Today, professionals involved in end-of-life care accept without question that the care provided to people at this stage must include, in a holistic manner, the management, care and support of people, in accordance with a global approach that encompasses comprehensive and compassionate care of patients with terminal illnesses, seeking support from all areas; medico-legal, ethical, social, psychological and care, while providing appropriate medical care to improve the quality of life of the terminally ill patient. Palliative care is a special type of care designed to provide comfort and support to patients (both adults and children) and their families in the final stages of a terminal illness.1 This support includes the prevention and relief of suffering through early identification, assessment and treatment of pain and other physical, psychosocial and spiritual problems.2 In essence, palliative care aims to address all aspects of a person's well-being.

This approach to end-of-life care is the basis and model for solving problems and advancing knowledge of this transcendent moment.

This article reviews the different paradigms, from the medico-legal, ethical, social, psychological and end-of-life care and support perspectives that constitute the global approach to end-of-life care.

At the regulatory level, there are no inconsistencies regarding the adequacy of end-of-life care. Our legislation3 clearly and unambiguously establishes the right to comprehensive and quality care and the right to respect the principle of patient autonomy, also during the last stages of life.4 Every person (or patient) has the right to receive truthful information about his or her disease process and illness, to refuse treatment, to limit therapeutic efforts and to choose from among the available options. Thus, the principle of patient autonomy in the dying process can be articulated through appropriate informed decision-making at that time or through the completion of an advance healthcare directive (AHD) or living will document. This document determines that a person of legal age, capable and free, expresses his or her wishes in advance in order for them to be fulfilled when situations arise in which he or she is unable to express them personally, covering the care and treatment of his or her health or, after death, what should happen to his or her body or its organs.

On the other hand, the recent enactment and implementation, after decades of debate, of Organic Law 3/2021, of 24 March, on the regulation of euthanasia,5 brought with it a number of new medico-legal issues.6 In relation to palliative care, the Act emphasises the need to promote a palliative approach to serious and incurable illness, which will improve the quality of life of patients and their families at the end of life.7 The aim of this law is to provide a legal, systematic, balanced and guaranteed response to a demand in today's society, namely euthanasia. In this context, the law regulates and decriminalises euthanasia in certain clearly defined cases and subject to sufficient guarantees that protect absolute freedom of choice, excluding any external pressure. In short, the law regulating euthanasia introduces a new individual right into our legal system, namely the right to request assistance in dying.

From a medico-legal point of view, it is also important to remember that the right to privacy is one of the fundamental rights of the patient. Therefore, the health professional must be particularly careful to respect this right in the end-of-life process. The patient, who enters this stage with full awareness, having been properly informed, has the right to share the ritual of farewell in privacy with those closest to him or her, and must be able to communicate with the people he or she considers appropriate and adequate, which means that he or she must have appropriate spaces for this, within a framework of intimacy and privacy.4

When addressing the ethical aspects of the end-of-life process, at least three aspects need to be highlighted: 1) respect for free and responsible decision-making, 2) truthfulness and tact, and 3) intimacy and warmth.

The concept of dying with dignity varies across different cultural and social contexts. In Western societies, it is often viewed as a challenge within the healthcare sector, where death is frequently approached as a taboo subject. Currently, the aim is to naturalise the idea of death by applying the methodology of person-centred care intervention, focusing on conscious participation and decision-making in the end-of-life process.

The end of life is understood as a process in which profound concerns arise in both the affected person and their family and relatives, not only medical issues are important but also emotional, spiritual, ethical and social ones that intermingle giving rise to specific care needs that go beyond the patient and require work with their family and relatives, as well as with their context.

Social needs at the end of life can have external or internal origins, as they can be caused by economic or employment factors or by family and social context issues, so it is necessary to carry out a good analysis of social issues in order to identify the risk and protection factors necessary for intervention in each case.

Social intervention in the end-of-life process should cover three phases: firstly, the "before" phase, in which it is important to consider the support given to family members during the illness; secondly, the "during" phase, when death occurs; and thirdly, the "after" phase, which involves dealing with the period of mourning. According to the World Health Organisation,11 palliative care requires a comprehensive psychosocial approach by multidisciplinary teams. Interventions must be holistic in nature and should be directed not only at the patient, but also at the people who accompany them in their environment, as is usually the case with family members. One of the key issues is to enable the whole group to cope with the suffering of such a transcendental moment as death.

The end-of-life process requires a particular social intervention, which implies the need for specialisation of the professions involved, and in the case of the social field, health social work must be approached from a specific training in palliative care.

The role of social intervention professionals is important in advising on the decision-making process and facilitating communication between the person, his or her family and other professionals. This comprehensive intervention facilitates the detection and prevention of potential risks of claudication among caregivers.

Despite the focus on family support, some individuals face loneliness, especially during the end-of-life process. Similarly, there are circumstances where individuals reside in institutions, necessitating the establishment of protocols for their accompaniment and care. Networking and coordination with other professionals at this time is important for the good management of the case, and it is also important to preserve the participation and decision-making of the person throughout the process, as well as to inform about the importance of carrying out the AHDs in case these are necessary.

Individuals with serious illnesses and experiencing loneliness require a strategy of social responsibility that includes projects developed in the health, social-health, and nursing-home sectors. Emphasis should be placed on the most relevant psychological aspects that help to optimise the care and well-being of people in end-of-life processes, in an attempt to reduce medicalisation and increase humanisation at this stage of life.

This involves incorporating various elements into psychosocial end-of-life care: effective communication between health and social care professionals and patients; psychological and spiritual support for the patient and their family, addressing unwanted loneliness, and providing bereavement care.

