Background: The PACE Steps to Success programme is a complex educational and development intervention to improve palliative care in nursing homes. Little research has investigated processes in the cross-cultural adaptation and implementation of interventions in palliative care across countries, taking account of differences in health and social care systems, legal and regulatory policies, and cultural norms. This paper describes a framework for the cross-cultural development and support necessary to implement such an intervention, taking the PACE Steps to Success programme as an exemplar.
Methods: The PACE Steps to Success programme was implemented as part of the PACE cluster randomised control trial in seven European countries. A three stage approach was used, a) preparation of resources; b) training in the intervention using a train-the-trainers model; and c) cascading support throughout the implementation. All stages were underpinned by cross-cultural adaptation, including recognising legal and cultural norms, sensitivities and languages. This paper draws upon collated evidence from minutes of international meetings, evaluations of training delivered, interviews with those delivering the intervention in nursing homes and providing and/or receiving support.
Results: Seventy eight nursing homes participated in the trial, with half randomized to receive the intervention, 3638 nurses/care assistants were identified at baseline. In each country, 1–3 trainers were selected (total n = 16) to deliver the intervention. A framework was used to guide the cross-cultural adaptation and implementation. Adaptation of three English training resources for different groups of staff consisted of simplification of content, identification of validated implementation tools, a review in 2 nursing homes in each country, and translation into local languages. The same training was provided to all country trainers who cascaded it into intervention nursing homes in local languages, and facilitated it via in-house PACE coordinators. Support was cascaded from country trainers to staff implementing the intervention.
Conclusions: There is little guidance on how to adapt complex interventions developed in one country and language to international contexts. This framework for cross-cultural adaptation and implementation of a complex educational and development intervention may be useful to others seeking to transfer quality improvement initiatives in other contexts.
Importance: High-quality evidence on how to improve palliative care in nursing homes is lacking.
Objective: To investigate the effect of the Palliative Care for Older People (PACE) Steps to Success Program on resident and staff outcomes.
Design, Setting, and Participants: A cluster-randomized clinical trial (2015-2017) in 78 nursing homes in 7 countries comparing PACE Steps to Success Program (intervention) with usual care (control). Randomization was stratified by country and median number of beds in each country in a 1:1 ratio.
Interventions: The PACE Steps to Success Program is a multicomponent intervention to integrate basic nonspecialist palliative care in nursing homes. Using a train-the-trainer approach, an external trainer supports staff in nursing homes to introduce a palliative care approach over the course of 1 year following a 6-steps program. The steps are (1) advance care planning with residents and family, (2) assessment, care planning, and review of needs and problems, (3) coordination of care via monthly multidisciplinary review meetings, (4) delivery of high-quality care focusing on pain and depression, (5) care in the last days of life, and (6) care after death.
Main Outcomes and Measures: The primary resident outcome was comfort in the last week of life measured after death by staff using the End-of-Life in Dementia Scale Comfort Assessment While Dying (EOLD-CAD; range, 14-42). The primary staff outcome was knowledge of palliative care reported by staff using the Palliative Care Survey (PCS; range, 0-1).
Results: Concerning deceased residents, we collected 551 of 610 questionnaires from staff at baseline and 984 of 1178 postintervention in 37 intervention and 36 control homes. Mean (SD) age at time of death ranged between 85.22 (9.13) and 85.91 (8.57) years, and between 60.6% (160/264) and 70.6% (190/269) of residents were women across the different groups. Residents’ comfort in the last week of life did not differ between intervention and control groups (baseline-adjusted mean difference, -0.55; 95% CI, -1.71 to 0.61; P = .35). Concerning staff, we collected 2680 of 3638 questionnaires at baseline and 2437 of 3510 postintervention in 37 intervention and 38 control homes. Mean (SD) age of staff ranged between 42.3 (12.1) and 44.1 (11.7) years, and between 87.2% (1092/1253) and 89% (1224/1375) of staff were women across the different groups. Staff in the intervention group had statistically significantly better knowledge of palliative care than staff in the control group, but the clinical difference was minimal (baseline-adjusted mean difference, 0.04; 95% CI, 0.02-0.05; P < .001). Data analyses began on April 20, 2018.
Conclusions and Relevance: Residents' comfort in the last week of life did not improve after introducing the PACE Steps to Success Program. Improvements in staff knowledge of palliative care were clinically not important.
Trial Registration: ISRCTN Identifier: ISRCTN14741671.
