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Palliative care, ethics and humanity
The following bibliographic review work details with the purpose of applying and also knowing more thoroughly the content of the study topic and when such tools of the title should be applied, in what type of patients and that norms are related in our country to use with the useand the application of these. Method: A narrative technique will be used from a review in several databases at a certain time that allows a comparison of the proposed sub -themes. Results and discussion: After the respective analysis of the different sub -themes, advantages and disadvantages of palliative care, their ethical dilemma and different points of view were evidenced. In addition to useful concepts such as pharmacotherapy for pain and everything starting from its definition and its principles. CONCLUSIONS: The care used in order to reduce suffering at the end of life and improve the quality of life during a disease are a tool that should be backed by law for use in different fields of medicine in all countries,Even more those with health care models that include the concepts of primary health care.
Keywords: palliative care;Patient care
Death for human being is a more than biological fact, since man has always wanted to find a meaning. The history of mankind chronologically acts and considers authentic actions of the human being recognizing or hiding its position before death. Support and human contact in the disease has always been a key point in the dignity of the patient and his quality of life, from birth to the end of the east, because mentioning the birth of health care and relief of sufferingPhysical and spiritual is talking about the history of humanity, pain and grief as conditions inherent in human nature.
Since the 1960s, palliative care emerged as another tool for health personnel and in 1990 the WHO welcomes the concept and defines it for 15 countries, it is extended for 2002 and is currently part of the health care models of manycountries that take it as a challenge to be fulfilled within its health development index. The objective of this work is to elucidate the primary skills required to offer primary palliative care, pain and symptom management, and care at the end of patients’ lives, especially geriatric and pediatric.
A bibliographic review was made in the Scientedirect, Pubmed, Clinicalkey and Scielo databases on some aspects of the internet palliative care taking as a search words the terms: palliative care, palliative medicine, geriatric palliative care, pediatric palliative care and pharmacology in pharmacology inPalliative care. From 2012 to 2018. As a result of this, 35 articles were obtained well classified and oriented after a screening of these, excluding those that contained discrepant information to the objectives of the work and retaining those that contained useful knowledge.
Discussion and results
Pediatric palliative care
Pediatric palliative care are those provided with children who are victims of a pathology that puts their lives at risk, so it covers a wide variety of clinical scenarios. In Ecuador, priority care groups include children and in the field of primary health care emphasizes palliative care, since unlike older adults the psychological impact on family that unfortunately faces a duel is a reason for a treatment for a treatmentimportant integral.
The State, Society and Family will prioritize the integral development of girls, boys and adolescents and ensure the full exercise of their rights;The principle of their best interest will be applied, and their rights will prevail over those of other people. In this way, girls, boys and adolescents have the right to their integral development, understood as a process of growth, maturation and deployment of their intellect and their abilities, potentialities and aspirations, in a family, school, social and community environment ofaffectivity and security (art. Four. Five). To do this, the State will adopt, among others, the measure of protection, care and special assistance when they suffer chronic or degenerative diseases.
The Association for Children With Life-Threatening Or Terminal Conditions and Their Families (ACT) raises four categories of infants who must receive palliative care . The diagnosis is only part of the process. It is necessary to take into account the spectrum of the disease, the severity of this and its possible complications, as well as the needs and impact on the child and the family. These four categories describe the four types of disease trajectories that will require the provision of children’s palliative care.
- Children in a position of threat to life and in which a healing treatment is possible, but can fail. The CP may be necessary during the uncertain forecast phase and when the treatment fails
- Cardiac abnormalities
- Possible healing
As in pedagogical methodology, the first element to take into account children who receive palliative care is communication, avoiding technical words and looking above all that the child understands the situation from his point of view. Being a comprehensive palliative care treatment involves a process of several steps with shock periods, denial until the acceptance of the disease for which it is necessary to apply these communication and accompaniment tools.
