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Learning from the grief experience during the COVID-19 pandemic
Valérie Buscemi1, Marta López2, Olga Bosch3, Silvia Crespo3, Xavier Costa4, Sara Eda Persentili5, Carlota Noguera6
1Hospital General de Granollers. EAPS Creu Roja. Fundació "la Caixa", Granollers. 2EAPS Creu Roja. Fundació "la Caixa", . 3PADES Granollers. EAPS Creu Roja. Fundació "la Caixa", . 4ICS - Càtedra de Cures Pal·liatives UVIC, . 5PADES Granollers/Hospital General de Granollers. EAPS Creu Roja. Fundació "la Caixa", . 6Programa Final de Vida i Soledat. Fundació "la Caixa",

Introduction: This descriptive cross-sectional study with qualitative methodology aims to approach the understanding of the experience of the patients’ relatives who died during the COVID-19 pandemic as well as to detect those aspects that play a protective role against the loss and grief emotional impact.
Material and methods: A semi-structured interview was carried out by phone for the evaluation, from the perspective of the family members, of different variables associated with the end of life process and the patient death (tasks related to the circumstances of death, protectors and risk factors of complicated grief, satisfaction with psychological support, and interest in receiving information about a Grief Support Service).
Results: A content analysis of 126 interviews allowed us to approach the main factors that (1) hindered the experience –state of alarm and its restrictions, other losses and concomitant circumstances, and the perception of the violation of a dignified death–, (2) facilitated the experience –family support, own resources, the search for meaning and the consideration of the patient as a source of support– or (3) factors than hinder or facilitate, depending on whether or not they could be present –presence and care, health care and the performance of rituals–.
Discussion: The results are discussed, based on the recent findings found in the scientific literature, concluding on the need for a comprehensive and integrative systemic healthcare.

DOI: 10.20986/medpal.2021.1243/2021
Results of a palliative care program in patients with advanced heart failure in the end-of-life stage
Raquel Liliana Vazquez1, Didier Andrés Bruno1, María Pilar Cean1, Mariana Cecilia Herrero2, Graciela Vita3, Andrés Gabriel Mendez Villarroel1, Enrique Mario Baldessari1
1Medicina Interna. Hospital Universitario de la Fundación Favaloro, CABA. 2Neurociencias. INECO- Fundación Favaloro, CABA. 3Enfermería. Hospital Universitario de la Fundación Favaloro, CABA

Introduction: The prevalence of heart failure is increasing, manifested as in the advanced stage (AHF) with symptoms affecting quality-of-life. Exacerbations and hospitalizations are frequent with high morbimortality; all conditions that could benefit from palliative care.
A cardiology palliative care (CPC) program was designed and consisted of symptom control, communication skills and determining advanced directive. The objective was to compare the care received by patients who died of AHF, before and after establishing the program.
Material and methods: Comparative and observational study. Inclusion criteria: AHF and/or frequently admission; excluding those for surgical treatment and transplant. Data from the control group (preCPC) was obtained from review of medical records of patients who died from AHF, admitted when CPC was not available. For statistical analysis, categorical variables were evaluated using non-parametric tests. Continuous variables were compared using the Mann-Whithey U test.
Results: Seventy-seven patients were included in preCPC group and 65 in CPC; similar demographic characteristics: age 75 years, male: 70 %. A decrease in the duration (27.3 vs.7.2; p < 0.001) and number (2.64 vs. 1.51; p < 0.001) of hospital stay of CPC group. Invasive procedures predominate in preCPC; mechanical ventilatory assistance (52.7 % vs. 7.8 %; p < 0.001), hemodialysis (41 % vs. 5.5 %; p < 0.001), cardiopulmonary resuscitation (88.2 % vs. 11 %; p < 0.001), central vascular access (75.7 % vs. 26.5 %, p < 0.01) and inotropics (70.5 % vs. 20 %; p < 0.001). Non-invasive ones in CPC: palliative sedation (3 % vs. 25 %), opioid use (35 % vs. 58.3 %), deactivation of implantable cardiodefibrillator (0 vs. 37,5 %) and do-not-resuscitate orders (3 % vs. 77 %; p < 0.001) were observed at end-of-life of CPC group. The mortality in high-complexity sectors predominates in preCPC group (51 % vs. 26 %; p < 0.005).
Discussion: CPC improves the attention quality in patients with AHF, preventing unnecessary and futile intervention. Also, it reduces the overuse of resources and therapeutic obstinacy.

