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Consentir, entre liberté et contrainte

CECCALDI, Joël
LAENNEC, 2018, vol.66, n°4, p. 34-44

Document en ligne

Thème : Ethique et déontologie. Cote : 00.07LAE

EUTHANASIE ; FIN VIE ; ARRET THERAPEUTIQUE ; LIMITATION TRAITEMENT ; CONSENTEMENT ECLAIRE ; PATIENT ; CHOIX ; ETHIQUE SOIN

Libre et éclairé : voilà comment devrait être un consentement viable, valable et authentique, tant dans le monde de la santé que dans celui des affaires. Mieux même, et plus conforme à l’actualité, est qu’il soit « libre et informé » : cela met en avant la personne concernée plutôt que le message et sa source lumineuse forcément en surplomb. Telles sont en tout cas les conditions qui lui donnent son label aux plans de la loi et de la déontologie, si ce n’est à celui de l’éthique. Pour autant, liberté et information se situent-elles exactement au même niveau fondateur ? Jouent-elles des rôles symétriques dans le processus qui conduit au oui ?

Origine : Cairn

Advance care plan barriers in older patients with end-stage renal disease - a qualitative nephrologist interview study

O'RIORDAN, Julien ; NOBLE, Helen ; KANE, P. M. ; SMYTH, Andrew
BMJ supportive and palliative care, 25/06/2019, Pagination inconnue

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Thème : Age de la vie, situations spécifiques liées à la fin de vie.

FIN VIE ; PLANIFICATION ; SOIN ; DIALYSE ; ARRET THERAPEUTIQUE ; INSUFFISANCE RENALE ; PHASE TERMINALE ; PRISE EN CHARGE ; PERSONNE AGEE

OBJECTIVES: Older patients with end-stage renal disease are willing participants in advance care planning but just over 10% are engaged in this process. Nephrologists fear such conversations may upset patients and so tend to avoid these discussions. This approach denies patients the opportunity to discuss their end-of-life care preferences. Many patients endure medically intensive end-of-life scenarios as a result. This study aims to explore the rationale underpinning nephrologists' clinical decision-making in the management of older patients with end-stage renal disease and to make recommendations that inform policymakers and enhance advance care planning for this patient group.
METHODS: A qualitative interview study of 20 nephrologists was undertaken. Nephrologists were asked about their management of end-stage renal disease in older patients, conservative management, dialysis withdrawal and end-of-life care. Eligible participants were nephrologists working in Ireland. Five nephrologists participated in a recorded focus group and 15 nephrologists participated in individual digitally recorded telephone interviews. Semistructured interviews were conducted; thematic analysis was used to distil the results.
RESULTS: Three key themes emerged: barriers to advance care planning; barriers to shared decision-making; and avoidance of end-of-life care discussion.
CONCLUSIONS: Advance care planning is not an integral part of the routine care of older patients with end-stage renal disease. Absence of formal training of nephrologists in how to communicate with patients contributes to poor advance care planning. Nephrologists lack clinical experience of conservatively managing end-stage renal disease and end-of-life care in older patients. Key policy recommendations include formal communication skills training for nephrologists and development of the conservative management service.

Origine : PubMed

Experiences of caregivers desiring to refuse life-prolonging treatment for their elderly parents at the end of life

MAURA, Yuki ; YAMAMOTO, Mariko ; TAMAKI, Tomoko ; ODACHI, Ryo ; ITO, Mikiko ; KITAMURA, Yuri ; SOBUE, Tomotaka
International journal of qualitative studies on health and well-being, 06/2019, vol.14, n°1, 10 p.

