors and causes of death. The likelihood of dying at home was consistently higher with increasing age, for those living in a rural area, and for those with a lower educational level (except in Argentina).

Conclusions

Most deaths in Latin America occur in hospitals, with a strong variation between countries. As clinical and sociodemographic factors included in this study did not explain country differences, other factors such as policy and health care system seem to have a crucial impact on where people die in Latin America.

Global, regional, and national trends in opioid analgesic consumption from 2015 to 2019: a longitudinal study

BACKGROUND

Previous studies have reported an extremely unbalanced global access to opioid analgesics. We aimed to determine contemporary trends and patterns of opioid analgesic consumption at the global, regional, and national levels.

METHODS

We analysed the global pharmaceutical sales data of 66 countries or regions from the IQVIA-Multinational Integrated Data Analysis System database on opioid analgesics between 2015 and 2019. Opioid analgesic consumption was measured in milligram morphine equivalent per 1000 inhabitants per day (MME per 1000/day). The global, regional, and national trend changes were estimated using linear regressions. Factors associated with consumption patterns and trend changes were explored in multivariable linear regression analyses.

FINDINGS

Overall opioid analgesic sales in the 66 countries or regions increased from 27·52 MME per 1000/day (16·63-45·54) in 2015 to 29·51 MME per 1000/day (17·85-48·79) in 2019 (difference per year 3·96%, 95% CI 0·26 to 7·80). Sales reduced yearly in North America (-12·84%; 95% CI -15·34 to -10·27) and Oceania (-2·96%; -4·20 to -1·70); increased in South America (28·69%; 7·18 to 54·53), eastern Europe (7·68%; 3·99 to 11·49), Asia (5·74%; 0·61 to 11·14), and western and central Europe (1·64%; 0·52 to 2·78); and did not differ in Africa or central America and the Caribbean. The global opioid consumption patterns were associated with country-level Human Development Index (p=0·040), cancer death rate excluding leukaemia (p=0·0072), and geographical location (p<0·0001). In 2019, opioid analgesic consumption ranged from 0·01 MME per 1000/day to 5·40 MME per 1000/day in the 17 countries and regions in the lowest consumption quartile, despite high income levels and cancer death rates in some of them.

INTERPRETATION

Global opioid analgesic consumption increased from 2015 to 2019. The trend changes were distinctive across regions, which could reflect the different actions in response to known issues of opioid use and misuse. Disparities in opioid analgesic consumption remained, indicating potential inadequate access to essential pain relief in countries with low consumption.

FUNDING

None.

An Intensive Care Unit Team Reflects on End-of-Life Experiences With Patients and Families in Chile

BACKGROUND

Deaths in the intensive care unit (ICU) represent an experience of suffering for patients, their families, and professionals. End-of-life (EOL) care has been added to the responsibilities of the ICU team, but the evidence supporting EOL care is scarce, and there are many barriers to implementing the clinical recommendations that do exist.

OBJECTIVES

To explore the experiences and perspectives of the various members of an ICU care team in Chile regarding the EOL care of their patients.

METHODS

A qualitative study was performed in the ICU of a high-complexity academic urban hospital. The study used purposive sampling with focus groups as a data collection method. A narrative analysis based on grounded theory was done.

RESULTS

Four discipline-specific focus groups were conducted; participants included 8 nurses, 6 nursing assistants, 8 junior physicians, and 6 senior physicians. The main themes that emerged in the analysis were emotional impact and barriers to carrying out EOL care. The main barriers identified were cultural difficulties related to decision-making, lack of interprofessional clinical practice, and lack of effective communication. Communication difficulties within the team were described along with lack of self-efficacy for family-centered communication.

CONCLUSION

These qualitative findings expose gaps in care that must be filled to achieve high-quality EOL care in the ICU. Significant emotional impact, barriers related to EOL decision-making, limited interprofessional clinical practice, and communication difficulties were the main findings cross-referenced.

