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Accompaniment to patients at the end of life during the Covid-19 pandemic
Marisa de la Rica Escuín1, E. Begoña García-Navarro2, Isidro García Salvador3, María Jesús De la Ossa Sendra4, Encarna Chisbert Alapont5
1Instituto de Investigación Sanitaria de Aragón. Universidad de Zaragoza. Grupo Investigación AECPAL, Zaragoza. 2Enfermería. Dirección de Salud UHU. Universidad de Huelva, El Rompido, Huelva. 3Servicio de Oncología. Hospital Dr. Peset de Valencia. Grupo Investigación AECPAL, Valencia. 4Fundación Cudeca. Instituto de Investigación Biomédica de Málaga. Grupo de Investigación AECPAL, Málaga. 5Hospital de Día. Hospital de la Fé. Grupo de Investigación AECPAL., Valencia

Objectives: This study describes accompanying and saying goodbye to patients in the last days of their lives in hospitals and nursing homes. It also describes the attitudes of health professionals towards the care of patients in the last days of their lives during the covid-19 pandemic
Method: A transverse descriptive study was made of nurses. Collection of data was done by an ad hoc questionnaire in April and May 2020 through Google Forms. Social demographic, work environment, training, satisfaction variables, motivation, work stress and the attitude scale towards patients at the end of life variables were collected. A descriptive univariant analysis of the subjects of the sample was carried out using SPSS 22.0 of proportions, frequencies, measurements of central tendencies and distribution.
Results: According to the professionals an important number of patients with a covid-19 diagnosis (38.8% n=110) were not accompanied in the last 48 hours of life. This was limited to hours (56.4% n=154), saying good bye was done in the majority before death (44.1% n143). A great number of professionals have noticed changes in accompanying and saying goodbye (77.3% n=211) including their way of caring. 52.4% n=143 said that they had found some patients dead on entering the room. 53.1% n=178 were aware of accompanying protocols.
Conclusions: It is obviously clear that many patients were alone during their last hours in spite of accompaniment protocols and the efforts of the staff looking after them. The professionals have modified the care given to patients at the end of life during the pandemic generating conflicts and negative emotional attitudes. Isolation has a great emotional cost for staff, and families during bereavement, which is important to study and evaluate in the medium term.

DOI: 10.20986/medpal.2020.1162/2020
The COIVD Pandemia in ourselves
Alberto Meléndez Gracia1, Iñaki Saralegui Reta1
1Unidad de Medicina Paliativa. OSI Araba Osakidetza - Servicio Vasco de Salud,

The current situation of the Covid-19 pandemic has influenced our way of working in a variable way. We have all collaborated to the best of our ability. The community has internalized values closely linked to the "palliative point of view". Values that on the other hand we continue missing in our health and social systems.

DOI: 10.20986/medpal.2020.1173/2020
Symptomatic manifestations in COVID-19 infection
María Varela-Cerdeira1, Leyre Díez-Porres2, Aránzazu Castellano-Candalija3, Teresa Pérez-Manrique1, Mariana Díaz-Almirón4
1Unidad de Cuidados Paliativos. Hospital Universitario La Paz, . 2Unidad de Cuidados Paliativos. Hospital La Paz, . 3Servicio Medicina Interna. Hospital Universitario La Paz, . 4Departamento de Bioestadística. Hospital Universitario La Paz,

The COVID-19 pandemic has spread rapidly around the world, producing high mortality. It has forced the reorganization of all health systems.
The Palliative Care Unit of the Hospital Universitario La Paz was transformed into a unit for the care of patients with COVID-19 infection in order to collaborate in the care of these patients. We faced the challenge of ensuring good control of the symptoms, which were assessed as systematically as possible, being aware of the difficulty in the context of the isolation and clinical situation of the patients. We present a narrative review of symptomatic manifestations and our experience as a Palliative Care Unit integrated in COVID-19 care in a third level hospital in Madrid. A profile of patients with advanced disease and high comorbidity was prioritized for admission in this unit. This integration contributed significantly to having a greater influence on the way end-of-life care is provided throughout the hospital.
Palliative care should be part of the care teams in any health emergency, such as a pandemic. It is essential for adequate symptomatology and end-of-life care. Systematic collection of symptoms is necessary because of the clinical impact on the patient, the need for specific treatment and its prognostic implications.