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Thème : Soins. Cote : eD02.03.03

FIN VIE ; SOIN ; PERSONNE AGEE ; AIDANT NATUREL ; FAMILLE ; RECHERCHE QUALITATIVE ; ARRET THERAPEUTIQUE ; JAPON

Purpose: This study aimed to clarify the experiences of caregivers desiring to refuse life-prolonging treatment for their elderly parents at the end of life.
Methods: A semi-structured interview was performed for four family caregivers who wanted to refuse life-prolonging treatment suggested by the physicians.
Results: In this study, four caregivers who refused life-prolonging treatment suggested by the physicians for their elderly parents completed semi-structured interviews. The obtained data were analyzed in relation to the theme "Experiences of caregivers who desire to refuse life-prolonging treatment for their elderly parents at the end of life." As a result, 38 subcategories and 12 categories were extracted.
Conclusions: Participants in this study initially had a negative view of life-prolonging treatment. However, they agonized over the decision when they received conflicting advice from the physicians. The participants indicated that physicians' advice and attitudes complicated their decisions to reject life-prolonging treatment for their elderly parents.

Origine : PubMed

Pain and distress management in palliative neonatal care

GARTEN, Lars ; BÜHRER, Christoph
Seminars in fetal and neonatal medicine, 20/04/2019, Pagination inconnue

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Thème : Médecine.

NEONATALOGIE ; DEMARCHE PALLIATIVE ; CONTROLE DOULEUR ; DETRESSE PSYCHOLOGIQUE ; CONTROLE SYMPTOME ; ARRET THERAPEUTIQUE ; NUTRITION ; HYDRATATION ; RECOMMANDATION

Palliative care concentrates on preventing and relieving suffering by reducing the severity of disease symptoms. Consistent treatment of pain and distress must therefore be an integral component of every palliative care concept. In this review non-pharmacological and pharmacological measures for pain and distress management in the context of palliative neonatal care are summarised. Furthermore, recommendations are given focusing on two special palliative neonatal care settings: compassionate extubation and withdrawing artificial nutrition and hydration.

Should long-term life-sustaining care be started in emergency settings?

MELTZER, Ellen C. ; IVASCU, Natalia S. ; EDWIN, Mark K. ; INGALL, Timothy J.
AMA journal of ethics, 01/05/2019, vol.21, n°5, p. E401-406

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Thème : Ethique et déontologie. Cote : eD13.02

ARRET THERAPEUTIQUE ; ETHIQUE SOIN ; MALADIE CARDIOVASCULAIRE

Decision making on behalf of an incapacitated patient is challenging, particularly in the context of venoarterial extracorporeal membrane oxygenation (VA-ECMO), a medically complex, high-risk, and costly intervention that provides cardiopulmonary support. In the absence of a surrogate and an advance directive, the clinical team must make decisions for such patients. Because states vary in terms of which decisions clinicians can make, particularly at the end of life, the legal landscape is complicated. This commentary on a case of withdrawal of VA-ECMO in an unrepresented patient discusses Extracorporeal Life Support Organization guidelines for decision making, emphasizing the importance of proportionality in a benefits-to-burdens analysis.

Origine : PubMed

An ethical discussion on voluntarily stopping eating and drinking by proxy decision maker or by advance directive

CHRISTENSON, Julie
JOURNAL OF HOSPICE AND PALLIATIVE NURSING, 06/2019, vol.21, n°3, p. 188-192

Thème : Ethique et déontologie. Cote : e00.07JHP

DEMENCE ; MALADIE ALZHEIMER ; ARRET THERAPEUTIQUE ; ETHIQUE SOIN ; NUTRITION ; DIRECTIVE ANTICIPEE ; HYDRATATION ; PERSONNE CONFIANCE

The number of people living with Alzheimer disease and other dementias continues to grow because of the aging of the US population. Increasingly, the issue of patient- and/or surrogate-directed withholding of oral, hand-fed food and fluids in cases of late-stage dementia is confronting caregivers. Major media outlets have covered several cases wherein patients with explicit directives or clear surrogate decision making were not allowed to face the end of their lives according to their wishes. Ethical and legal scholars, as well as many end-of-life advocacy groups, are working to develop a framework and provide guidance in these cases. A local hospice organization was faced with these ethical deliberations when an activated proxy decision maker advocated for caregivers to stop hand feeding an incapacitated patient with end-stage dementia. In this article, this case is summarized, and this important ethical issue is presented in the setting of a literature review and nursing implications.