End-of-life and hospice care for neurologic illness

Systems for end of life care around the world vary in availability, structure, and funding. When available, most end of life care is in the hospice model with an interdisciplinary team approach to care of people who are expected to die within months and whose primary goal is to maximize quality of life. Symptom management near the end of life is guided by prognosis and individual priorities. People dying with neurologic disease are likely to have impaired communication or mobility that adds to the complexity of prognostication and symptom management. Neurologic specialists have important roles to play in end of life care due to their unique understanding of disease prognosis as well as end of life symptom burden and management. Neurologic specialists need to become strong advocates for the importance of end of life care by being actively involved in the hospice movement and by addressing current disparities in access to care.

Healthcare Use during the Last Six Months of Life in Patients with Advanced Breast Cancer

Simple Summary

In the last decades, new treatment options for advanced (breast) cancer have resulted in increased use of health care resources near the end of life. We assessed health care use near the end of life of patients with advanced breast cancer (ABC). In this study, we have shown that ICU admission, and CPR occurred rarely during the last six months of life of ABC patients. However, hospital admissions occurred often, especially in patients who received new chemotherapy within 30 days of end of life. Those patients were also more likely to die in the hospital. However, death was most often due to disease progression. To improve quality of life near the end of life of advanced breast cancer patients, it is vital to develop tools to help clinicians identify those patients who will benefit from chemotherapy at the end of life.

Abstract

New treatment options in cancer have resulted in increased use of health care resources near the end of life. We assessed health care use near the end of life of patients with advanced breast cancer (ABC). From the Southeast Netherlands Breast cancer (SONABRE) registry, we selected all deceased patients diagnosed with ABC in Maastricht University Medical Center between January 2007 and October 2017. Frequency of health care use in the last six months of life was described and predictors for health care use were assessed. Of 203 patients, 76% were admitted during the last six months, 6% to the intensive care unit (ICU) and 2% underwent cardiopulmonary resuscitation (CPR). Death in hospital occurred in 25%. Nine percent of patients received a new line of chemotherapy ≤30 days before death, which was associated with age <65 years and <1 year survival since diagnosis of metastases. In these patients, the hospital admission rate was 95%, of which 79% died in the hospital, mostly due to progressive disease (80%). In conclusion, the frequency of ICU-admission, CPR or a new line of chemotherapy ≤30 days before death was low. Most patients receiving a new line of chemotherapy ≤30 days before death, died in the hospital.

Medical decisions concerning the end of life for cancer patients in three Colombian hospitals - a survey study

Background

Cancer patients’ end-of-life care may involve complex decision-making processes. Colombia has legislation regarding provision of and access to palliative care and is the only Latin American country with regulation regarding euthanasia. We describe medical end-of-life decision-making practices among cancer patients in three Colombian hospitals.

Methods

Cancer patients who were at the end-of-life and attended in participating hospitals were identified. When these patients deceased, their attending physician was invited to participate. Attending physicians of 261 cancer patients (out of 348 identified) accepted the invitation and answered a questionnaire regarding end-of-life decisions: a.) decisions regarding the withdrawal or withholding of potentially life-prolonging medical treatments, b.) intensifying measures to alleviate pain or other symptoms with hastening of death as a potential side effect, and c.) the administration, supply or prescription of drugs with an explicit intention to hasten death. For each question addressing the first two decision types, we asked if the decision was fully or partially made with the intention or consideration that it may hasten the patient’s death.

Results

Decisions to withdraw potentially life-prolonging treatment were made for 112 (43%) patients, 16 of them (14%) with an intention to hasten death. For 198 patients (76%) there had been some decision to not initiate potentially life-prolonging treatment. Twenty-three percent of patients received palliative sedation, 97% of all patients received opioids.

Six patients (2%) explicitly requested to actively hasten their death, for two of them their wish was fulfilled. In another six patients, medications were used with the explicit intention to hasten death without their explicit request. In 44% (n = 114) of all cases, physicians did not know if their patient had any advance care directives, 26% (n = 38) of physicians had spoken to the patient regarding the possibility of certain treatment decisions to hasten death where this applied.

Conclusions

Decisions concerning the end of life were common for patients with cancer in three Colombian hospitals, including euthanasia and palliative sedation. Physicians and patients often fail to communicate about advance care directives and potentially life-shortening effects of treatment decisions. Specific end-of-life procedures, patients’ wishes, and availability of palliative care should be further investigated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00853-9.

