Le Cure Palliative a domicilio:
quali modelli e quali evidenze
Cure Palliative: definizione
Palliative care is an approach that improves the quality of life of patients and their
families facing the problem associated with life-threatening illness, through the
prevention and relief of suffering by means of early identification and impeccable
assessment and treatment of pain and other problems, physical, psychosocial and
spiritual. Palliative care:
• provides relief from pain and other distressing symptoms;
• affirms life and regards dying as a normal process;
• intends neither to hasten or postpone death;
• integrates the psychological and spiritual aspects of patient care;
• offers a support system to help patients live as actively as possible until death;
• offers a support system to help the family cope during the patients illness and in their
own bereavement;
• uses a team approach to address the needs of patients and their families, including
bereavement counselling, if indicated;
• will enhance quality of life, and may also positively influence the course of illness;
• is applicable early in the course of illness, in conjunction with other therapies that are
intended to prolong life, such as chemotherapy or radiation therapy, and includes
those investigations needed to better understand and manage distressing clinical
complications.
Cure Palliative: definizione
• Applicabili a tutte le condizioni di
terminalità
• Sostegno alla qualità della vita e
all’indipendenza
• Basate su un approccio
multiprofessionale in equipe
• Sostegno alla famiglia
GERIATRIC PALLIATIVE MEDICINE
(EUGMS - JAGS 2010, Sophie Pautex, Vito Curiale et al)
GPM is the medical care & management of older
patients with health-related problems and progressive,
advanced disease for which the prognosis is limited
and the focus of care is quality of life. Therefore GPM
combines:
• the principles and practice of geriatric medicine & PC
• focuses on comprehensive geriatric assessment:
– relief from pain and other symptoms
– management of physical and psychological problems, integrating social,
spiritual, & environmental aspects
• recognizes the unique features of symptom & disease
presentation, the interaction between diseases, the need for
safe drug prescribing, & the importance of a tailored
multidisciplinary approach for older patients receiving
palliative care & their family
•
•
•
•
• addresses the needs of older
emphasizes the importance of autonomy, the
& their
families
involvement inpatients
decision-making,
& the
existence of
across all settings (home,
ethical dilemmas
hospices,
&&
calls for good long-term
communicationcare,
skills when
discussing
giving information
to older patients & their families
hospital)
addresses •the needs
older patients
& their families
paysofspecial
attention
to
across all settings (home, long-term care, hospices, &
transitions within/between
hospital)
settings
of care;within/between
and, offers a
pays special attention
to transitions
settings of care;
and, offers
a supporttosystem
support
system
helpto help
families cope during
the patient’s
families
cope terminal
duringphase
the of
care
patient’s terminal phase of
care
Where people die (1974-2030): past trends,
future projections and implications for care
Barbara Gomes & Irene Higginson, Palliative Medicine, 2008
Death statistics, age pyramids by age group and gender
♂
♀
Where people die…
Barbara Gomes & Irene Higginson, Palliative Medicine, 2008
Proportions of home deaths
Where people die…
Barbara Gomes & Irene Higginson, Palliative Medicine, 2008
♂
♀
Proportions of home deaths
by gender
Where people die…
Barbara Gomes & Irene Higginson, Palliative Medicine, 2008
Proportions of home deaths by age group
Factor influencing death at home in
terminally ill patients with cancer:
a systematic review
Barbara Gomes & Irene Higginson, BMJ, 2006
Modelli di erogazione delle
Cure Palliative a domicilio
• Primary healthcare team
• Hospice home care nurse
• Multidisciplinary home care
support team
• Comprehensive hospital at home
Primary healthcare team
Medico di Medicina Generale
+
Risorse dei distretti
• A domicilio
• Nelle residenze protette
• In Liguria: MMG + Cure Domiciliari I/II livello
Hospice home care nurse
• Sono modelli diffusi in UK: «Macmillan
nurses» e «Marie Curie nurses»
• Macmillan: consulenza, counseling,
educazione, supporto, collegamento tra il
territorio e i servizi specialistici, non offre
aiuto pratico
• Marie Curie: offre aiuto pratico nella fase
terminale, ore di presenza e prestazioni per
dare sollievo ai familiari
Multidisciplinary home care support team
• Team multiprofessionale: medici, infermieri,
fisioterapisti, assistenti sociali e altri.
