Jo Lisaerde

Oud en moe van dagen: levensmoeheid bij ouderen

Levensmoeheid bij ouderen kan aanleiding geven tot een wens om te sterven. Deze tekst biedt artsen een praktische handleiding over deze problematiek. De lichamelijke, psychische en sociaaleconomische risicofactoren voor levensmoeheid moeten opgespoord en geevalueerd worden op hun reversibiliteit en behandelmogelijkheden. Een multidisciplinaire evaluatie en aanpak van levensmoeheid is gezien de vaak multifactoriele etiologie wenselijk.De zorgverlener kijkt na of de levensmoeheid aanleiding geeft tot lijden dat uitzichtloos en ondraaglijk is. De uitzichtloosheid is een professioneel oordeel over het nog aanwezige behandelen zorgperspectief en is vaak objectiveerbaar. De ondraaglijkheid is een beleving van de patient, strikt persoonlijk en altijd subjectief.De criteria van de huidige wetgeving rond euthanasie, de reversibiliteit van de onderliggende oorzaken van levensmoeheid en de ondraaglijkheid van het lijden bepalen of een verzoek tot euthanasie van de patient met levensmoeheid in overweging kan worden genomen. Soms past een verzoek niet binnen het voorgestelde kader zodat een weloverwogen multidisciplinair advies van een commissie voor medische ethiek wenselijk is.

Defining a palliative care patient: Reaction on Groninger H. Letter to the Editor: Regarding a definition of the palliative care patient

Dr Hunter addresses some findings of our systematic review1 on the definition of a palliative care patient published in the March 2013 edition of Palliative Medicine. He suggests extending the definition of a palliative care patient to patients with chronic non-life-threatening conditions and proposes an alternative direction for defining the palliative care patient based on the needs for palliative care services. He correctly remarked the limitation of the reviewing process to randomized controlled trials (RCTs). We used a quantitative approach in a first step to clarify the palliative care patients’ concept in an original and feasible way. We choose this approach because RCTs’ inclusion and exclusion criteria give us the most precise definition from the authors of the study. We would like to emphasize an interesting shift in the discussion from the original reviewers’ question “What is a palliative care patient?” to the closely related question “What is palliative care?” and whether or not the care for chronic non-life-threatening conditions (e.g. chronic nonmalignant pain, chronic renal failure and chronic genetic disorders) should be “covered” by the term palliative care (PC). This discussion of semantics is structured in a recent systematic review where Hui et al.2 describe conceptual differences and similarities of three terms: supportive care (SC), PC, and hospice care (HC). The authors systematically searched medical literature for published peerreviewed articles from 1948 to 2011 that conceptualized, defined, or examined these terms and developed a preliminary conceptual framework unifying these terms along the continuum of care. Hui et al. found 24 different definitions of PC and identified that common concepts for all the three terms were symptom control and quality of life for patients with life-limiting illness. SC focuses more on patients on active treatment and less often involved interdisciplinary care. HC focuses more on volunteers, bereavement care, and community care and was not applicable earlier in the disease trajectory. Hui et al. propose a framework where HC is part of PC, which in turn is part of SC with the stage of disease (no evidence of disease, early stage disease, advanced disease, and near death and bereavement) as a key distinguishing factor. Based upon the definition of PC and the publication of Hui et al., we suggest to define the care for chronic non-life-threatening conditions (e.g. chronic nonmalignant pain, chronic renal failure, and chronic genetic disorders) as SC, thereby respecting and not extending the World Health Organization (WHO)’s definition of PC.3 However, we agree that identifying the transitions between these concepts (for different diseases) is difficult and challenging.4 Groninger made a valuable suggestion to define a palliative care patient according to their need for palliative care services. Indeed, criteria to identify a palliative care patient in clinical practice are often indicators for the need for extra SC (e.g. general or specific clinical indicators for advanced disease in the “Supportive and Palliative care IndiCator Tool” of the Gold Standards Framework: poor functional status, oxygen dependency, unexpected hospital admissions, etc.).5 Although, the elements we propose to integrate in a definition of a PC patient do include these palliative care needs. We actually describe a palliative care patient as a patient with an advanced, life-threatening condition in which it is no longer possible and/or desirable to influence the natural course of illness (not to restore or to stabilize or to restrain) and in which a need for PC consequently appears (the need for a holistic, multidisciplinary approach focusing on pain and symptom control, and quality of life). The overall goal of care should be a determinant factor to define a palliative care patient. If the intention of care delivery is to cure the patient (e.g. child with acute lymphoblastic leukemia treated with the intention to cure), we would not name this patient a palliative care patient although he or she may need SC.