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Cronicità, telemedicina e “reti empatiche”

Internet è un crocevia di storie, linguaggi, sguardi diversi che alimentano e costruiscono vissuti e percezioni. Se è vero che un po’ le echo-chambers ci imprigionano, è anche vero che con curiosità e voglia di vagare, si può ancora essere “cyberflâneur” e incrociare percorsi che, offline, faticano a incontrarsi e meriterebbero invece di ritrovarsi.

 

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Articolo di Cristina Cenci su nòva – Il Sole 24 Ore

E’ accaduto per due storie molto diverse che mi è capitato di leggere in casuale successione. La prima: “Lettera di un vecchio”, pubblicata da un’infermiera su Facebook e ripresa in un blog dedicato a racconti e poesie, dove potete leggerla tutta. Ne riporto una parte:

“Cosa vedi infermiera? Cosa vedete? Che cosa stai pensando mentre mi guardi? ‘Un povero vecchio’, non molto saggio, con lo sguardo incerto ed occhi lontani, che schiva il cibo, non dà risposte e che quando provi a dirgli a voce alta: ‘Almeno assaggia’ sembra che nulla gli importi di quello che fai per lui. […] Ma cosa stai pensando? E cosa vedi? Apri gli occhi infermiera! Perché tu non sembri davvero interessata a me… Ora ti dirò chi sono, mentre me ne sto ancora seduto qui a ricevere le tue attenzioni lasciandomi imboccare per compiacerti. Quindi aprite gli occhi gente… apriteli e guardate…  […]  ‘Non un uomo vecchio’… avvicinatevi meglio e… vedete ME!”

La seconda , un caso clinico, tra i tanti che è possibile trovare in archivi digitali:

“Uomo, 78 aa, pregresso intervento di adeno-tonsillectomia e appendicectomia. …. Ipertensione arteriosa di grado moderato, prevalentemente sistolica (ipertensione sistolica isolata), in trattamento efficace con terapia di associazione con ace inibitori, diuretici tiazidici, calcio- antagonisti e alfa bloccanti, in paziente anziano con pregressa abitudine tabagica, familiarità per malattie cardiovascolari e segni di danno d’organo (ipertrofia ventricolare sinistra, microalbuminuria, retinopatia ipertensiva, ispessimento miointimale). Ipercolesterolemia, in trattamento con atorvastatina.  Ipertrofia prostatica benigna, in trattamento con alpha-bloccanti. RISCHIO CARDIOVASCOLARE ELEVATO

Due storie, due mondi che non si vedono reciprocamente: il mondo del me e l’agglomerato di eterogenei in cui lo trasformano le categorie mediche. Cosa sentirà di avere il me? Per cosa penserà possa ancora valere la pena curarsi? Di quale delle tante malattie che lo accompagnano da anni avrà più paura? Cosa pensa che possa fargli più male? Si rende conto di avere “un rischio cardiovascolare elevato”? Come pensa di affrontarlo? Lo chiamano paziente complesso, paziente cronico, nuovo paziente, paziente che sfugge alle linee guida, perché ha almeno tre, quattro malattie diverse e prende sette o otto farmaci, di cui si ignorano le interazioni. Ma lui è un me che ha un progetto di vita, invisibile una volta che varca le varie soglie degli ambulatori, come diabetico, come cardiopatico, come carcinoma prostatico o come semplicemente “un vecchio”.

Possiamo cambiare prospettiva, possiamo far incontrare queste due storie nella clinica e non solo nei percorsi erranti di internet? Ho provato qualche tempo fa a delineare alcune strade in un articolo sullo European Journal of Internal Medicine,  Narrative medicine and the personalisation of treatment for elderly patients.

Il modello più bello e stimolante l’ho però trovato nel Piano Nazionale Cronicità 2016. La portata innovativa del Piano è raccontata da Paolo Trenta, Presidente di OMNI-Osservatorio Medicina Narrativa Italia, durante il  VI Convegno Nazionale di Medicina Narrativa, organizzato a Foligno e dedicato alla cronicità:

Il Piano Nazionale Cronicità 2016 usa un lessico, un vocabolario, che è quello della medicina narrativa: personalizzazione, co-costruzione, centralità dell’illness rispetto alla disease, programmi assistenziali che integrino progetti esistenziali”.

