Need for palliative care in patients with chronic diseases in a hospital in a developing country

Abstract

Introduction:

The World Health Organization defines palliative care (PC) as an approach aimed at improving the quality of life of patients and families facing life-threatening illness. In developing countries, gaps persist in coverage, late referrals, and limited integration of PC into hospital care, especially for non-oncologic conditions.

Objective:

To evaluate the relationship between chronic diseases and the need for PC among hospitalized patients in a hospital in southern Peru.

Methods:

Analytical cross-sectional study in a public referral hospital. We included adults ⩾18 years admitted to Internal Medicine, General Surgery, Obstetrics and Gynecology, or the Emergency Department; we excluded pregnant/postpartum patients, those managed exclusively in the ICU/Trauma Shock Unit, urgent surgical cases precluding assessment, and patients with cognitive impairment (Pfeiffer ⩾2). The need for PC was assessed using the SPICT-TM-ES (⩾2 general indicators + ⩾1 clinical indicator). Sociodemographic and clinical variables were collected via interview and chart review. Associations were estimated using Poisson regression with robust variance, reporting adjusted prevalence ratios (aPR) and 95% confidence intervals (95% CI).

Results:

We included 150 patients; 67.3% met criteria for PC need. Multimorbidity (⩾2 comorbidities) and ⩾2 hospitalizations in the past year were associated with a higher need for PC. In adjusted models, dementia (aPR = 1.15; 95% CI: 1.05–1.26) and malignancy (aPR = 1.14; 95% CI: 1.05–1.24) were positively associated with PC need, whereas type 2 diabetes mellitus was inversely associated (aPR = 0.85; 95% CI: 0.77–0.93).

Conclusion:

The need for PC among hospitalized patients with chronic conditions was high.

Keywords

chronic diseases palliative care pain Peru neoplasia

Introduction

The World Health Organization defines palliative care (PC) as an approach aimed at “improving the quality of life of patients and their families when they face problems of a physical, psychological, social, or spiritual nature inherent to a life-threatening illness.”¹ In line with this definition, the “need for PC” refers to situations of avoidable suffering and clinical complexity that justify comprehensive assessment and advance care planning, regardless of whether the diagnosis is oncological or non-oncological. In hospital settings, consensus guidelines recommend explicit screening and referral criteria to activate timely PC consultations,² within integrated models that accompany the entire course of chronic illness.³

Available evidence shows a high prevalence of PC needs among people with advanced chronic conditions. At the European population level, the prevalence of individuals with advanced chronic illnesses requiring PC is high and heterogeneous, depending on disease trajectories.⁴ In Asia, a sustained increase in the use of PC was observed during hospitalizations for COPD between 2007 and 2018, although gaps persist in other pathologies.⁵ In US hospitals, the use of PC among patients with common chronic diseases remains variable and below the estimated need.⁶ In Peru, two studies conducted in 2017 and 2018 reported that the hospital-level need for PC ranged between 4 and 7 out of every 10 hospitalized patients with chronic illnesses.^7,8

Nevertheless, in the Peruvian context, the evidence remains limited and originates from the period prior to the COVID-19 pandemic. The post-pandemic stage may have altered the epidemiology of chronicity in several diseases, increasing multimorbidity, frailty, and post-infectious sequelae. Moreover, the international literature highlights the underintegration of PC in admissions due to chronic illness and underscores the need for standardized operational criteria to activate timely consultations.^2,9 In this scenario, it is essential to characterize in a single analysis how demographic, socioeconomic, clinical, and healthcare factors are associated with the need for PC.

Therefore, the objective of this study was to assess the relationship between the presence of chronic diseases and the need for PC in a hospital in southern Peru

Materials and methods

Design and setting

We conducted an analytical, cross-sectional study between February 1 and March 31, 2024, at Hipólito Unanue Hospital of Tacna (HUHT), a public tertiary referral hospital in Tacna, southern Peru. Data were obtained through review of paper medical records and structured, face-to-face bedside interviews in the Internal Medicine, General Surgery, Obstetrics and Gynecology, and Emergency departments. Reporting follows the STROBE recommendations for observational studies (checklist in Supplemental Material 1).

