Implementation and Knowledge of the Clinical Practice Guide for Palliative Care in the Ecuadorian Primary Care Level

International Journal of Environmental Research and Public Health Article Implementation and Knowledge of the Clinical Practice Guide for Palliative Care in the Ecuadorian Primary Care Level Tamara Rodríguez Quintana 1, Viviana Dávalos-Batallas 1, Ana-Magdalena Vargas-Martínez 2,* , Lucelly López 3, Patricia Bonilla-Sierra 1, María-de-las-Mercedes Lomas-Campos 2and Fatima Leon-Larios 2   Citation: Rodríguez Quintana, T.; Dávalos-Batallas, V.; Vargas-Martínez, A.-M.; López, L.; Bonilla-Sierra, P.; Lomas-Campos, M.M.; Leon-Larios, F. Implementation and Knowledge of the Clinical Practice Guide for Palliative Care in the Ecuadorian Primary Care Level. Int. J. Environ. Res. Public Health 2021,18, 11573. https://doi.org/10.3390/ ijerph182111573 Academic Editors: María JoséCabañero-Martínez, Manuel Fernández Alcántara and Rafael Montoya Juárez Received: 23 September 2021 Accepted: 31 October 2021 Published: 4 November 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). 1Department of Health Sciences, Universidad Técnica Particular de Loja (UTPL), Loja 110107, Ecuador; [email protected] (T.R.Q.); [email protected] (V.D.-B.); [email protected] (P.B.-S.) 2Nursing Department, School of Nursing, Physiotherapy and Podiatry, University of Seville, 41009 Seville, Spain; [email protected] (M.M.L.-C.); [email protected] (F.L.-L.) 3Research Department, School of Medicine, Universidad Pontificia Bolivariana, Calle 78B # 72A-109, Medellín 050001, Colombia; lucelly[email protected] *Correspondence: avar[email protected] Abstract: Ecuador assumed the commitment of including Palliative Care (PC) in its health policies. In 2014, the Ministry of Public Health (Ministerio de Salud Pública, MSP) approved the Clinical Practice Guide for Palliative Care (Guía de Práctica Clínica sobre Cuidados Paliativos, GPCCP), with application at the national level, as a mandatory internal regulation in all institutions belonging to the National Health System. In 2021, there is no evidence about the degree of implementation. The objective was to evaluate the implementation (I) of the GPCCP guide and the knowledge (C) of the health personnel working in the Zone 7 Health Centers (HCs). This is a cross-sectional, descriptive, and prospective study. A total of 292 professionals were interviewed: managers (38), physicians (150), and nurses (104). Three surveys based on the GPCCP guide were elaborated: one for the implementation, which was applied to the individuals in charge, and the others to assess the health professionals’ knowledge. The SPSS program was used, version 25. In the three groups, more than half of the participants had no training in PC, 91.2% of the HCs have the GPCCP guide, there is PC medical history (MH) in 38.2%, and morphine is used in 14.7%. The implementation of the GPCCP guide was inadequate in 52.9% of the cases. Only 25% treat the agony symptoms and 30%, delirium; 4.4% acknowledge the use of morphine in dyspnea, and 13.3% identify the subcutaneous route as the first choice for hydration at the end-of-life phase. Strategies to implement the GPCCP guide and to improve the health personnel’s knowledge must be implemented in Zone 7 centers. Keywords: clinical practice guide; palliative care; knowledge 1. Introduction The view of palliative care (PC) in the world has changed over the years. It is acknowledged that it relieves suffering, controls symptoms, and improves quality of life and care quality [ 1 ]. Comprehensive care for patients with diseases that restrict life during their evolution offers an effective outcome–cost ratio for the patient, the family, and the health systems [2]. The Political Statement of the High-Level Meeting of the United Nations’ General Assembly on prevention and control of non-communicable diseases (2014) acknowledges the need to improve access to palliative care. The recommendation is to develop and implement palliative care policies to strengthen health systems [ 3 ]. Cost-effective and equitable palliative care services must be integrated in all levels, with an emphasis on primary, community, and home care [4]. The World Health Organization (WHO) proposes four key elements as a strategy to improve PC, namely: policy, education, availability of medication, and implementation of services [ 5 ]. The policy is considered indispensable to satisfy the other three