Context: To provide high-quality palliative care to nursing home residents, staff need to understand the basic principles of palliative care.
Objectives: to evaluate the extent of agreement with the basic principles of palliative care of nurses and care assistants working in nursing homes in five European countries and to identify correlates.
Methods: This is a cross-sectional study in 214 homes in Belgium, England, Italy, the Netherlands, and Poland. Agreement with basic principles of palliative care was measured with the Rotterdam MOVE2PC. We calculated percentages and odds ratios of agreement and an overall score between 0 (no agreement) and 5 (total agreement).
Results: Most staff in all countries agreed that palliative care involves more than pain treatment (58% Poland to 82% Belgium) and includes spiritual care (62% Italy to 76% Belgium) and care for family or relatives (56% Italy to 92% Belgium). Between 51% (the Netherlands) and 64% (Belgium) correctly disagreed that palliative care should start in the last week of life and 24% (Belgium) to 53% (Poland) agreed that palliative care and intensive life-prolonging treatment can be combined. The overall agreement score ranged between 1.82 (Italy) and 3.36 (England). Older staff (0.26; 95% confidence interval [CI]: 0.09–0.43, P = 0.003), nurses (0.59; 95% CI: 0.43–0.75, P < 0.001), and staff who had undertaken palliative care training scored higher (0.21; 95% CI: 0.08–0.34, P = 0.002).
Conclusions: The level of agreement of nursing home staff with basic principles of palliative care was only moderate and differed between countries. Efforts to improve the understanding of basic palliative care are needed.
OBJECTIVE: The Canadian province of Quebec has recently legalized medical aid in dying (MAID) for competent patients who satisfy strictly defined criteria. The province is considering extending the practice to incompetent patients. We compared the attitudes of four groups of stakeholders toward extending MAID to incompetent patients with dementia.
METHODS: We conducted a province-wide postal survey in random samples of older adults, informal caregivers of persons with dementia, nurses, and physicians caring for patients with dementia. Clinical vignettes featuring a patient with Alzheimer's disease were used to measure the acceptability of extending MAID to incompetent patients with dementia. Vignettes varied according to the stage of the disease (advanced or terminal) and type of request (written or oral only). We used the generalized estimating equation (GEE) approach to compare attitudes across groups and vignettes.
RESULTS: Response rates ranged from 25% for physicians to 69% for informal caregivers. In all four groups, the proportion of respondents who felt it was acceptable to extend MAID to an incompetent patient with dementia was highest when the patient was at the terminal stage, showed signs of distress, and had written a MAID request prior to losing capacity. In those circumstances, this proportion ranged from 71% among physicians to 91% among informal caregivers.
CONCLUSION: We found high support in Quebec for extending the current MAID legislation to incompetent patients with dementia who have reached the terminal stage, appear to be suffering, and had requested MAID in writing while still competent.
Purpose: The dignity of patients is a major concern among health professionals engaged in the care of individuals with advanced cancer. Although several dignity promoting interventions have been developed, none of them have focused on a positive, resource-based approach. The aim of our study, entitled Revie, was to assess the feasibility and acceptability of a theory-guided life-review intervention, focusing on strength and resources, for patients with advanced cancer and for nurses delivering the intervention.
Method: Our 2015–2016 study was conducted with patients with advanced cancer in an ambulatory and an inpatient setting of a Swiss university hospital. An embedded concurrent mixed method design was used. The feasibility and acceptability of Revie was explored, as were changes in the sense of dignity, posttraumatic growth, and satisfaction with life.
Results: A total of 41 patients received the intervention. The level of attrition was low (26%). Administering the Revie intervention proved to be feasible. Participants (patients and nurses) considered the intervention helpful with a high level of satisfaction. A merged data analysis highlighted the need to address the patients’ existential concerns. The majority of the participants found that the intervention helped them, and they recommend it for other patients.
Conclusions: This study indicates that the Revie intervention, which focuses on a resource-based approach, was perceived favorably by all of the participants. A change in the nurse-patient relationship was noted and it was deemed to be beneficial.
BACKGROUND: Despite their poor prognosis, patients with severe chronic obstructive pulmonary disease (COPD) have little access to palliative care and tend to have a high rate of hospital and intensive care unit (ICU) admissions during their last year of life.
OBJECTIVES: To determine the feasibility of a home palliative care intervention during 1 year versus usual care, and the possible impact of this intervention on emergency, hospital and ICU admissions, survival, mood, and health-related quality of life (HRQL).
