How to Manage the Suffering of the Patient and the Family in the Final Stage of Life: A Qualitative Study

Round 1

Reviewer 1 Report

Abstract

- They should revise line 13 - the word " goal " seems to be missing.

- We suggest describing the results more objectively, starting with the following: "the main results found were..."

Introduction

- Revise paragraph (47-50) - it's not clear.

- Review sentence (41-62) - not clear. 

Results

- Line 185 - I don't see any results in grey

- Review sentence (277) - not clear. 

We suggest creating a sub-chapter after the conclusion with the main recommendations that emerge from your results, given their importance for the practice of professionals who accompany individuals and families in the final process.

Author Response

Dear editor and reviewers,

We appreciate your interest and opinions about our research article. It is very pleasing to realize this topic is interesting and useful for you. We would like to express our gratitude for reviewing this manuscript and for the proper corrections, which help us conduct more rigorous and quality research.

We have detailed below the changes that have been made in the original article: " How to accompany the suffering of the patient and the family in the final process of life: A qualitative study”.

Modifications have been made following the reviewers’ comments. Each modification is indicated by quoting the reviewer´s comment in addition to the page and line number, followed by the change that has been made in response to that comment.

In the manuscript, the changes have been written in red to make it easier to detect.

As requested, we have carried out a full assessment of the English wording of the manuscript.

Thank you so much.

REVISOR 1

Abstract

- They should revise line 13 - the word " goal " seems to be missing.

Thank you very much for your appreciation, and we have also included the word objective.

- We suggest describing the results more objectively, starting with the following: "the main results found were..."

The wording of the results has been modified, so that the most significant ones are visibly exposed. Thanks

Introduction

- Revise paragraph (47-50) - it's not clear.

Thank you very much for your advice. We've modified the sentence to improve your reading comprehension and clarity.

- Review sentence (41-62) - not clear. 

Thank you very much for the appreciation. We have modified the sentence to improve its comprehension and improve the quality of the manuscript.

Results

- Line 185 - I don't see any results in grey

Thank you very much for your proposal, it is very pertainent. We have highlighted in gray the results, emerging categories.

- Review sentence (277) - not clear. 

Thanks again, The sentence has been modified to improve its understanding and clarity.

We suggest creating a sub-chapter after the conclusion with the main recommendations that emerge from your results, given their importance for the practice of professionals who accompany individuals and families in the final process.

We think that this recommendation is very interesting and can help the public a lot to transfer after reading the paper. Thank you so much. We've included it.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments for author File: Comments.pdf

Author Response

Dear editor and reviewers,

We appreciate your interest and opinions about our research article. It is very pleasing to realize this topic is interesting and useful for you. We would like to express our gratitude for reviewing this manuscript and for the proper corrections, which help us conduct more rigorous and quality research.

We have detailed below the changes that have been made in the original article: " How to accompany the suffering of the patient and the family in the final process of life: A qualitative study”.

Modifications have been made following the reviewers’ comments. Each modification is indicated by quoting the reviewer´s comment in addition to the page and line number, followed by the change that has been made in response to that comment.

In the manuscript, the changes have been written in red to make it easier to detect.

As requested, we have carried out a full assessment of the English wording of the manuscript.

Thank you so much.

REVISOR 2

Appreciation

Very interesting article, with a current and very significant topic for the reality of healthcare.

The summary is well constructed.

The introduction places us in the context of the problem of monitoring the suffering of the person and family with people at the end of life. An excellent approach, which culminates in the purpose of the study.

In the method, it presents us with clear objectives. Presents the type of study and justifies it. Consider that the strategy used in defining the sampling aims to establish greater control of biases in the selection of participants. This justification is debatable, given that we are dealing with a study of a qualitative nature and the control of biases, it fits into language of a positivist nature. You must reformulate this justification.

