What benefits can we find transfunsing blood products in terminal patients? A systematic review
Estela Hernández Bello1, Ángel Gasch Gallén2, Concepción Tomás Aznar2
1Unidad de Medicina Interna. Hospital Clínico Universitario Lozano Blesa, Zaragoza. 2Departamento de Fisiatría y Enfermería. Universidad de Zaragoza, Zaragoza
Introduction: Chronic anemia is a common process in terminal patients, requiring blood transfusion between 5 and 17,5 % of these patients. The main indications for transfusion are base on hemoglobin levels (< 12 g/dl) and symptomatology. The objetive was to analyze the benefits of treatment with Blood transfusions in these patients.
Methods: A systematic review searching in Medline, IBECS, and The Cochrane Library. Criteria for inclusion: written in Spanish or English, adult terminal patients population, and types of studies: clinical trials, case-control studies, cohort studies and descriptive studies.
Results: 17 articles were selected from 297. 1 cases and controls, 1 clinical case, 1 qualitative and 14 descriptions. 9 showed benefits in symptoms, 4 improvement in serum hemoglobin, and the 4 combined the two measurements.
Conclusions: All the articles had applied the hemoglobin level criterion to indicate transfusion. Fatigue, dyspnoea, and hemoglobin levels improve after therapy, but it does not improved quality of life or survival.
Mediation at the end of life in advanced diseases
Pilar Munuera Gómez1, Anna Novellas Aguirre de Cárcer2
1Facultad de Trabajo Social. Universidad Complutense de Madrid, Madrid. 2Asesora en intervención psicosocial del Observator. Qualy. Instituto Catalán de Oncología,
The possibilities of mediation are presented in response to the management of individual, family and social conflicts that patients in a terminal or advanced situation have. The use of conflict resolution techniques is necessary in advanced diseases to implement communication between family members and professionals to reach agreements in decision making at the end of life. People who participate generally manage to reduce the emotional cost and the probability of litigation disappears by increasing the quality of care.
Addressing issues related to prolonged care, through a mediation process helps to respect the values of all stakeholders, aims to provide quality at this time. The mediator transforms the formulation of the problem into the opposing parties, separating the person from the problem. This change makes the problem more manageable, which allows the positive management of conflicts that arise when respecting the people involved. The new perception of the problem is built from the recognition of people facing the problem, which can be faced with the logic of reaching an agreement that benefits everyone.
Mediation helps to focus on the common interests that people show in decision-making, based on objective criteria that benefit families facing the end of their loved one's life. This achievement favors dialogue and respect for the decisions made.
Do palliative care proffesionals know about advanced care planning document? a critic review
Joana Maria Julià-Móra1, Miguel Ángel Rodríguez-Calero2
1equipo de soporte hospitalario en atención paliati. Hospital de Manacor, Manacor. 2departamento de Enfermería y Fisioterapia. Universitat de les Illes Balears,
Rationale: 'Previous instructions' or 'Advance directives' document (PI/ADD) constitute a group of formal documents in which a patient can express the way he/she would like to die or be treated in the last days of life. These documents ensure patients’ final wishes will be considered and respected. The emerging trend of Advance Care Planning appeared in 1998, and the ADD was proposed in this context as a broad-based communication effort, which requires that healthcare professionals have proper training for end of life care. In this respect, previous studies show that inadequate training with regard to end of life care, especially in critical care units (ICU), hinder communication skills and attitudes, provision of care and finally, preservation of patient dignity during the process of death.
Objective: To analyse the competency (knowledge, skills and attitudes) about PI/ADD among physicians and nurses of ICUs in the region of Madrid.
Design: Cross-sectional study.
Place and timing: Nine hospitals in the region of Madrid, from October to December 2010.
Participants: All physicians and nurses from all adult ICUs of the nine participating hospitals constituted a convenience sample.
Instrument: An anonymous, structured, self-completed ad hoc questionnaire was sent to participants with dichotomous and Likert scale variables.
Data collection and analysis: Socio-demographic variables, as well as knowledge, skills and attitudes-related variables were collected. Previous to data collection, medical and nurse supervisors were contacted, information sessions carried out and informative posters displayed in participating units. The questionnaires were distributed through key informants and deposited in closed boxes after completion. Previous informed consents were obtained; the study was approved by the Committee of Clinical Research Ethics of San Carlos Hospital, Madrid.
Qualitative variables were described with absolute and relative rates and percentages according to categories. Association analysis included chi-squared and exact Fisher tests. A confidence interval with 5% error was applied, using the statistic package SPSS v. 18.0.
Results: A total of 649 questionnaires was delivered and 331 of them were sent back during the pre-established period of 3 months. The response rate was 51%. As for socio-demographic variables, 73,4% (253) of responders were women and 67,2 % (222) were older than 31 years old; 20,5% (68) of professionals were physicians and 79,5 % (263) were nurses. Regarding knowledge, 64,4% of participants reported not to know about the different documents available for patients to formalise their last wills. With respect to concrete measures included in the PI, such as the limitation of therapeutic effort, palliative care, organ donation, rejection of therapeutic obstinacy and the assignation of a legal representative, only 9,7% of professionals knew all of them. 82,8% of participants believed that ADD was a useful instrument for professional decision-making. 50,2% believed ADD were not respected. 85,3% of physicians would respect ADD in case of vital emergency, in contrast to 66,2% of nurses (p=0,007). Only 19,1% of physicians and 2,3% of nurses actually knew whether the patients they had in charge at the moment had a ADD or not (p<0,001).
Conclusions: Although healthcare professionals present a low level of knowledge about PI, they show a favourable attitude about their utility. However, most of the participants do not actually know if their patients have a ADD and some professionals, even when they know about the existence, would not respect it in case of an emergency. In this regard, further training is required with relation to PI.