Does decision-making in end-of-life care differ between graduating medical students and experienced physicians?

ALMINOJA, Aleksi ; PIILI, Reetta P. ; HINKKA, Heikki ; METSÄNOJA, Riina ; HIRVONEN, Outi ; TYYNELÄ-KORHONEN, Kristiina ; KALEVA-KEROLA, Jaana ; SAARTO, Tiina ; KELLOKUMPU-LEHTINEN, Pirkko-Liisa I. ; LEHTO, Juho T.
In Vivo, 06/2019, vol.33, n°3, p. 903-909

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Thème : Soins. Cote : eD02.03

DECISION MEDICALE ; FIN VIE ; ETUDIANT ; MEDECINE ; ATTITUDE ; MEDECIN GENERALISTE ; FINLANDE ; ARRET THERAPEUTIQUE ; ETHIQUE SOIN ; EUTHANASIE

BACKGROUND/AIM: Appropriate decision-making in end-of-life (EOL) care is essential for both junior and senior physicians. The aim of this study was to compare the decision-making and attitudes of medical students with those of experienced general practitioners (GP) regarding EOL-care.
MATERIALS AND METHODS: A questionnaire presenting three cancer patient scenarios concerning decisions and ethical aspects of EOL-care was offered to 500 Finnish GPs and 639 graduating medical students in 2015-2016.
RESULTS: Responses were received from 222 (47%) GPs and 402 (63%) students. The GPs withdrew antibiotics (p<0.001) and nasogastric tubes (p=0.007) and withheld resuscitation (p<0.001), blood transfusions (p=0.002) and pleural drainage (p<0.001) more often than did the students. The students considered euthanasia and assisted suicide less reprehensible (p<0.001 in both) than did the GPs.
CONCLUSION: Medical students were more unwilling to withhold and withdraw therapies in EOL-care than were the GPs, but the students considered euthanasia less reprehensible. Medical education should include aspects of decision-making in EOL-care.

Origine : PubMed

Conservative care, dialysis withdrawal, and palliative care - results from a survey of a non-profit dialysis provider in Germany

POMMER, Wolfgang ; WAGNER, Sarah ; THUMFART, Julia
Kidney and blood pressure research, 2019, vol.44, n°2, p. 158-169

Document en ligne

Thème : Médecine.

ARRET THERAPEUTIQUE ; DIALYSE ; DEMARCHE PALLIATIVE ; ALLEMAGNE ; NEPHROLOGIE ; DECISION MEDICALE

BACKGROUND: In Germany, practice patterns of conservative renal care (CRC), dialysis withdrawal (DW), and concomitant palliative care in patients who choose these options are unknown.
METHOD: A survey was designed including 13 structured and one open questions on the management and frequency of CRC and DW, local palliative care structure, and fundamentals of the decision-making process, and addressed to the head physicians of all renal centers (n = 193) of a non-profit renal care provider (KfH - Kuratorium für Dialyse und Nierentransplantation, Neu-Isenburg, Germany).
RESULTS: Response rate was 62.2% (n = 122 centers) comprising 14,197 prevalent dialysis patients and 159,652 renal outpatients. Two-thirds of the respondents were men (85% in the age group between 45 and 64 years). Mean time of experience in renal medicine was 22.2 years in men, 20.8 years in women. 94% of all centers provided CRC with a different frequency and proportion of patients (mean 8.4% of the center population, median 5%, range 0-50%). Mean proportion of DW was 2.85% per year (median 2%, range 1-15%). Physicians and center features were not significantly associated with utilization of CRC or DW. Palliative care management varied including local palliative teams, support by general physicians, or by the renal team itself. Hospice care was only established in patients undergoing CRC. Fundamentals of the decision-making process were the desire of the patient (90% in CRC, 67% in DW). Patients undergoing CRC changed their opinion towards treatment modality "frequently" in 18% of the cases, "occasionally" in 73%. Physicians' decisions were mostly driven by presumed fatal prognosis and poor physical or mental conditions of the individual patient. Different barriers to provide palliative care for the renal population like lack of education in palliative medicine, shortness of staff, lack of financial resources, and local palliative care structures were reported.
CONCLUSION: Compared to international numbers, in Germany, proportion of CRC and DW reported by non-profit renal centers is in the lower range. Center practice of palliative care management varies and is driven by availability of local palliative care resources and presumably by attitudes of the renal teams. Quality of palliative care and the decision-making process need further evaluation.