Characteristics of Palliative Care Publications by South American Authors in the Last 20 Years: Systematic Literature Review With Bibliometric Analysis

CONTEXT

Research on palliative care (PC) can be used as a direct measure to assess the level of PC development in a country or region.

OBJECTIVES

To investigate the scientific production in the field of PC in South American countries over the last two decades.

METHODS

The search was performed using the terms "palliative care," "hospice care," "hospices," and "terminal care" combined with the names of South American countries in several databases. The trend in publications over time was analyzed by linear equations (R²) and by calculating the annual percentage change (APC). The article citations were extracted from Web of Science (WOS), Scopus and Google Scholar, and the countries' impact factors (IFc) were calculated.

RESULTS

Of the 4259 identified articles, 641 were included in the analysis. There was a clear increase in the number of publications over the analyzed period (R² = 0.8794, APC = 14.42%). Brazil was the country with the highest number of publications (n = 389); however, after adjustments by population, GDP and number of researchers, Chile was the country with the greatest prominence, including the highest IF in WOS (4.409). Only 8.3% of publications were systematic review, clinical trial or cohort studies; only 15.4% were funded.

CONCLUSION

This bibliometric review identified an annual increase of 14% in the number of scientific publications by researchers from South America over the last 20 years. Although Brazil produced the most articles, Chile, had the most efficient scientific production. In general, the articles had low potential for scientific impact.

Attitudes and preferences towards palliative and end of life care in patients with advanced illness and their family caregivers in Latin America: A mixed studies systematic review

BACKGROUND

Achieving universal access to palliative care is considered a global and equity priority. Understanding patients and caregivers' attitudes and preferences towards palliative and end-of-life care in Latin America is essential to develop person-centred services in the region.

AIM

To synthesize and appraise the evidence about patients with advanced illness and their caregivers' attitudes and preferences towards palliative and end-of-life care in Latin America.

DESIGN

Mixed studies systematic review with sequential exploratory synthesis (thematic and narrative synthesis). Quality was assessed using the Mixed-Methods Appraisal Tool.

DATA SOURCES

MEDLINE, Embase, PsychINFO, Lilacs, Web of Science, Scielo and Scopus to March 2021. Empirical studies examining patient or caregiver attitudes and/or preferences towards palliative and end-of-life care were included.

RESULTS

Of 3575 records screened, 45 articles were included, comprising 7 countries and a total of 1220 patients and 965 caregivers (26.8% non-cancer-related participants). Data were organized around seven themes: Symptom management and nutrition; End-of-life medical decisions; Communication patterns; Place of end-of-life care and death; God and religious community as source of hope and support; Caregiver's role; and Mixed understandings of palliative care. Main findings include; conflicted views around palliative care and pain relief; patients' preference to be informed about their condition contrasting with caregivers' reluctance to discuss this with patients; common preference for shared decision-making; and overburdened caregivers lacking professional home-care support. Methodological flaws were found in general.

CONCLUSION

Core themes provide context-specific evidence to inform the design of culturally sensitive palliative and end-of-life care services, models and public policies in Latin America.

Palliative sedation in patients with advanced cancer in a specialized unit in a middle-income country: A retrospective cohort study

OBJECTIVE

To describe the 5-year practice on palliative sedation in a specialized palliative care unit in a deprived region in Brazil, and to compare survival of patients with advanced cancer who were and were not sedated during their end-of-life care.

METHOD

Retrospective cohort study in a tertiary teaching hospital. We described the practice of palliative sedation and compared the survival time between patients who were and were not sedated in their last days of life.

RESULTS

We included 906 patients who were admitted to the palliative care unit during the study period, of whom, 92 (10.2%) received palliative sedation. Patients who were sedated were younger, presented with higher rates of delirium, and reported more pain, suffering, and dyspnea than those who were not sedated. Median hospital survival of patients who received palliative sedation was 9.30 (CI 95%, 7.51-11.81) days and of patients who were not sedated was 8.2 (CI 95%, 7.3-9.0) days (P = 0.31). Adjusted for age and sex, palliative sedation was not significantly associated with hospital survival (hazard ratio = 0.93; CI 95%, 0.74-1.15).

SIGNIFICANCE OF RESULTS

Palliative sedation can be accomplished even in a deprived area. Delirium, dyspnea, and pain were more common in patients who were sedated. Median survival was not reduced in patients who were sedated.

