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.