Algunos aspectos del final de la vida, comunicación con el paciente terminal y su familia. Presentación en Congreso de Tanatología . Santa Fe 2008

1. III JORNADAS DE TANTOLOGÍA Santa Fe. Agosto 2008 Cuidados Paliativos AGONÍA COMUNICACIÓN Dr. Hugo A. Fornells. Cuidados Paliativos y Oncología Sanatorio Británico- Rosario .

2. Cuidados Paliativos “… Son los cuidados apropiados para el paciente con enfermedad avanzada y progresiva donde el control del dolor y otros síntomas, así como los aspectos psicosociales y espirituales cobran la mayor importancia. El objetivo es lograr la mejor calidad de vida posible para el paciente y su familia. Afirma la vida y considera el morir como un proceso normal…” OMS 1997

4. Development of a Municipal Palliative Care Program in the Public Health Department in Rosario, Argentina Fornells H, Mc Garrell D, Alvarez M, Conforti V, Willems D, Binelli S, Armando A , Amigo P*. Municipal Palliative Care Program, Department of Public Health, Rosario, Argentina. *Capital Health Palliative Care Program, Edmonton, Alberta, Canada. Introduction: Rosario is a city in Argentina with a million inhabitants. The public health system serves 300,000 people, with around 500 deaths per year due to cancer. The Municipal Palliative Care Program was created in 2004, consisting of the Adult Palliative Care Unit (UCPAR), the Pediatric Palliative Care Unit (UCPP) and the Domiciliary Palliative Care Unit (UCPD). Methods : Data from all patients admitted to the program from 2004 to 2005 was reviewed. The opioid consumption was evaluated and compared to the year before the creation of the program. Other items evaluated were the percentage of the palliative population seen, the waiting time for the admission to the program, symptom control using ESAS and place of death. Results: The opioid consumption per year by adult patient expressed in MEDD (Morphine equivalent daily dose) increased from 1,038 grams before the creation of the program to 4,576.18 grams the year after the creation of the program and to 4,691.31 grams the subsequent year. Before the program : 2003 1038.76 grs After the program : 2004 4576.18 grs 2005 4691.31 grs Access: In the year 2004, of the population served by the Municipal Health Service of Rosario, 500 deaths were due to advanced cancer. Of these, 136 patients were seen by the ambulatory service and 72 patients were admitted to the UCPAR. It is estimated that 41.6% of the population requiring palliative care services was seen by the Program, and the waiting time for the patient to be assessed was 1 day (mean). Symptom control: In over 50% of the patients seen, adequate symptom control was obtained for pain, dyspnea, nausea, anxiety and low mood. Place of death : 39% of adult patients admitted to the UCPAR died in hospital (45 of 93 patients in 2004, 31 of 71 patients in 2005), whereas 100% of the pediatric palliative patients admitted to the UCPP died in hospital (85 patients in 2004, 70 patients in 2005). 66% of the palliative patients admitted to UCPD died at home (45 of 69 patients in 2004 and 2005). Conclusion : It was possible to provide good interdisciplinary palliative care services with little waiting time and good symptom control, increasing the opioid consumption and providing adequate support for those who chose to die at home and their families. Future goal : to increase access to the service and to extend this care to non-cancer patients. The development of the Municipal Palliative Care Program in Rosario, Argentina was made possible by an agreement between the IAHPC and the Public Health Department of Rosario Multidisciplinary team : In all the Units, the teams are comprised by full-time nurses and physicians; and part-time pharmacists, physiotherapists, social workers and psychologists. The care is provided mainly to palliative cancer patients. 64,8% 72,5% Pain 50% 15% Nausea 57% 27% Dyspnea 50% 47% Anxiety 50% 54,9% Low mood Controlled On admission Symptom

50. Pronóstico impreciso 9 29 (13-62) 42 (28-84) 1,591 Total 24 (12-58) 77 (28-133) 325 Christakis et al 8 33 (14-62) 42 (21-70) 451 Maltoni et al 7 15 (9-25) 21 (14-35) 21 Oxenham et al 6 32 (13-62) 42 (28-70) 530 Maltoni et al 5 32 (13-63) 42 (28-56) 100 Maltoni et al 4 14 (7-28) 56 (33-84) 50 Heyse-Moore et al 3 120 (43-180) 81 (28-182) 42 Evans et al 2 21 (9-34) 28 (45-56) 71 Parkes et al 1 AS Promedio (días) CPS promedio (días) # Pacientes Estudio Estudios de Predicciones Clinicas de Supervivencia vs Supervivencia Real

54. Impacto de Pronóstico 3 Efusión pleural 4 Metástasis cerebral sin cirugía 9.5 Metástasis cerebral más cirugía 1 - 4.5 Hipercalcemia Supervivencia promedio (Meses) Índice

55. Signos y síntomas clínicos como indicadores de pronóstico en pacientes con enfermedad avanzada <28 días Pérdida de peso (  10 kg) <50 días Xerostomia 20 <28 días Confusión/delirio 23,24 <30 días Disfagia 5 <30 días Disnea 5 Supervivencia promedio Síntoma

56. . . . Escala de Karnofsky como predictor de supervivencia Reuben DB, Mor V, Hiris J. Arch Intern Med . 1988. 16.8 10-20 49.8 30-40 86.1  50 Supervivencia en días KPS

61. Dolor total

69. Cuidados Paliativos para una región (adaptado de Frank Ferris)

70. Muchas Gracias