Caregiving for Patients With Frontotemporal Dementia in Latin America

Latin America is a vast heterogeneous territory where chronic diseases such as mild cognitive impairment or dementia are becoming higher. Frontotemporal dementia (FTD) prevalence in this region is estimated to be around 12-18 cases per thousand persons. However, this prevalence is underestimated given the lack of awareness of FTD even among healthcare professionals. Family members are responsible for the care of patients with FTD at home. These caregivers deliver care despite being ill-equipped and living in the context of austerity policies and social inequities. They often face unsurmountable financial and social burdens that are specific to the region. The most important step to support caregivers in Latin America is to increase awareness of the disease at all levels. Healthcare diplomacy is fundamental to create joint efforts that push policies forward to protect caregivers of FTD patients.

Short-form quality care questionnaire-palliative care has acceptable measurement properties in Brazilian cancer patients

BACKGROUND

Our objective was to perform the translation, cross-cultural adaptation, and validation of the Quality Care Questionnaire-Palliative Care (QCQ-PC) into Brazilian Portuguese for cancer patients in palliative care. The translation and cross-cultural adaptation comprised the following stages: translation, synthesis of translations, back-translation, analysis by a committee of experts, testing of the pre-final version, and definition of the final version. The evaluated measurement properties were: structural validity using factor analysis, test-retest reliability using the intraclass correlation coefficient (ICC), internal consistency using Cronbach's alpha, and construct validity using the correlations between the QCQ-PC and other questionnaires already validated in Brazil.

RESULTS

Two hundred and twenty-five cancer patients were included for validity analyses, and a subsample of 30 patients was used for test-retest reliability. The most adequate fit indexes were for the short version of the QCQ-PC (SF-QCQ-PC), with two domains and 12 items. There was adequate reliability and internal consistency, with values of the ICC ≥ 0.83 and Cronbach's alpha ≥0.82. There were correlations > 0.30 between the SF-QCQ-PC and the Karnofsky Performance Scale, the Palliative Prognostic Index, the sadness domain of the Edmonton Symptom Assessment System, the Barthel Index, and all domains related to the McGill Quality of Life Questionnaire and the European Organization for Research in the Treatment of Cancer Questionnaire-core.

CONCLUSION

The short version of the SF-QCQ-PC has acceptable psychometric properties for use in Brazil.

Quality Indicators in Pediatric Palliative Care: Considerations for Latin America

Pediatric palliative care is a growing field in which the currently available resources are still insufficient to meet the palliative care needs of children worldwide. Specifically, in Latin America, pediatric palliative care services have emerged unevenly and are still considered underdeveloped when compared to other regions of the world. A crucial step in developing pediatric palliative care (PPC) programs is delineating quality indicators; however, no consensus has been reached on the outcomes or how to measure the impact of PPC. Additionally, Latin America has unique sociocultural characteristics that impact the perception, acceptance, enrollment and implementation of palliative care services. To date, no defined set of quality indicators has been proposed for the region. This article explores the limitations of current available quality indicators and describes the Latin American context and how it affects PPC development. This information can help guide the creation of standards of care and quality indicators that meet local PPC needs while considering the sociocultural landscape of Latin America and its population.

Lessons Learned from Countries That Have Introduced Palliative Care Services into Their National Health System: A Narrative Review

OBJECTIVE

This review aims at gaining a broad overview of national approaches about Palliative care (PC) implementation into health care systems in countries that have PC identified within their national policies and strategies.

METHODS

Paper searching was conducted using both peer-reviewed databases and gray literature sources covering governmental reports with PC strategies from 2000 onward. Articles published in English that cited at least 1 category of the WHO's public health PC model were included. Qualitative content analysis was used for data analysis and synthesis of findings.

RESULTS

Thirteen reports met the inclusion criteria. Education and appropriate policies were the most frequent strategies covered by all countries included. Under education; information about training health care providers was needed for the effective introduction of a PC program. Reviewing standards of care required to deliver PC effectively, and financial support for PC service development were considered the central policies needed. Furthermore, partnerships and collaborations across the health systems as well as providing care based on patients' needs were required for the provision of a PC program.

