Le Cure Palliative a domicilio: quali modelli e quali evidenze

Vito Curiale

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

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

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

GERIATRIC PALLIATIVE GERIATRIC PALLIATIVE MEDICINE MEDICINE (EUGMS - JAGS 2010, (EUGMS - JAGS 2010,

Sophie Pautex, Vito Curiale et al)Sophie Pautex, Vito Curiale et al)

• addresses the needs of older patients & their families across all settings (home, long-term care, hospices, & hospital)

• pays special attention to transitions within/between settings of care; and, offers a support system to help families cope during the patient’s terminal phase of care

• emphasizes the importance of autonomy, the involvement in decision-making, & the existence of ethical dilemmas

• calls for good communication skills when discussing & giving information to older patients & their families

• addresses the needs of older patients & their families across all settings (home, long-term care, hospices, & hospital)

• pays special attention to transitions within/between settings of care; and, offers a support system to help families cope during the patient’s terminal phase of care

Where people die (1974-2030): past trends, future projections and implications for careBarbara Gomes & Irene Higginson, Palliative Medicine, 2008

Death statistics, age pyramids by age group and gender

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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 deathsby gender

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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 Cochrane1.1. Hospital at home: home based end of Hospital at home: home based end of

life carelife care. Shepperrd, Wee, Straus. 20112.2. Effectiveness and cost-effectiveness of Effectiveness and cost-effectiveness of

home palliative care services for adults home palliative care services for adults with advanced illness and their with advanced illness and their caregiverscaregivers. 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 inclusiRISULTATI: studi inclusi

Autore Anno Metodo Età (anni) LuogoBrumley 2007 RCT 74 ± 12 USAGrande 2000 RCT Treatment 72 ± 11

Control 73 ± 14UK

Hughes 1992 RCT Treatment 65,7Control 6,3

USA

Jordhøy 2000 Cluster-RCT Treatment 70 (38-90)Control 69 (37-93)

Norvegia

favours control favours intervention

Altri outcome• Sintomi: =• Soddisfazione: ↑• Durata della degenza: ↓• Uso di altri servizi: ↓• Costi: ↓• Caregiver: ↑ - ↓ dopo i 30 gg

Hospital at home: home based end of life care. Shepperd, Wee, Straus. 2011

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 interventionsA 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.

23 studi

•RCT: 13•Cluster-RCT: 3•CCT: 2•Cluster-CCT: 2•CBA: 2•ITS: 1 con CBA annidato

Effectiveness and cost-effectiveness of home palliative careGomes, Calanzani, Curiale, McCrone, Higginson. 2012 in press

RISULTATI: studi inclusiRISULTATI: studi inclusi

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

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