Thank you so much for your kind words, we are glad to have done a job that you find so rewarding. We totally agree with you in the comment regarding biases, in fact we write it that way because our experience in reviewing papers with this methodology is that reviewers request this section that talks about bias control, that is the justification, since it has no other under the hermeneutic or phenomenological primary.  but positivist as you propose, so we have reformulated the justification.

In ethical terms, the project was approved by the ethics committee of the Andalusian government, (protocol with code 01/2020 CEPP and date of approval 18/01/2020).

The description of the procedures relating to interviews and focus groups is comprehensive and gives credibility to the data collection process in a qualitative approach.

In the verification, validation and validity process, it is not explicit that the meanings extracted from the coding process with the study participants were validated. The researchers discussed all decisions until consensus was reached during the analysis process.

They used external observers to look for discrepancies to ensure confirmability and this defends the quality of this study. However, they did not return the results of the analysis to the participants to confirm the researchers' interpretations. And, having not exhausted all hypotheses in defense of credibility, as a guarantee of the quality of qualitative studies, this must be presented as a limitation of the study.

Again, I am very grateful for your very accurate comments. It denotes a great knowledge of discourse analysis with this methodology.

In this case we have sacrificed this part of the final analysis of interpretation by the participants because of the difficulty of access, some because of their death and others because of their worsening state of health, I am very sorry to explain this cruel reality, but we have not put it in limitations because it seemed implicit to us. But I reiterate my thanks in your proposal and I would love to be able to chat with you about this methodology since it is very difficult to find people as knowledgeable in this matter as you are.

The results are presented in a comprehensive, clear way and valuing the subjectivity of the

experiences. They're excellent.

The discussion is very interesting and responds consistently to the findings that emerge from the qualitative analysis.

There were no study limitations. They must express it (they exist).

In conclusion, I looked for the answer to the central objective of the study and did not find it. The conclusion must answer the central questions of the study. Needs to be improved

Thanks again, we have modified the conclusions section in order to answer the central questions of the studio. We are very grateful for your review, it is a pleasure to have been able to count on someone who with their knowledge and advice has improved the writing, methodology and understanding of the paper.

Thank you so much.

Author Response File: Author Response.pdf

Reviewer 3 Report

Title: How to accompany the suffering of the patient and the family in the final process of life. A qualitative study 

I am very grateful for the opportunity to read and review this paper from colleagues in Spain, who are obviously dedicated to providing quality, meaningful care to both patients and families at the end of the patient’s life. It is a very important field, and this paper offers some important insights into patient and family needs. There are a number of issues that need to be addressed, however, before it is ready for publication. 

Firstly, the paper needs to be thoroughly edited for English spelling and particularly grammar. Below, among my detailed comments, I have picked out some obvious issues that jumped out as I was reading through; however, I strongly suggest that the authors ask a native English speaker, preferable an expert in the field, to edit the paper. Using grammar-checking software might also help to improve the paper. A good editor might also make suggestions for improving the flow of ideas.

Secondly, I would like the authors to address the limitations of the study in the discussion.

Thirdly, I would like the authors to mention the future directions, or next steps for the research in the discussion and/or conclusion. The authors offer many suggestions and admonitions: E.g., “a sustainable, quality and accessible palliative care system must be integrated into the context of primary health care…” However, the authors do not give any suggestion of how we might go about doing that. Addressing future research directions might go some way to answering that issue.

Below I offer some detailed comments. I hope they are useful.

1. Title: change the period after “life” to a colon 

2. Abstract: The abstract is full of spelling and grammar issues. Line 9, for example, contains the spelling error “Blackground”, the word “the” preceding “death” is redundant, and the comma following “death” is not necessary. This is just one line; the whole abstract/manuscript needs checking.

3. Line 9: You use the word “problem” for describing end of life and death; I’m not sure this is the correct word. Death is not really a problem, it is a natural occurrence.

4. Lines 10-11: “being the exclusive domain of health institutions. The patient no longer dies at home..” Is this perhaps exaggerated or does it describe the situation in Spain? While many in the country I live do die in institutions, a large percentage die at home. 