elements; Int. J. Environ. Res. Public Health 2021,18, 11573. https://doi.org/10.3390/ijerph182111573 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2021,18, 11573 2 of 14 however, the existence of national PC laws or plans does not ensure that there will be more PC services, at least in Latin America (LA). In Latin America, with a population of more than 600 million inhabitants, 75% of the population dies due to non-communicable diseases. In 2018, more than 3.5 million people living with some severe health problems were reported, reason why it is indispensable to continue developing this care. Despite this increase, the care provided is still insufficient and unequal [ 6 , 7 ]. Currently, coverage of PC needs in Latin America is only 7.6% and only 3.5% in Ecuador [8]. Important changes have been implemented in the public and health policies, favoring the integration of PC in the National Health System and assisting in the creation of public policies aimed at developing and implementing PC in Ecuador. In 2014, and as part of these strategies, the Ministry of Public Health approved the Clinical Practice Guide for Palliative Care and established its application in the entire National Health System as a mandatory internal regulation [9]. In relation to the training of future health professionals, although inclusion of the PC component in the Health Sciences courses is mandatory, previous studies have found that it is still necessary to advance in training, as a number of knowledge gaps have been identified [10,11]. The purpose of this article is to assess the implementation degree of the MSP Palliative Care Guide in Zone 7 Health Centers, as well as the level of knowledge about palliative care of the health personnel working in these centers, six years after approval of the Palliative Care National Plan in Ecuador 2. Materials and Methods This was a cross-sectional, descriptive, and cross-sectional study. It was developed during the 2019–2020 period in Health Zone 7, which encompasses three provinces: Loja, El Oro, and Zamora Chinchipe. 2.1. Population and Sample There are 1554 health centers that depend on the Public Health Ministry (Ministerio de Salud Pública, MSP) in Ecuador. Health Zone 7, comprised by the provinces of Loja, El Oro, and Zamora Chinchipe, has 153 health centers, 66 of them in urban areas. The total population of this zone is 1,341,334 inhabitants who receive care, some in MSP health units and others in units from the public health network such as the different health centers belonging to the various social insurance systems in the country. To assess the implementation of the GPCCP guide, the administrative managers of 38 health centers in urban areas where the Family and Community Medicine specialization students were doing their internships were interviewed. To assess the health personnel’s level of knowledge about palliative care, all the administrative personnel, physicians, and nurses who met the inclusion criteria were interviewed. The following were established as inclusion criteria: for the health professionals in managerial positions, holding such positions for at least three months; and, for the physicians and nurses, working in the health center for at least three months; there were no exclusion criteria. Non-probabilistic convenience sampling was performed. 2.2. Ethical Considerations All the participants were informed about the study objectives and were asked to sign a written informed consent of their participation in the study. They were guaranteed anonymity of the information provided and data confidentiality. Approval was obtained from the Committee of Ethics in Research with Human Beings of UTPL under Edict No. UTPL-CEISH-2020-RI05; in addition, authorization from the Zone 7 Health Coordination Office and the participants’ written and signed informed consent were also obtained. Int. J. Environ. Res. Public Health 2021,18, 11573 3 of 14 2.3. Procedures and Data Collection To assess the implementation of the Palliative Care Guide, an ad hoc survey was applied, based on the guidelines set forth in the MSP guide, consisting of 27 questions: 11 collecting general information and the rest being specific about implementation of the guide. This instrument was applied to the health center administrative manager, and was self-administered with the interviewer present. From the specific questions, inadequate implementation was only considered when one of the answers was negative. Whereas, to assess the knowledge about PC among the health personnel, separate surveys for the physicians and for the nursing personnel were elaborated. Both included 34 items, 9 for collecting general data of the interviewee and the rest to assess knowledge about palliative care. The two surveys were based on the guidelines set forth in Ecuador’s GPCCP guide, designed by the research authors and applied in the health centers. 