DOI: 10.20986/medpal.2021.1234/2021
Advance Care Planning in people with cancer disease in a monographic cancer institute: restrospective cross-sectional study
Cristina Lasmarías1, Candela Calle Rodríguez2, Anna Esteve Gómez3, Jordi Trelis Navarro4
1Departament de Persones / Direcció Assistencial. Institut Català d'Oncologia , Hospitalet del Llobregat. 2Directora General. Institut Català d'Oncologia , . 3Servicio de Oncologia Médica. Institut Català d'Oncologia , . 4Dirección asistencial. Instituto Catalán de Oncología,

Background: Advance Care Planning (ACP) encourages people to express wishes, preferences and concerns in order to facilitate a shared care process between patient, family and professionals. This is especially relevant in cancer context.
Materials and Methods: A cross-sectional study was carried out to analyze the ACP process practices of the professionals through the Clinical records (HC) of the last 3 months of life of a sample of deceased patients in one month in a monographic cancer hospital. Sociodemographic variables, diagnosis, level of therapeutic intensity (LTI), cognitive status and ACP variables were defined: preferences, concerns, preference for place of care and place of death, choice of surrogate and advance directive document (ADC) existence.
Results: N= 54; 61.1% men; median age: 64.5 years. Main cancer disease: respiratory (22.2%); 79.6% expressed themselves. The ACP variables were: preferences 74,1 %(n=40); concerns 75,9%(n=41); surrogate 7.4% (n=4); place of care: 27.8% (n = 15); place of death: 16.7% (n = 9). None had an ADC Preferences and concerns records are mainly carried out by the palliative care) teams. The LTI in the preferences / concerns record was 3A. Concerns were associated with self- expression of the patient (p<0,001).
Conclusions: Registration of ACP dimensions is poor and occurs mainly in end of life context. Variables such as the representative figure or the ADCs are scarce. Early integration of ACP in clinical practice would facilitate decision-making with cancer patients and would help to define the care process according to their wishes and preferences.

DOI: 10.20986/medpal.2021.1258/2021
Antibiotic therapy at the end of life in cancer patients
Andrea Sesma1, Mara Cruellas2, Marta Gascón Ruiz3, Natalia Alonso Marin3, Maitane Ocáriz Díez3, María Zapata García3, María Zurera Berjaga3, Alba Moratiel Pellitero3, Inés Ruiz Moreno3, María Álvarez Alejandro3, Rodrigo Lastra del Prado3, Jose Ramón Paño Pardo4
1Oncología médica. Hospital Universitario Lozano Blesa, . 2ONCOLOGÍA MÉDICA. Vall d´Hebron, . 3Oncología médica. Hospital Clínico Universitario Lozano Blesa, . 4Enfermedades Infecciosas. Hospital Clínico Universitario Lozano Blesa,

Introduction: Infections at the end of life in cancer patients are an important cause of morbidity and mortality, and the indications for antibiotic therapy in this context are not clear.
Objectives: Describe the use of antibiotics at the end of life and analyze its relationship with the characteristics of the oncological disease, functional status and probability of discharge upon admission.
Methodology: Retrospective study of deceased patients in the oncology ward limited to a period of 7 months between May 1 and December 31, 2019. The number of patients included was 101. The percentage of patients who received antibiotic treatment during their admission and the time elapsed between the last dose and exitus lethalis were evaluated.
Results: The mean age was 65.3 years and 54.5 % were men. 23.7 % had an ECOG<2, 63.3 %≥2. The most frequent location of the primary tumor was the lung (38.6 %). 53 % of the patients received palliative chemotherapy at the time of admission, and 66.3 % were in disease progression. In 72.3 % the probability of discharge upon admission was low. The main suspected infectious focus was the respiratory (27.7 %) followed by the abdominal (18.8 %). 58.4 % received antibiotic treatment. The most frequently used antimicrobial was amoxicillin-clavulanate (36.2 %). Regarding the search for the microorganism responsible for the patient's probable infectious condition, blood culture was obtained in 23 patients (23 %), urine culture in 12 (12 %), stool culture in 7 (7 %) and sputum culture in 10 patients (10 %). Microorganisms were isolated in 9 blood cultures, 4 urine cultures, one stool culture and 2 sputum cultures respectively. The most frequently isolated microorganisms in the positive cultures were: Escherichia coli (4), Pseudomonas aeruginosa (2) and Clostridium perfringens (2).
Conclusion: The population of patients receiving antimicrobials at the end of life is quite homogeneous in terms of its clinical characteristics and presents a high incidence of infections with a high frequency of antimicrobial use. Although 58 % of the patients received antimicrobials, in only 23 % the causative agent was identified. This is a retrospective study with a small sample of patients and further prospective studies are necessary.