Origine : PubMed

De la non-décision en situation complexe - le cas des personnes en état végétatif permanent

CRETIN, Elodie
" Le malade et la décision médicale ", PU de Franche-Comté - PUFC , 11/2018 , p. 77-98

Thème : Ethique et déontologie.

ETAT VEGETATIF ; PRISE DECISION ; ARRET THERAPEUTIQUE ; NUTRITION ARTIFICIELLE ; HYDRATATION ; RELATION PERSONNEL SOIGNANT FAMILLE ; RELATION PERSONNEL SOIGNANT PATIENT ; FAMILLE ; AUTONOMIE

Les personnes en état végétatif permanent posent des questions éthiques, sociétales notamment sur la poursuite ou non de la nutrition et de l'hydratation artificielles. Dans cet article, l'auteur explore les processus décisionnels à l'oeuvre dans ces situations.

Le bien mourir et la mort médicalisée

DAMAS, François
Droit et cultures, l'Harmattan, 2018, n°75, p. 165-181

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Thème : Ethique et déontologie. Cote : 13.00FOU

FIN VIE ; ARRET THERAPEUTIQUE ; SEDATION ; CONSENTEMENT ECLAIRE ; SUICIDE MEDICALEMENT ASSISTE ; EUTHANASIE ; DROIT ; BELGIQUE ; PATIENT

L’accompagnement médical de la vie finissante a évolué très fortement ces dernières décennies. Les décisions d’arrêts de traitements susceptibles de prolonger la vie sont devenues la norme des fins de vie en réanimation. Ailleurs la pratique de la sédation influence souvent le moment de la mort en raccourcissant la durée des agonies. L’intention du médecin de faire mourir son malade doit être reconnue et clairement assumée. Mais elle est secondaire par rapport à ce que souhaite le malade lui-même dans sa fin de vie. Quand celui-ci n’est plus capable de s’exprimer, les membres de sa famille ou ceux qu’il a désignés peuvent déterminer ce qu’aurait été sa volonté. Alors le médecin peut s’appuyer sur ces informations pour que le malade décède dans les meilleures conditions possibles correspondant à ses souhaits y compris un raccourcissement de son agonie. Radicalement autre est l’acte euthanasique réservé à ceux qui sont capables de demander une mort lucide et volontaire dans les conditions légales des pays qui l’ont rendu possible.

Requested withdrawal of mechanical ventilation in six patients with motor neuron disease

MESSER, Ben ; ARMSTRONG, Alison ; DORIS, Thomas ; WILLIAMS, Tim
BMJ supportive and palliative care, 03/04/2019, Pagination inconnue

Document en ligne

Thème : Ethique et déontologie.

FIN VIE ; SOIN ; ETHIQUE ; MALADIE NEUROLOGIQUE ; MALADIE RESPIRATOIRE ; ROYAUME UNI ; ARRET THERAPEUTIQUE ; VENTILATION ARTIFICIELLE

OBJECTIVES: Mechanical ventilation (MV) has been shown to improve survival and quality of life in motor neuron disease (MND). However, during the progression of MND, there may come a point when MV is no longer felt appropriate. Association of Palliative Medicine Guidelines have been recently published to help clinicians withdraw MV at the request of patients with MND in a safe and compassionate manner to ensure that symptoms of distress and dyspnoea are minimised.
METHODS: In this report, we discuss the palliative and ventilatory management of six ventilator-dependent patients with MND who had requested the withdrawal of MV as part of their end-of-life care.
RESULTS: We have withdrawn MV from six patients with MND at their request and our practice has been influenced by the Association of Palliative Medicine Guidelines.
CONCLUSION: Withdrawal of MV in MND at a patient's request is challenging but is also a fundamental responsibility of healthcare teams. We discuss the lessons we have learnt which will influence our practice and help other teams in the future.

