Roberto A. Lourenço
All of us, geriatricians and gerontologists, deal with death as an undeniable reality. It is present in our plans and in our patients’ plans, regardless of age, disease, severity, or setting of care. We are used to seeing death approach slowly and then change patients, often detracting from their dignity and producing pain and other symptoms over which there is no control of the will; or rapidly, surprising us by the speed with which it reaps the harvest of life that was entrusted to our care. No matter what, death will eventually ensue.
As health professionals dedicated to caring for older persons, we know when nothing else can be done medically — it is when patients most need our support and knowledge; it is when everything is to be done. We are used to alleviating suffering when no fatal diagnosis has yet appeared on the horizon. However, it is when such sentences come to the forefront that we, geriatricians and gerontologists, are called to do our best. Palliative care is the modern expression of this care that our patients need or will need, organized as systematized knowledge and appropriate protocols. It is our ethical obligation to provide it.
In Brazil, however, what are currently the material, training, human resource and knowledge production conditions for such principles to be respected?
The Brazilian Academy of Palliative Care (Academia Nacional de Cuidados Paliativos, ANCP) gives us an overview of part of this reality. In 2018, the document “Palliative Care Overview in Brazil” was published,1 which accounted for 177 palliative care service units operating in the country, most of them within hospitals; that is, less than 5% of the health institutions have teams to provide this type of care.
In 2014, the Global Atlas of Palliative Care at the End of Life2 classified Brazil as 3A level, that is, as a country with isolated provision of palliative care, not systematized from the point of view of the delivery of interventions, medications, and care environments; patchy in scope; sourcing of funding that is donor-dependent; limited availability of opioids; and a small number of palliative care services relative to population size.
In Brazil, palliative medicine is not recognized as a medical specialty by the Brazilian Medical Association, but it is acknowledged as a field of expertise in 10 specialties: Brazilian Society of Anesthesiology, Brazilian Society of Clinical Medicine, Brazilian Society of Geriatrics and Gerontology, Brazilian Society of Family and Community Medicine, Brazilian Academy of Neurology, Brazilian Society of Pediatrics, Brazilian Association of Intensive Care Medicine, Brazilian Society of Clinical Oncology, Brazilian Society of Surgical Oncology, and Brazilian Society of Head and Neck Surgery.
A survey conducted by ANCP showed that only 14% of undergraduate medical programs offer Palliative Care as a discipline, but the course is mandatory in only 6% of them. At that survey, data were not collected for other health professions.1
Regarding scientific research, in Brazil no data has been gathered on the scientific production in this field. However, a literature search using palliative care as a search term in the Scientific Electronic Library Online (SciELO) database and palliative care + Brazil in the PubMed database, covering a period of more than 50 years, retrieved 283 and 609 references, respectively. It is too few, both in absolute numbers and in number of references retrieved using the same search strategy for other countries. Sanches et al.,3 using a more comprehensive search strategy, concluded that there are many articles on the topic but of low scientific evidence.
In summary, despite the importance of palliative care and the efforts that have been undertaken by the palliative care community, in Brazil, structure is deficient in the training of human resources, in the relief of suffering, and in knowledge production.
In view of this scenario, it is essential that we act now to overcome these hurdles by creating palliative care service units and by introducing palliative care as a discipline in undergraduate health sciences programs and in both sensu lato and sensu stricto graduate training of human resources.
Finally, it is imperative that we foster the development of lines of research in master’s and doctoral programs that address topics relevant to palliative care and that we create special opportunities for publication — a task to which we will now devote ourselves.
With that in mind, GGA created a special palliative care section, managed by a specific associate editor, a noted specialist in the field. Of course, we are always concerned about the quality of what is published, but we hope that this move encourages a number of researchers to develop projects and submit their results to our journal for peer review.
Enjoy your reading!
1. Academia Nacional de Cuidados Paliativos. Panorama dos Cuidados Paliativos no Brasil. São Paulo: Academia Nacional de Cuidados Paliativos; 2018. 15 p.
2. World Health Organization (WHO). Worldwide Palliative Care Alliance. Global Atlas of Palliative Care at the End of Life. Londres: WHO; 2014. 111 p.
3. Sanches KDS, Rabin EG, Teixeira PTO. The scenario of scientific publication on palliative care in oncology over the last 5 years: a scoping review. Rev Esc Enferm USP. 2018;52:e03336. http://dx.doi.org/10.1590/s1980-220x2017009103336