METHODS: Prospective controlled study of patients with severe COPD (GOLD stage III or IV) and long-term oxygen therapy and/or home noninvasive ventilation and/or one or more hospital admissions in the previous year for acute exacerbation, randomized to usual care versus usual care with add-on monthly intervention by palliative care specialists at home for 12 months.
RESULTS: Of 315 patients screened, 49 (15.5%) were randomized (26 to early palliative care; 23 to the control group); aged (mean ± SD) 71 ± 8 years; FEV1 was 37 ± 14% predicted; 88% with a COPD assessment test score > 10; 69% on long-term oxygen therapy or home noninvasive ventilation. The patients accepted the intervention and completed the assessment scales. After 1 year, there was no difference between groups in symptoms, HRQL and mood, and there was a nonsignificant trend for higher admission rates to hospital and emergency wards in the intervention group.
CONCLUSION: Although this pilot study was underpowered to formally exclude a benefit from palliative care in severe COPD, it raises several questions as to patient selection, reluctance to palliative care in this group, and modalities of future trials.
BACKGROUND: Despite having similar palliative needs to patients with lung cancer, advanced chronic obstructive pulmonary disease (COPD) patients are less likely to receive palliative care. To evaluate the effect of introducing specialized palliative care with severe to very severe COPD patients, a randomized controlled trial (RCT) was conducted in Switzerland.
AIM: To explore COPD patients' recollection of the trial, their needs and the usefulness of the palliative care interventions.
DESIGN AND SETTING: Qualitative study with advanced COPD patients who participated in a specialized palliative care intervention, conducted in a general hospital.
METHOD: Eighteen patients with severe to very severe COPD were interviewed about their experiences. Interviews were transcribed and thematic content analysis was performed.
RESULTS: Patients had poor recollection of the trial and difficulties understanding the palliative care intervention. No major differences were observed between patients who received the specialized intervention and those who did not. Content analysis emphasized that although they experienced disabling symptoms, participants tended to attribute their limitations to problems other than COPD and some declared that they were not sick. Patients reported restrictions due to oxygen therapy, and the burden of becoming dependent on it. This dependence resulted in intense anxiety, leading participants to focus on the present only. A strong feeling of perceived helplessness emerged from the patients' interviews.
CONCLUSIONS: Our findings suggest that poor recollection and understanding of the palliative care intervention act as barriers to the conduct of clinical trials with severe and very severe COPD patients. Their cognitive difficulties, perception of COPD, functional limitations, overwhelming anxiety, focus on the present and perceived helplessness also seem to hinder the implementation of such care.
Objectives: To elicit Quebec physicians’ attitudes towards extending medical aid in dying (MAiD) to incompetent patients and to compare the attitudes of family physicians to those of other medical specialists.
Methods: We conducted a postal survey among physicians caring for patients with dementia. We used hypothetical vignettes to elicit their attitudes towards MAiD and continuous deep sedation (CDS) to relieve suffering at end of life. Two patients were depicted in the vignettes: one with cancer eligible for MAiD and one with dementia. The generalized estimating equation approach was used to investigate factors associated with attitudes, including the stage of the illness (advanced vs terminal dementia) and the presence or absence of a prior written request.
Results: A total of 136 physicians out of 653 returned the questionnaire. Physicians favoured CDS over MAiD for relieving suffering in the cancer vignette (93% vs 79%; p = 0.002). In advanced dementia, 45% of physicians supported giving the patient access to MAiD with a written request and 14% without such request. At the terminal stage of dementia, these proportions increased to 71% and 43%, respectively (p < 0.001), reaching 79% and 52% among family physicians. Support for CDS in terminal dementia was lower than in end-stage cancer (68% vs 93%; p < 0.001) and equal to MAiD with a written request (68% vs 71%; p = 0.623).
Conclusion: Many Quebec physicians support extending MAiD to incompetent patients with dementia to relieve suffering at the terminal stage. This finding will inform current deliberations as to whether MAiD should be extended to these patients.
BACKGROUND: Given the worldwide increase of chronic diseases, expatriate health workers on assignment with humanitarian emergency organisations can face more clinical situations that require advanced pain control or palliative care. Multiple reasons can prevent the provision of this care.
AIM: To better know how health workers react to and cope with this dilemma.
DESIGN: A qualitative interview study using inductive thematic analysis was performed.
SETTING/PARTICIPANTS: A total of 15 expatriate health workers took part in individual in-depth interviews after their assignment with the organisation 'Médecins sans Frontières'.