Origine : PubMed

Should an advance care directive refusing life-sustaining treatment be respected after an attempted suicide? - development of an algorithm to aid health care workers

PHILPOT, Steve John
Journal of law and medicine, 04/2019, vol.26, n°3, p. 557-570

Thème : Ethique et déontologie.

SUICIDE ; ETHIQUE ; REANIMATION ; DIRECTIVE ANTICIPEE ; ARRET THERAPEUTIQUE ; AUSTRALIE

An advance care directive (ACD) is a written expression of a person's preferences in relation to health care, which can appoint a trusted substitute decision-maker, describe personal values, and make explicit decisions consenting to, or refusing, certain treatments. When a person with a directive refusing life-sustaining treatments attempts suicide, opinions are divided as to the degree to which health care staff are bound by such a directive. In this section, I will provide an example of a patient who presents to hospital after attempting suicide who has a valid ACD refusing life-sustaining treatment. I will then describe the legislation relevant to ACDs in Victoria, Australia and ethical arguments relating to the application of an ACD in this context. I will present a decision-making algorithm for health care staff faced with the difficult decisions arising from such a presentation.

Origine : PubMed

La décision d’arrêt des traitements spécifiques en oncologie

LAOUISSET, Céline ; WAECHTER, Lorraine ; ROSSI, Audrey ; LOUREIRO, Édith ; BAHYOU, Sabrina ; MARCHAL, Timothée ; BURNOD, Alexis ; BOULEUC, Carole
SOINS LA REVUE DE REFERENCE INFIRMIERE, 03/2019, vol.64, n°833, p. 38-40

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Thème : Ethique et déontologie.

DECISION MEDICALE ; ARRET THERAPEUTIQUE ; CANCEROLOGIE ; ETUDE LONGITUDINALE ; PRISE DECISION ; ACTEUR SOIN ; ETHIQUE SOIN

La décision médicale partagée est un processus complexe, notamment concernant l’arrêt des traitements spécifiques en oncologie. D’une part, le patient, plus vulnérable du fait d’une maladie avancée, et ses proches, redoutent cette interruption. D’autre part, l’oncologue dispose de plus en plus de possibilités thérapeutiques grâce aux avancées médicales réalisées ces dernières années. Une étude prospective observationnelle a été menée en oncologie. Elle s’est intéressée aux motifs faisant émerger le questionnement, au degré de concordance entre les différents interlocuteurs (équipe de soins palliatifs, oncologue, patients et proches) et à la décision finalement prise.

Deactivation of implantable defibrillators at end of life - can we do better?

KINCH WESTERDAHL, Annika ; MAGNSJÖ, Jackline ; FRYKMAN, Viveka
International journal of cardiology, 04/03/2019, Pagination inconnue

Document en ligne

Thème : Médecine.

ARRET THERAPEUTIQUE ; FIN VIE ; MALADIE CARDIOVASCULAIRE ; RECOMMANDATION ; SUEDE

INTRODUCTION: Dying patients with implantable defibrillators (ICD) have a risk of receiving unnecessary shocks before death. The aim of this study was to investigate if deactivation of shock therapy at end-of-life has increased since publication of new guidelines in 2010 on ICD management.
METHOD AND RESULTS: This is a study of two groups of ICD patients who died in hospitals before and after publication of new guidelines. Group 1 consists of 89 patients who died between 2003 and 2010. Group 2 consists of 252 patients, the total number of ICD patients in Sweden who died in hospital during 2014. Data was obtained from the Swedish ICD and Pacemaker Registry, Swedish Tax Agency and patient medical notes. Two-thirds died in wards other than Cardiology. Fifty-four percent in group 1 had a Do-Not-Resuscitate-order (DNR) compared to 73% in group 2. Shock deactivation was present in 52% in group 1 and 67% in group 2. The difference in shock deactivation between group 1 and 2 was only significant (p = 0.014) for DNR-patients treated in Cardiology. A significant difference (p = 0.036) was found in deactivation within group 2 between DNR-patients in Cardiology vs. DNR-patients in Non-Cardiology wards.
CONCLUSION: Two-thirds of ICD patients die in wards other than Cardiology. Since publication of guidelines on ICD management there is a general increase in shock deactivation for DNR-patients, but only significant for patients in Cardiology. This implicate that actions have to be taken for patients treated in Non-Cardiology wards to bridge the gap between guidelines recommendations and clinical practice.