5. Line 13: The meaning of this is unclear: “the externalization of the end of life at home” 

6. Line 13: is there a word missing here? “The main of this article…” “The main purpose…”? 

7. Line 17: “This research adheres to…” Change verb “adheres” to past tense.  

8. Lines 19-21: The results section reads more like a conclusion statement. 

9. Line 20: The meaning of “in the final process” is not clear. It is not a phrase commonly used in English to describe end of life issues (as far as I am aware). 

10. Introduction: Line 29. There is no need to start a new paragraph here. 

11. Lines 32-35: This sentence is not complete; the clause: “where the availability of informal caregivers” is not resolved.

12. Lines 37-38: This part of the sentence is not well articulated: “so we are facing a process of suffering of the patient and the family, as well as a demand for care that increases without obtaining a response” 

13. Lines 39-40: See my comment 3 about the word “problem.”

14. Line 40-41: Change “Patient no longer dies at home” to “These days, patients rarely die at home…”

15. Line 42: Add a comma after “unknown”. For clarity, I think it is best to the Oxford comma throughout your manuscript: https://www.oxford-royale.com/articles/oxford-comma/

16. Line 44: “the meaning of it will be designed to the extent” I can’t understand what is meant by “meaning of it will be designed”

17. Line 45: “The meaning of “so” is unclear.

18. Line 45-46. You should start a new sentence beginning at the point of “this construct…” 

19. Line 49: “human death and death” should this be “human life and death”?

20. Line 51: The meaning of “the closest human behavior” is unclear.

21. Line 55: “Death” doesn’t need capitalization here.

22. Line 55: Comma needed after “family”.

23. Lines 56-57: The meaning is unclear: “in which we tend more to have than to be and to achieve 56 the facts with great immediacy, added to a great social intolerance to frustration,” 

24. Line 61: No need for capitalization here “Family Unit, Patient and Family” 

25. Line 62: “during this stage” is redundant

26. Line 67: “their role” is repeated; please rephrase. 

27. Line 73: Change “article” to “study”

28. Line 74: “what patients and families need at the end of life” Only the patient is at the end of life, not the family. You’ll need to rephrase this.

29. At some point in the introduction, I think you should explain the concept of end-of-life accompaniment, before you discuss it as being the objective of your study. I think this would also help the flow of the introduction.

30. Objectives: Lines 77-87: I think it would be better to form this section into paragraphs rather than lists. 

31. Line 96: Begin a new sentence here: “a search process” 

32. Line 101: “MYP” Please define all abbreviations at first mention in the text.

33. Lines 121-122: “thematic guide developed by 121 the research team” Maybe it would be helpful to share this as an appendix.

34. Lines 123-124: “Do you feel accompanied during this process, what would you need to be accompanied?” This seems to be two questions.

35. Line 134: These paragraphs can be joined.

36. Line 154: Please use square brackets for references “(17)” [17] 

37. Line 160: This seems contradictory: “a research team member who did not belong to the same research group” 

38. Line 162: “ATLAS.ti software” Please include details of the software manufacturer, city, and country. 

39. Line 166: What is the meaning of: “23.”

40. Line 172: “group” should be plural 

41. Lines 181-182: These paragraphs can be joined. 

42. Lines 182-185: For clarity, I think it would be better to separate the sentences, introducing the contents of tables 1 and 2 separately. 

43. “The emerging results obtained are highlighted in grey” Nothing in the tables is highlighted in grey. 

44. Table 2: “Family claudication” I don’t think “claudication” is the correct word. I think it refers to a pain in your legs (thigh, calf, or buttocks).

45. Lines 194 and 201: The meaning of “them” is unclear in these sentences. 

46. Line 195: Change “following graphic” to Figure 1 and rename “Illustration 1” as Figure 1, too. 

47. Line 204-205: These paragraphs can be joined.

48. Lines 212-215 should come before Table 3.

49. Line 222: Table 4: “in the end of life” change to “at the end of life”

50. Line 225: Please delete “On the other hand” 

51. Line 226: “going through this stage” not clear, change to something like “approaching the end of life”

52. Line 277: I can’t understand this sentence: “Once the common dimensions for both were analyzed, we found 2 of the patients.” 