Participants and eligibility criteria

The target population consisted of adult inpatients at HUHT during the study period. Inclusion criteria were: age ⩾18 years; admission to Internal Medicine, General Surgery, Obstetrics and Gynecology, or Emergency; anticipated length of stay ⩾24 h; and sufficient clinical stability to complete the interview. Exclusion criteria were: pregnant or postpartum women (<6 weeks); patients managed exclusively in the Intensive Care Unit or the Trauma Shock Unit; those with an urgent surgical condition that precluded evaluation; and patients with cognitive impairment, defined as a score ⩾2 on the Pfeiffer Short Portable Mental Status Questionnaire (Pfeiffer SPMSQ).

Sources and methods of selection

A convenience sampling strategy was used due to the narrow recruitment window (February–March 2024), daily variability in bed occupancy, and the need to interview only patients with clinical stability confirmed by the treating team. The statistical power was 83.9%, based on the difference in PC need between patients with and without diabetes (52.0% and 76.0%), calculated in Stata Statistical Software: Release 17 (StataCorp LLC, College Station, TX, USA).

Procedures

Following study approval, two investigators (A.V.Q. and B.M.C.) conducted consecutive recruitment across four services. A.V.Q. reviewed medical records and administered patient interviews in Internal Medicine and Surgery from 8:00 to 12:00, while BMC performed the same tasks in Gynecology–Obstetrics and Emergency from 13:00 to 17:00. Activities ran Monday through Sunday during February and March 2024. Each interview lasted ~15 min and was conducted after written informed consent.

Data collection combined two complementary sources aligned with the study objectives: (i) a brief structured interview to obtain sociodemographic variables and to apply the SPICT-TM-ES; and (ii) medical record review to extract prespecified clinical and care-delivery variables (comorbidities, prior hospitalizations, cause of the last admission, service of provenance, most frequent symptom, and analgesics used).

Instrument and variables

We used a standardized case report form with three sections: (A) sociodemographic characteristics, (B) clinical/care characteristics, and (C) the SPICT-TM-ES questionnaire (Supplemental Material 2).

Primary outcome

The primary outcome was the need for PC, operationalized using the Supportive and Palliative Care Indicators Tool (SPICT). This instrument was originally validated in 2010 in Scotland among 130 adults with advanced chronic diseases following unplanned hospital admission.¹⁰ Its Spanish adaptation (SPICT-TM) was subsequently validated in 2017 in 188 patients from multiple healthcare centers in Spain, demonstrating adequate internal consistency (Cronbach’s alpha = 0.71).¹¹

The SPICT consists of 27 dichotomous (yes/no) items organized into 7 general indicators of deteriorating health (e.g., unplanned hospital admission, functional limitation, dependence on others for care, caregiver requiring more support, significant weight loss, persistent symptoms despite treatment, and patient request for PC) and 20 clinical indicators of advanced disease. Following published recommendations, we defined “need for PC” as the presence of ⩾2 general indicators combined with ⩾1 clinical indicator, and applied this operational rule uniformly to all participants.^12,13

Explanatory variables and data source

Interview (survey): Age (including terciles), sex, number of brothers, number of children, monthly economic income (USD: <263, 263–532, >532), educational level (no studies/illiteracy, school, technical, university), and religious belief (Catholic, Evangelical, Christian, Adventist, Atheist).

Medical records: Number of comorbidities (1; ⩾2) and specific comorbidities (type 2 diabetes mellitus, dementia, cerebrovascular disease, hepatopathy, neoplasia, COPD, nephropathy, heart disease); number of hospitalizations in the last year (1; ⩾2); cause of last hospitalization (sepsis, previous decompensation, start of treatment, superimposed disease); provenance service (Medicine, Surgery, Gynecology, Emergency); most frequent symptom (pain, neurological, dyspnea, others); and analgesics used for pain (morphine, pethidine, tramadol, others).

Ethical considerations

This study aligned with the international standards established by the Declaration of Helsinki. The protocol was approved by the research ethics committee of the Private University of Tacna (identification code: FACSA-CEI/173-12-2023). Participation in this study was entirely voluntary and required the prior acceptance of informed consent, validated with the patient’s physical signature.