Il Piano Nazionale Cronicità opera uno spostamento di punto di vista, introduce una cultura nuova, ecco alcuni passaggi fondamentali:

C’è bisogno di nuove parole-chiave, capaci di indirizzare verso nuovi approcci e nuovi scenari: salute “possibile”, cioè lo stato di salute legato alle condizioni della persona; malattia vissuta con al centro il paziente/persona (illness), e non solo malattia incentrata sul caso clinico (disease); analisi integrata dei bisogni globali del paziente, e non solo “razionalità tecnica” e problemi squisitamente clinici; analisi delle risorse del contesto ambientale, inteso come contesto fisico e socio-sanitario locale, fattori facilitanti e barriere; mantenimento e co-esistenza, e non solo guarigione; accompagnamento, e non solo cura; risorse del paziente, e non solo risorse tecnico-professionali gestite dagli operatori; empowerment inteso come abilità a “fare fronte” alla nuova dimensione imposta dalla cronicità e sviluppo della capacità di autogestione (self care); approccio multidimensionale e di team e non solo relazione “medico-paziente”; superamento dell’assistenza basata unicamente sulla erogazione di prestazioni, occasionale e frammentaria, e costruzione condivisa di percorsi integrati, personalizzati e dinamicipresa in carico pro-attiva ed empatica e non solo risposta assistenziale all’emergere del bisogno; “Patto di cura” con il paziente e i suoi Caregiver e non solo compliance alle prescrizioni terapeutiche.” (pag. 14)

Poi però, sottolinea Paolo Trenta: “nella sezione attuativa, riemerge il modello riduzionista-deterministico centrato sulla patologia. La sfida è trasformare il nuovo modello culturale che emerge chiaramente dal Piano, in pratica quotidiana dei reparti degli ospedali e delle strutture sanitarie e questo è uno degli obiettivi di OMNI”.

Nel Piano Nazionale Cronicità si parla allo stesso tempo di piano di cura e di patto di cura. La sfida è il più possibile integrare piano e patto, EBM e NBM. Come?

Un’ipotesi di risposta la offre lo stesso Piano, nelle raccomandazioni relative all’uso della Telemedicina e della E-health. In particolare nel piano leggiamo:

“Infatti, le tecnologie e-Health garantiscono la realizzazione di una modalità operativa a rete, facilitando l’integrazione tra le varie figure deputate all’assistenza e alla erogazione dei servizi. In particolare, nella integrazione ospedale/territorio e nelle nuove forme di aggregazione delle cure primarie, la Telemedicina e la Teleassistenza rappresentano esempi di come le tecnologie possano migliorare l’operatività, nel luogo dove il paziente vive, favorendo così la gestione domiciliare della persona e riducendo gli spostamenti spesso non indispensabili e i relativi costi sociali. Inoltre il cittadino/paziente usufruisce con facilità degli strumenti tecnologici che lo aiutano e lo accompagnano nella gestione della propria salute nella vita di tutti i giorni, attraverso diversi dispositivi e ovunque esso si trovi, anche nell’emergenza”.

L’obiettivo del Piano è “l’incremento di modelli di assistenza che sappiano coniugare soluzioni tecnologiche con i bisogni di salute del paziente-persona”. Quindi non solo monitoraggio in remoto di parametri clinici ma anche delle storie, dei bisogni, dei progetti mutevoli di vita della persona e dei caregiver.

Solo raccomandazioni di un testo ministeriale? Credo di no, perché non nasce top down, ma bottom up, recepisce esplicitamente, ma anche implicitamente, quanto già è avvenuto e sta avvenendo.

Un libro bellissimo, Il mondo invisibile dei pazienti fragili, curato da un medico di medicina generale Stefano Ivis, oggi presidente di ASSIMS, con Alberto De Toni, ingegnere e Rettore dell’Università di Udine e Francesca Giacomelli, ingegnere gestionale, e basato sull’esperienza sul campo di decine di MMG, mostrava  già nel 2010 come operativizzare tutto questo. Come scrivono gli autori: “Il supporto della tecnologia moderna, l’utilizzo dei sistemi gestionali applicati alla complessità e la capacità di tenere uniti high-tech con high-touch permetteranno la co-costruzione di una rete empatica, nata con il contributo di tutti gli attori coinvolti, trasformando la comunicazione prevalentemente focalizzata allo scambio di informazioni, in una comunicazione che costruisce significati”.

Forse è arrivato il momento di introdurre un’altra importante variazione lessicale e passare da “il paziente/persona al centro”, rimasto per lo più uno slogan, a “la rete al centro”, fiduciosi che questa volta veramente qualcosa cambierà.

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