2.4. Instrument Information was collected about sociodemographic and labor variables, as well about experience and training in palliative care. Specifically, the variable related to the training hours, which was asked categorically, was transformed into a numerical variable for certain analyses that are detailed later in this article (“0 h” = 0; “less than 20 h” = 10; “between 20 and 50 h” = 35; “between 50 and 100 h” = 75; and “more than 100 h” = 100). Questions were asked about the existence of the GPCCP guide, the annual training plan including the theme, number of training sessions, written performance protocol for coordination with the reference hospital, palliative care medical history, essential PC medications, population that required palliative care, trained interdisciplinary team, time available for the PC team to evaluate the first appointment of a patient with palliative needs in external consultation, coordination between the different assistance services to ensure care continuity, opioid availability, and other techniques that can help relieve the symptoms. A number of variables were studied, such as: instruments used in PC, medication use, criteria to include patients in the program, number of symptoms that are assessed with the Edmonton scale, use of a prognostic scale to predict survival in a patient on PC, use of another scale to assess pain, criteria to include a patient with an advance-stage disease and a life expectancy of less than one year in the PC program, ICD-10 code used for palliative care, criteria to refer a patient, use of morphine at the end-of-life phase, first choice route for home hydration, aspects included in the psychosocial evaluation of the patient and the family, information provided by the family physician about the terminal phase and the need to transfer the patient to palliative care, about the changes in evolution of the disease, about palliative sedation and identification of pathological grief, among others. 2.5. Statistical Analyses In data description, absolute and percentage frequencies were used for the qualitative variables; and means and standard deviations were employed for the quantitative variables. In addition, a comparison of means and frequencies by professional group (managers, physicians, and nurses) was carried out, showing statistical significance after analyses by means of the t-test and ANOVA or Pearson’ chi-square tests, depending on the type of variable. Likewise, an analysis by means of Pearson’s chi-square was performed to compare the physicians’ and nurses’ knowledge about Palliative Care regarding certain aspects of the Clinical Practice Guide. The relationship between this knowledge and the years of general professional experience in palliative care and training in this area for each professional group (physicians and nurses) was studied using t-test, except for the variable related to first choice hydration route for patients at the end-of-life phase in their homes for which the ANOVA analysis was used. Data processing was performed in R statistical software (version R-4.0.5, Free Software Foundation’s GNU General Public License: https://www.r-project.org/about.html, access date: 18 May 2021). A 5% statistical significance level was adopted in all the analyses. Int. J. Environ. Res. Public Health 2021,18, 11573 4 of 14 3. Results Descriptive characteristics of the sample are shown in Table 1. The total of subjects studied was 292, divided as follows: 38 health center administrative managers, 150 physicians, and 104 nurses. Table 1. Characteristics of the sample (n = 292). Variables Total Managers (n = 38) Nurses (n = 104) Physicians (n = 150) Sociodemographic Gender [female] 199 (69.1) 19 (55.9) 83 (79.8) 97 (64.7) *** Age x(SD) 37.49 (10.80) 35.32 (9.52) 37.38 (10.50) 38.05 (11.27) Canton Loja 20 (52.63) 20 (52.6) N.A. N.A. Machala 3 (7.89) 3 (7.89) N.A. N.A. Pasaje 1 (2.63) 1 (2.63) N.A. N.A. Yacuambi 2 (5.26) 2 (5.26) N.A. N.A. Yantzaza 2 (5.26) 2 (5.26) N.A. N.A. Zamora 5 (13.16) 5 (13.16) N.A. N.A. Zaruma 