Data analysis

The analysis was performed using Stata V17. Variables were described using frequencies, percentages, measures of central tendency, and dispersion. To address the research question, Poisson regression models with robust variance were employed. First, clinical and sociodemographic variables were tested for associations in crude models. Subsequently, factors potentially associated with the need for PC in the crude regression (p < 0.05) were included in the adjusted model. Adjusted prevalence ratio (aPR) and its respective 95% confidence intervals (CI) were then calculated.

Results

Of the 182 hospitalized patients at HUHT during February and March 2024, 10 patients were not assessed for eligibility due to acute surgical conditions. Therefore, 172 patients were approached, of which 6 patients refused to sign the informed consent, and 16 were in the Intensive Care Unit or Trauma Shock Service. Finally, 150 individuals were included in our study (Figure 1).

Figure 1.

Flowchart of patients approached for the study.

The median age of the patients was 66 years (IQR: 54–75 years). Regarding gender, an equal distribution was observed. Fifty-two percent of the patients had a single comorbidity, while 48% had two or more comorbidities. The most common comorbidities were type 2 diabetes mellitus (38%), followed by neoplasia (25.3%), nephropathy (20%), hepatopathy (12%), heart disease (12.7%), cerebrovascular disease (10.7%), chronic obstructive pulmonary disease (9.3%), and dementia (5.4%; Table 1).

Table 1.

Sociodemographic and clinical characteristics of patients.

Variables	n (%)
Age*	66 (54–75)
Age in terciles
20–58	52 (34.67)
59–71	48 (32.00)
72–93	50 (33.33)
Sex
Female	75 (50.0)
Male	75 (50.0)
Number of brothers*	2 (2–4)
Number of children*	2 (1–3)
Monthly economic income (USD)
<263	3 (2)
263–532	112 (74.67)
>532	35 (23.33)
Degree of instruction
No studies/Illiteracy	16 (10.67)
School studies	118 (78.67)
Technical studies	10 (6.67)
University studies	6 (4.00)
Religious belief
Catholic	109 (72.67)
Evangelical	16 (10.67)
Christian	12 (8.00)
Adventist	9 (6.00)
Atheist	4 (2.67)
Number of comorbidities
1 comorbidity	78 (52.00)
2 or more comorbidities	72 (48.00)
Comorbidities**
Diabetes mellitus 2	57 (38.00)
Dementia	8 (5.37)
CVD	16 (10.67)
Hepatopathy	18 (12.00)
Neoplasia	38 (25.33)
COPD	14 (9.33)
Nephropathy	30 (20.0)
Heart disease	19 (12.67)
Number of hospitalizations in the last year
A hospitalization	110 (73.33)
Two or more hospitalizations	40 (26.67)
Cause of last hospitalization
Sepsis	37 (24.67)
Previous decompensation	78 (52.00)
Start of treatment	7 (4.67)
Superimposed disease	28 (18.67)
Provenance service
Medicine	93 (62.00)
Surgery	10 (6.67)
Gynecology	7 (4.67)
Emergency	40 (26.67)
Most frequent symptom
Pain	63 (42.00)
Neurological	15 (10.00)
Dyspnea	37 (24.67)
Others***	35 (23.33)
Most commonly used pain medications
Morphine	2 (3.17)
Pethidine	1 (1.58)
Tramadol	43 (68.25)
Others	17 (27.00)
Need for palliative care according to SPICT
Yes	101 (67.33)
No	49 (32.67)

CVD: cerebral vascular disease; COPD: chronic obstructive pulmonary disease; SPICT: Supportive and Palliative Care Indicators Tool; USD: United States dollar.

Median (interquartile range).

Some patients had more than one comorbidity.

***

Others include symptoms such as nausea, vomiting, dysphagia, bleeding.

73.3% of the patients included in our study had experienced a single hospitalization in the last year, while 26.7% had been hospitalized two or more times during the same period. The most common cause of the last hospitalization was previous decompensation, accounting for 52% of cases, followed by sepsis (24.7%), comorbid disease exacerbation (18.7%), and initiation of treatment (4.7%). Regarding the originating service, most patients came from the Medicine service (62%), followed by Emergency (26.7%), Surgery (6.7%), and Gynecology (4.7%). The most frequent symptom reported by patients was pain (42%), followed by neurological symptoms (10%) and dyspnea (24.7%; Table 1).

