Palliative care in Cuba

Palliative care is a of health care that improve the life quality of patients suffering chronic, debilitating or threatening illnesses, and also that of their careers. The aim of this article was to describe the evolution of Palliative care since its appearance and the tendencies that have characterized their development in the world and in Cuba. We consider documented references that explain how Palliative care has been introduced into many health systems all over the world in recent decades. A large amount of information was collected on interdisciplinary teams as being the main work unit for palliative care in various contexts of both health and the home. Applications of Palliative care were found in priority planning for application in the Cuban Primary Health Care with the intention of restoring the essential human dimensions in these patients and in their careers. It was necessary to study historical sources in order to ascertain the evolution and the fundamental stages of the development, the relation of Palliative care with other elements of the same environment and the collection of widespread information in a general setting that gave form to a single whole in the evolution of Palliative care. As a result, this article historical data of great importance was obtained about how palliative care was introduced and how they evolved in care of critically ill patients suffering chronic or debilitating diseases. At the same time the principles on which Palliative care is sustained were described as were the functions of the interdisciplinary team. Both aspects suppose a theoretical contribution. Work projections in Cuba were put forward for the period 2008-2010 on the basis of the incidence of threatening chronic illnesses in that country. *Correspondence to: Mariuska Forteza Sáez, Department of Oncopediatric. National Institute of Oncology and Radiobiology of Cuba, E-mail: mforteza8324@gmail.com


Introduction
Palliative Care is a model of health care that improves the quality of life of patients with chronic, debilitating or threatening diseases and their caregivers. The purpose of this article was to describe the evolutionary development of Palliative Care since its emergence and the trends that have characterized its development in Cuba. In the course of the history of mankind, the attitude of man before death has not always been the same. In the Middle Ages there was the so-called "domestic death". It consisted of the dying man inviting his loved ones to gather around his bed and perform the so-called "rite of the room" [1]. This ceremony took place in union with the loved ones of those who were about to die.
With the First World War began a process called "forbidden death", where death is separated from the daily events of life [2]. Stop being the expected death, accepted and accompanied to be cornered and eliminated from language as a shameful and strange process. The precursor of palliative medicine Cecily Saunders refers that hiding the dying person, their diagnosis and the truth of their prognosis has become a current trend. In addition, the home is replaced by the hospital as the place for the dying process to occur [3].
The relief of symptoms was the primary task of medical treatment until the end of the 19th century. The medicine already in the twentieth century is heading towards the search of the etiology and the treatment of the diseases providing its cure. It is due to the scientific-technical advances and the increase in life expectancy that the management of the symptoms goes into the background. Currently, the objective pursued by medicine rather than caring for the quality of life of the population is to prolong the life expectancy of them [4].
At present, the treatment indicated by different specialists can only lead to the therapeutic harassment of the patient, instead of attending to the dimensions of the quality of life that may be affected. It is also reflected in the great void that exists in the curricula of medicine and nursing in relation to how to properly care for incurable patients with limited life Sanz and Pascual point out before this circumstance that "we must rescue and rediscover, if possible, the phenomenon of "caring" now eclipsed by the overexpansion of the healing aspects of medicine. We do not have to forget that medicine is born as a response of help, consolation and accompaniment for sick and dying human beings" [5].

Material and method
For the realization of this article the following methods of scientific investigation were used: • Logical-Historical: It is linked to the knowledge of the different stages of objects in their chronological succession. To know the evolution of the object or phenomenon of investigation, in this case the Palliative Care, it became necessary to reveal its history, the fundamental stages of its development and the fundamental historical conditions.
• Analysis: The study of an object is made from the relationship that exists between the elements that make up the object as a whole. Here we studied the existing literature on Palliative Care, the principles on which Palliative Care is based, the functions of the interdisciplinary teams, the Palliative Care in Cuba, particularly in the City of Havana and the projections up to the year 2016.
• Synthesis: It is the rational meeting of several dispersed elements in a new totality. For this article, Palliative Care and how it can meet the requirements of the Cuban health system have been taken as essential elements.

Palliative care in Cuba
In 1992, the Program for Attention to Pain and Palliative Care for Cancer Patients (PADCP) was created in the National Institute of Oncology and Radiobiology (INOR) with a modern approach [6].
In 1994, the first Project was proposed for the creation and operation of the Pain and Palliative Care Clinic at INOR. In 1996, after research for the adaptation and validation of instruments and procedures for the training of personnel in the City of Havana, the Program document was prepared, immediately beginning its implementation in 4 provinces of the country: Santiago de Cuba, Camagüey, Villa Clara and City of Havana. Its general objective was defined as: "to increase the subjective well-being and the quality of life of the oncological patient that requires palliative care and their families through an integral care that considers the physical, social, emotional and spiritual aspects, without affectations for the team of Health". Since then, multiple working meetings were held with the National Pharmacy Directorate for the annual prediction of opioid consumption, courses and conferences were offered at INOR, where several experts and experts from PAHO / WHO visited the country with the objective of know the Program and offer their experiences, bibliographic materials were delivered to several institutions, and 26 specialists from across the country were trained in two international distance courses. In addition, two other projects were created to create an Inpatient Palliative Care Unit [7,8].
The massive training by the national team of the Program of Attention to the Pain and Palliative Care to the oncological patient began in 1998 in 5 provinces of the country, conforming the provincial teams that would be in charge of the training "in cascade". These provincial teams were provided with the auxiliary means to carry out this task. In addition, 3 INOR professionals (1 Bachelor of Nursing and 2 doctors) had in-person scholarships in a Palliative Medicine Unit in Las Palmas de Gran Canaria. Lectures on morphine were offered at a National Workshop of the National Pharmacy Directorate. In spite of the efforts made, the systematic production of oral morphine for the Program could never be achieved. Between 2000 and 2003 another Project was created for the creation of a Palliative Care Unit in the INOR, it was discussed in a Workshop with specialists in September 2004, several boxes of donations were given in medicines and the Drug and Health Plan was elaborated. Material available for the Program on two occasions (1999 and 2000). In 2001, a Multicentre Research Project on the Evaluation of the Pain and Palliative Care Program for the oncological patient was completed, which offered data to be discussed at a meeting of the National Program Commission, defining projections and indicators for its generalization in the coming years. The first formal training course for residents of 1st. to 4th. of INOR, with the participation of nurses and some specialists from various services of the Institute, a course that is currently established as a module in the training of residents [7,9]. • Complete the necessary bank of medicines for the control of symptoms in the actions of support and palliation • Edit a manual, widely disseminated and used for multiple purposes, with the experience accumulated in Cuba so far.
• Increase exchange and training in specific aspects of ongoing care and palliative care with foreign specialists (Program management, symptom control, family care, etc.).
Develop research and projects in these aspects, considering especially those that allow obtaining indicators of impact and leading to scientific degrees (Masters and Doctorates) [16,17].

