International panorama of palliative care: barriers in its implementation and perspectives for the future

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REVISTA

UNIMONTES CIENTÍFICA

(ISSN 2236-5257) I Congresso Nacional de Oncologia

da Associação Presente - Agosto de 2017.

INTERNATIONAL PANORAMA OF PALLIATIVE CARE: BARRIERS IN ITS

IMPLEMENTATION AND PERSPECTIVES FOR THE FUTURE

Panorama internacional dos cuidados paliativos: barreiras em sua implementação e perspectivas

para o futuro

Felipe Ferraz Trindade1

Tatyane Ribeiro de Castro Palitot2

Gizely Teixeira Fernandes1

Altair Reis dos Santos Júnior1

Abstract: Palliative Care is a model of health assistance aimed at improving the quality of life of patients and

their families in the face of serious life-threatening illnesses. This is done through the prevention and relief

of suffering, by the treatment of physical, psychosocial and spiritual problems. Given the scarcity of studies

in the area, obvious aging population and increase in chronic-degenerative diseases, this research, based on

a narrative literature review, aimed to describe concepts related to palliative care, as well as exposing needs,

barriers and solutions for its effective implementation. It can be seen, therefore, that although palliative care

was initially applied to the end of oncologic life, this practice has expanded to several other areas and has

been applied since the moment of diagnosis and no longer as a last option for the patient when the medicine

cannot stop the natural course of the disease. For the purpose of achieving this end, several countries have

been implementing palliative care despite some of them have social, political and financial obstacles to do

it. These countries show us that despite the difficulties one can enter this practice so that their patients can

have peace and comfort at the end of their history.

Keywords: Palliative care; Health investment; Quality of life; Terminality.

________________

Corresponding author: Felipe Ferraz Trindade. E-mail: ferrazft@yahoo.com.br

1 Faculdades Integradas Pitágoras de Montes Claros. 2 Universidade Federal do Rio Grande do Norte.

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REVISTA UNIMONTES CIENTÍFICA

Montes Claros, I Congresso Nacional de Oncologia da Associação Presente - Agosto de 2017.

254 Resumo: Os Cuidados Paliativos são um modelo de assistência à saúde com o objetivo de melhorar a

qualidade de vida dos pacientes e de seus familiares diante de doenças graves que ameaçam a vida. Isso se

realiza através da prevenção e alívio do sofrimento, pelo tratamento de problemas físicos, psicossociais e

espirituais. Diante da escassez de estudos na área, evidente envelhecimento da população e aumento das

doenças crônico-degenerativas, esta pesquisa, seguindo os moldes de uma revisão de literatura narrativa,

teve como objetivo descrever conceitos tangentes aos Cuidados Paliativos, bem como expor necessidades,

entraves e soluções para a sua implementação efetiva. Percebe-se que, apesar de inicialmente o palliative

careo ter sido aplicado para o fim de vida oncológico, tal prática vem se expandindo para diversas outras

áreas e sendo aplicada desde o momento do diagnóstico, não mais como última opção para o paciente

quando a medicina não consegue frear o curso natural da doença. Com a finalidade de alcançar esse fim,

vários países vêm implementando o palliative careo apesar de alguns deles possuírem entraves sociais,

políticos e financeiros para tal. Esses países nos mostram que, apesar das dificuldades, há alternativas para

inserir essa prática para que seus pacientes possam ter paz e conforto ao finalizar sua história.

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International panorama of palliative care: barriers in its implementation and perspectives for the future

TRINDADE, F. F.; PALITOT, T. R. C.; FERNANDES, G. T.; SANTOS JÚNIOR, A. R. ISSN 2236-5257

255 INTRODUCTION

Learning how to deal with the losses in a

context of a chronic illness like cancer is a challenge

that a few propose to discuss, and much less to face,

and its acceptance varies among different cultures

and beliefs.

