Fontecha-Gómez Benito Jesús, Amblàs-Novellas Jordi, Betancor-Santana Évora, Rexach-Cano Lourdes, Ugarte Marina Isabel, López-Pérez Araceli, Planas Kenneth, Gutiérrez Jiménez Nuria, Casas Floriano Rosario, García-Fortea Cristina, Serrano Bermúdez Gala, Rotllàn-Terradellas María, Fernández-Ponce Daniel
Servei de Geriatria i Cures Pal·liatives, Hospital Gral. de L'Hospitalet, Consorci Sanitari Integral, L'Hospitalet de Llobregat (Barcelona), España; Servei de Geriatria i Cures Pal·liatives, Hospital de Sant Joan Despí, Consorci Sanitari Integral, Sant Joan Despí (Barcelona), España; Consorci de Salut y Social de Cataluña, Àmbit Sociosanitari, Barcelona, España.
Unidad Territorial de Geriatría y Cuidados Paliativos, Consorci Hospitalari de Vic/Hospital Universitari de la Santa Creu de Vic, Centro de Estudios Sociales y Sanitarios (CESS)/Cátedra de Cuidados Paliativos, Universitat de Vic-Universitat Central de Catalunya, Vic (Barcelona), España.
Rev Esp Geriatr Gerontol. 2018 Jul-Aug;53(4):217-222. doi: 10.1016/j.regg.2018.01.003. Epub 2018 Feb 21.
The identification of patients with advanced and complex chronic diseases, and the fragmentation of care towards the end of life, requires the drawing up a long-term therapeutic plan. This should take into account the values and preferences of the patients, as well as the vital and functional prognosis. Having an adjustment tool for determining the diagnostic and therapeutic effort is helpful in the continuity of care, as well as in decision-making in the transitions and dynamic changes of patients as they approach the end of life process.
识别患有晚期和复杂慢性病的患者以及临终关怀的碎片化问题，需要制定长期治疗计划。这应考虑患者的价值观和偏好，以及生命和功能预后。拥有一个用于确定诊断和治疗力度的调整工具，有助于护理的连续性，以及在患者接近生命末期过程中的过渡和动态变化时进行决策。