67.3% of the evaluated patients required PC (Table 1). The distribution by age tertiles showed a significant association with the need for PC (p < 0.05) in patients aged 72 years or older. A significant association was reported between the originating service and the need for PC (p = 0.015), with patients from the Medicine service needing PC the most (73.1%). Additionally, it was observed that 88.9% of patients with >2 comorbidities required PC, compared to 47.4% of those with a single comorbidity. Similarly, 92.5% of patients with >2 hospitalizations in the last year required PC, compared to 58.2% of those with a single hospitalization. These differences were statistically significant (p < 0.05; Table 2).

Table 2.

Factors associated with the need for palliative care in hospitalized patients.

Variable	Need palliative care (n = 189), n (%)	Doesn’t require palliative care (n = 25), n (%)	p Value
Agedª	71 (58–79)	58 (45–66)	0.000
Age in terciles			0.000
20–58	26 (50.0)	26 (50.00)
59–71	30 (62.50)	18 (37.50)
72–93	45 (90.00)	5 (10.00)
Sex			0.601
Female	52 (69.33)	23 (30.67)
Male	49 (65.33)	26 (34.67)
Monthly economic income (USD)			0.735
<263	3 (100.00)	0 (0.00)
263–532	75 (66.96)	37 (33.04)
>532	23 (65.71)	12 (34.29)
Degree of instruction*			0.102
No studies/Illiteracy	14 (87.50)	2 (12.50)
School studies	78 (66.10)	40 (33.90)
Technical studies	7 (70.00)	3 (30.00)
University studies	4 (66.67)	2 (33.33)
Number of comorbidities			0.000
1 comorbidity	37 (47.44)	41 (52.56)
2 or more comorbidities	64 (88.89)	8 (11.11)
Number of hospitalizations in the last year			0.000
A hospitalization	64 (58.18)	46 (41.82)
Two or more hospitalizations	37 (92.50)	3 (7.50)
Cause of last hospitalization			0.762
Sepsis	26 (70.27)	11 (29.73)
Previous decompensation	54 (69.23)	24 (30.77)
Start of treatment	4 (57.14)	3 (42.86)
Superimposed disease	17 (60.71)	11 (39.29)
Provenance service*			0.015
Medicine	68 (73.12)	25 (26.88)
Surgery	6 (60.00)	4 (40.00)
Gynecology	1 (14.29)	6 (85.71)
Emergency	26 (65.00)	14 (35.00)
Most frequent symptom*			0.649
Pain	40 (63.49)	23 (36.51)
Neurological	10 (66.67)	5 (33.33)
Dyspnea	28 (75.68)	9 (24.32)
Others^	23 (65.71)	12 (34.29)

ªThe Mann Whitney U test was used to calculate the p value.

To calculate the p value, Fisher’s Exact test was used, unlike the rest, where Chi square was used (p < 0.05).

The prevalence of the need for PC was higher in patients with dementia (aPR: 1.15; 95% CI: 1.05–1.25) and neoplasia (aPR: 1.14; 95% CI: 1.05–1.24) compared to patients without these conditions. Conversely, patients with diabetes mellitus had a lower need for PC (aPR: 0.85; 95% CI: 0.77–0.92; Table 3).

Table 3.

Estimated association of chronic diseases with the need for palliative care.

Variables	Crude PR (95% CI)*	Adjusted PR (95% CI)**
Diabetes mellitus 2	0.866 (0.784–0.955)	0.845 (0.773–0.925)
Dementia	1.205 (1.149–1.263)	1.147 (1.048–1.255)
CVD	1.094 (0.974–1.229)	1.102 (0.986–1.233)
Hepatopathy	1.110 (0.998–1.235)	1.080 (0.981–1.189)
Neoplasia	1.140 (1.048–1.240)	1.140 (1.048–1.240)
COPD	1.123 (1.005–1.253)	1.023 (0.925–1.132)
Nephropathy	1.071 (0.968–1.184)	1.077 (0.987–1.175)
Heart disease	0.936 (0.807–1.086)	0.903 (0.797–1.025)

CVD: cerebral vascular disease; COPD: chronic obstructive pulmonary disease.