Origine : PubMed

A tool to assess patient and surrogate knowledge about the POLST (Physician Orders for Life-Sustaining Treatment) program

HICKMAN, Susan E. ; TORKE, Alexia M. ; SACHS, Greg A. ; SUDORE, Rebecca L. ; MYERS, Anne L. ; TANG, Qing ; BAKOYANNIS, Giorgos ; HAMMES, Bernard J.
JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, 07/03/2019, Pagination inconnue

Document en ligne

Thème : Recherche - Evaluation - Méthodologie.

OUTIL ; EVALUATION ; CONNAISSANCE ; ARRET THERAPEUTIQUE ; PATIENT ; PERSONNE CONFIANCE

CONTEXT: It is especially important that patients are well-informed when making high stakes, preference-sensitive decisions like those on the Physician Orders for Life-Sustaining Treatment (POLST) form. However, there is currently no way to easily evaluate whether patients understand key concepts when making these important decisions.
OBJECTIVES: To develop a POLST knowledge survey.
METHODS: Expert (n = 62) ratings of key POLST facts were used to select items for a POLST Knowledge Survey. The survey was administered to nursing facility residents (n = 97) and surrogate decision-makers (n = 112). A subset (n = 135) were re-administered the survey after a standardized advance care planning discussion to assess responsiveness of the scale to change.
RESULTS: The 19-item survey demonstrated adequate reliability (α = 0.72.). Residents' scores (x = 11.4, standard deviation 3.3) were significantly lower than surrogate scores (x = 14.7, standard deviation 2.5) (p < .001). Scores for both groups increased significantly following administration of a standardized advance care planning discussion (p < .001). Although being a surrogate, age, race, education, cognitive functioning, and health literacy were significantly associated with higher POLST Knowledge Survey scores in univariate analyses, only being a surrogate (p < 0.001) and being white (p = 0.028) remained significantly associated with higher scores in multivariate analyses.
CONCLUSION: The 19-item POLST Knowledge Survey demonstrated adequate reliability and responsiveness to change. Findings suggest the survey could be used to identify knowledge deficits and provide targeted education to ensure adequate understanding of key clinical decisions when completing POLST.

Origine : PubMed

Early withdrawal of life support after resuscitation from cardiac arrest is common and may result in additional deaths

MAY, Teresa L. ; RUTHAZER, Robin ; RIKER, Richard R. ; FRIBERG, Hans ; PATEL, Nainesh ; SOREIDE, Eldar ; HAND, Robert ; STAMMET, Pascal ; DUPONT, Allison ; HIRSCH, Karen G. ; AGARWAL, Sachin ; WANSCHER, Michael J. ; DANKIEWICZ, Josef ; NIELSEN, Niklas ; SEDER, David B. ; KENT, David M.
Resuscitation, 02/03/2019, Pagination inconnue

Document en ligne

Thème : Ethique et déontologie.