The palliative care procedure in a pediatric patient is already relatively clear, but the most important thing is to take into account what should not be done. In this situation the healing effort must be limited. Not everything technically possible is ethically acceptable, less if it is caused damage. The terminal child should not be revived, discuss it, use vasoactive drugs, assisted ventilation, parenteral nutrition or high oxygen concentrations.
Geriatric palliative care:
Another priority group lends to receive palliative care are. Acute or chronic diseases that can be overcome add complications of physical or mental dependence, however, the attention and disposition of palliative care to this care group is inversely proportional to their need while their age progresses.
Older adults are considered to those who have completed or exceed 65 years. The art. 35, in Chapter 3, offers for this sector that has contributed so much for society, priority and specialized attention in public and private spheres, especially in the fields of social and economic inclusion, and protection against violence. To do this, the State will guarantee (art. 38) To older adults the following rights such as free and specialized health care, as well as free access to medicines.
Taking into account the patient’s dignity and its acceptance of the purpose of the human condition are the 2 essential positions that guide the exercise of palliative medicine in this group of patients, fulfilling these two skills and a well -defined clinical prognosis could help usto plan and provide adequate care that integrates active and palliative management.
Depending on the place and culture of a population, a practical methodology can be used in patients. Spirituality is the bridge between the earthly and the transcendental, what gives meaning to the life of someone. It is everything that is related to the individual and what he considers sacred, and that manifests itself in various ways, through religious practices or not. Spirituality as part of palliative care would help patients to an integral acceptance of the culmination of life.
The identification of patients who die in their residence that are suitable for palliative care, and their consequent inclusion in palliative care programs, since it shows an important opportunity for improvement especially in patients with chronic non -cancer diseases should also be taken into account, without differences by sex in such identification.
Pain and pharmacotherapy
According to the International Association for Pain Study, it defines this as “an unpleasant sensory and emotional experience that is related to tissue or real or potential damage, or that is described in terms of that damage.
When we refer to pain what we must first do is explain to the patient the steps we are going to perform, starting from a physical exam, to the interpretation of the symptom, and this relieves and reduces its emotional impact and indirectly gives some relief to thepain. While pain is true in palliative care patients has important aspects that must be taken into account, such as personality, emotions and many characteristics that are art of human quality and the patient’s biopsychosocial state and his family.
The explanation is a fundamental point for the family and even more for the patient in palliative care, because any type of symptom can alert an advance in the disease, that is, if it has a discomfort in a certain part, they will assume that it is a metastasis,If the case is of cancer, of the same, but if it was a low back pain it would not necessarily be the worsening of the disease, without a urinary infection or muscle pain due to the prostration in which the patient is.
The objective of an adequate explanation is that all kinds of result be known so that the patient has a better response to the treatment to the one who is being subjected, since if it does not happen in this way there will be anxiety and fear and reduce attachmentto the therapeutic treatment that is given.
There is talk of proper pain control when the person under treatment does not have pain to a large extent for a long time, and if it refers to it for a very short time, on the contrary of speaking of a control of the control of the control of theNot adequate pain when the pain presented is between severe and moderate for a long time or in most of the day and needs more attention, in addition to having adverse effects.
When we talk about pain and its treatment, it is when we refer to the pharmacological and several important points such as the route of administration, it is sparked that according to the Palliative Care Manual for Primary Health Care or that the oral route is the way of preference forThe drugs, due to the ease and non -discomfort for the patient, and thus give solution to the symptoms that are presented, but in the case that this cannot be given there are also roads of other types is so that there is talk of routesubcutaneous by means of catheters or subcutaneous when morphine, wavestrón, ranitidine;Or when talking about medications that are administered in a sublingual, transmucose, transdermal way among others, when it is intramuscular, it is not recommended by the aggregate pain that is given to the patient and also has less effectiveness in time to comparisonof subcutaneous.
