Los cuidados paliativos: un modelo de atención integral al niño gravemente enfermo y a su familia

[The Death of Children: Ethical dilemmas about the limitation of therapeutic effort]

Ethical dilemmas take importance in current medical practice, especially at the end of life. Limitation of therapeutic effort, understood as not starting or withdrawing life support measures, is an alternative to preserve patient dignity when death approaches. Ethical dilemmas in this context have been widely studied in adults; not in children, in which the big psychological tension experienced by parents and professionals makes difficult to take accepted and consensual ethical decisions. The objective of this work has been to understand the concept of limitation of therapeutic effort and the deontological principles that support them in the pediatric field. The purpose was none other than to establish improvements in dying children whom peculiar life-end makes necessary a different approach of adults and an ethical conceptual clarification which justify LET practice in youngers.

Intervención cognitivo-conductual en cuidados paliativos pediátricos: un caso clínico

Objetivo: El cáncer infantil es una enfermedad que modifica el estilo y calidad de vida de los niños y sus familias debido al impacto físico, emocional y económico que provoca. Los Cuidados Paliativos Pediátricos tienen entre sus funciones otorgar atención psicológica a los niños y sus familiares desde la etapa prediagnóstica con la finalidad de mejorar el estado anímico del paciente y promover pensamientos y conductas que le permitan adaptarse a su nueva condición y mejoren la adherencia al tratamiento. Se expone el caso de una paciente pediátrica con diagnóstico de Sarcoma Sinovial que presenta sintomatología depresiva y evitación ansiosa a raíz de su padecimiento. Método: La evaluación se realizó mediante entrevista conductual y observación directa de la sintomatología ansiosa y depresiva intrahospitalaria y la Escala Visual Análoga (EVA) para el dolor. El tratamiento se llevó a cabo en siete sesiones en las que se emplearon técnicas de la Terapia Cognitivo-Conductual. Resultados: Entre los resultados se obtuvieron verbalizaciones adaptativas sobre su padecimiento, posibles tratamientos médicos, autoconcepto, una mejora en la expresión emocional y control del dolor. Conclusiones: El presente caso es una muestra de la importancia que tiene la labor del psicólogo en los Cuidados Paliativos Pediátricos, así comoel impacto del trabajo con los niños que padecen enfermedades oncológicas y sus familiares. La Terapia Cognitivo-Conductual ha demostrado ser altamente eficaz en este tipo de pacientes, aún en intervenciones breves.

[Respiratory treatments in neuromuscular disease]

In a previous article, a review was presented of the respiratory pathophysiology of the patient with neuromuscular disease, as well as their clinical evaluation and the major complications causing pulmonary deterioration. This article presents the respiratory treatments required to preserve lung function in neuromuscular disease as long as possible, as well as in special situations (respiratory infections, spinal curvature surgery, etc.). Special emphasis is made on the use of non-invasive ventilation, which is changing the natural history of many of these diseases. The increase in survival and life expectancy of these children means that they can continue their clinical care in adult units. The transition from pediatric care must be an active, timely and progressive process. It may be slightly stressful for the patient before the adaptation to this new environment, with multidisciplinary care always being maintained.

[Non-invasive ventilation improves comfort in pediatric palliative care patients]

OBJECTIVE

To analyze the appropriate use of non-invasive ventilation and its contribution to improving comfort in pediatric palliative care patients.

PATIENTS AND METHOD

This is a descriptive cross-sectional study comprising 55 palliative care patients from San Juan de Dios Hospital in Barcelona. The effectiveness was evaluated using a register of socio-demographic, clinical-ventilatory and oxymetric parameters, the comfort and dyspnea's grade using Silverman Anderson scale, and pain level using pediatric scales.

RESULTS

The effectiveness of the technique was proved by a decreased heart rate (133.53±25.8 vs. 111.04±23.1; p<0.0001), respiratory rate (35.02±12.9 vs. 25.63±5.7; p<0.0001) and an increase of partial oxygen saturation (95.7±2.9 vs. 96.87±7.2; p<0.0001) and partial oxygen saturation/fraction of inspired oxygen ratio (297.12±113.4 vs. 336.97±100.7; p<0.0001). Dyspnea and pain levels improved in 100% of the patients.

CONCLUSIONS

The therapy was effective and the comfort improved in 100% of the patients.

Assistance to children in palliative care in the Brazilian scientific literature

Objective:

To describe what has been published in Brazilian scientific literature regarding pediatric palliative care.

Data sources:

Bibliographic review with a descriptive approach. In LILACS and SciELO databases, the descriptors "palliative care", "child", "pediatrics", "terminal illness" and "death" were sought, from January 2002 to December 2011. The eight selected articles were analyzed according to year of publication, type of study, data collected, target population, pathology, professionals involved, types of care and main findings.

Data synthesis:

Regarding the year of publication, there was an increase in the number of publications related to pediatric palliative care. Regarding the type of study, four articles were literature reviews and four were qualitative researches. Data was collected mainly by semi-structured interviews. The participants of the majority of the studies were children's relatives and health professionals. The main pathology addressed was cancer and the nurses were the most frequently cited professionals. The types of care provided were related to physical aspects, general care and psychological, social and spiritual aspects (less emphasis). The main findings were: little emphasis on the children's needs, the importance of including the family in the care provided and the lack of preparation of the health team.

Conclusions:

Despite the difficulties and the challenges in establishing pediatric palliative care, many articles brought important considerations for the development of this practice in the country.

El pediatra ante la muerte del niño: integración de los cuidados paliativos en la unidad de cuidados intensivos pediátricos

Palliative care is essential in the pediatric intensive care unit (PICU). Because of the mortality rates and the presence of life-threatening conditions in children admitted to the PICU, pediatricians must be prepared to provide palliative care independently of cure-directed therapies. The present article reviews certain issues, including the decision-making process in the PICU, psychosocial needs and susceptibility to burnout among PICU staff, and the emotions and attitudes of the staff when a child dies. We provide some guidelines on how to act when a child dies, how to meet with parents after the child's death and how to follow-up parental bereavement. Strategies that can help PICU pediatricians to cope with the numerous loses they experience are suggested.