CONCLUSION

It is of the essence to learn from countries demonstrating enhanced PC practices before the implementation of a new PC program in a given country. Such practices could be used as a guide and to address barriers that may hinder the development of PC at a national level. Best practices can be achieved by focusing on educational and policy-based strategies through identifying patients' needs, assessing general public awareness, health care providers' knowledge and training as well as incorporating stakeholders' perspectives.

Countrywide Situational Analysis of Palliative Care in Bolivia

Background: There are substantial disparities in distribution of palliative care (PC) services within Latin America, with Bolivia historically lagging behind neighboring countries in PC metrics. Comprehensive data on PC in Bolivia were last collected in 2012 through the Latin American Association for Palliative Care (ALCP) Atlas of PC. Objective: To update the 2012 data and describe the current state of PC in Bolivia to aid in their ongoing efforts to expand PC services. In addition, to develop an instrument for assessment of national PC capacity that can be adapted for use in other countries. Design: A cross-sectional study was conducted using personal and online structured interviews of PC team directors from all 19 PC teams around the country. Measurements: A new survey was developed for this study based on the ALCP Atlas of PC and international PC guidelines. Results: PC teams in Bolivia have slowly increased in number since 2008. There are currently 19 PC teams in Bolivia, highly concentrated in urban centers. Multidisciplinary teams typically include physicians, nurses, psychologists, and social workers. The majority of teams offer treatments for all 16 essential PC symptoms included in our study. Teams report significant barriers for their patients to obtain opioid pain medications. Conclusions: Bolivian PC teams utilize multidisciplinary teams and have the capability to treat many of the essential PC symptoms with guideline-recommended treatments. However, it is unclear whether availability of services translates to accessibility for most patients, especially given their geographic distribution and cost of services.

Influence of advance directives on reducing aggressive measures during end-of-life cancer care: A systematic review

CONTEXT

Although the literature recognizes the participation of patients in medical decisions as an important indicator of quality, there is a lack of consensus regarding the influence of advance directives (ADs) on reducing aggressive measures during end-of-life care involving cancer patients.

OBJECTIVE

A systematic review was conducted to analyze the influence of ADs on reducing aggressive end-of-life care measures for cancer patients.

METHOD

We searched the Medline, Embase, Web of Science, and Lilacs databases for studies published until March 2018 using the following keywords, without language restrictions: "advance directives," "living wills," "terminal care," "palliative care," "hospice care," and "neoplasms." Article quality was assessed using study quality assessment tools from the Department of Health and Human Services (NHLBI).

RESULTS

A total of 1,489 studies were identified; 7 met the inclusion criteria. The studies were recently published (after 2014, 71.4%). Patients with ADs were more likely to die at the site of choice (n = 3) and received less chemotherapy in the last 30 days (n = 1). ADs had no impact on intensive care unit admission (n = 1) or hospitalization (n = 1). One study found an association between ADs and referral to palliative care, but other did not find the same result.

SIGNIFICANCE OF RESULTS

Of the seven articles found, four demonstrated effects of ADs on the reduction in aggressive measures at the end of life of cancer patients. Heterogeneity regarding study design and results and poor methodological quality are challenges when drawing conclusions.

Exploring the attitudes of health science students in Spain and Bolivia towards death. A cross sectional survey

Background

One of the most difficult and stressful tasks faced by health science students is having to cope with death and dying due to the emotional burden of the same. Furthermore, the moral, ethical and professional values of future health professionals are influenced by the cultures where they live.

Purpose

This study sought to compare and analyze the perception on end of life among a sample of health science students in Spain and Bolivia.

Methods

A descriptive, cross-sectional and multi-centric study. The total sample (548 students) was comprised of three groups: medical, nursing and physiotherapy students, of whom 245 were from Bolivia, and 303 were Spanish students. The measurement instruments used were the Bugen’s Coping with Death Scale and the Death Self-Efficacy Scale by Robbins.

Results

No statistically significant differences were observed between Spanish and Bolivian students (t (546) = − 0.248, p = 0.804) using the Bugen scale. This implies that there are no differences between the perception of both groups of students and that both groups use similar strategies to cope with death. Additionally, the beliefs and attitudes of both groups were similar, with Bolivian students presenting a trend towards improved scores. No differences were found between Spain and Bolivia in the results obtained on the Robbins scale, with students from both countries displaying similar skills and capabilities for facing death.