5 (13.16) 5 (13.16) N.A. N.A. Cycle I 13 (6.19) 13 (39.4) 0 (0.0) 0 (0.0) *** IV 11 (5.24) 2 (6.1) 3 (4.3) 6 (5.6) V 9 (4.29) 1 (3.0) 4 (5.8) 4 (3.7) VI 120 (57.14) 8 (24.2) 43 (62.3) 69 (63.9) IX 57 (27.14) 9 (27.3) 19 (27.5) 29 (26.9) Parrish Catamayo 35 (13.89) 1 (2.6) 9 (11.0) 25 (18.9) *** Machala 56 (22.22) 1 (2.6) 25 (30.5) 30 (22.7) Pasaje 18 (7.14) 1 (2.6) 7 (8.5) 10 (7.6) Zamora 53 (21.04) 3 (7.9) 19 (23.2) 31 (23.5) Others 130 (35.71) 32 (84.2) 22 (26.8) 36 (27.3) Professional training and experience Professional experience (years)x(SD) 11.08 (9.54) 9.73 (8.61) 10.19 (8.53) 12.02 (10.33) Time as administrative manager (years)x(SD) 3.34 (7.24) 3.34 (7.24) NA NA Experience in PC [Yes] 116 (40.28) 13 (38.2) 47 (45.2) 56 (37.3) Experience in PC (years) 1.89 (3.74) 1.90 (4.39) 2.54 (4.91) 1.46 (2.43) Training in PC (hours) 0 h 17 (8.72) 2 (7.7) 0 (0.0) 15 (16.0) *** Less than 20 h 102 (52.31) 14 (53.8) 50 (66.7) 38 (40.4) Between 20 and 50 h 53 (27.18) 7 (26.9) 17 (22.7) 29 (30.9) Between 50 and 100 h 13 (6.67) 1 (3.8) 4 (5.3) 8 (8.5) More than 100 h 10 (5.13) 2 (7.7) 4 (5.3) 4 (4.3) Graduate Courses in PC [Yes] 15 (7.11) 2 (7.1) 3 (4.0) 10 (9.3) Higher Education in PC [Yes] 149 (65.07) 10 (34.5) 32 (38.6) 38 (32.5) Continuing Education in PC [Yes] 31 (14.09) 3 (10.3) 11 (13.6) 17 (15.5) Higher Education in PC + Continuing Education in PC [Yes] 15 (7.32) 4 (15.4) 8 (10.7) 3 (2.9) ** Note: x (SD), the mean values and standard deviation are shown in between round brackets when the variable is numerical. The frequency and percentage are shown in between round brackets when the variable is categorical. *** and ** represent 1% and 5% statistically significant differences between the variables by professional category (administrative clerk, nurse and physician). N.A. (Not applicable). In relation to the sociodemographic characteristics, women prevailed in the three groups, which represented more than half of the participants, reaching approximately 80% in the group of nurses. The overall mean age of the sample was around 37 years old. Among the administrative managers of the centers participating in the study, generalist physicians were a majority with 76.5%, and only 14.7% were specialists in Family and Community Medicine. Among the physicians, 38% were generalists, 28% were specialists in Family and Community Medicine, and 14.67% were surgeons. Int. J. Environ. Res. Public Health 2021,18, 11573 5 of 14 The general professional experience presented a mean of 11 years, exceeding a mean of 12 years in the group of physicians. Less than 50% of the subjects interviewed acknowledged having experience in palliative care, and the nurses were those who most reported having had experience and whose mean time of experience in this care field was longer. Regarding the type of training received, medical professionals were those who most underwent graduate training and continuing education, whereas nursing professionals asserted having mostly undergone university undergraduate training. 34.5% of the administrative managers who stated having undergone training did so at the undergraduate level, 10.3% in continuing education and only 7% at the graduate level. In the case of the physicians, 33% state having undergone undergraduate training, 15.5% continuing education and only 9.3% graduate education, whereas 38.6% of the nurses underwent PC training at the undergraduate level, 13.6% in continuing education, and only 4% at the graduate level. In addition, 52.3% attended less than 20 h of training in this topic (Table 1). 3.1. Implementation of the Clinical Practice Guide for Palliative Care in the HCs When analyzing the criteria to assess the implementation of the Clinical Practice Guide for Palliative Care based on the information provided by the administrative managers (Table 2), it was found that 91.18% of the health centers have this Guide; whereas there is a training program that includes PC only in 35.29% of the cases. There is a written performance protocol for coordination with the reference hospital in 36.36% of the HCs. It is noteworthy that there is PC medical history only in 38.24% of the cases. Table 2. Implementation of the Clinical Practice Guide for Palliative Care. N % CPG for Palliative Care [Yes] 31 91.18 Annual training program in the HC (including PC) [Yes] 12 35.29 Number of annual training sessions 1 (SD: 1.98) Coordination protocol with reference hospital [Yes] 12 36.36 Medical