Communication, which is a priority in social and health care settings, should be prioritised in the training of professionals through the provision of practical workshops that teach the basics of effective communication in medically complex situations, with particular emphasis on the effective delivery of bad news, the importance of empathy and active listening in the patient encounter, how to talk about poor prognosis and adverse events, how to transition from active treatment to palliative care, and how to respond to difficult questions (e.g., "Am I going to die?" or "Life has no meaning, I don't want to fight anymore").

Also how to talk to children about serious illness and death, and issues related to advance directives (living will) and managing the emotional reactions of patients who often experience this end-of-life situation with deep sadness, anger, helplessness and guilt, are topics that also need to be addressed. This type of training takes on special relevance given that health and social care professionals rarely receive it during their professional curriculum and yet they often find themselves in situations of high medical, social and emotional complexity that they must face with the appropriate tools.

Learning to provide compassionate care in this context is essential, and it is particularly important to help health and social care professionals cope with the impact on them of daily exposure to the pain, suffering and disability of others, which includes exposure to our own mortality and feelings of vulnerability and helplessness. Compassion is an important component of pro-social behaviour and the desire to help. It goes beyond empathy in that it helps us to understand the suffering of others and motivates us to try to alleviate it; it creates a deeper connection with others. In this sense, personal work and connection with our inner world helps us to provide care and attention in which compassion, respect and connection with the other are paramount.

There are currently several psychological techniques whose effectiveness has been described in advanced illness and end-of-life processes. These include Meaning-Centred Therapy,12 based on Frankl's logotherapy,13 and Dignity Therapy, described by Chochinov et al.14 The former provides a therapeutic approach that enhances meaning and significance, spiritual well-being and quality of life, postulating that the definition of meaning is a primary force of human motivation. Finding meaning can reduce suffering and facilitate an individual's emotional well-being. Dignity Therapy addresses emotional and existential distress at the end of life. It invites people to address the life issues that are most important to them or that they would like to be remembered for. Both, with a humanistic approach, complement the use of other psychological interventions and the important work with spirituality described by Puchalski et al.15 in these populations.

Mourning is painful and complex and depends on many variables: the way the death occurred, the relationship with the deceased, the age of the deceased and many other variables. Learning how to facilitate the grieving process and how to intervene from a psychological point of view is particularly important in situations of complex loss: sudden or unexpected deaths, deaths in complex family relationships, suicides and requests for euthanasia, etc.

End-of-life care aims to maintain a quality of life free from suffering, focusing on the person's life history and taking into account the spiritual, transcendental meaning of life for the person we care for.16 However, its application should not focus only on the end-of-life process, nor even on palliative care, which should be initiated at earlier stages with a view to early intervention17 but should guide the entire care of the person.

Comprehensive end-of-life care requires a multidisciplinary approach, in which medical and nursing care is complemented by psychological, social and spiritual care, both for the person at the end of life and for the support of their close environment and family. The aim is to alleviate suffering, promote quality of life and ensure dignity and respect for the person.

There are important aspects of the care process to consider, including appropriate pain and symptom control; emotional support, active listening and understanding to help manage the feelings of the bereaved and their family; clear and honest communication to enable us to be aware of the person's wishes, goals of care and any concerns they may have, although advance care planning is a valuable tool that allows the person to express their preferences and enables professionals to ensure that their wishes are respected and appropriate care is provided; and spiritual support, taking into account the spiritual and religious needs of the person and their family, respecting the religious beliefs and practices that the person may find comforting and providing access to a spiritual leader or counsellor of their choice.

It is important that the person is in the level of care in which he or she wishes to die and, in the case of home care, that the family is informed about possible complications and has the necessary medication to deal with them. It is essential that the referring professionals establish daily visits and telephone support systems to clarify any doubts.18

The environmental aspects are important, so it is important to ensure that it can be located in a single room that allows maintaining an intimate atmosphere, with appropriate management of light, ventilation or music as facilitating elements that can be adapted to the preferences of the person and the family.

Physical care encompasses a wide range of aspects, including the detection of inadequate alleviation of suffering by clinical monitoring or by training the family to detect it.18 Throughout the process, it is important to identify all situations arising from care (cleaning, mobilisation, etc.) that may cause discomfort or suffering, in order to adapt them to the person's real needs or to establish a therapeutic approach to control or alleviate them. In addition to prioritising pain and symptom control in end-of-life care, it is important to address oral and skin care, manage dependency-related injuries (such as pressure ulcers and moisture-related lesions), treat tumour lesions, handle lymphoedema, manage fistulas or ostomies, and oversee subcutaneous venous reservoirs or routes of drug administration and nutrition, among other considerations.

This situation becomes more critical during the final days or the terminal phase, when care is essential for the individual, their family, and the healthcare professionals involved, as it is a unique and significant period.19 At this stage, the person will have reached a high level of dependency together with greater emotionality20 and all our attention will be focused on maintaining physical well-being and alleviating the emotional, spiritual and social suffering of the patient and family.21 Care must be adapted to prioritize essential interventions that promote and ensure the well-being of the individual.

The aim of this article is to describe the current approach to end-of-life care from a number of perspectives, which is well defined in the scientific literature, but which needs to be remembered and included in a transversal action, with updating of legislation and with ethical, social, psychological and care support, framed within a medico-legal framework, in line with standard care practice and at the same time providing legal security for those involved, doctors, nurses, carers and relatives, without forgetting that the patient has rights which must be safeguarded. End-of-life care should focus on humanising and dignifying the final stages of life through a multidisciplinary and holistic approach, enabling comprehensive management of such care. This also includes fostering an environment of trust that ensures effective communication at all levels with the patient and their family members.

The authors confirm that this work did not involve the use of human subjects, and therefore, ethical considerations such as obtaining informed consent do not apply.

No artificial intelligence tools have been used in this article.

The authors declare that they have not received any funding for this article.