• Hospital-based, community-based, hospice-based
• I team possono essere specifici per
problematiche: bambini, AIDS
• A seconda dei modelli i team possono supportare
le Cure Primarie e/o erogare cure direttamente
e/o dare sollievo a ciclo diurno o di ricovero in
hospice
• In Liguria: associazioni no profit
Comprehensive hospital at home
• Ospedalizzazione a domicilio
• E’ un servizio che si propone come alternativo al
ricovero in ospedale o hospice
• Possibilità di eseguire terapie complesse,
gestione vie venose, trasfusioni, uso farmaci e
presidi ospedalieri
• Può essere di supporto al MMG o prendere in
carico in modo esclusivo
• In Liguria: Spedalizzazione Territoriale ASL3 e
Galliera
• In Lombardia: «passaggio in cura» AO Salvini di
Garbagnate Milanese
Revisioni Cochrane
1. Hospital at home: home based end of
life care. Shepperrd, Wee, Straus. 2011
2. Effectiveness and cost-effectiveness of
home palliative care services for adults
with advanced illness and their
caregivers. Barbara Gomes, Natalia
Calanzani, Vito Curiale, Paul McCrone,
Irene J Higginson. 2012 in press
Hospital at home: home based end of life care
Shepperd, Wee, Straus. 2011
• Tipo di studi: RCT, CBA, ITS
• Partecipanti: adulti con malattia in fase terminale
che richiede cure di fine vita
• Interventi: cure di fine vita a domicilio vs
ospedale e/o hospice
• Outcome: luogo del decesso, preferenza del
paziente, controllo dei sintomi, tempo di attesa
del servizio, stress dei caregiver, esaurimento dei
caregiver, ansia del paziente e dei caregiver,
ricoveri improvvisi
Hospital at home: home based end of life care
Shepperd, Wee, Straus. 2011
RISULTATI: studi inclusi
Autore
Brumley
Grande
Anno
2007
2000
Hughes
1992
Jordhøy
2000
Metodo
RCT
RCT
Età (anni)
74 ± 12
Treatment 72 ± 11
Control 73 ± 14
RCT
Treatment 65,7
Control 6,3
Cluster-RCT Treatment 70 (38-90)
Control 69 (37-93)
Luogo
USA
UK
USA
Norvegia
favours control
favours intervention
Altri outcome
Hospital at home: home based end of life care. Shepperd, Wee, Straus. 2011
• Sintomi: =
• Soddisfazione: ↑
• Durata della degenza: ↓
• Uso di altri servizi: ↓
• Costi: ↓
• Caregiver: ↑ - ↓ dopo i 30 gg
Effectiveness and cost-effectiveness of home palliative care
services for adults with advanced illness and their caregivers
Gomes, Calanzani, Curiale, McCrone, Higginson. 2012 in press
• Tipo di studi: RCT & CCT (patient or cluster), CBA, ITS
• Partecipanti: adulti con malattia in fase avanzata e
loro carigiver
• Interventi: Cure Palliative a domicilio vs approccio
standard
• Outcome: Decesso a domicilioAltri outome: tempo
trascorso in ospedale, soddisfazione, sintomi , stato
funzionale, qualità della vita, lutto, dati economici
(costi ospedalieri e del territorio, costi per le famiglie,
costi per farmaci e ausili)
Types of interventions
A team delivering home PC with the presence of 4 elements:
1. Primarily for patients with a severe and/or advanced
malignant or non-malignant disease, no longer responding
to curative/maintenance treatment and/or is symptomatic,
or their lay caregivers, or both; interventions that did not
directly deliver care to patients or caregivers were excluded.
2. Aiming to support patients or caregivers, or both, outside
hospital and other institutional settings as far as possible
and to enable patients to stay at home; services delivered in
skilled nursing facilities, day care centres, residential homes
or prisons were excluded.
3. Providing either specialist or intermediate palliative/hospice
care.
4. Providing comprehensive care and aiming at different
physical and psycho-social components of palliative care.
Effectiveness and cost-effectiveness of home palliative care
Gomes, Calanzani, Curiale, McCrone, Higginson. 2012 in press
RISULTATI: studi inclusi
23 studi
•
•
•
•
•
•
RCT: 13
Cluster-RCT: 3
CCT: 2
Cluster-CCT: 2
CBA: 2
ITS: 1 con CBA annidato
Altri outcome
• Tempo trascorso a domicilio: NS
• Dolore e altri sintomi: modesto beneficio con gli interventi
• Outcome relativi al caregiver: risultati contrastanti
Soddisfazione: risultati contrastanti
• Uso di risorse ospedaliere: NS
• Risorse ambulatoriali: meno utilizzate con gli interventi
• Farmaci, esami, procedure: + analgesici, - esami, - procedure
invasiva con gli interventi
• Costi: minori costi con gli interventi (18%-35%)
• Costo/efficacia: ?
Conclusioni
• La probabilità di morire a domicilio è
più che raddopiata nel paziente
oncolgico e no
• Effetto positivo sul controllo dei
sintomi
• Dubbi: maggior carico fisico ed
emozionale sui caregiver