History in PC [Yes] 13 38.24 Availability of essential PC medications suggested by the WHO [Yes] Paracetamol/Ibuprofeno/Diclofenac/Ketorolac/Naproxen 33 97.06 Codeine/Tramadol 18 52.94 Morphine/Buprenorphine 5 14.71 Butylscopolamine/Hyoscine Bromide 24 72.73 Lactulose/Glycerol 25 73.53 Loperamide 1 3.03 Metroclopramide 32 94.12 Furosemide/Spironolactone 27 81.82 Omeprazole 33 97.06 Metronidazole 34 100 Prednisone/Dexamethasone 26 78.79 Fluconazole 34 100 Fenitoine/Phenobarbital/Clonazepam/Carbamazepine/Valproic Acid/Alprazolam/Diazepam 27 79.41 Amitriptyline 9 26.47 Haloperidol 7 21.21 Salbutamol 32 94.12 Opioid availability [Yes] 14 41.18 HC population that required PC (2018) Less than 50 31 93.94 Between 50 and 100 1 3.03 Between 100 and 150 1 3.03 More than 150 0 0.00 Interdisciplinary PC team Physician 19 57.58 Nurse 11 34.38 Psychologist 6 18.75 Physiotherapist 2 6.25 Social Worker 6 18.75 Care time available, first appointment in external consultation 15 min 1 3.03 30 min 13 39.39 45 min 7 21.21 60 min 12 36.36 Int. J. Environ. Res. Public Health 2021,18, 11573 6 of 14 Table 2. Cont. N % Coordination between different 24 h care services [Yes] 17 51.52 Other techniques to be considered Hypnosis 4 12.50 Relaxation therapy 17 53.12 Aromatherapy 1 3.12 Homeopathy 1 3.12 Acupuncture 7 21.88 Ozone therapy 1 3.12 Reiki 1 3.12 In relation to the essential PC medications that must be included in the basic medication chart in primary care units, it was found that there is Tramadol in 52.9% of the HCs and, regarding Morphine, it is present in only 14.7%. Other medications were also found in proportions below 50%, such as Amitriptyline (26.5%) and Haloperidol (21.2%). However, there is opioid availability in slightly more than 40% of the health centers. The interdisciplinary teams for this type of care have physicians trained in PC (57.58%), with trained nurses (34.38%), a psychologist, and a social worker (18.75%) of the teams and only one physiotherapist (6.25%); whereas only 36.36% acknowledges that the regulated time available for the team to evaluate the first appointment is 60 min, according to the MSP’s PC care standard. Slightly more than half of the health centers coordinate care with other secondary care level hospital institutions 24 h a day, considering that the study area does not have tertiary-level hospitals or 24 h home care teams. The following were mentioned among the difficulties acknowledged to implement the MSP’s palliative care model flowchart, with integration of all the resources: lack of training in the theme, deficit in human resources and medications/medical inputs, limited time availability to provide care, and the physicians’ instability in contractual terms, including professionals who comply with the one-year rural service and others with fixed contracts. 3.2. Knowledge and Handling of the CPG Guide for PC by Physicians and Nurses Approximately 50% of the physicians use both the ESAS and Pfeiffer’s and Karnofsky’s scales when approaching patients in palliative care. 24.83% uses some survival prediction scale; whereas 60.42% of the physicians interviewed use a scale to assess pain and more than one-third employ survival time and the symptoms as criteria to include a patient with a chronic disease in an advanced stage and lower life expectancy in the program. Nearly one-third of the physicians know the ICD-10 code corresponding to palliative care and 62.5% refer the patient to a PC unit when diagnosing an incurable disease and shortened life prognosis, always based on the disease, the life prognosis, and the expected evolution (Table 3). The end-of-life symptoms that are treated by almost all the physicians are severe pain, constipation, and vomiting. It draws the attention that only 20.91% treat agony symptoms and 25.89%, delirium. In relation to the use of morphine at the end-of- life phase, 76.3% use it for pain; however, only 5.41% acknowledge the need to use it in dyspnea and 27.12% state using it for palliative sedation although it is a non-hypnotic analgesic drug. In relation to the first-choice route to hydrate patients at the end-of-life phase in their homes, 71.32% prefer the intravenous route and only 16.96% has a preference for the subcutaneous route, which is the one recognized and recommended in the CPG guide (Table 3). This is similar among nurses, referring to the intravenous route as the first choice for home rehydration. The differences between physicians