1

_{Assisting individuals with advanced}

diseases and potentially fatal and their relatives in

one of the most crucial moments to their lives is an

activity or a health care model that is being called

“Palliative Care” (PC). It is explained that the word

“palliative” comes from the Latin pallium and

IT means cape, vestment, blanket. The word was

used to refer to the robes that the pilgrims received

when leaving hostelries in Europe, called hospices.

The purpose of this mantle was protection and

hospitality and this is directly related to the purpose

of CP.

2

In this context, the Palliative Care is often

confused with historically the term hospice whose

the oldest report dates back to the 5th century

3

A manual of clinical practice in palliative care

provides a definition for this practice as being

interdisciplinary care (doctors, nurses, social work,

psychology and other areas when necessary) that

focuses on improving the quality of life of people

of any age who deal with some serious illness,

besides providing assistance to members of their

families. When treating treat pain, other symptoms

and psychological and spiritual suffering through

communication skills, the palliative cares provide

an additional layer of support to patients, their

loved ones, and options of clinical treatments

4

Still according to the same manual, Hospice

is a formal system of interdisciplinary care that

provides palliative care in individuals in end of life.

It was first developed in 1967 by Dame Madagascar

Saunders to provide a model of care for people who

are dying of advanced cancer. The precepts of this

movement seek to offer the patient an end of life

close to family, quiet and based on respect.

2

Therefore, based on the scarcity of studies in

this area, clear aging of the population and growing

demand for palliative activities, it is realized the

need to analyze the international panorama of

implementation of palliative care in developing

countries, thereby justifying the implementation of

this review. From this perspective, the aim of this

study was to describe the concepts of palliative

cares and hospice to establish the difference and

similarity between both, as well as analyze the

literature which the international panorama in the

implementation of palliative care in developing

countries and what difficulties presented by those

who cannot stand such practice, and finally present

the solutions found by the countries that have

achieved success and accession of palliative care in

its population and deployment in their health care

system.

METHODOLOGY

This research followed the lines of a

literature review narrative.

5

_{A priori criteria were}

defined to be followed regarding the type of study,

publication period, among others. The searches

were carried out in national and international

databases (PubMed, LILACS, Scielo, BMJ

Supportive & Palliative Care, NEJM, Capes

Journals and Science Direct). Articles published

between the years of 1992 and 2017 were selected,

written in English or Portuguese and, after previous

reading of the abstracts, it was selected those whose

theme were in line with the objective of writing of

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256 this article. Due to the differences of indexation in

different databases, it was decided by the search

terms, without the use of controlled vocabulary

(descriptors). Therefore, it was ensured the recovery

of a greater number of references, ensuring the

central theme without limiting the tangent matters.

In the databases already mentioned the following

words were previously sought: ¨palliative care AND

health investment¨, ¨palliative care AND quality

life¨, ¨palliative care AND terminality¨ e ¨palliative

care AND hospices¨, such a search returned

68,978 articles. The first exclusion criterion was

the repetition of returns among the different bases,

resulting in 12,616 different articles. Then it was

selected preferentially those published in the last

10 years, thereby having 7,518 publications. Those

articles which, starting from the analysis of its

titles were excluded, had thematic biases and the

targeting of palliative care for diseases in specific

or in certain hospital services , leaving 374 works.

Finally, the prior reading of abstracts of these

374 works allowed to filter those that were in

accordance with the objectives, leaving 48 articles

that were used in this review.

LITERATURE REVIEW

Overview:

Initially, in the year 1998, the Palliative

Cares were categorized by WHO as the last stage

of care, however, it is known that these should be

offered as early as possible in the course of any

chronic disease is potentially fatal. The most recent

definition of the World Health Organization (WHO,

2012) published in its website states that

[...] Palliative Care is an approach that improves the quality of life of patients and their families facing the problems associated with terminal illness, through the prevention and relief of suffering by

identifying, assessing and treating pain and other physical, psychosocial and spiritual problems [...].6

An analysis showed the main purpose of

palliative care, and they summed up to a philosophy

that: a) affirms the death as a normal process of

living; b) it does not rush or postpone death; c) it

seeks to relieve pain and other distressing symptoms

; d) it integrates the psychological, social, and

spiritual aspects in the care of the patient; e) it

offers a support network to assist the patient to live

as actively as possible until his death; f) it offers

a support system to the patient’s family in the

experience of the mourning process.