Situation in the city of havana at the beginning of the current decade
New health service in the "Plaza de la Revolución" Municipality through the dispensarization of all patients with advanced cancer and their primary caregivers, with the aim of: "Preserve the subjective wellbeing and the quality of life in the oncological patient diagnosed in advanced stage, when the therapeutic plan is established, continuing during the stage in which survival with quality is sought, and, finally, in the terminal stage of life, in addition to preserving the subjective well-being and quality of life of their relatives, through personalized, interdisciplinary, integral and continuous attention, which considers the physical, social, emotional and spiritual aspects, with the least impact on the health team " [6].

Program achievements until 2010
Progressive awareness of professionals in the sector  • It was recommended to form a national multi-profile group, with representatives of all the medical specialties involved [17][18][19][20].

Education and training
In 2015, a study was conducted to determine the level of information on palliative care in physicians where 63 doctors from different specialties were surveyed. The (49.9%) of the respondents had less than 10 years of graduation and 24 (52.1%) had more than 10 years of work experience at the time of the study. When exploring the aspects that define palliative care, it is observed that 100% of the doctors answered correctly that palliative care is aimed at reducing suffering and raising the quality of life, 38 (82.6%) acknowledge that it has the objective to offer a support system to help patients lead a life as active as possible until death occurs and 40 (86.9%) accept that the family should always participate in palliative care. However, they handle elements that contradict the meaning of palliative care, we see that 2 (4.3%) believe they should not be provided in the home, when about 60% (only in the case of cancer patients), they die in the currently home, 6 (13.0%) do not recognize the spiritual aspects as part of palliative care and 8 (17.4%) report that they are offered to delay the death of the patient, when the WHO has proposed that palliative care have In order to establish a process that does not accelerate the arrival of death or postpone it, the psychological and spiritual aspects must be integrated into the treatment of the patient and care must be provided at both the home and hospital levels;100% of the doctors surveyed correctly recognize that mixed therapeutic strategies should be used (pharmacological and non-pharmacological, biomedical and psychosocial methods) [13].
The existence of myths surrounding the use of morphine was recognized by the subjects investigated. We see that they adequately identify that the route of choice for the parenteral administration of morphine is the subcutaneous 67.4% of the doctors surveyed, but none recognized that it has no therapeutic ceiling.
At the same time, they maintain erroneous concepts, since 73.9% consider that their use can lead to drug addiction, 84.9% that always gives respiratory depression, that tolerance develops quickly so that in the end it will not be as effective (50% of those investigated) and 34.7% believe that orally it is ineffective. A similar level of responses is observed in both groups [11].
For the WHO, the consumption of morphine (for medical use) is a good indicator of pain control associated with cancer in different countries. It is an essential condition for pain relief, in a Public Health system that guarantees the general availability of morphine and other opioid derivatives for oral administration or by other routes. Many patients with cancer and other chronic diseases do not receive adequate analgesic treatment, either due to improper use or due to underuse of major opioids. According to this organization, only a small minority of the more than one million people who die every week throughout the world receive palliative care to reduce their suffering. The low use of morphine is combined with inadequate use due to the lack of training and general preparation of professionals, which also occurs in our environment. There are certain myths that associate morphine to the last moments of life and its shortening, precisely because it has been reserved as a last resort in the most dramatic pain processes. The problems of dependence cannot be an excuse, since they are absolutely negligible in terminal processes of medium and short duration and secondary in longer or transitory processes compared with the benefits that the elimination of pain produces to the patient [17][18][19][20].

Final considerations
The characteristics of modern life, the lack of training in the symptomatic and interdisciplinary management of patients with serious diseases in advanced stages, are elements that explain the growing recognition of the need to incorporate Palliative Care into the work of current medicine. Palliative Care has experienced a great development over the last decades worldwide to respond in a timely and effective way to the growing number of patients who would benefit from them. The definition of the principles that sustain palliative care and the functions of the interdisciplinary team constitute a theoretical contribution to the enrichment of knowledge, which on palliative care should be available to professionals who are dedicated to providing this care. In addition to be a tool to provide personalized care from the biological, psychological, social and spiritual dimensions identified in these patients and their caregivers. The development of Palliative Care in Cuba, the work projections and the characteristics of the interdisciplinary team in the current Cuban context, would provide knowledge on the current status of this topic for health professionals in the country and increase the level of excellence In the attention, a great strength of the Palliative Care in the country has been the training of the personnel, which should continue, assimilating academic accreditation figures, such as graduates and master's degrees.