Les connaissances anciennes et nouvelles de la notion d'éternité sont regroupées dans cette BD très concise et très claire permettant de comprendre la recherche actuelle et les enjeux philosophiques des choix de recherche par rapport à la mort.
Currently,Swiss Medical Weekly boasts a highly interesting and time-relevant contribution of Hug and colleagues, titled “Medical end-of-life decisions in the oldest old in Switzerland” which examines the differences between the oldest old and younger patients in terms of the frequency of various end-of-life decisions such as intensified alleviation of pain and other symptoms and, most notably, withholding and withdrawing life-sustaining treatments.
[Début de l'article]
AIMS OF THE STUDY: To analyse medical end-of-life decision making among the oldest old (80+ years) in Switzerland, focusing not only on treatments withheld or withdrawn but also on those continued until death.
METHODS: This was a retrospective follow-up study of deaths registered in Switzerland between August 2013 and January 2014 using a standardised questionnaire completed by the attending physician. All individuals aged 65 years and older who did not die suddenly and completely unexpectedly, and who had met the responding physician prior to death were included (n = 2842). We examined three age groups: 65–79, 80–89, and 90+ years. Logistic regression analysis was used to identify age-related differences, controlled for place of death and sociodemographic characteristics.
RESULTS: In 83.8% of the study population at least one medical end-of-life decision was made, and for 39.4% the use of a potentially life-sustaining treatment was documented. Alleviation of pain and other symptoms with a possible life-shortening effect was performed with 29% higher odds among the 90+-year-olds (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.01–1.66) than in the youngest age group. Withholding or withdrawing potentially life-sustaining treatment with or without the explicit intention to hasten death did not differ with age. However, when the frequency of withholding a potentially life-sustaining treatment was compared with the frequency of using this treatment (either continued until death or withdrawn later on), the former was more common in old age (80–89 years), and particularly in very old age (90+ years) for most of the treatments studied. This applied especially for ventilator therapy (80–89 years: OR 2.83, 95% CI 1.82–4.41; 90+ years: OR 6.17, 95% CI 2.89–13.17, compared with 65–79 years), artificial nutrition (ORs 2.33, 95% CI 1.46–3.71 and 4.44, 95% CI 2.28–8.65, respectively), and antibiotics (ORs 1.53, 95% CI 1.11–2.09 and 1.57, 95% CI 1.05–2.35, respectively). Age had no independent impact on artificial hydration.
CONCLUSIONS: The use of some potentially life-sustaining treatments decreased with older age and, in relation, the relative frequency of withholding such treatments increased. There may be various reasons for this finding: less benefit of a particular treatment in older patients for instance due to comorbidities, higher burden of treatment, and finally a tacit consensus of physicians and patients that death is nearing.
Interrogeons-nous sur la condition faite aux plus âgés d'entre nous. Leur vulnérabilité n'est-elle pas le résultat d'une accumulation de faits sociaux qui nous rendraient tous vulnérables ? Solitude et isolement, regard méprisant, sentiment d'inutilité, bouc émissaire économique... Faut-il ajouter, dès lors que l'on entre dans le secteur médico-social, l'incompréhension totale du dispositif, la multiplication des intervenants, les parcours ératiques ?
La personne qui vieillit, avec ses difficultés plus ou moins grandes, reste le sujet de son histoire et demande à être reconnue comme telle. La rencontre de la personne dans son plus grand dénuement déstabilise fortement. La reconnaissance d'une vulnérabilité récipropre pourrait être garante de la dimension éthique de la relation à l'autre. La vulnérabilité est ainsi du côté de l'interdépendance et de la responsabilité collective.
In the Netherlands, approximately 1300 women aged =75 years die every year of metastatic breast cancer (MBC). Data on palliative chemotherapy (CT) in very elderly patients are rare, and prospective studies appeared cumbersome. Therefore, we retrospectively analyzed the outcome and feasibility of chemotherapy in elderly MBC patients. Records of all patients with MBC aged =75 years who received first-line palliative chemotherapy between January 2000 and December 2014 at two large teaching hospitals in the Netherlands were reviewed. We registered patient and tumor characteristics together with data on previous adjuvant treatment, palliative endocrine treatment, comorbidities, clinical benefit (defined as =6 months progression-free survival), toxicity, and the reason for stopping chemotherapy. Patients with progressive disease (PD) or death within 30 days after starting CT were censored from analysis. A total of 54 patients with a median age of 77.6 years (range 75-90) were treated with palliative chemotherapy for MBC. Of them, 20 patients (37%) were aged = 80 years. There was clinical benefit in 28 patients (52%). Median progression-free survival and median overall survival were 6.0 and 14.0 months, respectively. One year after the diagnosis of MBC, 27 patients (50%) were still alive and 15 patients (28%) lived longer than 2 years. Reasons for stopping CT were progressive disease (n = 32) or toxicity (n = 13). Most patients (n = 48) died of MBC while two patients died of toxicity. In selected patients with MBC aged 75 years or older, single-agent palliative chemotherapy is feasible and may have clinical benefit.
The effect of hospice care on place of death among centenarians remained unexplored. Using data obtained from National Health Insurance Research Database (2002-2010), we compared the differences in place and cause of death between centenarians and noncentenarians. These data were stratified into centenarian (n = 2495) and noncentenarian (n = 820 563) death. Data in place and cause of death and hospice care interventions were retrieved. Poisson regression models were used to evaluate factors associated with the centenarians' place of death. Time series models were used to predict the number of centenarian deaths until 2025. Most (63.8%) of the centenarians died at their own homes, followed by 30.5% who died in hospital. Hospice home care was involved in only 0.3% of the centenarian deaths but in 1.8% of the noncentenarian deaths. The leading causes of death among centenarians were respiratory diseases (16.6%), circulatory diseases (15.2%), and pneumonia (14.8%). Among the centenarians, those who died of circulatory disease, old age, and respiratory diseases were more likely to die at their own homes. We forecasted the number of annual centenarian deaths to reach 800 in 2025. Therefore, an increase in the provision of advanced care planning and earlier home hospice care intervention may enable centenarians to die at their own residence.