7

In 2012, it was issued a clinician’s report

by the American Society of Clinical Oncology

stating that patients with metastatic cancer should

receive palliative care and standardized oncology

curative treatments simultaneously from the time

of diagnosis

.8

_{This recommendation of earliness}

was based on the evidence found in randomized

controlled studies that demonstrated that the

association between curative and palliative cares

result in improving the quality of life, humor and

stress of caregivers. Despite the increase in survival

has not been considered in the publication of the

American Society of Clinical Oncology, a study

has shown that palliative care interventions have

positive impact on the survival curve of oncology

patients, affirming that the duration of services of

palliative care was proportional to the duration of

survival.

9

It is known that there are evidences clinically

significant from an increase of almost 3 months

in the survival of patients in palliation, compared

to those who followed only the standardized

oncologic treatment. Curiously, the specific

mechanisms could still not be fully clarified by

which the palliative care culminated in increasing

the survival of these patients, since this finding

is considered to be the result of a multifactorial

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257 health, especially those who have mental illnesses

already established. According to an international

report on Alzheimer’s disease published in 2015

15

_,

it is estimated that 46 million people in the world

have dementia, a number that can triple by 2050

and, already today, it should be noted that the

majority of these patients end up dying in hospital

and with high load of medical and pharmacological

intervention, which does not relieve the symptoms

and prolong the outcome at the end of life.

16

Being the dementia a disease that limits

life and has no curative treatments, it would be

essential that patients and families were assisted by

the scope of Palliative Cares.

17

_{However, a study}

showed that patients with dementia often receive

care of end of life in an inadequate way, without

access to pain control and services offered in the

oncologic palliation.

18

It is known that patients with dementia are

subjected to iatrogenic suffering and unnecessary

investigations during the course of their disease.

19

Accordingly, it was demonstrated that psychiatric

patients are, in fact, more prone to iatrogenic

diseases because health professionals prefer to

make the pharmacological control of possible

psychomotor manifestations with high doses

rather than calm them down with the usual doses

of medications and with psychological control.

Furthermore, the lack of direct communication

with the patient on the part of team professionals

also aggravates the disturbances, because it creates

anxiety and insecurity among patients.

16

It is a fact that communication with patients

with dementia and their families requires special

skills, since the cognitive problems complicate

the decision-making process. The support and

communication with families is essential to help

them if the worsening of the signals makes it

impossible for the patient to decide for themselves,

the measures adopted, as well as to assist with the

set of improvements.

10

_{Furthermore, it has been}

demonstrated that the early palliative care is related

with a lower number of decompensations and visits

to emergency rooms.

11

It was hypothesized, then, that, to affect

the well-being of the patient, his experience with

the suffering, social support and improving the

understanding before the process of illness, the

palliative cares have potential for increasing

the overall survival. Although the survival rate

improved in oncologic patients may be a result of

the activities of palliation, this finding should not

overshadow all other benefits of this practice, and

not to be considered primary objective of palliative

cares.

12

_{There is agreement that many times the}

doctors still overestimate the increase in the survival

of cancer patients, using this factor in an inadequate

way as a main motivation for reference to palliative

cares.

13

In addition, Palliative Cares seek to treat the

patient holistically, both in the field of the physical

body as in the spiritual field and attention to these

dimensions should be egalitarian because it is

natural to human beings to seek not only to cure

the disease but also give meaning and significance

to everything that is around, justifying the search

by the strengthening of spirituality, especially in

moments of physical suffering for the purpose of

acquiring wellness and quality of life.

