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Durante a minha formação académica não tive qualquer formação em cuidados paliativos.
Quando no início da formação como Interno de Medicina Geral e Familiar tive a oportunidade
de escolher entre a realização de um estágio de Oncologia, a realizar no Centro Hospitalar de
Trás os Montes e Alto Douro, e um estágio de Cuidados Paliativos, a realizar no Instituto
Português de Oncologia do Porto, apenas escolhi o ultimo pela possibilidade de voltar à cidade
do Porto. Pensava na altura que em termos de objetivos e dinâmicas de trabalho, os estágios
seriam semelhantes. Apenas quando iniciei o estágio é que me comecei a aperceber das
diferenças e do que eram “os cuidados paliativos”. O estágio foi de curta duração. Três
semanas “apenas” serviram para a tomada de consciência da importância dos cuidados
paliativos e de alguns princípios básicos no controlo da dor.
Porque “às vezes um acaso nunca vem só”, estes princípios, ainda muito pouco sedimentados,
tiveram logo que ser utilizados nas semanas seguintes. Era eu interno de medicina geral e
familiar, a trabalhar numa extensão de saúde, apenas com a minha orientadora de formação e
uma enfermeira, e surgiu-me na consulta, na semana em que a minha orientadora estava de
férias, uma doente com um sarcoma em fase avançada e com dor intensa. Esta doente queria
permanecer em casa, mas estava num sofrimento atroz. Com a utilização dos princípios
básicos apreendidos durante o estágio consegui realizar um bom controlo da dor dessa doente
e satisfazer a sua vontade. Contudo, após o controlo da dor, veio a vontade de fazer mais.
Embora a doente tenha ficado muito grata com o controlo da dor, senti que ainda havia muito a
fazer, desde o controlo da dor à comunicação e a apoio psicossocial. Foi aí que senti
necessidade de complementar a minha formação académica. Por questões financeiras não me
inscrevi logo no mestrado de cuidados paliativos. Tentei primeiro uma pós graduação em
geriatria, pensando que nela iria abordar muitos dos princípios dos cuidados paliativos.
Infelizmente isso não aconteceu, pelo que finda a pós graduação em geriatria resolvi inscrever me no mestrado em Cuidados Paliativos da Universidade Católica. Nesse intervalo, e mais
uma vez porque “um acaso nunca vem só” tive a oportunidade de conhecer, num Congresso
de Medicina Geral e Familiar, aquele que viria a ser o meu orientador de mestrado, o Professor
José Luís Pereira. Ouvi-lo falar da sua experiência no Canadá levou-me logo a iniciar contactos
para uma possível realização de um estágio de Cuidados Paliativos na sua Unidade.
Quando após o término do primeiro ano do mestrado, que englobou uma forte componente
teórica me foi dada a possibilidade de realização de uma tese ou de um relatório de estágio,
nem pensei duas vezes. A possibilidade de aplicar os conhecimentos adquiridos, através da
realização de um estágio era aliciante de mais.
Foi assim que cheguei a Ottawa, no Canadá. A integração foi fácil, pela grande hospitalidade
de todas as pessoas com quem contactei. Iniciei o estágio na Unidade de Cuidados Paliativos
de Bruyère, local onde eram admitidos doentes com grave descontrolo sintomático. Aqui tive a
oportunidade de acompanhar a Dra. Katie Marchington e a Dra. Paula Enright. Todas muito
jovens, mas muito competentes e com uma enorme preocupação em atender às minhas
Relatório de Estágio observacional em Cuidados Paliativos na Unidade de Bruyère
4
dúvidas. Passei depois 3 semanas na Equipa Intra-Hospitalar do Civic Hospital, com o Dr. John
Scott, num hospital muito semelhante, pelo tipo de doentes e de patologias, ao Hospital de
Santa Luzia, o hospital de referência para a região do Alto Minho. Aqui pude perceber a
importância das competências de comunicação para a promoção da autonomia do doente e
para a definição do objetivo de cuidados. No General Hospital, acompanhei o Dr. Edward
Fitzggibon nas suas actividades diárias, acompanhando doentes de maior complexidade em
termos de controlo sintomático, com necessidade de utilização de fármacos como por exemplo
a cetamina e de técnicas anestésicas, para um satisfatório controlo da dor. Terminei o estágio
com uma breve passagem pela equipa de suporte na comunidade, a PPSMCS (Palliative and
Pain Symptom Management Consultation Service), acompanhando a Dra. Jill Rice e a Enf.