53. Line 278: Check spacing after “dimension”

54. Line 280: Put a comma after “receive care” 

55. Lines 282 and 287: Text in bold face.

56. Line 287: “Family claudication” See comment 44 above.

57. Lines 295 and 297: Change the verb here: “put the medication” to “give the medication” 

58. Line 314: I think “tandem” is the wrong word here.

59. Lines 312 and 315: Repeating of the same phrase “The results highlight the importance of” This sounds very awkward. 

60. Line 318: “refers to” Change to “gives for” 

61. Line 321: “The needs demanded in this study both by the patients interviewed and in the family population…”  change to “The needs of the patients and in their families identified in this study…”  

62. Line 323: “as needs that need to be addressed by health professionals” the double need and needs here sounds awkward. 

63. Lines 324, 326, 328: these lines also use “need”; it might be good to use a range of synonyms.

64. Line 329: The meaning here is not clear: “during the helping relationship of the person who suffers” 

65. Line 337: Comma after “psychological”

66. Line 340: “for help” change to “to help” 

67. Line 344: “The presence” delete “The”: “Presence…”  

68. Lines 355-358: This sentence is very awkwardly written, which makes it a little difficult to understand.

69. Line 367: “his family” change to “their family” 

70. Line 371: “relationshiptag”? I think this must be a mistake.

71. Line 371-373: Please rephrase this sentence. 

72. Line 374: “to face their fears and fears in the face of” the double “fears” here is confusing.

73. Line 382-383: “protect him from the impact that knowing about the situation of his disease may have on his life” change to “protect them from the impact that knowing about the situation of their condition may have on their life”

74. Line 388: “All this situation…”

75. Line 390: “the veracity of the information by the people” the meaning here is unclear; should this be the veracity of the information provided by the people”?

76. Line 392: “to an improvement of…” I think this should be: “with an improvement in…” 

77. Line 394: “the moment of the process he is living” change to: “their end-of-life stage.”

78. Line 399: “protection of added suffering” change to “protection from added suffering” 

79. Line 401: Delete “himself”

80. Line 405: Space after “perceive”

81. Line 409: “refers that this search” “refers” is the wrong word; states, implies, suggests? 

82. Line 411: “his” change to “their” 

83. Line 418: Delete “of it” 

84. Line 422: “the professionals they accompany” This is confusing; how about "for health care professionals.”

85. Line 429-430 “low percentage of patients with palliative needs who receive this care (14% of those who need it).” Change to: “low percentage (14%) of patients with palliative needs who receive this care.”

86. Line 431: Unnecessary hyphen “pa-liative care” 

87. Line 437: Unnecessary quotation marks: “professionals".” 

88. Line 439: “and that respond” change to “responsive” 

89. Line 440: “identify the competencies of health professionals who comprehensively address” change to “identify the competencies necessary for health professionals to comprehensively address”

I repeat my first comment: The paper needs to be thoroughly edited for English spelling and particularly grammar. Below, among my detailed comments, I have picked out some obvious issues that jumped out as I was reading through; however, I strongly suggest that the authors ask a native English speaker, preferable an expert in the field, to edit the paper. Using grammar-checking software might also help to improve the paper. A good editor might also make suggestions for improving the flow of ideas.

Author Response

Dear editor and reviewers,

We appreciate your interest and opinions about our research article. It is very pleasing to realize this topic is interesting and useful for you. We would like to express our gratitude for reviewing this manuscript and for the proper corrections, which help us conduct more rigorous and quality research.

We have detailed below the changes that have been made in the original article: " How to accompany the suffering of the patient and the family in the final process of life: A qualitative study”.

