The approach to a patient in LHDOL is in fact different comparing the previous training of each clinician and the plan drawn up for their patient. The human and holistic component has an important and fundamental weight for the exercise of a more complete medicine, being an essential component (but not individual) in the practice of a Palliative Medicine Doctor.
Assuming a user as being "Palliative" is having the humility/courage to break the myth of "medical omnipotence of the cure". A step where the healing process ends and begins (it ideally continues), the real process of caring. It is therefore not in fact assumed that the so-called Therapeutic Reconciliation or Simplification could be a difficulty for a large number of professionals. Defining which drugs are futile and which ones will actually bring some benefit to the patient can give rise to discussion and the need for meetings with family members and other professionals in order to explain the situation.
Palliative Medicine Physicians are trained in a thoughtful and balanced exercise of pharmacological therapy, using all the potential of a drug, from the use of side effects for the benefit to pharmacological interactions, in order to do the most with the least possible number of drugs. The difference was noticeable in this study when evaluating the number of drugs prescribed in LHDOL in patients who had a palliative approach compared to those who did not. The futility or therapeutic zeal can become a sliding ramp, either by the professionals themselves, by the desire and commitment to “not give up” on the patient, or by the influence of families or caregivers who often, if not properly informed, can create resistance by discontinuing a drug that he has taken throughout his life for diseases such as hypertension, diabetes, or supplementation. It would be interesting to assess the impact at an economic level for institutions providing care, since with the use of fewer drugs, there is only spending on drugs that would have an effective beneficial effect for patients.
Covid19, like any disease, has characteristic signs and symptoms, which lead to essential clues for a correct diagnosis. The approach of palliative medicine does not only aim to control existing symptoms, but also to prevent any suffering that the patient may, or is likely to have, through the preventive placement of baseline and controlled doses, individually assessed, of drugs that may prevent the symptom even before it appears, optimising the dose in case it becomes a source of discomfort.
It is a fact that there was no difference in the basal administration of drugs for dyspnoea and for fever between the 2 groups, but knowing the most common symptoms and those to be controlled in the person with LHDOL and the high probability of the appearance of terminal agitation (whether physiological, whether in response to discomfort caused by dyspnoea or fever), it should be noted that the difference between baseline drugs for agitation was significant. It should also be noted that one can take advantage of the double effect of these drugs, mostly benzodiazepines, to control dyspnoea.
In Palliative Medicine, it is current practice to use predictable drugs in case of decompensation of the underlying disease, so that situations of acute suffering can be immediately corrected.
The most frequent symptoms should be systematically researched and treated, but it is important to give due importance to their prevention. This does not seem to have happened, since statistically significant differences were found with regard to agitation and dyspnoea, although not with regard to fever, pain and secretions. Still regarding previously placed SOS drugs, the fact that there is no statistically significant difference in their prescription for fever, pain or secretions may also result from a bias by the drug used, since drugs used almost automatically, as is the case of paracetamol, are counted as elective for two symptoms (fever and pain). It would be interesting in the future to specifically evaluate the drug and the purpose for which it was prescribed.
Oxygen therapy aimed at O2 saturation target values to the detriment of user comfort should also be seen as a futile means of treatment. If, on the one hand, the use of supplemental oxygen therapy could be used with a view only to comfort, assessed through signs/symptoms, on the other hand, its use was also seen with a view to obtaining target saturations within the recommendations defined for each person, regardless of present clinical signs/symptoms or not. The philosophy underlying Palliative Medicine is always "to treat people and not numbers", so the use of O2 will have as its main effect the relief of dyspnoea and not the achievement of tabulated values as "normal" observed in a saturation meter, which may also be a justification for the significant difference when it comes to the decision to definitively stop oxygen therapy.
The decision to withdraw NGTs is also something with a lot of impact, considering the true usefulness of their use in IDS, considering the therapeutic simplification to avoid bloodshed and the possibility of route rotation, using the comfortable subcutaneous route as the main means of meeting all the true needs of the person in this situation. The result was the same with regard to bladder catheterisation, which could be a source of infection and discomfort for the person. We cannot ignore the fact that Palliative Medicine professionals have better training in terms of recognizing IDS signs, which can help in decisions, namely in the removal of devices.
Despite all of this, some limitations must be taken into account. This study was carried out during the outbreak, but we should remember that Covid19 is not coming to an end, and Palliative Medicine and symptom control will always be helpful to manage, in addition to Covid19, this kind of "quality of life robber" diseases and conditions. As this hospital was the only one known to provide this type of care of integrating a doctor specializing in Palliative Medicine as part of the primary team, adding to the short duration of this back-up unit (just three months of activity), the sample for the study was reduced and may not be representative of the entire population. Additionally, the possible bias of being a retrospective study base on clinical records may result in less accurate results. More studies will be needed to validate these exploratory results, so we hope that this study, as well as this unit, can act as a booster for improvement and future researches in this field