Marysse Bouvette no seu apoio aos doentes na comunidade, através de consultoria aos seus
médicos de família. Nas diversas conversas que tive com o meu orientador, o Prof. José Luís
Pereira e com a Enf. Marrysse Bouvette pude perceber a importância deste trabalho em
conjunto com os médicos de família, pois só desse modo será possível capacitá-los a seguir de
forma autónoma, a grande maioria dos seus doentes, reservando as equipas de cuidados
paliativos, para doentes de maior complexidade.
Em todos os serviços em que passei tentei-me aperceber das diferentes dinâmicas e
necessidades para um bom funcionamento das equipas, de modo a realizar um projecto de
implementação de uma equipa de Suporte em Cuidados Paliativos na Unidade Local de Saúde
do Alto Minho, com uma componente de suporte hospitalar e uma componente de suporte na
comunidade. Este projeto encontra-se descrito no anexo 1.
During my academic training I haven´t any training in Palliative Care. But in the beginning of the training, as Internal Family medicine,I had the opportunity to choose between performing a stage of Oncology at the Hospital of Tras-os-Montes and Alto Douro or a stage of Palliative Care, to be carried out at the Portuguese Institute Oncology of Porto, so I chose the last because the of possibility to returning to the city of Porto. At the time I thought that in terms of objectives and work dynamics, the stages would be similar. Just when I started the internship I started to see the difference and what was "palliative care". The stage was short-lived. Three weeks "only" served to the awareness of the importance of palliative care and some basic principles for managing pain. Because "sometimes a chance never comes alone," these principles, very little has sedimented, were soon to be used in the following weeks. I was general internal medicine and family, working on a range of health, in the week that my supervisor was on vacation, my counselor training and a nurse came to me in consultation, one patient with a sarcoma in advanced stage was in severe pain. This patient wanted to stay home, but was in terrible suffering. With the use of the basic principles seized during stage I did a good control of the pain from this patient. However, after controlling pain came the will to do more. Although the patient was very grateful to the management of pain, felt that there was still much to do, from pain management to communication and psychosocial support. At this moment I felt the need to supplement my academic training. For financial reasons I didn´t sign up right at the master's hospice. First tried a post graduate degree in geriatrics, thinking that it would address many of the principles of palliative care. Unfortunately it didn´t, by ending the post graduate degree in geriatrics I decided to sign up for Masters in Palliative Care at Catholic University. At this time, and again, "sometimes a chance never comes alone," I had the opportunity to meet in a Congress of Family Medicine, who was to became my mentor Master, Professor José Luís Pereira. Hearing him talk about his experience in Canada led me right to initiate contacts for a possible realization of a internship of palliative care in their unit. When after the first year of the Masters, which included a strong theoretical component I was given the opportunity to conduct a thesis or an internship report, I didn´t think twice. The ability to apply the knowledge acquired through the completion of an internship was more attractive. So it was, I went to Ottawa, Canada. The integration was easy, for the great hospitality of all the people contacted. I began my internship at the Palliative Care Unit of Bruyère, where they were admitted patients with severe symptomatic uncontrolled. Here I had the opportunity to accompany Dr. Katie and Dr Marchington. Paula Enright. All very young but very competent and a huge concern in meeting my doubts. Then spent three weeks in the Hospital-Team Civic Hospital, with Dr. John Scott, a very similar hospital, the type of patients and pathologies, the Hospital Santa Luzia, the referral hospital for the region of Alto Minho. Here I could see the importance of communication skills to promote patient's autonomy and to define the goal of care. On General Hospital, Dr. Edward Fitzggibon followed in their daily activities, Relatório de Estágio observacional em Cuidados Paliativos na Unidade de Bruyère 6 accompanying patients to greater complexity in terms of symptom control, requiring the use of drugs such as ketamine and anesthesia techniques for satisfactory pain control. I finished the stage with a brief passage by the support team in the community, the PPSMCS (Palliative Pain and Symptom Management Consultation Service), following Dr. Jill Rice and emphysema. Marysse Bouvette on your support to patients in the community, through consulting their family doctors. In several conversations I had with my advisor, Prof. José Luís Pereira and the Nurse. Marrysse Bouvette could realize the importance of working closely with family doctors, because only that way you can train them to follow autonomously, the vast majority of their patients, allowing teams of palliative care for patients with more complex . In all services that I've experience, i trie to realize the different dynamics and needs for a proper functioning of the teams, in order to achive a project to implement a team of Support in Palliative Care Unit of the Local Health Alto Minho, with a hospital support component and a support component in the community. This project is described in Annex 1.