Simple Poisson regression with robust variance.

Multiple Poisson regression with robust variance, a model was generated adjusting each chronic disease with the variable sex and age.

Discussion

Summary of findings

A study of 150 patients hospitalized in various services at Hipólito Unanue Hospital in Tacna found that 67.33% had a need for PC. Key findings indicated that a diagnosis of dementia or a neoplasm was associated with a greater need for PC, while patients with type 2 diabetes mellitus were associated with a lower need for this service.

Limitations

This study has limitations that should be considered when interpreting the findings.¹ Its analytical cross-sectional design precludes causal inference and, in the absence of follow-up, did not allow assessment of clinically relevant outcomes (mortality, readmissions, length of hospital stay).² Convenience sampling, the narrow time window (February–March 2024), and daytime recruitment (8:00–12:00; 13:00–17:00), together with the requirement of “clinical stability,” may have introduced selection and seasonality biases, underrepresenting more severely ill patients or those admitted overnight; the exclusion of the ICU and the Trauma Shock Unit further restricts generalizability.³ The single-center nature of a public referral hospital in southern Peru limits external validity and the extrapolation to other levels of care and to the private sector.⁴

Prevalence of the need for PC

Our study revealed that 67.3% of hospitalized patients require PC. Similar results have been reported in low- and middle-income countries that applied the SPICT™ tool. In Peru, a cross-sectional study conducted in 2021 in a general hospital showed that 71.5% of patients with chronic diseases met criteria for PC need.⁷ In Brazil, a situational assessment carried out in 2019 in a university hospital found that 54.7% of hospitalized patients with chronic diseases required PC,¹⁴ and in 2024, a study in a tertiary hospital in the country’s northeast again found a high prevalence (63%) of PC need.¹⁵ These findings show that, in resource-limited settings, SPICT™ enables the systematic identification of a high demand for PC, likely associated with a greater burden of multimorbidity and low integration of specialized services.

In contrast, studies conducted in high-income countries report considerably lower prevalences when applying SPICT™. In Japan, a multicenter study conducted in 2017 documented that 17.3% of hospitalized patients met criteria for PC need, while in Australia in 2019, the figure was 16%.^16,17 Likewise, a British study in hepatology wards showed that 32% of admitted patients met criteria to receive PC.¹⁸ In addition, primary care research in Germany and the Netherlands found that between 20% and 30% of patients assessed with SPICT had previously unrecognized palliative needs.^19,20 These lower figures in high-income countries may be related to greater service availability, earlier diagnosis, and more structured care pathways.

Taken together, the higher prevalence of PC need in low- and middle-income countries reflects a combination of complex case-mix and the hospital setting (greater multimorbidity, frailty, and unplanned admissions).^7,20–22 Meanwhile, in high-income countries, earlier detection and referral and stronger community/home-based services “decompress” hospitals and reduce the prevalence estimated with the same instrument.^21,23 Finally, later referral and lower integration of PC in resource-limited systems, along with the historical gap in non-oncological conditions, increase the “unmet need” detectable in hospitals.^6,24,25

The connection between chronic illness and PC

A second important finding of our study is the association between the need for PC and the presence of comorbidities such as dementia, neoplasia, and type 2 diabetes mellitus. This finding aligns with similar results obtained in previous research that also highlighted the association of PC need with diseases such as cirrhosis, chronic kidney disease, and cerebrovascular disease.^3,14,26 While PC is usually intended for patients in the terminal stage of diseases such as cancer, both our study and the aforementioned ones suggest that other chronic diseases that do not necessarily lead to death in a short period of time also require PC. Therefore, we propose to expand the focus of PC beyond traditional terminal illnesses, recognizing its importance as an integral component of healthcare for patients with chronic diseases. This will ensure effective symptom relief and improved quality of life, regardless of short-term prognosis. It is curious that both our study and that of Pinedo-Torres et al. found a negative association between PC need and diabetes mellitus.⁷ This could be attributed to non-communicable disease control programs, which manage to halt disease progression toward complicated stages.