RESULTS: Clinical situations requiring advanced pain control or palliative care do occur during assignments. Expatriate health workers have different levels of knowledge of pain control and palliative care. Lacking opioids were a main reason for inadequate pain control. The expatriates felt helpless, distressed and frustrated in such situations. Peer support was sometimes helpful. Guidelines for palliative care in emergency settings would have been useful.
CONCLUSION: Pain control and palliative care needs occur during clinical practice in emergency humanitarian assistance. Training for expatriate health workers should be improved. Humanitarian organisations should strengthen their capacity to provide pain control and palliative care by developing and applying adapted guidelines.
BACKGROUND: Several studies have highlighted the need for improvement in palliative care delivered to older people long-term care facilities. However, the available evidence on how to improve palliative care in these settings is weak, especially in Europe. We describe the protocol of the PACE trial aimed to 1) evaluate the effectiveness and cost-effectiveness of the 'PACE Steps to Success' palliative care intervention for older people in long-term care facilities, and 2) assess the implementation process and identify facilitators and barriers for implementation in different countries.
METHODS: We will conduct a multi-facility cluster randomised controlled trial in Belgium, Finland, Italy, the Netherlands, Poland, Switzerland and England. In total, 72 facilities will be randomized to receive the 'Pace Steps to Success intervention' or to 'care as usual'. Primary outcome at resident level: quality of dying (CAD-EOLD); and at staff level: staff knowledge of palliative care (Palliative Care Survey).
SECONDARY OUTCOMES: resident's quality of end-of-life care, staff self-efficacy, self-perceived educational needs, and opinions on palliative care. Economic outcomes: direct costs and quality-adjusted life years (QALYs). Measurements are performed at baseline and after the intervention. For the resident-level outcomes, facilities report all deaths of residents in and outside the facilities over a previous four-month period and structured questionnaires are sent to (1) the administrator, (2) staff member most involved in care (3) treating general practitioner, and (4) a relative. For the staff-level outcomes, all staff who are working in the facilities are asked to complete a structured questionnaire. A process evaluation will run alongside the effectiveness evaluation in the intervention group using the RE-AIM framework.
DISCUSSION: The lack of high quality trials in palliative care has been recognized throughout the field of palliative care research. This cross-national cluster RCT designed to evaluate the impact of the palliative care intervention for long-term care facilities 'PACE Steps to Success' in seven countries, will provide important evidence concerning the effectiveness as well as the preconditions for optimal implementation of palliative care in nursing homes, and this within different health care systems.
TRIAL REGISTRATION: The study is registered at www.isrctn.com - ISRCTN14741671 (FP7-HEALTH-2013-INNOVATION-1 603111) Registration date: July 30, 2015.
Euthanasia is a controversial and complex issue, especially when involving incompetent patients. On December 10, 2015, Quebec became the first Canadian province to give access to medical aid in dying (MAiD) (ie, euthanasia performed by a physician) to competent patients who satisfy strictly defined criteria. Less than 2 years later, Quebec is considering extending MAiD to incompetent patients who made an advance request. With the objective of contributing scientific data to current societal debates, we conducted a survey among 471 informal caregivers of persons with dementia, reached through Alzheimer Societies. We used a series of vignettes featuring a person with Alzheimer disease to investigate respondents' attitudes towards MAiD. The response rate was 69%. Two-thirds [68%; 95% confidence interval, 63%-73%] found it acceptable to extend MAiD to an incompetent patient at an advanced stage of Alzheimer disease who had made a written request while competent, and 91% (95% confidence interval, 87%-94%) found it acceptable at the terminal stage. Self-determination was the most widely endorsed argument in favor of access to MAiD for incompetent patients. Findings suggest strong support among informal caregivers for extending MAiD to incompetent patients, provided they are terminally-ill and had made a written request before losing capacity.
BACKGROUND: Humanitarian emergency organizations have only recently integrated care for non-communicable diseases into their relief action. The needs for palliative care in emergencies are still largely unmet.
OBJECTIVE: A systematic review of health programmes run by international humanitarian organizations that take palliative care and/or enhanced pain control into account.
METHODS: Electronic databases were searched for publications of health programmes providing palliative care and/or enhanced pain control in emergency situations. Health departments of major international organizations and experts were contacted for relevant information.
RESULTS: One publication on pain treatment in amputees in Freetown, Sierra Leone, fulfilled the selection criteria. International humanitarian organizations shared information on their programmes in the Democratic Republic of the Congo, Haiti, Kenya and Ukraine/Russia.