14

Thus, in which treats the spiritual field, it

was written that the attention to this aspect becomes

increasingly necessary in the practice of health care

and emphasize that several studies have examined

the relationship of religiousness and/or spirituality

with various aspects of mental health. The majority

of them points for better indicators of mental health

and adaptation to stress in people who practice

religious activities.

14

As an adjuvant to the treatment of the physical

body, the patient must go through care in mental

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258 suffering caused by the continuing deterioration of

the patient.

17

Even in the face of growing interest about

palliative cares, there are few studies on palliative

care before the dementias. In consequence of this

lack, several voluntary organizations working in

the area of mental disorders, such as Alzheimer’s

Society

20

_{, recognized that research on palliative}

care in psychiatric patients are a priority.

Due to that, with the objective of supplying

this demand for clinical advice and guidance

about palliative care in dementias, a Delphi study

of 5 stages was carried out with the participation

of 64 experts from 23 countries, culminating in

the production of the first definition of Palliative

Cares in dementia. This document is structured

based on 11 postulates and 57 recommendations.

Initially, there was total and immediate consensus

about 8 of 11 postulates, namely: care focused on

the person; communication; decision of shared

decisions; optimization of symptomatic treatment;

promotion of comfort; health care staff education;

ethical issues; and social issues. After the revision

of the material, it was a consensus as regards the

definition of prognosis and timely recognition of

death. The postulates about the recommendations

for nutrition and hydration and correlation of

the goals of care with the stage of dementia had

moderate consensus.

17

It is added to the holistic care the integrated

care to the socio-economic-family context. One of

the important points of the palliation is the comfort

at the end of life and, therefore, many patients

decide to die at home, however, in the developed

world, most people die in hospital. Dying at home

requires that complex factors of health and informal

networks of care be established as a support and

an analysis of how the health systems, services and

health professionals influence the care at home at the

end of life. A current issue is the constant doubt if

the informal household services, used mainly when

there is a shortage of family financial resources,

are a help or a barrier in the palliative care, since

much of the support is not provided in the proper

environment and is often carried out by professionals

with little preparation in terms of palliative care.

21

It was reported that the families which cannot keep

their beloved family members in domicile palliation,

either by the patient’s state of impairment or lack

of family structure and/or financial information,

they submit the family member to a higher risk of

hospitalization with intervention with too much

medical care.21 Yet, from the 20th century, the

power of intervention of the doctor has grown

enormously, without occurring simultaneously a

reflection on the impact of this new reality on the

quality of life of the sick people.

22

Analyzing the ideas, it becomes apparent that

the biggest challenge of palliative care is to integrate

the curative care. Palliating is a critical dimension

of care in health and all health professionals should

know when palliative care is necessary. When any

individual is approaching the last moments of a

debilitating health condition, the need for palliative

care increases. At that moment (and after death),

ensuring this kind of attention provides a careful

quality no matter if offered in a health institution or

in the residence of the individual.

1

Demand expansion:

The census conducted by the Brazilian

Institute of Geography and Statistics (IBGE) in

2016

23

_{indicated an increase of about 29 years}

in life expectancy of the Brazilian, since 1940.

However, the increase in the time of life does not

mean, necessarily, an improvement in the quality

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259 of life in old age or illness. It was noticed that the

constant struggle for the quest for healing and the

sophistication in the area of health created a reality

of denial of death and personification of failure

training before this fact.

24

_{Thus, many protocols}

prioritize the maintenance of life at high costs,

taking little account of the quality of life of patients

in the last months. The result is demonstrated by the

fact that most of the hospitals in Brazil do no have

a guideline on the care of patients in the terminal

stage.

25

According to the Atlas published in 2014

by the World Alliance of Palliative Cares

26

_{, in spite}

of more than 100 million people already benefit by

the amplitude of the protocols of palliative cares,

including family members and caregivers, this

still represents less than 8% of the total number of

individuals who need this type of assistance. This

scenario is more alarming in the face of feasible

reality that the human being is living longer.

