Decision-making for adjusting therapeutic efforts at the end of life of patients with cancer at Colombia’s National Cancer Institute
DOI:
https://doi.org/10.5294/pebi.2023.27.1.3Keywords:
Decisions, medical futility, futility, education, end of life, adequacy of therapeutic effort, prognosisAbstract
Purpose: Adjusting therapeutic efforts is an evidence-based clinical decision that aims to avoid medical futility. Varied factors that can influence this decision-making have been pointed out, related to the patient, the medical professional who makes the decisions, system barriers, culture, and the economy, among others. The present study aims to identify those factors that help the specialists working in a cancer referral institution in Colombia to plan actions that improve the approach to decision-making regarding the adequacy of therapeutic efforts in cancer patients. Methodology: This qualitative design is based on 13 in-depth interviews with Colombia’s National Cancer Institute specialists. Results: Three women and ten men participated, with an average age of 36 years; seven belonged to the specialty of adult oncology, two to pediatric oncohematology, one to adult intensive care, and three to pediatric intensive care. The factors found were grouped into four categories: 1) knowledge, 2) aspects related to decision-making, 3) the decision-maker, and 4) the type of decision made. These categories were clustered into themes that allude to the factors swaying specialists’ decision-making to adjust therapeutic efforts. Conclusion: Adjusting therapeutic actions is vital to avoid futile medical procedures that prolong suffering. Some factors that influence the specialists’ decision-making were noted: lack of preparation of health professionals on end-of-life decision-making, reduced use of scales to improve prognostic information, and ignorance about advance directives. These factors must be strengthened to improve the approach to this issue.
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Belloc Rocasalbas M, Girbes ARJ. Toma de decisiones al final de la vida, el modo neerlandés a traves de ojos españoles. Med Intensiva [Internet]. 2011 [citado 9 de enero de 2022];35(2):102-6. DOI: https://doi.org/10.1016/j.medin.2010.09.013
Escobar Triana J. Morir como ejercicio final del derecho a una vida digna. 3a. edición. Bogotá: Ediciones Universidad El Bosque; 2012. 160 p.
McMurray RJ, Clarke OW, Barrasso JA, et al. Decisions Near the End of Life. JAMA [Internet]. 1992 [citado 9 de enero de 2022];267(16):2229–2233. DOI: https://doi.org/10.1001/jama.1992.03480160087040
Gómez-Sancho M, Altisent-Trota R, Bátiz-Cantera J, Ciprés Casanovas L, Gándara del Castillo Á, Herranz Martínez JA, et al. Atención médica al final de la vida: conceptos y definiciones: Gac Med Bilbao. 2015 [citado 9 de enero de 2022];112(4):216-18. Disponible en: http://www.gacetamedicabilbao.eus/index.php/gacetamedicabilbao/article/view/38/0
Gonzalo Morales V. Limitación del esfuerzo terapéutico en cuidados intensivos pediátricos. Rev Chil Pediatría [Internet]. 2015 [citado 9 de enero de 2022];86(1):56-60. DOI: https://doi.org/10.1016/j.rchipe.2015.04.011
Douplat M, Berthiller J, Schott A, Potinet V, Le Coz P, Tazarourte K, et al. Difficulty of the decision‐making process in emergency departments for end‐of‐life patients. J Eval Clin Pract [Internet]. 2019 [citado 9 de enero de 2022];25(6):1193-99. DOI: https://doi.org/10.1111/jep.13229
Wilkinson DJ, Savulescu J. Knowing when to stop: futility in the ICU. Curr Opin Anaesthesiol [Internet]. 2011 [citado 9 de enero de 2022];24(2):160-65. DOI: https://doi.org/10.1097/ACO.0b013e328343c5af
Sprung CL, Woodcock T, Sjokvist P, Ricou B, Bulow H-H, Lippert A, et al. Reasons, considerations, difficulties and documentation of end-of-life decisions in European intensive care units: the ETHICUS Study. Intensive Care Med [Internet]. 2008 [citado 9 de enero de 2022];34:271-77. DOI: https://doi.org/10.1007/s00134-007-0927-1