CONCLUSIONS: There is very little information available on palliative care and/or enhanced pain control in emergency settings. First programmes have just been initiated in the field. More emphasis on sharing experiences and publication could accelerate a broader integration of palliative care into humanitarian programmes.
BACKGROUND: Alzheimer's disease and related disorders affect a growing number of people worldwide. Quality of life is generally good in the early stages of these diseases. However, many individuals fear living through the advanced stages. Such fears are triggering requests for medical assistance in dying (MAiD) by patients with dementia. Legislation was recently passed in Canada and the province of Quebec allowing MAiD at the explicit request of a patient who meets a set of eligibility criteria, including competence. Some commentators have argued that MAiD should be accessible to incompetent patients as well, provided appropriate safeguards are in place. Governments of both Quebec and Canada are currently considering whether MAiD should be accessible through written requests made in advance of loss of capacity.
OBJECTIVE: Aimed at informing the societal debate on this sensitive issue, this study will compare stakeholders' attitudes towards expanding MAiD to incompetent patients with dementia, the beliefs underlying stakeholders' attitudes on this issue, and the value they attach to proposed safeguards. This paper describes the study protocol.
METHODS: Data will be collected via a questionnaire mailed to random samples of community-dwelling seniors, relatives of persons with dementia, physicians, and nurses, all residing in Quebec (targeted sample size of 385 per group). Participants will be recruited through the provincial health insurance database, Alzheimer Societies, and professional associations. Attitudes towards MAiD for incompetent patients with dementia will be elicited through clinical vignettes featuring a patient with Alzheimer's disease for whom MAiD is considered towards the end of the disease trajectory. Vignettes specify the source of the request (from the patient through an advance request or from the patient's substitute decision-maker), manifestations of suffering, and how close the patient is to death. Arguments for or against MAiD are used to elicit the beliefs underlying respondents' attitudes.
RESULTS: The survey was launched in September 2016 and is still ongoing. At the time of submission, over 850 respondents have returned the questionnaire, mostly via mail.
CONCLUSIONS: This study will be the first in Canada to directly compare views on MAiD for incompetent patients with dementia across key stakeholder groups. Our findings will contribute valuable data upon which to base further debate about whether MAiD should be accessible to incompetent patients with dementia, and if so, under what conditions.
La bronchopneumopathie chronique obstructive (BPCO) est une maladie fréquente, évolutive et mortelle. Contrairement à d’autres maladies chroniques, comme les maladies cardiovasculaires, sa prévalence ne cesse d’augmenter. De plus, il a été démontré que les patients atteints de BPCO peuvent développer une invalidité importante liée à leur maladie dans les années qui précèdent leur décès. L’objectif d’une prise en charge palliative des personnes vivant avec une BPCO avancée est de diminuer l’impact des symptômes et d’offrir un accompagnement pluridisciplinaire, dans le but de leur permettre de maintenir la meilleure qualité de vie possible.
CONTEXT: The Edmonton Symptom Assessment System is a brief, widely adopted, multidimensional questionnaire to evaluate patient-reported symptoms.
OBJECTIVES: To define a standard French version of the ESAS (F-ESAS), to determine the psychometric properties in French speaking patients Methods: In a first pilot study health professionals (n: 20) and patients (n: 33) defined the most adapted terms in French (F-ESAS). In a prospective multicentric study, palliative care patients completed the three forms of F-ESAS (F-ESAS-VI; VE; NU), the Hospital Anxiety and Depression Scale (HADS). All patients had a test-retest evaluation during the same half-day. Standardized distraction material was used between each scale. RESULTS: 124 patients were included (mean age (±SD): 68.3 ±12; 70F; 54 M). Test retest reliability was high for all 3 F-ESAS and the correlation between these scales was nearly perfect (Spearman rs=0.66-0.91; p< 0.05). F-ESAS-VI, VE and NU performed similarly and were equally reliable, although there was a trend towards lower reliability for F-ESAS-VI. Correlation between respectively F-ESAS depression and anxiety and HADS depression and anxiety were positive (Spearman rs=0.38-0.41 for depression; Spearman rs=0.48-0.57 for anxiety p< 0.05). Among patients, respectively 59 (48 %), 45 (36%) and 20 (16 %) preferred to assess their symptoms with F-ESAS-VE, F-ESAS-NU and F-ESAS-VI.