During my academic training I haven´t any training in Palliative Care. But in the beginning of the training, as Internal Family medicine,I had the opportunity to choose between performing a stage of Oncology at the Hospital of Tras-os-Montes and Alto Douro or a stage of Palliative Care, to be carried out at the Portuguese Institute Oncology of Porto, so I chose the last because the of possibility to returning to the city of Porto. At the time I thought that in terms of objectives and work dynamics, the stages would be similar. Just when I started the internship I started to see the difference and what was "palliative care". The stage was short-lived. Three weeks "only" served to the awareness of the importance of palliative care and some basic principles for managing pain. Because "sometimes a chance never comes alone," these principles, very little has sedimented, were soon to be used in the following weeks. I was general internal medicine and family, working on a range of health, in the week that my supervisor was on vacation, my counselor training and a nurse came to me in consultation, one patient with a sarcoma in advanced stage was in severe pain. This patient wanted to stay home, but was in terrible suffering. With the use of the basic principles seized during stage I did a good control of the pain from this patient. However, after controlling pain came the will to do more. Although the patient was very grateful to the management of pain, felt that there was still much to do, from pain management to communication and psychosocial support. At this moment I felt the need to supplement my academic training. For financial reasons I didn´t sign up right at the master's hospice. First tried a post graduate degree in geriatrics, thinking that it would address many of the principles of palliative care. Unfortunately it didn´t, by ending the post graduate degree in geriatrics I decided to sign up for Masters in Palliative Care at Catholic University. At this time, and again, "sometimes a chance never comes alone," I had the opportunity to meet in a Congress of Family Medicine, who was to became my mentor Master, Professor José Luís Pereira. Hearing him talk about his experience in Canada led me right to initiate contacts for a possible realization of a internship of palliative care in their unit. When after the first year of the Masters, which included a strong theoretical component I was given the opportunity to conduct a thesis or an internship report, I didn´t think twice. The ability to apply the knowledge acquired through the completion of an internship was more attractive. So it was, I went to Ottawa, Canada. The integration was easy, for the great hospitality of all the people contacted. I began my internship at the Palliative Care Unit of Bruyère, where they were admitted patients with severe symptomatic uncontrolled. Here I had the opportunity to accompany Dr. Katie and Dr Marchington. Paula Enright. All very young but very competent and a huge concern in meeting my doubts. Then spent three weeks in the Hospital-Team Civic Hospital, with Dr. John Scott, a very similar hospital, the type of patients and pathologies, the Hospital Santa Luzia, the referral hospital for the region of Alto Minho. Here I could see the importance of communication skills to promote patient's autonomy and to define the goal of care. On General Hospital, Dr. Edward Fitzggibon followed in their daily activities, Relatório de Estágio observacional em Cuidados Paliativos na Unidade de Bruyère 6 accompanying patients to greater complexity in terms of symptom control, requiring the use of drugs such as ketamine and anesthesia techniques for satisfactory pain control. I finished the stage with a brief passage by the support team in the community, the PPSMCS (Palliative Pain and Symptom Management Consultation Service), following Dr. Jill Rice and emphysema. Marysse Bouvette on your support to patients in the community, through consulting their family doctors. In several conversations I had with my advisor, Prof. José Luís Pereira and the Nurse. Marrysse Bouvette could realize the importance of working closely with family doctors, because only that way you can train them to follow autonomously, the vast majority of their patients, allowing teams of palliative care for patients with more complex . In all services that I've experience, i trie to realize the different dynamics and needs for a proper functioning of the teams, in order to achive a project to implement a team of Support in Palliative Care Unit of the Local Health Alto Minho, with a hospital support component and a support component in the community. This project is described in Annex 1.