DOI: 10.20986/medpal.2021.1265/2021
Effects of hospital clowns on the quality of life of people in a Paediatric Oncology Palliative Care Unit
Victoria Valdebenito Mac Farlane1, Renata Sánchez Egaña2
1Escuela de Psicología. Universidad Adolfo Ibáñez, Viña del Mar. 2Escuela de Psicología. Universidad Adolfo Ibáñez, Calera de Tango

Objective: The aim of this research is to understand the perceptions of families about the effects of hospital clowns on the quality of life of children and families in an Oncological Palliative Care Unit of a Chilean public hospital.
Method: Under a qualitative, emergent, cross-sectional design and strict ethical considerations, we used in-depth interview technique and discussion group. Sixteen mothers who went through the experience of palliative care with their children were interviewed using a script based on six quality of life dimensions: perception of physical activity and health, psychological state, self-esteem, family, friends and school. In addition, a discussion group was held to consolidate the topics of the analysis of the interviews. The transcripts and documents were first analyzed separately and then a data triangulation process was performed. An interpretivist paradigm guides the analysis, through discourse analysis and grounded theory techniques.
Result: The discourses of participants reveal that the presence of clowns produces psychological effects on emotional regulation, as well as being a mechanism to cope with both periods of palliative care and those after death by establishing “family” ties with clowns. Likewise, both the clowns and the space they occupy in the hospital affect the construction of community in this health context, an aspect of great relevance for families in the care provided.
Conclusions: The presence of clowns has impacts especially in two of the six quality of life dimensions, psychological state and family relationships, being also highly relevant in the context to deliver humanized care, helping mothers to cope with the situation during palliative care and after death of their children.

DOI: 10.20986/medpal.2021.1246/2021
Latin American Participation in the Scientific Production of Medicina Paliativa
Ronald M. Hernández1, Rafel Garay-Argandoña1, Juan José Flores-Cueto1
1Unidad de Virtualización Académica. Universidad de San Martín de Porres, Lima

DOI: 10.20986/medpal.2021.1256/2021
Comprehensive geriatric assessment in palliative care: Bibliographic review
Jose Mauricio Ocampo-Chaparro1, Carlos Reyes-Ortiz2, Edwin Etayo-Ruiz3
1Departamento de Medicina Familiar. Universidad del Valle, Cali. 2Institute of Public Health. Florida A & M University, Tallahassee. 3Red Integrada Gesencro UT,

The progressive aging of the population is explained by the advance in health care, the demographic and epidemiological transitions present worldwide. This phenomenon implies changes in the social and economic field, in the education and health systems, and in social security. Consequently, it is characteristic to find older adults with multimorbidity, presenting chronic diseases with different trajectories at the end of life, and that are going to require attention in the palliative care model.
Comprehensive geriatric assessment (CGA) is the technology currently available to address the complex situation of older adults, particularly those who need care for palliative care. The CGA process offers a comprehensive approach that is based on the biopsychosocial model and is operationalized through the performance of an interdisciplinary team that provides assessment and palliative care in an individualized and continuous way and adapted throughout the course of the disease, helping to determine a prognosis and potential quality of life in each older adult.
In the CGA within palliative care, advance care planning and shared decision-making are of special importance, from the moment the older adults are indicated to be cared for until the end of their life, and after their death, giving support to their relatives and caregivers.