It is worth noting that our study is part of a marked trend toward a greater need for PC in developing countries. This situation may be related to insufficient coverage of these care services due to the absence of clear guidelines, access difficulties, limited physician knowledge, scarcity of specific medications, and limited government funding.²⁷ The significant impact of pain and other symptoms on quality of life is undeniable and transcends the patient, also impacting families and generating a considerable economic burden on the healthcare system.^28,29 These adversities not only deteriorate the physical and emotional well-being of the patient, predisposing to psychiatric conditions such as depression, delirium, anxiety, and feelings of worthlessness, but also can increase dependence on psychotropic medication.^30,31 This scenario is exacerbated in the elderly population, who have a higher prevalence of PC needs due to the accumulation of comorbidities and the progression of chronic diseases. In fact, we have identified that the presence of multiple comorbidities and previous hospitalizations is directly related to an increase in the need for these care services, suggesting a more complex and advanced underlying pathology. Given the global demographic aging and the increasing prevalence of chronic diseases, it is foreseeable that the demand for PC will intensify.³² Therefore, the implementation of PC units that adopt a comprehensive and multidisciplinary approach from early stages of the disease becomes essential. These units should focus not only on pain relief and other physical symptoms but also on meeting the psychosocial and spiritual needs of the patient, providing comprehensive support that allows for living with dignity and fullness, even during the most challenging moments.

Conclusion

In conclusion, there is a high need for PC in patients with chronic diseases. Among these, dementia and neoplasms were associated with a higher demand for PC, while diabetes mellitus showed an inverse relationship with the need for these services. PC-focused units are needed not only for patients with terminal illnesses but also for patients with chronic diseases to improve their quality of life.

Supplemental Material

sj-docx-1-pcr-10.1177_26323524251404072 – Supplemental material for Need for palliative care in patients with chronic diseases in a hospital in a developing country

Supplemental material, sj-docx-1-pcr-10.1177_26323524251404072 for Need for palliative care in patients with chronic diseases in a hospital in a developing country by Anthony Villanueva-Quispe, Marco Rivarola-Hidalgo, Andre Fuentes-Yufra, Marina Ale-Sánchez, Cesar Copaja-Corzo, Javier A. Flores-Cohaila and Brayan Miranda-Chavez in Palliative Care and Social Practice

Supplemental Material

sj-docx-2-pcr-10.1177_26323524251404072 – Supplemental material for Need for palliative care in patients with chronic diseases in a hospital in a developing country

Supplemental material, sj-docx-2-pcr-10.1177_26323524251404072 for Need for palliative care in patients with chronic diseases in a hospital in a developing country by Anthony Villanueva-Quispe, Marco Rivarola-Hidalgo, Andre Fuentes-Yufra, Marina Ale-Sánchez, Cesar Copaja-Corzo, Javier A. Flores-Cohaila and Brayan Miranda-Chavez in Palliative Care and Social Practice

Footnotes

ORCID iDs

Marco Rivarola-Hidalgo

Cesar Copaja-Corzo

Brayan Miranda-Chavez

Ethical considerations

The protocol was approved by the research ethics committee of the Private University of Tacna (identification code: FACSA-CEI/173-12-2023).

Consent to participate

Participation in this study was entirely voluntary and required the prior acceptance of informed consent, validated with the patient’s physical signature.

Author contributions

Anthony Villanueva-Quispe: Conceptualization; Data curation; Methodology; Writing – original draft; Writing – review & editing.

Marco Rivarola-Hidalgo: Conceptualization; Formal analysis; Investigation; Methodology; Writing – original draft; Writing – review & editing.

Andre Fuentes-Yufra: Conceptualization; Data curation; Visualization; Writing – original draft; Writing – review & editing.

Marina Ale-Sánchez: Conceptualization; Data curation; Investigation; Writing – original draft; Writing – review & editing.

Cesar Copaja-Corzo: Data curation; Methodology; Validation; Writing – original draft; Writing – review & editing.

Javier A. Flores-Cohaila: Conceptualization; Formal analysis; Investigation; Methodology.

Brayan Miranda-Chavez: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Writing – original draft; Writing – review & editing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

Available upon reasonable request.

Supplemental material

Supplemental material for this article is available online.

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