Conclusions

The beliefs on death of health science students from Spain and Bolivia were not affected by the respective cultures, type of degree studied, students’ age, or the country of origin, however, we found that students in Bolivia value death as something more natural than their Spanish counterparts.

Practice implications

To appropriately prepare students for this topic, education on coping with death and dying must be included within the university curriculum.

Trial registration

2016DEC018.

Pediatric Palliative Care During End of Life: A Privilege of a Few in a Tertiary Referral Hospital From Colombia

BACKGROUND

We aim to describe the access to palliative care (PC) in hospitalized children during end-of-life care and compare the circumstances surrounding the deaths of hospitalized children as a basis for implementing a pediatric PC program at our institution.

METHODS

We performed a retrospective chart review of deceased pediatric patients at a tertiary referral hospital in Colombia. The study group was selected by randomly drawing a sample of 100 observations from the 737 deceased children from 2013 to 2016. A 1:1 propensity score (PS) matching was performed to compare the characteristics and outcomes between PC and non-PC treated patients.

RESULTS

We included 87 patients. After PS matching, we found that patients under the care of non-PC physicians were more likely to die in the pediatric intensive care unit (non-PC: 6/10 vs PC: 1/10; P = .02), to be on vasopressor agents and mechanical ventilation (non-PC: 7/10 vs PC: 1/10; P = .02), and to receive cardiopulmonary resuscitation at the end of life (non-PC: 5/10 vs PC: 0/10; P = .03). In contrast, a significantly higher proportion of patients under the care of the pediatric PC team died with comfort measures (non-PC: 2/10 vs 8/10; P = .02) and nonescalation of care in physician orders (non-PC: 5/10 vs PC: 10/10; 0.03).

CONCLUSION

In this study, only 10 of 87 patients were treated by the pediatric PC team at the end of life. The latter finding is concerning and is a call to action to improve access to pediatric PC at our institution.

Challenges on the provision of palliative care for patients with cancer in low- and middle-income countries: a systematic review of reviews

BACKGROUND

Despite the significant benefits of palliative care (PC) services for cancer patients, multiple challenges hinder the provision of PC services for these patients. Low- and middle-income countries (LMICs) are witnessing a sharp growth in the burden of non-communicable diseases. There is a significant gap between demand and supply of PC in LMICs in current health services. This review aims to synthesise evidence from previous reviews and deliver a more comprehensive mapping of the existing literature about personal, system, policy, and organisational challenges and possible facilitators on the provision of PC services for cancer patients in LMICs.

METHODS

A systematic review of reviews was performed following PRISMA guidelines. PubMed, EMBASE, SCOPUS, PsycINFO, Web of Sciences, CINAHL, and Cochrane Library databases were searched to identify review papers published between 2000 and 2018 that considered challenges and possible facilitators to PC provision. A modified socioecological model was used as a framework for analysing and summarising findings.

RESULTS

Fourteen reviews were included. The reviews varied in terms of aim, settings, and detail of the challenges and possible facilitators. The main challenges of personal and health care systems included knowledge deficits and misunderstandings from patients, families, the general public, and health care providers about PC; and inadequate number of trained workforce. Besides, limited physical infrastructure, insufficient drugs for symptom relief and lack of a comprehensive national plan for implementing PC were the core organisational and policy level challenges that were recognised. Furthermore, the main possible facilitators that were identified included provision of adequate training for health care providers and health education for patients, families and the general public to enhance their knowledge, beliefs, and attitudes to PC. Finally, involvement of policymakers and making drugs available for symptom relief should also be in place to improve the health care systems.

CONCLUSIONS

Understanding challenges to the provision of PC for people with cancer could help in the development of a PC pathway in LMICs. This knowledge could be used as a guide to develop an intervention programme to improve PC. Political influence and support are also required to ensure the sustainability and the provision of high-quality PC.

Quality Indicators of End-of-Life Care Among Privately Insured People With Cancer in Brazil

PURPOSE

To examine quality indicators of end-of-life (EOL) care among privately insured people with cancer in Brazil.