Despite scientific and technological advances have

representative rates for the reduction of mortality

on the planet, the majority of patients affected

by severe diseases and chronic-degenerative

diseases still cannot take advantage of these more

modern resources. Therefore, the aging of the

population requires that countries develop policies

to implement support and Palliative Cares

27

_{to not}

only get the efficient management of symptoms

in their patients

18

_{but also to improve the quality}

of care by caregivers and family members as an

assisted and well -conducted palliation reduces

symptoms of stress, depression and anxiety in

addition to improving the confidence of caregivers

and patients.

28

In addition, an increase in the interest

of society regarding issues such as euthanasia

and assisted death has led to many questions and

research about the wish of death and depression

in chronic patients.

27

_{In this way, several studies}

presented conflicting numbers, but still relevant,

which demonstrated the presence of desire for

death, even if transient, between 11% and 55% of

terminal patients surveyed.

30-36

A survey carried out concluded that the

correlation with the desire of death comes before

symptoms such as pain, extreme fatigue, anxiety

and other characteristics such as loss of functional

status, hopelessness, low social support and

depression.

29

It is realized that, many times, the anticipated

death is seen as a hypothetical strategy to prevent

the foretold suffering. Before the fact that some

patients present the real and immediate desire for

death, it was perceived a dichotomy that fits this

aspiration as an expression of momentary despair

or manifestation of giving up.

37

In an association established between

the newspaper The Economist Unit and the

philanthropic organization Lien Foundation, from

Singapore, it was elaborated an index of quality of

death

38

_{, which positions each country in relation to}

its provision of care for end of life. From scores

obtained through topics such as the environment

of palliation, availability of human resources,

accessibility of palliative care, quality of the

measures adopted and community engagement, the

countries are analyzed and classified. The first report

became public in 2010, analyzing the palliative care

in 40 countries, including Brazil which occupied

the 38th position. In 2015, this alliance published a

second report, more up-to-date and comprehensive,

which included 80 countries and Brazil in the 42nd

position.

Barriers and solutions:

The Index of Death Quality

38

_{identifies that}

the financing of palliative care is still a major barrier

to be transposed, especially as regards political

barriers for the release of funds. It is necessary the

development of laws that recognize the palliative

care as public health policy ; to obtain standards,

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260 guidelines and protocols that describe, govern and

guide the care; to establish the Palliative Care as a

specialty or sub-specialty care and that public funds

are intended to finance such practice.

27

Such guidance is due to the perception that

income levels have been strong indicator of greater

or lesser presence of palliative care in the healthcare

system of a country. More developed countries

and, consequently, with older populations

26

_tend

to receive more pressure for the implementation

of policies for the elderly, while in less developed

countries the pressure is lower even though there

are already growing demand of palliative care.

The low economic development of a country

does not prevent it from finding alternatives for

the insertion of public health policies in palliation,

the example of Mongolia, in 15 years, joined the

palliative care in its legislation on health and social

well-being and the national program for cancer

control.

27

Regarding education as a barrier key

element, the area of palliative care is recent and still

arouses many questions and low compliance, some

countries do not have even aware of its existence

28

However, a growing number of knowledge has been

accumulated over the past 40 years in the science of

Palliative Cares and Palliative Medicine. Currently,

there are at least 12 professional journals devoted

to CP, a growing body of literature reviewed,

numerous books, internet sites, blogs and forums

dedicated to all aspects of the palliative care. But

in spite of that, in theory, being an ancient practice

and accumulated knowledge in recent decades,

only in 1990 WHO published its first definition

and therefore becomes a little known principle of

care. It is recommended that all medical schools

should include basic training in palliative care

and education vocational training should include

palliative care for health professionals.

39

It was noticed that the expertise in Palliative

Care became prominent only after the drugs were

controlled more effectively and, in this beginning,

based on misconceptions, health professionals

established a close relationship of this expertise

with the Oncology, starting to apply it only in cases

of cancer in which there were no more curative

treatments possible, associating directly to palliation

with loss of hope of cure.