DOI: 10.20986/medpal.2021.1163/2020
Elderly man with breast cancer treated with opioids in the palliative care unit of the Public Hospital in El Salvador.
Hilda Aracely Magaña Guardado1
1Medicina Paliativa. Hospital Nacional Zacamil, Mejicanos

Breast cancer in men is a rare disease, it represents less than 1% of all male cancers; and almost 1% of breast cancers, and is responsible for 0.1% of cancer deaths in men. (1)
The most common type of breast cancer seen in men is invasive ductal carcinoma, which accounts for approximately 90% of all male breast cancers. (3)

The present study reports the case of a 97-year-old man who was diagnosed with invasive infiltrating ductal carcinoma who was treated with opioids in a palliative care unit.

In this case, which is rare in the medical literature due to the type of diagnosis, sex and age of the patient, we observe that the proper use of opioids, teamwork, closeness with the family member and follow-up over time make better decisions are made about treatment, comfort and quality of life is better.

DOI: 10.20986/medpal.2021.1251/2021
Lung ultrasound at the end of life at home: a new diagnostic approach to understand the pathophysiology of death. Case series.
Juan Santos Suárez1
1SESPA. Equipo de Apoyo de Cuidados Paliativos de Oviedo, Oviedo

Introduction: Pulmonary ultrasound has not yet been used to determine the state of the lung and its evolution in the course of a terminal illness. The objective of this work is to know how the lung behaves in people at the end of life using POCUS (Point of Care UltraSound) at home and to detect the benefits that this procedure will have for the patient, the family and the future of palliative medicine.
The ultrasound machine used is digital and it is the probe itself, weighing 313 g and 185 x 56 x 35 mm dimensions, attached to a device with a variable-size screen, easy to carry. A systematic examination, in two-dimensional mode, of four points was made in each hemitorax and three cardiac views.
Patients and methods:
Observational study sample of seven patients referred, between May and July 2020, to our home palliative care team and who died within 72 hours after performing lung ultrasound: two with cancer, another with Parkinson's disease and four without a clear cause of death.
Results: The pleural line was altered in all cancer patients which also presented a pleural effusion and another one a pericardial effusion with a variable edema of the lung parenchyma; three of them had reduced ventricular function. The Parkinson's patient had a normal aerated lung but significant respiratory dysfunction.
Discussion: lung ultrasound offers relevant information for professionals by improving the diagnostic capacity at the end of life and those causes of death, identify pleural and pericardial effusions, will make it possible to optimize therapeutic decisions.

DOI: 10.20986/medpal.2021.1199/2020
Influence of knowing diagnosis and prognosis on resilience and social support at the end of life
Tamara Redondo Elvira1, Celia Ibáñez del Prado2, Sara Barbas Abad3, Juan Antonio Cruzado Rodríguez4
1Psicooncología. AECC Guadalajara, Guadalajara. 2Hospital Virgen de la Poveda, Madrid; UCM, Pozuelo de Alarcón. 3Fundación Aladina, Madrid, . 4UCM,

OBJETIVE: To study the relationship between information about diagnosis and prognosis and resilient coping and social support. Besides, try to analyse the relationship between sociodemographic and clinical variables and information about their illness.
METHOD: Resilience (BRCS) and Social Support (MOS) and informational variables were assessed. A sample of 192 hospitalised palliative patients was chosen, of which the average age was 69,05 (DT=15,106), and 50.5% were men. Oncologic diagnosis = 82.8%, low cultural level = 52.6%; married = 45.3%, and average PPS = 49.11.
RESULTS: Relationship between emocional support and knowing prognosis (0,151; p=0,036) and perception of death (0,186; p=0,010). Resilience was positively correlated with knowing prognosis (0,258; p=0,000) and perception of death (0,146; p=0,044).
CONCLUSIONS: Emotional support shows the relevance of health professionals, who should adapt their communication style to patients´needs. Also, resilient coping helps to manage information and to adapt to end-of-life situation.

DOI: 10.20986/medpal.2021.1222/2020
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