METHODS

We evaluated medical records linked to health insurance databank to study consecutive patients who died of cancer. We collected information about demographics, cancer type, and quality indicators of EOL care including emergency department (ED) visits, intensive care unit (ICU) admissions, chemotherapy use, medical imaging utilization, blood transfusions, home care support, days of inpatient care, and hospital deaths.

RESULTS

We included 865 patients in the study. In the last 30 days of life, 62% visited the ED, 33% were admitted to the ICU, 24% received blood transfusions, and 51% underwent medical imaging. Only 1% had home care support in the last 60 days of life, and 29% used chemotherapy in the last 14 days of life. Patients had an average of 8 days of inpatient care and 52% died in the hospital. Patients with advanced cancer who used chemotherapy were more likely to visit the ED (78% vs 59%; P < .001), undergo medical imaging (67% vs 51%; P < .001), and die in the hospital (73% vs 50%; P = .03) than patients who did not use chemotherapy. In the multivariate analysis, chemotherapy use near death and advanced cancer were associated with ED visits and ICU admissions, respectively (odds ratio >1).

CONCLUSION

Our study suggests that privately insured people with cancer receive poor quality EOL care in Brazil. Further research is needed to assess the impact of improvements in palliative care provision in this population.

Inpatient palliative chemotherapy is associated with high mortality and aggressive end-of-life care in patients with advanced solid tumors and poor performance status

Background

The benefit of palliative chemotherapy (PC) in patients with advanced solid tumors and poor performance status (ECOG-PS) has not been prospectively validated, which makes treatment decision challenging. We aimed to evaluate the overall survival, factors associated with early mortality, and adoption of additional procedures in hospitalized patients with advanced cancer and poor ECOG-PS treated with PC.

Methods

We analyzed a retrospective cohort of patients with advanced cancer treated with PC during hospitalization at an academic cancer center in Brazil from 2014 to 2016. Eligibility criteria included: ECOG-PS 3–4 and start of first-line PC; or ECOG-PS ≥ 2 and start of second or subsequent lines. Primary endpoint was 30-day survival from start of PC. Kaplan-Meier method was used for survival estimates and Cox regression for factors associated with 30-day mortality.

Results

Two hundred twenty-eight patients were eligible. 21.9, 66.7 and 11.4% of patients had ECOG-PS 2, 3 and 4, respectively. 49.6% had gastrointestinal tumors. Median follow-up was 49 days (range 1–507). 98.2% of patients had died, 32% during the index hospitalization. The 30-day and 60-day survival rates were 55.7 and 38.5%, respectively. 30% of patients were admitted to the intensive care unit. In a multivariable analysis, ECOG-PS 3/4 (HR 2.01; P = 0.016), hypercalcemia (HR 2.19; P = 0.005), and elevated bilirubin (HR 3.17; P <  0.001) were significantly associated with 30-day mortality.

Conclusions

Patients with advanced cancer and poor ECOG-PS had short survival after treatment with inpatient PC. Inpatient PC was associated with aggressive end-of-life care. Prognostic markers such as ECOG-PS, hypercalcemia and elevated bilirubin can contribute to the decision-making process for these patients.

Symptom Assessment and Early Access to Supportive and Palliative Care for Patients With Advanced Solid Tumors in Mexico

BACKGROUND

Early specialized palliative care improves quality of life of patients with advanced cancer, and guidelines encourage its integration into standard oncology care. However, many patients fail to obtain timely palliative/supportive care evaluations, particularly in limited-resource settings. We aimed to determine the proportion of patients with advanced cancer who received an assessment of symptoms and were referred to supportive and palliative care services during the first year after diagnosis in a Mexican hospital.

METHODS

Individuals with newly diagnosed advanced solid tumors and 1 year of follow-up at the oncology clinics in the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran in Mexico City from October 2015 to April 2016 were included in this retrospective study.

RESULTS

Seventy-seven patients were included. Forty-two (54.5%) were referred to the various supportive care services during the first year after diagnosis, and 23 (29.8%) were referred to the palliative care clinic. The most commonly assessed symptoms by oncologists were pain (77.9%), anorexia (74.0%), fatigue (68.8%), and nausea (55.8%), while depression/anxiety were evaluated in 10 (12.9%) patients. The oncologist offered to clarify treatment goals in 39 (50.6%) cases and evaluated the understanding of diagnosis/illness and prognosis in 22 (28.5%).

