Palliative care in hospital: Why is it so difficult?

Morphine Manifesto

“…All physicians must have the capacity and skills to perform basic palliative interventions -first line measures to reduce suffering in patients with an advanced chronic and serious illness and end of life care interventions (last 12 months of life). 7,8 The prevalence of these patients in hospital wards is highmore than 30%. 9,10 The correct treatment implies adequate training of the clinicians who care for them.…”

“…Not knowing how to use morphine correctly adds suffering to many patients and families, leaving clinicians unprepared for how to deal with the reality of death and dying. 7,8 This basic intervention in the last days and hours of life does not exempt the need of specialist palliative care teams, who provide consultation and support, particularly in the treatment of the most complex patients, with greater impact if they are involved in the early phase of an advanced and serious illness. [7][8][9][10] To conclude, it is fundamental to keep informing and spreading good end of life practices, so that the crucial value of a gold standard drug like morphine is not compromised ( Table 1).…”

“…7,8 This basic intervention in the last days and hours of life does not exempt the need of specialist palliative care teams, who provide consultation and support, particularly in the treatment of the most complex patients, with greater impact if they are involved in the early phase of an advanced and serious illness. [7][8][9][10] To conclude, it is fundamental to keep informing and spreading good end of life practices, so that the crucial value of a gold standard drug like morphine is not compromised ( Table 1). -The main indications for using morphine are severe pain, refractory dyspnea and diarrhea -Morphine has strict rules for administration: initiation at low dosage, progressive titration; preference for oral route; increases not larger than 30 -50% of the previous dose -Morphine has no maximum dose -Palliative sedation is a medical treatment for refractory symptoms and does not intent to shorten life -Palliative sedation, when correctly performed, does not shorten life -Morphine is not used in palliative sedation -The so-called 'morphine infusions for comfort' are not a correct treatment for the last days and hours of life and should not be used…”

Hospice Admission Assessment

“…This is rather antithetical to a mechanistic approach to medical assessments, which tend to take for granted biographical history and subjective expectations of care. 2 Further, their offered accounts, as well as the received accounts by the hospice worker, are necessarily interpreted stories; such (offered received) stories are not totally objective or judgmentally sterile. It is that patients relay personally perceived and interpreted accounts of illness which health care professionals, in turn, subjectively recycle (translate) into accounts of disease.…”

Análise da decisão de médicos atuantes em cuidados paliativos sobre o uso de antibióticos em pacientes com doenças terminais

“…Existem algumas iniciativas de elaboração de diretrizes de utilização racional para antibióticos no fim da vida, mas ainda falta um guia mais objetivo para decisões direcionado para cada tipo de doença terminal (9,49) . Se considerarmos a elevada demanda de atendimentos hospitalares em cuidados paliativos, tanto os setores de infectologia quanto de cuidados paliativos deveriam estar em estado de alerta para a forma como vem sendo utilizados os antibióticos para pacientes no fim da vida, e implementarem diretrizes para facilitar a tomada de decisão na instituição (50)(51)(52) .…”