Modifications have been made following the reviewers’ comments. Each modification is indicated by quoting the reviewer´s comment in addition to the page and line number, followed by the change that has been made in response to that comment.

In the manuscript, the changes have been written in red to make it easier to detect.

As requested, we have carried out a full assessment of the English wording of the manuscript.

Thank you so much.

REVISOR 3

I am very grateful for the opportunity to read and review this paper from colleagues in Spain, who are obviously dedicated to providing quality, meaningful care to both patients and families at the end of the patient’s life. It is a very important field, and this paper offers some important insights into patient and family needs. There are a number of issues that need to be addressed, however, before it is ready for publication. 

Firstly, the paper needs to be thoroughly edited for English spelling and particularly grammar. Below, among my detailed comments, I have picked out some obvious issues that jumped out as I was reading through; however, I strongly suggest that the authors ask a native English speaker, preferable an expert in the field, to edit the paper. Using grammar-checking software might also help to improve the paper. A good editor might also make suggestions for improving the flow of ideas.

We fully agree with what you say, we appreciate the recommendations made and the time spent on them. The article will be reviewed again by a native translator to correct existing spelling and grammar errors. We thank you again for your valuable contribution to the improvement of this study.

Secondly, I would like the authors to address the limitations of the study in the discussion.

Thirdly, I would like the authors to mention the future directions, or next steps for the research in the discussion and/or conclusion. The authors offer many suggestions and admonitions: E.g., “a sustainable, quality and accessible palliative care system must be integrated into the context of primary health care…” However, the authors do not give any suggestion of how we might go about doing that. Addressing future research directions might go some way to answering that issue..

Thank you very much for this accurate assessment, we have included at the end of the discussion a section on limitations, as well as another section on conclusions of interesting aspects that are transferred from this research. We are very grateful for such a brilliant suggestion.

Below I offer some detailed comments. I hope they are useful.

1. Title: change the period after “life” to a colon 

Thank you for the appreciation, We have proceeded to update the title by including 2 points.

2. Abstract: The abstract is full of spelling and grammar issues. Line 9, for example, contains the spelling error “Blackground”, the word “the” preceding “death” is redundant, and the comma following “death” is not necessary. This is just one line; the whole abstract/manuscript needs checking.

Thank you for the appreciation, Spelling errors have been corrected and the manuscript has been thoroughly revised by a native translator to improve reading comprehension

2. Line 9: You use the word “problem” for describing end of life and death; I’m not sure this is the correct word. Death is not really a problem, it is a natural occurrence.

Thank you very much for the appreciation, we have made a semantic error, to solve it, we have replaced the word "problem" with another that gives a meaning of natural occurrence.

3. Lines 10-11: “being the exclusive domain of health institutions. The patient no longer dies at home..” Is this perhaps exaggerated or does it describe the situation in Spain? While many in the country I live do die in institutions, a large percentage die at home. 

Thank you, it was a phrase magnified by the original author which is referenced, but understanding what you are proposing, we have corrected the sentence by: “assuming it as part of life, as the majority domain of health institutions. The patient dies less and less at home”

4. Line 13: The meaning of this is unclear: “the externalization of the end of life at home” 

Again, you are very correct with your proposal, we have changed the sentence to "assuming in this new hedonistic society, the need to promote the end of life at home".

6. Line 13: is there a word missing here? “The main of this article…” “The main purpose…”? 

Thank you for your appointed, The word "objective" has been added.

7. Line 17: “This research adheres to…” Change verb “adheres” to past tense.  

Thank you for your advice, it was a grammatical error, we have modified it.

8. Lines 19-21: The results section reads more like a conclusion statement. 

Thank you, we have modified the wording of the results to improve your reading comprehension and emphasize the most significant ones.

9. Line 20: The meaning of “in the final process” is not clear. It is not a phrase commonly used in English to describe end of life issues (as far as I am aware). 

