Online First

The epidemic of chronicity has grown exponentially in recent years. In our country, nearly 5% of the population lives with chronic diseases and conditions, while 1.5% have advanced chronic conditions with palliative care needs and a limited life expectancy. Among them, approximately 0.4% are affected by social vulnerabilities, such as loneliness, poverty, or difficulties related to housing or access to services, This represents an irreversible structural and systemic change, whith impact in all health and social care services.
This transformation requires an approach that ensures comprehensive care, integrated across all services and settings within a territory. It should promote early identification, assessment and care addressing all dimensions of need, shared and anticipatory care planning, and the adaptation of all services to chronicity, with a population-based, community-oriented, and public health approach applied at the territorial level.
In response to this challenge, the experience in Catalonia has involved the sequential design and implementation of a Palliative Care Programme that established specific structures and services, followed by a Chronic Care Programme that developed comprehensive generalist care in primary care settings, and subsequently a proposal for an Integrated Health and Social Care Agency. These initiatives have achieved results in palliative care coverage and in improving the identification and comprehensive, integrated care of people with complex and advanced chronic conditions, including the palliative care model, psychosocial and spiritual care, and community participation, generating outcomes in coverage and effectiveness.
This development has been facilitated by the integration of contributions from palliative care, family and community medicine, geriatrics, among others, which have cooperatively and synergistically contributed to generating a comprehensive and integrated model, as well as by continuity in the design, implementation, and evaluation of public policies that have incorporated palliative care as an essential component and chronicity, and as an opportunity for extension to all groups that require it.

Background and Objectives: Preoccupation is a frequent cognitive phenomenon among palliative care patients and their caregivers. Despite variability in its content and intensity, it may significantly influence treatment preferences within palliative care settings. This study aimed to systematically review the most commonly reported preoccupations and to identify potential longitudinal differences and variations according to the type of informant.

Materials and Methods: A systematic review with narrative synthesis was conducted using the databases PubMed, Medline, PsycInfo, and EMBASE up to July 1, 2024. Original studies reporting on the preoccupations of palliative care patients or their formal and informal caregivers were included.

Results: A total of 39 articles met the inclusion criteria. The majority were qualitative studies, with patients themselves being the most frequent informants. Most studies examined general prevalence of preoccupations without thematic restrictions.

Conclusions: Three overarching domains of worry were identified: (1) psychological or emotional, (2) support and interpersonal connection, and (3) illness-related. No single domain was found to predominate. The focus of preoccupation appears to vary depending on the stage of illness and is not consistently associated with symptom intensity. Symptom-related preoccupations may serve as useful indicators for identifying palliative care targets in collaboration with patients and caregivers.

Objective: To ascertain the level of spirituality among family caregivers of children with cancer by evaluating their spiritual practices and beliefs.
Method: A cross-sectional quantitative design conducted in two specialized foundations dedicated to supporting children with cancer in the city of Cartagena. A convenience census sampling was employed, resulting in a sample size of 111 participants. Caregivers without blood ties, agnostics, and individuals with diagnosed mental illnesses were excluded. The Spiritual Perspective Scale by Pamela Reed was utilized, with a Cronbach's alpha of 0.87. Scores ranged from 10 to 60 points, with spirituality directly proportional to the score obtained. Data collection occurred between January and August 2023 and was analyzed using Stata 11.0 software. Descriptive statistics based on means and absolute and relative frequencies were calculated. Informed consent was obtained, and participants were informed about the ethical handling of information in accordance with the principles outlined in the Declaration of Helsinki.
Results: A total of 111 family caregivers of children with cancer participated, with ages ranging from 18 to 37 years. Of these, 94 (85%) were women, 75 (68%) were mothers, and 64 (58%) were in stable unions. Twenty-eight participants (25%) had completed secondary education, 71 (64%) were unemployed, and 63 (57%) of the mothers were homemakers. The majority, 109 (98.2%), identified as Christians, predominantly Catholics (69, or 62%). Regarding income, 55% reported earning less than $293 USD, equivalent to a minimum wage of $1,300,000 COP. A high level of spirituality was observed, with a mean score of 54/60. Participants unanimously (100%) reported that their spiritual beliefs played a significant role in their lives and frequently expressed feeling a profound closeness to God (Jesus Christ).
Conclusion: The family caregivers of children with cancer in Cartagena exhibited a high level of spirituality, further emphasizing that spirituality was regarded as a cornerstone in their lives.