40

_{Therefore, the creation}

of paths to enable a greater public awareness and

training of professionals becomes urgent, as well as

the integration of palliative care to health systems,

creating incentives so that society is more willing

to invest in the area and attract skilled professionals

trained in the field in order to complement the small

number of specialists who already work.

27

Whereas in terms of availability of drugs,

there are certain obstacles. Some of the main

drugs for management of symptoms in patients

are opioids used for pain control. Access to these

drugs is a global problem, in which 80% of the

population, especially in poor countries, has

difficulty of access. In contrast, richer countries

are responsible for 90% of the use of opioids,

revealing a clear discrepancy in the distribution of

these drugs among the countries and leading to the

conclusion that patients requiring palliation in most

developed countries receive greater support for pain

management. Thus, the worldwide community

of palliative care and human rights organizations

argue that the balance is restored since that it is

called the attention both for the conscious medical

use and the prevention of illicit use.

41

On the other hand, it is discoursed on the

real need of opioid use per capita, because this

information will vary according to the patients’

age, the cause of morbidity, the country and several

(9)

261 other influential factors.

42

_{In accordance with the}

report of the International Narcotics Control Board

(INCB) 201243, there are several barriers that limit

the use of drugs for palliative care, among them

the too strict rules ; limitations on the forms of

medication available, particularly the oral opioids;

lack of supply and distribution; limitations on who

may prescribe; fear of police intervention in the

medical use and so on. However, in Uganda, the

collaboration with local narcotics agents facilitated

the access, allowing the professionals registered to

prepare colored solutions of morphine so that the

patients could take home with a measuring glass,

avoiding an overdose.

42

_{This was a simple, cheap}

and effective solution, that demystified the idea

that having more resources would lead to a more

effective palliative care.

Categorize the morphine as an essential

medication is simple, but it promotes a great

impact, because it indicates to the doctors that

it is necessary to adopt a change of attitude in

relation to opioids. The opioids need to be more

accessible and, although the current measures of

distribution limit the quantities distributed to avoid

indiscriminate use and addiction in big cities, this

control of quantity is done also for inhabitants of

rural areas that have difficult access to larger cities

for the acquisition of opioids, and, with it, spend

more time without the drug, since larger quantities

are not supplied to them.

27

The implementation of palliative cares in

developing countries has been made very unequally

and this distribution is closely linked to Human

Development Index.

44

_{Without political support}

and financial resources for the implementation of

the palliative care, all the development achieved is

restricted to the creativity of health professionals,

help from institutions and non-governmental

organizations (NGOS) and the leaders who make

personal sacrifices and financial resources to

implement palliative care in their community.

27

Therefore, the implementation of this practice must

obey a government strategy, not a chaotic spray of

resources. Any strategy has as its starting point a

necessity assessment, which, when not identified in

real form, can be estimated.

45

In the end, the implementation of palliative

cares are not restricted only to the factors already

mentioned but also the psychological, social and

financial barriers of the community itself.

10

_Since

the beginning, the palliative care was strongly

associated to the end of life, and psychologically,

most people avoid recognizing any issue related

to death.

46

_{Even in the face of the possibility of}

dying soon, it is pointed that it is harmful to mental

health of the patient excessive reflection on this

theme, directly influencing the palliative treatment.

In many countries informing the patient about

his or her diagnosis and prognosis is prohibited

or strongly discouraged when there is a threat to

life. Previously, this was the case in most cultures,

however, today it is encouraged that the patient not

only learn, but actively participate in the decisions

taken by the health team for his or her case.

47,48

In another angle, WHO, in its Atlas

26

_,

reports that the disease that threatens the life

can have a big impact on financial plan. In many

countries, effective medical treatment can only be

available to those with financial resources to pay for

the care. In the United States, for example, at least

half of bankruptcy is due to medical bills. Although

palliative care has been considered profitable

in many studies, these are mainly in developed

countries.