CONCLUSION

Palliative and supportive care services were widely underutilized, which may be related to a lack of standardized symptom assessments and poor end-of-life communication. Novel strategies are needed to improve the implementation of tools for systematic symptom assessment and to optimize the integration of supportive care interventions into oncology care in developing countries.

The practice of intensive care in Latin America: a survey of academic intensivists

Background

Intensive care medicine is a relatively young discipline that has rapidly grown into a full-fledged medical subspecialty. Intensivists are responsible for managing an ever-increasing number of patients with complex, life-threatening diseases. Several factors may influence their performance, including age, training, experience, workload, and socioeconomic context. The aim of this study was to examine individual- and work-related aspects of the Latin American intensivist workforce, mainly with academic appointments, which might influence the quality of care provided. In consequence, we conducted a cross-sectional study of intensivists at public and private academic and nonacademic Latin American intensive care units (ICUs) through a web-based electronic survey submitted by email. Questions about personal aspects, work-related topics, and general clinical workflow were incorporated.

Results

Our study comprised 735 survey respondents (53% return rate) with the following country-specific breakdown: Brazil (29%); Argentina (19%); Chile (17%); Uruguay (12%); Ecuador (9%); Mexico (7%); Colombia (5%); and Bolivia, Peru, Guatemala, and Paraguay combined (2%). Latin American intensivists were predominantly male (68%) young adults (median age, 40 [IQR, 35–48] years) with a median clinical ICU experience of 10 (IQR, 5–20) years. The median weekly workload was 60 (IQR, 47–70) h. ICU formal training was between 2 and 4 years. Only 63% of academic ICUs performed multidisciplinary rounds. Most intensivists (85%) reported adequate conditions to manage patients with septic shock in their units. Unsatisfactory conditions were attributed to insufficient technology (11%), laboratory support (5%), imaging resources (5%), and drug shortages (5%). Seventy percent of intensivists participated in research, and 54% read scientific studies regularly, whereas 32% read no more than one scientific study per month. Research grants and pharmaceutical sponsorship are unusual funding sources in Latin America. Although Latin American intensivists are mostly unsatisfied with their income (81%), only a minority (27%) considered changing to another specialty before retirement.

Conclusions

Latin American intensivists constitute a predominantly young adult workforce, mostly formally trained, have a high workload, and most are interested in research. They are under important limitations owing to resource constraints and overt dissatisfaction. Latin America may be representative of other world areas with similar challenges for intensivists. Specific initiatives aimed at addressing these situations need to be devised to improve the quality of critical care delivery in Latin America.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-1956-6) contains supplementary material, which is available to authorized users.

Identifying patients for palliative care in primary care in Brazil: Project Estar ao Seu Lado’s experience

Objective: To present the process of identification of palliative care patients in a Family Health Strategy´s team in Brazil. Methods: The identification process ocurred 1) using the system of work of a Family Health Strategy Team and the principles of primary care and 2) by applying the SPICT, a tool to help identify patients who might benefit with palliative care. Results: Twenty-three patients were enrolled in the palliative care program at the beginning of the project. By the end of the 12 month period, we had identified 38 patients. Six patients died during the time period. Thus during 2015, 38 people were identified with palliative needs from a total population of 3,000 (1.2% of the practice population). Of these 58% (n=22) were women, 63% (n=24) over 65 years, 74.7% (n=28) reported white ethnicity. The most frequent major diagnoses were cancer (39.5%), psychiatric disease (18.4%), cardiovascular disease (15.8%), frailty (10.5%), dementia (10.5%), and respiratory disease (7.9%). Multimorbity was higher in patients over 65 years (t-test, p=0.009) with a median of four diseases. The most prevalent conditions among those suffering multimorbidity were cardiovascular disease (73.7%), psychiatric disease (65.8%), cancer (50%), frailty (39.5%), diabetes mellitus (31.6%), and respiratory diseases (23.7%). Conclusion: We applied a tool for identifying patients who would benefit from palliative care in primary care in a community of Rio Grande. It was practical and feasible. Its further refinement, implementation and evaluation in Brazil is indicated at community centres of Family Health Strategy, specifically taking account of social and economic factors.