The use of drugs in patients with palliative care has certain specifications that are important. There are times that many of the symptoms are so violent that they do not respond to the recommended drugs, they are called refractory symptoms, and the only solution is to try to lower the level of consciousness so there is talk of a palliative sedation.People with palliative care in an advanced or terminal stagethat if the CA is spoken, radiotherapy can be used to treat the pain caused by a CA that has spread to bone tissue.
WHO has made an analgesic ladder, in which a type of treatment guide is determined in relation to pain in cases of CA that are the most common, it consists of three levels that indicate the steps to follow for the choiceof a drug depending on the severity or intensity that the pain occurs.
Each of the steps have analgesics that in turn can be merged with adjuvants, that is to say some medications that have an analgesic effect in certain pains presented or also that they can serve as part of the control of the effects of another type or secondaryOpioids.
When a pharmacological treatment begins for pain, it should be started at the level that the pain is located, that is, if the person feels an austere or severe pain, the ideal would be to administer an opioid such as morphine etc.(27), and not start with a medication located in the number one step, if a moderate pain occurs, you should start with opioids from the step two, such as tramadol, codeine among others, and then it is a slight painWe use NSAIDs taking into account that many of the time these may have a type of ceiling effect and must be observed by their toxicity presented in certain cases such as gastrointestinal bleeding among others among others. (Graph 1) (24)
As we have treated briefly about opioids these are the first to handle pains such as the severe and moderatethat do not have a roof effect and that there is an absence of adverse effects that cannot be tolerated by the patient. If we refer to the adverse effects we refer to the presence of drowsiness, constipation, vomiting, neurotoxicity, respiratory depression among other adverse effects that are associated with the use of opioids such as the dryness of the mouth diaphoresis or sweating, pruritus among others.
Euthanasia and ethical dilemmas
While the issue of euthanasia is true in relation to ethical approaches have generated a very large controversy in which, if it is acceptable to make such decisions, if living or dying, of a patient who is in palliative care,However, there is talk of sedation and euthanasia as such, which leads to two themes that are still under discussion and even more focusing on Ecuador. Euthanasia according to WHO defines as “that action of the doctor who deliberately causes the patient’s death.InOn the side, the question opens if it is human to have a person in agony with extreme pain in a state without health just by respecting that right to live, if according to the WHO and PAHO of Argentina they tell us “health is a state of perfect well -beingphysical, mental and social, and not only of the absence of the disease ”.
While it is true we have several countries in the world that have opened the space to the right to live or die at a certain moment, a right that is attributed to both the patient as such, as to their relatives, giving as a point of view That the suffering to more than being by the person in palliative care, is also for their family, however from an ethical point of view referring to palliative care, the status of a patient must be identified, if it is in a stage Terminal is not a biological object by which it cannot be done more, and that your life of being prolonged would be a useless, but what they argue in a paragraph of ethical issues of an article on new perspectives in palliative care is that it should be Give all care and care to a patient in palliative care as well as a normal patient, so that it is maintained and enjoyed by their rights, in addition to presenting autonomy, it also has the right to reject the treatment to.
It is important to note that each country has its freedom to express on the issue, both in its political, social and cultural interests, in addition that it has the freedom to obtain as an example the actions of other countries in relation to this issue as delicate as euthanasia is, but for now what all coincide all nations is to give comprehensive care to patients in palliative state euthanasia is still in question if it is ethical, well, bad, or necessary, but each one decides according to their laws the lawsTake it as legitimate or maintain ethics above pain, suffering and others.
The analysis of the intervention of palliative medicine in the pediatric and geriatric priority care groups allow us to appreciate that not everything technically possible is ethical, clinical and humanly appropriate. For example, in clinical medicine apply resuscitation protocols is substantially necessary while in palliative medicine it is something that should not be taken into account.
The treatment of pain in patients in palliative care by drugextended time.
Ethics and euthanasia do not yet go hand in hand because there are discrepancies on the subject, involving the right to live and on the other hand putting as a counterpoint the suffering of the patient that affects it biopsychosocially.
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