Introduction: Palliative sedation (PS) is used to manage patients experiencing refractory symptoms of terminal illnesses in end-of-life scenarios. Dexmedetomidine (DXM) is a valuable medication owing to its analgesic and sedative properties. This article aimed to synthesize the available evidence concerning the use of DXM in patients undergoing PS intervention.
Methods: A systematic search was conducted using the MEDLINE (PubMed), SCOPUS, Ovid, Lilacs, and Scielo databases. Observational studies (case reports, case series, cohort studies), experimental studies (clinical trials or quasi-experimental studies), narrative reviews, and systematic reviews related to the use of DXM in PS.
Results: Eleven articles that met the inclusion criteria were analyzed. Only two articles explicitly defined PS. The primary settings were specialized palliative care facilities (42.8%), conventional hospitalization (6.2%), and intensive care units (5%). Most of the patients had an oncological diagnosis (45.9%).
The primary symptoms prompting the inclusion of DXM in the PS protocols were refractory pain (62%), delirium (31%), or dyspnea (11%). There was considerable variability in the scales used to assess the symptom severity. Control of the primary symptoms was achieved in most cases.
The predominant route of administration was intravenous (71.7%), while the subcutaneous (SC) route was used less frequently. The main adverse effects reported were hypotension and sedation; however, no reported case required infusion discontinuation. The use of dexmedetomidine facilitated better communication with the family and treatment team, and enhanced patient comfort.
Conclusions: There is insufficient evidence to recommend the use of DXM for patients with PS. Nonetheless, it is a promising medication to consider in protocols within this context, as it may help alleviate the intensity of refractory pain, sensation of dyspnea, and refractory delirium. No adverse effects were observed, which would contraindicate its use in PS.

Introduction: Refractory cancer pain (RCP) affects 10-20 % of patients with cancer. Ketamine, an anesthetic agent, has been evaluated as a therapeutic alternative in the management of RCP. The aim of this study was to describe the pattern of oral ketamine use in oncology patients. Secondary objectives included assessing opioid consumption, analyzing the proportion of patients achieving predefined a pain control criteria, and describing the drug’s safety profile.
Material and methods: A multicenter prospective observational study was conducted over an 18-month period. All hospitalized patients who initiated oral ketamine were included. Rescue opioid use was recorded on days −5 and −2 before, and on days +2 and +5 after ketamine initiation. A criterion for controlled pain was defined. Adverse events (AEs) were recorded and graded according to CTCAE v5.0.
Results: A total of 37 patients were included. Overall, 97.3% of patients initiated ketamine at a dose of 0.5 mg/kg/day, with 30 mg/day being the most frequent starting dose (70.2%). The mean daily oral morphine equivalent (OME) dose was 354 mg. Median survival from ketamine initiation was 41 days. Breakthrough opioid use was 4.43 (D-5) and 5.30 (D-2) before initiation, decreasing to 3.51 (D+2) and 3.24 (D+5) afterward (mean difference -1.49 breakthrough doses; p < 0.001). A total of 54.1% of patients met the criteria for controlled pain. Fourteen adverse events were recorded in 9 patients (24.3%), including one grade 3 adverse event (2.7%).
Conclusion: Oral ketamine was associated with patients with limited life expectancy and high opioid requirements. A significant reduction in rescue opioid consumption was observed after ketamine initiation, and more than half of the patients achieved controlled pain. The safety profile was acceptable. Further randomized studies are needed to evaluate the efficacy and appropriate indications of oral ketamine.

Malignant psoas syndrome (MPS) is a rare condition resulting from malignant involvement of the psoas muscle. It is characterized by ipsilateral lumbosacral plexopathy and painful hip flexion and is often refractory to multiple therapeutic approaches. We report the case of a woman with MPS secondary to lymphadenopathy and a soft tissue mass caused by sigmoid adenocarcinoma.

Introduction:
Point-of-care ultrasound (POCUS) has become established as a diagnostic and therapeutic support tool in multiple specialties. In palliative care, its usefulness has been described primarily in the hospital setting, with limited evidence in the home setting, where rapid decision-making and the avoidance of unnecessary transfers are particularly relevant.
Objective: To describe the clinical indications for clinical ultrasound in home-based palliative care, the sociodemographic and functional characteristics of the patients in whom it is used, and to analyze its impact on therapeutic management and hospital referrals.
Methods: This was an observational, descriptive, and multicenter study conducted in Home-Based Palliative Care Support Teams (ESAPD) in the Community of Madrid. Patients over 18 years of age with advanced cancer receiving home-based care were included, and clinical ultrasound was performed according to professional criteria. Sociodemographic variables, clinical variables (ICD-10, Palliative Performance Scale), type and location of ultrasound scan, findings, therapeutic changes, and hospital referrals were collected. The analysis was descriptive.

Results: 285 ultrasound scans were performed over a six-month period by 15 physicians from 6 Palliative Care Services (ESAPD). The mean age of the patients was 79.2 years (SD: 13.95), 52% were women, and the median Palliative Performance Scale score was 50. The most frequent scans were abdominal (43.5%) and thoracic (22.8%). Pathological findings were identified in 67% of the ultrasound scans. After the ultrasound scan, a change in therapeutic approach occurred in 62% of cases, and hospital referrals were avoided in 70%.

Conclusions: Clinical ultrasound in home-based palliative care is a feasible and useful tool, integrated into clinical practice, that helps reduce diagnostic uncertainty, optimize therapeutic decision-making, and avoid unnecessary hospital transfers, prioritizing patient comfort and quality of life.