As you explain in your review, we have had many problems in the translation, as well as many reading comprehension failures that have been improved thanks to the complete translation by a native translator, in this case, we have changed "in the final process" to "at the end of life".

10. Introduction: Line 29. There is no need to start a new paragraph here. 

Thank you, the paragraphs have been consolidated.

11. Lines 32-35: This sentence is not complete; the clause: “where the availability of informal caregivers” is not resolved.

Thanks again, the phrase has been rephrased to make sense.

12. Lines 37-38: This part of the sentence is not well articulated: “so we are facing a process of suffering of the patient and the family, as well as a demand for care that increases without obtaining a response” 

Thanks, The question has been rephrased to make sense.

13. Lines 39-40: See my comment 3 about the word “problem.”

Thank you again for your thorough and clarifying review, in this case the word "problem" has been replaced by "issue".

14. Line 40-41: Change “Patient no longer dies at home” to “These days, patients rarely die at home…”

Changed

15. Line 42: Add a comma after “unknown”. For clarity, I think it is best to the Oxford comma throughout your manuscript: https://www.oxford-royale.com/articles/oxford-comma/

A comma has been added after "unknown".

16. Line 44: “the meaning of it will be designed to the extent” I can’t understand what is meant by “meaning of it will be designed”.

The phrase has been reworded to make sense, thank you very much.

17. Line 45: “The meaning of “so” is unclear.

The sentence has been deleted and reworded, in line with the previous one.

18. Line 45-46. You should start a new sentence beginning at the point of “this construct…” 

Thank you again, we have taken into account the proposal you are proposing and a new sentence begins.

19. Line 49: “human death and death” should this be “human life and death”?  

Sure enough, the error has been corrected and "human life and death" has been added.

20. Line 51: The meaning of “the closest human behavior” is unclear.

Thank you very much, the phrase has been rephrased to make sense.

21. Line 55: “Death” doesn’t need capitalization here.

The word "death" has been lowercased.

22. Line 55: Comma needed after “family”.

Thank you, Comma has been added.

23. Lines 56-57: The meaning is unclear: “in which we tend more to have than to be and to achieve 56 the facts with great immediacy, added to a great social intolerance to frustration,” 

The sentence has been reworded so that it has a better reading comprehension thanks to the native translator.

24. Line 61: No need for capitalization here “Family Unit, Patient and Family” 

Corrected capitalization.

25. Line 62: “during this stage” is redundant

Redundant information has been removed from the text.

26. Line 67: “their role” is repeated; please rephrase. 

Repeated information has been removed and modified to improve reading comprehension, thank you very much

27. Line 73: Change “article” to “study”

The word article has been replaced by study.

28. Line 74: “what patients and families need at the end of life” Only the patient is at the end of life, not the family. You’ll need to rephrase this.

The phrase has been reworded, thank you very much

29. At some point in the introduction, I think you should explain the concept of end-of-life accompaniment, before you discuss it as being the objective of your study. I think this would also help the flow of the introduction.

Thank you very much for your appreciation, which we will take into account in the development of the manuscript introduction

30. Objectives: Lines 77-87: I think it would be better to form this section into paragraphs rather than lists. 

The objectives have been reformulated in paragraphs.

31. Line 96: Begin a new sentence here: “a search process” 

Thank you for your appreciation, we have started a new sentence.

32. Line 101: “MYP” Please define all abbreviations at first mention in the text.

Your appreciation is very timely, we have changed the acronym to PAI, and they have been previously specified.

33. Lines 121-122: “thematic guide developed by 121 the research team” Maybe it would be helpful to share this as an appendix.

Once the research team has been assembled, we wanted to ignore this as an appendix, since it is deduced from the previous and emerging categories, but we can provide it to you if you need it, as well as any other tool of the study.

34. Lines 123-124: “Do you feel accompanied during this process, what would you need to be accompanied?” This seems to be two questions.

Thank you very much, that's right, as you perceive it, They have been rephrased as two questions.

35. Line 134: These paragraphs can be joined.

The paragraphs have been joined.