CONCLUSION: The F-ESAS is a valid and reliable tool for measuring multidimensional symptoms in French speaking patients with an advanced cancer. All forms of F-ESAS performed well with a trend for better psychometric performance for F-ESAS-NU, but patients preferred the F-ESAS-VE.
L'auteure, travaillant dans l'unité de gériatie et de soins palliatifs communautaires aux Hôpitaux Universitaires de Genêve, apporte son point de vue sur les directives anticipées : elles sont un droit du patient et non une obligation. Elle évoque également le projet de soins anticipé.
Lors de la confrontation à un cancer avancé, les patients peuvent éprouver un niveau élevé de détresse existentielle. Des pensées et des préoccupations autour de la mort peuvent surgir ; accompagnées de sentiments de perte de sens ou de découragement. Il est important de développer des interventions qui visent à soulager la détresse existentielle afin de promouvoir la dignité des personnes avec un cancer avancé. Dans le cadre d'une étude de faisabilité, une intervention intitulée Revie+ a été développée et réalisée auprès de 41 patients avec un cancer avancé dans un secteur ambulatoire et un secteur hospitalier d'un hôpital universitaire suisse. Le but de cet article est de présenter les résultats liés à l'acceptabilité de l'intervention pour les infirmières à travers un questionnaire, le suivi de notes personnelles et l'animation d'un focus groupe. Des statistiques descriptives sont utilisées pour l'analyse du questionnaire. Une analyse thématique a été effectuée pour le suivi des notes des infirmières et le focus groupe. Le croisement des résultats met en évidence que les infirmières perçoivent un effet bénéfique des interventions Revie+ autant pour les patients que pour leur posture professionnelle et souhaitent son implantation dans la pratique. Des recommandations sont proposées pour favoriser l'implémentation. [R.A.]
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La diminution des apports liquidiens oraux chez les patients cancéreux ou souffrant d’une autre maladie chronique avancée en fin de vie est un phénomène extrêmement fréquent et peut être une importante source d’anxiété pour le patient, sa famille ou les soignants. Une fois que toutes les mesures possibles pour améliorer la prise orale ont été tentées, se pose alors souvent la question d’introduire une hydratation artificielle pour laquelle les réponses divergent. Certains considèrent l’hydratation comme un traitement dont il est possible de s’abstenir ou de l’arrêter au même titre qu’un autre, alors que d’autres estiment que l’hydratation est un besoin fondamental à maintenir en toute circonstance. Les différents arguments participant à la décision d’introduire ou non une hydratation en fin de vie sont discutés.
Les auteurs présentent une étude prospective ouverte qui a duré un an concernant tous les patients hospitalisés pendant cette période pour qui une DAD (demande d'aide au décès) était formulée lors de leur séjour dans l'établissement.
[Contient] : p. 3 : Editorial - S Pautex. - p. 4-9 : Opioïdes dans le traitement des douleurs dues aux maladies chroniques évolutives - C Mazzocato. - p. 10-14 : Achtsamkeit, Akzeptanz und Imagination bei therapieresistenten Schmerzen [Attention, acceptation et imagination dans le traitement des douleurs résistantes] - F Mathier, S Büchi. - p. 15-20 : Il dolore neuropatico nelle cure palliative [La douleur neuropathique dans les soins palliatifs] - A Pigni, A Caraceni. - p. 21-28 : Interventionelle Schmerztherapie und therapieresistente Schmerzen in der Palliativmedizin [Traitement interventionnel de la douleur et douleurs persistantes en médecine palliative] - L M Macrea - p. 29-33 : Chronischer Schmerz, auch eine spirituelle Herausforderung [La douleur chronique - également un défi spirituel]/A. Eglin. Le dossier se termine par les recommandations (Bigorio 2006) Bigorio 2006 : Empfehlungen zu "Durchbruchschmerz" : Konsens zur best practice für Palliative Care in der Schweiz, Expertengruppe von palliative ch, der Schweiz/Gesellschaft für Palliative Medizin, Pfllege und Begleitung. Ein Projekt im Rahmen der Qualitätsförderung von Palliative Care in der Schweiz. Bigorio 2006 : Recommendations sur l'exacerbation douloureuse : consensus sur la meilleure pratique en soins palliatifs en Suisse/Groupe d'experts de palliative ch, Société Suisse de Médecine et de Soins Palliatifs. Un projet pour promouvoir la qualité en soins palliatif en Suisse. [+10 pages de recommendations]
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