Even in the face of many difficulties in

the establishment of effective Palliative Care, the

Global Atlas of Palliative Cares at the End of Life

26

highlighted examples of how these services are

offered in several regions of the world, in different

political, cultural and economic contexts. There

(10)

262 are models that use effectively volunteering in

community health, applied in India and Tanzania;

an initiative of education and training in Palliative

Cares implemented in Romania; programs to

increase adherence to protocols of palliation, used

in the United States; a movement of installation of

quality hospices started in the United Kingdom.

There are also many other methods of development

of palliative cares that found a successful way to

promote assistance even in the face of limitations

and lack of resources.

The network of neighborhood in Palliative

Cares (NNPC), a program installed in communities

of India, is a project started in 2000 in which the

volunteers from the local community are trained to

identify problems of chronic diseases in their area

and to work effectively, with the active support

of a network of trained professionals. Essentially,

the NNPC has as objective to empower local

communities to take care of chronic patients and

moribunds in the region. Within 10 years, the

initiative became a vast network that handles more

than 15,000 patients, has a workforce of more than

15,000 trained volunteers, 50 physicians and 100

nurses in palliative cares.

26

The Hospice Casa Sperantei is a charity

institution in Romania, founded in 1992 in

Bucharest, in partnership with a British hospice. Its

mission is to support the development of hospices

and Palliative Cares for patients with incurable

diseases em terminal stages. The organization has

actively participated since 1997 in the education of

professionals interested in creating new services of

palliative cares.

26

At Hope Hospice, Florida, professionals

noted the growing need for a special type of care,

directed to those who were not eligible for the

hospices. Thus, this team was one of the pioneers in

the concept of broad access to palliative care. This

was done through the continuous improvement

of the palliation skills, including pain control,

management of symptoms, counseling and care

focused on the person. This care is provided

through an approach of interdisciplinary team

that allows adults to remain in their own homes,

providing daily assistance, proactive medical care

and innovative management of diseases. This

coordinated approach to palliative cares addresses

the fragmented services in that the caregivers often

must look for in the healthcare system of the United

States.

26

FINAL CONSIDERATION

In short, dealing with the loss or with disease

itself has always been a challenge, and death is a

subject that a few propose to discuss, leading to a

mechanism of denial. Historically, arose in Europe,

even in the 5th century, the initiative of hospices,

places where patients at end of life were housed,

with the goal of providing care and relief of pain

until their last day. This continued until the 1990s,

when there was the renewal of the model of the

hospices, starting to encompass multidisciplinary

practices, called Palliative Cares, seeking to offer

patients a life close to family, without pain and

based on respect.

Based on the relevance of the subject, came

the proposal for literature review focusing on the

basic concepts related to the topic, the situation of

palliative cares internationally, the main barriers to

their implementation and possible solutions to their

applicability.

It was noted that although initially the

palliative care having been employed for the

purpose of the end of oncologic life, this practice

has expanded to several other areas and being

(11)

263 applied from the time of diagnosis with the aim to

control the symptoms, and not as a last option in

the face of the impossibility of halting the natural

course of the disease. However, the implementation

of palliative cares has been made very unequal

among countries, since some of them are not able

to overcome the difficulties that present themselves

throughout the implementation process.

Thus, in addition to some countries being

totally unaware of this practice, those who have

knowledge of the theme still find legislative,

educational, financial barriers, pharmacological,

psychological and sociocultural restrictions.

However, even if there are barriers in implementation,

there are also examples of success in the insertion

of palliative care in different political, cultural and

economic contexts, as in India, Romania and the

United States. These models have proved that, even

with limited human and financial resources (India

and Romania) or with a health system heavily

privatized and focused on profit (the USA), one

can find viable and effective alternatives for the

implementation of the palliative care and that, even

if death is an inevitable visit, there is urgent need

to give comfort to those who had a history and who

need peace, absence of pain and comfort to relive it

and, thus, end it in the best way.

The authors declare that this article is free

of conflicts of interest. They also declare that there

is no source of external financing.

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