DOI: 10.20986/medpal.2020.1176/2020
Ethical reflections from the practical experience of COVID-19 crisis
Jaime Boceta Osuna1, Helena García Llana2, Rogelio Altisent3
1M. Interna / Paliativos. Hosp. Univ. Virgen Macarena, Sevilla. 2NEFROLOGIA. HOSPITAL UNIVERSITARIO LA PAZ, MADRID. 3Cátedra de Profesionalismo y Ética Clínica. Universidad de Zaragoza. IIS Aragón, Zaragoza

The aim of this article is to conduct an ethical reflection based on documents generated during the COVID-19 pandemic, providing conclusions about what has been learned and what we still have to learn. Six areas of action will be developed: prioritization of resources, face-to-face consultation and telemedicine, (un) protection of professionals, care in nursing homes, social response and last days care. Facing lack of resources, public authority can establish criteria that limit the right to health protection. The allocation can be justified according to the patient's ability to recover, without discriminating by age or disability. Telematic consultation can keep patient-clinician relationship, but require time and training. The clinical relationship has deontological requirements, and requires improving technology and telematic communication skills. The war metaphor generates pressure and confusion over the scope of duty, in the face of the serious lack of protection suffered by professionals. The value of interdependence and responsibility must be enhanced, not "romanticizing" the risk, and compensating professionals and their families. Nursing homes in our country are predominantly large centers, organized by tasks, with little autonomy and privacy. We must decide which models we want, and can afford, and which shared risks we assume from common values. Civil society can respond to crises. Democracy is "government of the people", which must begin in public life, not in politicians. Accompaniment at death are recognized rights. Exceptional limitation of resources cannot be a total deprivation. Advance care planning requires talking about fears and values with patients and their families. It is a deliberative process we must recover in COVID-19 era.

DOI: 10.20986/medpal.2020.1187/2020
Reflections on vulnerability: i was never alone
Rogelio Altisent Trota1
1Universidad Zaragoza. Centro de Salud Actur Sur, Zaragoza

The account of the personal experience of a doctor who had COVID-19. I wrote this as a form of personal therapy and to express my gratitude to the people who made me feel I was never alone. I hope this reflection helps us to value the professionalism and excellent teamwork that goes into the care of the people who suffer. As a patient, I am proud to have had the best professionals in the world working as a team on my care.

DOI: 10.20986/medpal.2020.1175/2020
Palliative care in nursing homes during THE COVID-19 pandemic in Spain
Jordi Amblàs Novellas1, Raquel Martínez Gómez2, Montserrat Blasco Rovira3
1Cátedra Cuidados Paliativos. Universitat de Vic, Vic. 2Residencia geriátrica Sant pau, Barcelona. 3Fundació Hospital de la Santa Creu de Vic. Residència El Nadal, Vic

The COVID-19 pandemic has been very aggressive in nursing homes, where mortality accounts for more than 50% of all deaths from this disease. But the physical and emotional repercussions go far beyond these data, both for residents, their families and professionals.

On the one hand, we review the impact of the pandemic in Nursing Homes, from the review of the existing bibliography, the data available in Sapin and the experience lived by some of these professionals.

On the other hand, some proposals developed by organizations with the objective of providing a response to this crisis from the perspective of Palliative Care are described. Finally, and based on the published evidence and their own experience, the authors make a series of specific and pragmatic recommendations on palliative care in Nursing Homes, in the short, medium and long term.

DOI: 10.20986/medpal.2020.1169/2020
Shared Care Planning: the COVID-19, is it a chance?
Cristina Lasmarias1, Tayra Velasco Sanz2, Virginia Elena Carrero Planes3, Nani Granero-Moya4, Asociación Española de Planificación Compartida de la Atención5
1Departament de Persones / QUALY. Institut Català d'Oncologia , Barcelona. 2Unidad de Cuidados Intensivos. Hospital Clínico San Carlos, Madrid. 3Departamento de Psicología. Universitat Jaume I, Castellón. 4Centro de Salud Baeza, Baeza. 5AECPA,

Shared Care Planning: the COVID-19, is it a chance?

DOI: 10.20986/medpal.2020.1164/2020
Delirium in a palliative care unit: incidence and associated risk factors
José Gutiérrez Rodríguez1, Lucía Sáenz de Santa María Benedet1, Rocío García Ronderos2, Gloria Ordoñez Estébanez2, Margarita Garía Rodríguez2, Juan José Solano Jaurrieta1
1AGC de Geriatría. Hospital Monte Naranco, . 2Equipo Atención Psicosocial. Obra Social La Caixa. Hospital Monte Naranco,