and nurses regarding the proportions in their answers were statistically significant. Int. J. Environ. Res. Public Health 2021,18, 11573 7 of 14 Table 3. Use and knowledge about instruments, inclusion criteria, and prescription in PC by the physicians. Physicians n % n % Instruments ESAS [knows it] 19 30.16 Barthel [knows it] 27 30.00 [Uses it] 31 49.21 [Uses it] 30 33.33 [Knows it and uses it] 13 20.63 [Knows it and uses it] 33 36.67 NECPAL [knows it] 24 35.82 Symptoms assessed by the Edmonton scale [Uses it] 31 46.27 0–3 28 22.95 [Knows it and uses it] 12 17.91 4–6 60 49.18 Karnofsky [knows it] 46 42.59 7–10 34 27.87 [Uses it] 22 20.37 Use of the survival prognosis scale [Yes] 36 24.83 [No] 52 35.86 [Knows it and uses it] 40 37.04 [Does not know any scale] 57 39.31 Pfeiffer [knows it] 18 26.87 Use of a scale to assess pain [Yes] 87 60.42 [No] 35 24.31 [Uses it] 33 49.25 [Does not know any scale] 22 15.28 [Knows it and uses it] 16 23.88 Inclusion criteria Patient with advanced-stage disease and life expectancy of less than one year [it does include it] 124 83.78 When a patient is referred to a PC unit Criterion/Criteria to include it When diagnosing an incurable disease and shortened life prognosis, always based on the disease, the life prognosis and the evolution expected 90 62.50 Time 15 10.87 The patient and/or family requires so 6 4.17 Presence of symptoms 11 7.97 Progressive and irreversible deterioration, with increase in the number of complications and/or needs 42 29.17 Time and presence of symptoms 112 81.16 In agony 3 2.08 ICD-10 code Never 3 2.08 Z21 11 8.27 Difficulty referring a patient to a PC unit Z50.4 10 7.52 Yes, I don’t know any unit nearby 50 34.72 Z51.5 96 72.18 Yes, the family gets scared at the word “palliative” 11 7.64 Z52.1 16 12.03 Yes, I’d rather be treated in PHC 11 7.64 No, I refer the patient so that they can be followed-up in both services (PHC and Hospital) 61 42.36 No, I refer the patient so that they are followed-up in a PC unit 11 7.64 Drug prescription Dyspnea 51 44.35 Agony 23 20.91 Delirium 29 25.89 Use of morphine as end-of-life treatment for: Vomiting 74 63.79 Pain 103 76.3 Constipation 80 67.23 Palliative sedation 32 27.12 Severe pain 81 66.39 Dyspnea 6 5.41 Asthenia-Anorexia-Cachexia 38 32.48 Pain and dyspnea 37 31.36 Regarding the knowledge investigated in physicians and nurses, it can be seen ( Tables 3and 4 ) that there are no statistically significant differences in their answers, except for the assertions related to: “Morphine is the standard used to compare the analgesic effect of other opioids” and “People who take opioids should adopt certain measures to improve bowel elimination”, where the physicians showed greater knowledge. Int. J. Environ. Res. Public Health 2021,18, 11573 8 of 14 Table 4. Comparison between physicians and nurses regarding knowledge/beliefs related to palliative care. Physicians Nurses p-Value n % N % Knowledge/Beliefs First choice hydration route for patients at the end-of-life phase in their homes Oral 37 31.09 15 14.4 0.003 Subcutaneous 19 16.96 3 2.9 0.001 Intravenous 92 71.32 86 82.7 0.003 Morphine is the standard used to compare the analgesic effect of other opioids [Yes] 101 68.71 51 49.0 0.002 Adjuvant therapies are important in pain management [Yes] 132 89.80 90 87.4 0.551 Somnolence associated with electrolyte imbalance can reduce the effect of sedation [Yes] 73 49.66 52 50.5 0.898 People who take opioids should adopt certain measures to improve bowel elimination [Yes] 116 78.91 60 58.3 0.001 The drugs that can cause respiratory depression are appropriate to treat severe dyspnea [Yes] 32 21.77 15 14.6 0.154 At high doses, codeine causes more nausea and vomiting than morphine [Yes] 68 46.26 48 47.1 0.901 Dolantine is not an effective analgesic in the control of chronic pain [Yes] 29 19.73 25 24.5 0.369 Note: Pearson’ chi-square tests were used to compare the different variables related to knowledges/beliefs between doctors and nurses. Numbers in bold indicates that p-value is less than 0.05, being statistically significant. When investigating how physicians assess the psychosocial sphere of the patients in palliative care and of the families, it was found that approximately 90% address the impact of the disease, although less than 70% evaluate the spiritual resources. More than 90% of the interviewees inform the family about the patient’s terminal phase and about the transfer to palliative care, as well as about evolution and palliative sedation. 