36. Line 154: Please use square brackets for references “(17)” [17] 

Brackets have been changed to square brackets.

37. Line 160: This seems contradictory: “a research team member who did not belong to the same research group” 

You are absolutely right, we are referring to a member of the research team (more numerous), who does not coincide with those researchers who have developed this study from which this manuscript emerges.

Thank you for the appreciation because it is true that it was not well understood, thank you very much.

38. Line 162: “ATLAS.ti software” Please include details of the software manufacturer, city, and country. 

This information has been included "©2023 ATLAS.ti Scientific Software Development GmbH, based in Berlin, Germany".

39. Line 166: What is the meaning of: “23.”

The meaning of 23 refers to the version of the software, we have specified it in the article by adding version 23.

40. Line 172: “group” should be plural 

It has been written group in the plural, thanks

41. Lines 181-182: These paragraphs can be joined. 

The paragraphs have been joined.

42. Lines 182-185: For clarity, I think it would be better to separate the sentences, introducing the contents of tables 1 and 2 separately. 

We really appreciate your appreciation, but we really want to emphasize the resulting categories between the two groups by detailing specifically how each of them came about and on what basis of what techniques. Although they were initially in a single table, we had to divide it into two so that the reader can discern the thinking of each group of informants.

While we greatly appreciate his advice, in fact, it was initially like this and we broke it down to improve reading comprehension

43. “The emerging results obtained are highlighted in grey” Nothing in the tables is highlighted in grey. 

Thank you very much for your wise comment, we have highlighted the emerging results in grey.

44. Table 2: “Family claudication” I don’t think “claudication” is the correct word. I think it refers to a pain in your legs (thigh, calf, or buttocks).

What an interesting comment, in the Mediterranean area of Europe, we associate this term, surrender, when the family is so exhausted that it withdraws, burns out or gives up, that's how we define it. Your appreciation is very important, so we allow ourselves to modify it.

45. Lines 194 and 201: The meaning of “them” is unclear in these sentences. 

The word "them" has been replaced by a clearer word on both lines.

46. Line 195: Change “following graphic” to Figure 1 and rename “Illustration 1” as Figure 1, too. 

Changed "next chart" to Figure 1 and renamed Figure 1 to Figure 1.

47. Line 204-205: These paragraphs can be joined.

Paragraphs have been joined.

48. Lines 212-215 should come before Table 3.

Thank you very much, we have modified it.

49. Line 222: Table 4: “in the end of life” change to “at the end of life”.

The fix has been made.

50. Line 225: Please delete “On the other hand” 

"On the other hand" has been removed.

51. Line 226: “going through this stage” not clear, change to something like “approaching the end of life”

Se ha cambiado “going through this stage” for “approaching the end of life”.

52. Line 277: I can’t understand this sentence: “Once the common dimensions for both were analyzed, we found 2 of the patients.” 

Thank you so much. We've added "we found 2 differences about needs of patients" to make it more meaningful.

53. Line 278: Check spacing after “dimension”

Sure enough, there were two spaces. A space has been deleted.

54. Line 280: Put a comma after “receive care” 

A comma has been added.

55. Lines 282 and 287: Text in bold face.

Bold text has been removed.

56. Line 287: “Family claudication” See comment 44 above, thank you so much
57. Lines 295 and 297: Change the verb here: “put the medication” to “give the medication” 

The verb "put" has been changed to "give".

58. Line 314: I think “tandem” is the wrong word here.

The word "tandem" has been changed.

59. Lines 312 and 315: Repeating of the same phrase “The results highlight the importance of” This sounds very awkward. 

Se ha modificado la frase por “Besides, it is really important to have a comprehensive approach”

60. Line 318: “refers to” Change to “gives for” 

Changed "refers to" to "gives for".

61. Line 321: “The needs demanded in this study both by the patients interviewed and in the family population…”  change to “The needs of the patients and in their families identified in this study…”  

Thank you very much for this appreciation, this amendment has been taken into account.