Introduction: Delirium is a very common neuropsychiatric disorder in patients admitted to Palliative Care Units.
Objectives: Study the incidence of delirium in a population of patients admitted to a Palliative Care Unit (PCU); analyze sociodemographic, clinical, functional and mental factors associated with the risk of delirium.
Material and methods: Longitudinal epidemiological study on a population of patients hospitalized in the PCU between March 13 and April 13, 2019. Sociodemographic, clinical, functional (Barthel and Karnofsky Index) and mental variables were collected (Global Deterioration Scale). The diagnosis of delirium was made based on the Confussional Assessment Method (CAM) and was classified as hyperactive, hypoactive and mixed.
Results: 35 subjects were included in the study (77.69 ± 11.66 years, 51.4 % women, Barthel 35.14 ± 31.54, Karnofsky 30 ± 19.40). Incidence of delirium was 65.7 % (11.4 % hyperactive, 20.4 % hypoactive y 34.3 % mixed). Statistical association with delirium was observed: score in Barthel and Karnofsky, presence of brain metastases and treated with antidepressants.
Conclusions: 65.7 % of the subjects admitted to the PCU developed a delirium. Score in Barthel and Karnofsky as well as the existence of brain metastases and the prescription of antidepressants are factors associated with risk of delirium.

DOI: 10.20986/medpal.2020.1096/2019
Disability care preferences in a sample of hospitalized patients
Pablo Gallardo Schall1, María Fernanda Alonso Carrillo2, Michelle Herrera Verdejo2, Susana Hidalgo Soto2
1Geriatría. Instituto nacional de geriatria, santiago. 2Geriatría. Universidad de Santiago de Chile, santiago

Background: In Chile, 16 % of the population are over the age of 60, from them 25 % have some degree of functional dependence and 10 % severe dependence. In this context, one of the problems of health teams is the definition of objectives of care when the patient cannot express them, a decision that could facilitate defining directives.
Material and methods: Cross-sectional, descriptive study. It included patients aged 40-60 years who received care between September-October of 2017 at San José’s Hospital of Santiago de Chile. A survey on the knowledge of their functional dependence risk was applied and their advances preferences.
Results: 150 patients, average age 51.4 years, 56 % single/divorced, average 1.2 children and schooling medium 46 %. The most prevalent diseases were hypertension 50 % and diabetes 30 %. 40 % had regular health-self perception. 50 % mentioned knowing their chronic diseases and their associated risk of dependence. Regarding the advances preferences, in the hypothetical situation of severe dependence, 60 % would choose a relative as caregiver, 72 % would prefer to live in their own home and 55.3 % reject resuscitation in case of cardiac arrest. There was no statistical correlation between schooling and knowledge of health status, risk of dependence associated with their illnesses or with the decision to receive resuscitation in case of cardiac arrest.
Conclusions: From our simple we can interpret that there is a gap regarding the meaning of successful aging, correct management of potentially invalidating chronic diseases and preparation of advance directives by those who suffer from them.

DOI: 10.20986/medpal.2020.1011/2018
Ethical and legal aspects in the conspiracy of silence according to the health professionals
Ángela Cejudo-López1, Eugenia Gil-García2, Ana María Porcel-Gálvez2
1Bellavista y los Bermejales. Sevilla. Centro de salud , Sevilla. 2Departamento de Enfermería. Universidad de Sevilla,

Objetive. To know the discourses of health professionals about the ethical and legal framework in the context of the pact of silence, as the origin of the phenomenon and its consequences: participation in decision-making, therapeutic cruelty, limitation of therapeutic effort and palliative sedation.
Qualitative descriptive study, phenomenological approach.
Placement and Participants. Nurses and Physicians in primary care, palliative care, hospital and emergency in Seville.
Methods. Semi-structured interviews. Explored areas: initial communication about diagnosis, prognosis and end-of-life, opinion about the conspiracy of silence, consequences in coping with death and participation in decision making. Analysis of interpretive content.
Results. They inform to the family, most of them ignore the ethical principles at the end-of-life, they confused intimacy, autonomy and confidentiality, if the conspiracy of silence is present they keep it. Autonomy is annulled, beneficence and nonmaleficence are applied from the profesional’s point of view, lack of justice is present in their discurses. The participation of the patient in decision making process turns impossible in this context, professionals overact to avoid death, falling in the therapeutic cruelty. The limitation of the therapeutic effort is not usually practiced and the rejection of the treatment is impossible. Euthanasia appears as an emergent category, it is confused with palliative sedation.
Conclusion. Ignorance of the ethical and legal normative framework at the end-of-life, as a cause of the pact of silence, having consequences the lack participation decision-making, therapeutic cruelty and non-application of limitation of therapeutic effort.

DOI: 10.20986/medpal.2020.1110/2019
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