67.59% is able to recognize pathological grief. However, around 25% of the physicians feel trained in the diagnosis and management of urgencies in PC and 55.78% feel trained to provide psychosocial and spiritual support to patients and families (Table 5). Table 5. Management of the psychosocial sphere by physicians. N % Training to provide psychosocial and spiritual support to the patient and the family [Yes] 82 55.78 Training to diagnose and manage urgencies in PC [Yes] 37 25.17 Psychosocial assessment (aspects included) Impact of the disease [Yes] 131 89.73 Coping styles [Yes] 116 81.12 Spiritual resources [Yes] 97 68.31 Information provided to the family About the terminal phase and the need to refer to PC 139 94.56 About the changes in evolution of the disease 142 96.6 About palliative sedation 133 91.10 Identification of pathological grief Clinical case about pathological grief (situation that this person is going through) Depression 43 29.66 Anxiety 4 2.76 Pathological grief 98 67.59 Int. J. Environ. Res. Public Health 2021,18, 11573 9 of 14 Regarding the nurses’ knowledge about different aspects included in the GCPCP guide, it is worth noting that 48% relates PC to deterioration or worsening of the clinical condition, which is associated with the fact that 73% consider that the pain treatment method is based on disease extension and not on its severity, and that only 53% of the interviewees consider that the PC philosophy is compatible with active treatments. In this line, they consider addiction as a problem for the use of morphine in patients who require long-term pain treatment in the PC context. Seventy-five percent of the nurses consider that it is appropriate to use a placebo in pain treatment. On the other hand, less than 50% acknowledge the impact of the disease and of fatigue on the manifestation of physical pain. More than 50% and 75% of the interviewees ignore the secondary effects of codeine and of meperidine, respectively. Regarding the psychoemotional aspects and team care, it draws the attention that 60% believe that the accumulation of losses makes development of the Burnout syndrome inevitable in health personnel and that 34% did not answer this question. In relation to grief or loss, 72% consider that they are easier to solve when there is a distant or conflictive relationship. 3.3. Relationship between General Knowledge about the Different Aspects of PC and the Physicians’ and Nurses’ Training and Experience General professional experience showed a statistically significant difference in the group of physicians with the knowledge related to “Morphine is the standard used to compare the analgesic effect of other opioids”, “Adjuvant therapies are important in pain management”, and “The drugs that can cause respiratory depression are appropriate to treat severe dyspnea”. Among the nurses, a statistically significant relationship was only observed for the following assertion: “Meperidine is not an effective analgesic in the control of chronic pain” (Table 6). Table 6. Physicians’ and nurses’ knowledge according to general professional experience and experience in palliative care. Professional Experience (Years) Experience in Palliative Care (Years) Medicine Mean (SD) p-Value Nursing Mean (SD) p-Value Medicine Mean (SD) p-Value Nursing Mean (SD) p-Value Morphine is the standard used to compare the analgesic effect of other opioids 0.016 0.466 0.368 0.171 Yes No Prefers not to answer 11.67 (10.22) 5.93 (4.86) 15.42 (11.26) 9.69 (7.79) 9.22 (7.98) 11.80 (10.09) 1.63 (2.45) 0.58 (0.79) 1.38 (2.81) 2.96 (5.07) 3.43 (6.62) 0.91 (1.08) Adjuvant therapies are important in pain management 0.005 0.300 0.861 0.580 Yes No Prefers not to answer 11.11 (9.77) 12.00 (0.00) 20.43 (12.58) 9.77 (8.06) 7.00 (0.00) 13.75 (11.82) 1.52 (2.54) 1.00 (0.00) 1.15 (1.34) 2.41 (4.25) 0.00 (0.00) 1.20 (1.87) Somnolence associated with electrolyte imbalance can reduce the effect of sedation 0.851 0.311 0.638 0.021 Yes No Prefers not to answer 11.96 (10.64) 11.41 (10.09) 12.79 (10.31) 10.35 (8.00) 8.33 (6.86) 12.00 (11.10) 1.68 (2.79) 1.24 (2.26) 1.32 (1.76) 3.34 (5.07) 1.30 (2.27) 0.68 (1.00) People who take opioids should adopt certain measures to improve bowel elimination 0.129 0.518 0.430 0.661 Yes No Prefers not to answer 11.39 (10.24) 10.00 (7.70) 16.05 (11.36) 10.28 (8.60) 7.93 (6.15) 11.14 (9.53) 1.34 (2.26) 1.89 (3.79) 2.05 (2.67) 2.56 (4.89) 1.50 (1.29) 2.04 (3.12)