62. Line 323: “as needs that need to be addressed by health professionals” the double need and needs here sounds awkward. 

Las necesidades de los pacientes y sus familias identificadas en este estudio abarcan todas las dimensiones del ser humano como deseos que requieren ser atendidos por los profesionales de la salud”.

64. Line 329: The meaning here is not clear: “during the helping relationship of the person who suffers” 

The phrase has been modified to make it easier to understand, thank you so much

65. Line 337: Comma after “psychological”

Comma has been added.

66. Line 340: “for help” change to “to help” 

Se ha cambiado “for” por “to”.

67. Line 344: “The presence” delete “The”: “Presence…”  

"the" has been deleted.

68. 68. Lines 355-358: This sentence is very awkwardly written, which makes it a little difficult to understand.

Thank you for the comment, we have proceeded to translate the entire manuscript again by a native translator,

69. Line 367: “his family” change to “their family” 

It has been replaced by "their".

70. Line 371: “relationshiptag”? I think this must be a mistake.

You are absolutely right, the error has been corrected.

71. Line 371-373: Please rephrase this sentence. 

We have proceeded to translate the manuscript again, including this sentence.

72. Line 374: “to face their fears and fears in the face of” the double “fears” here is confusing.

"and fears" has been deleted.

73. Line 382-383: “protect him from the impact that knowing about the situation of his disease may have on his life” change to “protect them from the impact that knowing about the situation of their condition may have on their life”

The sentence has been replaced by the proposal.

74. Line 388: “All this situation…”

"all" has been deleted.

75. Line 390: “the veracity of the information by the people” the meaning here is unclear; should this be the veracity of the information provided by the people”?

The phrase has been clarified to include "the veracity of the information provided by the people".

76. Line 392: “to an improvement of…” I think this should be: “with an improvement in…” 

Changed "to" to "with".

77. Line 394: “the moment of the process he is living” change to: “their end-of-life stage.”

His recommendation has been taken into account. Thanks

78. Line 399: “protection of added suffering” change to “protection from added suffering” 

Changed "of" to "from".

79. Line 401: Delete “himself”

"himself" has been deleted

80. Line 405: Space after “perceive”

A space has been deleted. There were 2.

81. Line 409: “refers that this search” “refers” is the wrong word; states, implies, suggests? 

Changed "refers" to "suggests".

82. Line 411: “his” change to “their” 

"his" has been changed to "their".

83. Line 418: Delete “of it” 

"of it" has been deleted

84. Line 422: “the professionals they accompany” This is confusing; how about "for health care professionals.”

Thank you very much, your suggestion has been taken into account.

85. Line 429-430 “low percentage of patients with palliative needs who receive this care (14% of those who need it).” Change to: “low percentage (14%) of patients with palliative needs who receive this care.”

Your suggestion has been taken into account, Thanks

86. Line 431: Unnecessary hyphen “pa-liative care” 

The hyphen has been deleted, Thanks

87. Line 437: Unnecessary quotation marks: “professionals".” 

Quotation marks have been removed.

88. Line 439: “and that respond” change to “responsive” 

Changed "and that respond" to "responsive"

89. Line 440: “identify the competencies of health professionals who comprehensively address” change to “identify the competencies necessary for health professionals to comprehensively address”

Your suggestion has been taken into account. Thanks

I repeat my first comment: The paper needs to be thoroughly edited for English spelling and particularly grammar. Below, among my detailed comments, I have picked out some obvious issues that jumped out as I was reading through; however, I strongly suggest that the authors ask a native English speaker, preferable an expert in the field, to edit the paper. Using grammar-checking software might also help to improve the paper. A good editor might also make suggestions for improving the flow of ideas.

We appreciate the recommendations and the time spent on them. The article will be reviewed again by a native speaker to correct existing spelling and grammar errors. We thank you again for your valuable contribution to the improvement of this study.

Author Response File: Author Response.pdf