Castaño Yepes RA, Arias Nieto G, Borráez Gaona OA, Nino Murcia A, Támara Patiño L, Moreno Molina J. Recomendaciones de la Academia Nacional de Medicina de Colombia para enfrentar los conflictos éticos secundarios a la crisis de COVID-19 en el inicio y mantenimiento de medidas de soporte vital avanzado. Rev Colomb Cir [Internet]. 2020 [citado 9 de enero de 2022];35:351-62. DOI: https://doi.org/10.30944/20117582.725
Pérez Pérez FM. Adecuación del esfuerzo terapéutico, una estrategia al final de la vida. SEMERGEN - Med Fam [Internet]. 2016 [citado 9 de enero de 2022];42(8):566-74. DOI: https://doi.org/10.1016/j.semerg.2015.11.006
Guest G, Bunce A, Johnson L. How Many Interviews Are Enough?: An Experiment with Data Saturation and Variability. Field Methods [Internet]. 2006 [citado 28 de marzo de 2022];18(1):59-82. DOI: https://doi.org/10.1177/1525822X05279903
Thomas DR. A General Inductive Approach for Analyzing Qualitative Evaluation Data. Am J Eval [Internet]. 2006 [citado 28 de marzo de 2022];27(2):237-46. DOI: https://doi.org/10.1177/1098214005283748
Muñoz Camargo JC, Martín Tercero MP, Nuñez Lopez MP, Espadas Maeso MJ, Pérez Fernandez-Infantes S, Cinjordis Valverde P, et al. Limitación del esfuerzo terapéutico. Opinión de los profesionales. Enferm Intensiva [Internet]. 2012 [citado 22 de marzo de 2022];23(3):104-14. DOI: https://doi.org/10.1016/j.enfi.2011.12.008
Esteban A, Gordo F, Solsona L, Alía I, Caballero J, Bouza C, et al. Withdrawing and withholding life support in the intensive care unit: a Spanish prospective multi-centre observational study. Intensive Care Med [Internet]. 2001 [citado 22 de marzo de 2022];27:1744-49. DOI: https://doi.org/10.1007/s00134-001-1111-7
González Cruz LR. Consideraciones sobre la Limitación del Esfuerzo Terapéutico (LET) en pediatría [trabajo de grado Especialización en Pediatría].Bogotá (Colombia): Universidad Nacional de Colombia; 2014. Disponible en: https://repositorio.unal.edu.co/bitstream/handle/unal/21488/luisricardogonzalezcruz.2014.pdf?sequence=1&isAllowed=y
Ho F, Lau F, Downing MG, Lesperance M. A reliability and validity study of the Palliative Performance Scale. BMC Palliat Care [Internet]. 2008 [citado 22 de marzo de 2022];7:a10. DOI: https://doi.org/10.1186/1472-684X-7-10
Álvarez Acuña AM, Gomezese Ribero ÓF. Advance Directives Document: knowledge and experiences of healthcare professionals in Colombia. Colomb J Anesthesiol [Internet]. 2022 [citado 22 de marzo de 2022]; 50:e1012 DOI: https://doi.org/10.5554/22562087.e1012
Sprung CL, Maia P, Bulow H-H, Ricou B, Armaganidis A, Baras M, et al. The importance of religious affiliation and culture on end-of-life decisions in European intensive care units. Intensive Care Med [Internet]. 2007 [citado 22 de marzo de 2022];33:1732-39. DOI: https://doi.org/10.1007/s00134-007-0693-0
McAndrew NS, Leske JS. A Balancing Act: Experiences of Nurses and Physicians When Making End-of-Life Decisions in Intensive Care Units. Clin Nurs Res [Internet]. 2015 [citado 22 de marzo de 2022];24(4):357-74. DOI: https://doi.org/10.1177/1054773814533791
De Vries E, Leal Arenas FA, Van der Heide A, Gempeler Rueda FE, Murillo R, Morales O, et al. Medical decisions concerning the end of life for cancer patients in three Colombian hospitals – a survey study. BMC Palliat Care [Internet]. 2021 [citado 22 de marzo de 2022];20:a161. DOI: https://doi.org/10.1186/s12904-021-00853-9
Piili RP, Lehto JT, Metsänoja R, Hinkka H, Kellokumpu-Lehtinen P-LI. Has there been a change in the end-of-life decision-making over the past 16 years? BMJ Support Palliat Care [Internet]. 2019 [citado 22 de marzo de 2022];bmjspcare-2019-001802. DOI: https://doi.org/10.1136/bmjspcare-2019-001802
Hamano J, Hanari K, Tamiya N. Attitudes and Other Factors Influencing End-of-Life Discussion by Physicians, Nurses, and Care Staff: A Nationwide Survey in Japan. Am J Hosp Palliat Med [Internet]. 2020 [citado 22 de marzo de 2022];37(4):258-65. DOI: https://doi.org/10.1177/1049909119876568
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