ARRET THERAPEUTIQUE ; REANIMATION ; ETATS-UNIS ; MORTALITE

AIM: "Early" withdrawal of life support therapies (eWLST) within the first 3 calendar days after resuscitation from cardiac arrest (CA) is discouraged. We evaluated a prospective multicenter registry of patients admitted to hospitals after resuscitation from CA to determine predictors of eWLST and estimate its impact on outcomes.
METHODS: CA survivors enrolled from 2012-2017 in the International Cardiac Arrest Registry (INTCAR) were included. We developed a propensity score for eWLST and matched a cohort with similar probabilities of eWLST who received ongoing care. The incidence of good outcome (Cerebral Performance Category of 1 or 2) was measured across deciles of eWLST in the matched cohort.
RESULTS: 2688 patients from 24 hospitals were included. Median ischemic time was 20 (IQR 11, 30) minutes, and 1148 (43%) had an initial shockable rhythm. Withdrawal of life support occurred in 1162 (43%) cases, with 459 (17%) classified as eWLST. Older age, initial non-shockable rhythm, increased ischemic time, shock on admission, out-of-hospital arrest, and admission in the United States were each independently associated with eWLST. All patients with eWLST died, while the matched cohort, good outcome occurred in 21% of patients. 19% of patients within the eWLST group were predicted to have a good outcome, had eWLST not occurred.
CONCLUSIONS: Early withdrawal of life support occurs frequently after cardiac arrest. Although the mortality of patients matched to those with eWLST was high, these data showed excess mortality with eWLST.

Origine : PubMed

A review and analysis of new Italian law 219/2017 - "provisions for informed consent and advance directives treatment"

DI PAOLO, Marco ; GORI, Federica ; PAPI, Luigi ; TURILLAZZI, Emanuela
BMC medical ethics, 04/03/2019, vol.20, n°1, p. 1-7

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Thème : Aspects juridiques. Cote : eD12.00

ITALIE ; LOI ; CONSENTEMENT ECLAIRE ; DIRECTIVE ANTICIPEE ; REFUS SOIN ; ARRET THERAPEUTIQUE ; AUTONOMIE

BACKGROUND: In December 2017, Law 219/2017, 'Provisions for informed consent and advance directives', was approved in Italy. The law is the culmination of a year-long process and the subject of heated debate throughout Italian society. Contentious issues (advance directives, the possibility to refuse medical treatment, the withdrawal of medical treatment, nutrition and hydration) are addressed in the law.
MAIN TEXT: What emerges clearly are concepts such as quality of life, autonomy, and the right to accept or refuse any medical treatment - concepts that should be part of an optimal relationship between the patient and healthcare professionals. The law maximizes the value of the patient's time to decide. Every patient is allowed to make choices for the present (consenting to or refusing current treatment) as well as for the future, conceived as a continuation of the present, and to decide what comes next, based on what he/she already knows. The law identifies three distinct but converging paths towards the affirmation of a care relationship based on reciprocal trust and respect: the possibility to consent to or refuse treatment, the shared care planning, and advance directives.
CONCLUSIONS: The fundamental point to emerge from the new Italian law is that consensus is an essential connotation of the treatment relationship. Consensus is not limited to the acceptance/rejection of medical treatment but is ongoing. It is projected into the future through shared care planning and advance directives which act as tools for self-determination and the manifestation of the beliefs and preferences of persons unable to express their will. These principles are in line with the idea of appropriate care as evaluated from two different perspectives, one of scientific adequacy and the other commensurate with the individual's resources, fragility, values, and beliefs. Surely, however, the new law is not the end of the matter on issues such as conscientious objection, which is deeply rooted within the Italian cultural and political debate. In this regard, healthcare institutions and policymakers will be called upon to develop and implement organizational policies aimed at the management of foreseeable conscientious objection in this field.

Origine : PubMed

Reduction of healthcare costs by implementing palliative family conference with the decision to withdraw life-sustaining treatments

CHANG, Hou-Tai ; JERNG, Jih-Shuin ; CHEN, Duan-Rung
Journal of the Formosan Medical Association, 12/03/2019, p. 1-8

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Thème : Santé. Cote : eD01.01.02

ETUDE RETROSPECTIVE ; SOIN INTENSIF ; REUNION ; FAMILLE ; ARRET THERAPEUTIQUE ; COUT

BACKGROUND: Evidence regarding the impact of early palliative family conferences (PFCs) and decision to withdraw life-sustaining treatment (DTW) on healthcare costs in an intensive care unit (ICU) setting is inconsistent.
METHODS: We retrospectively analyzed patients who died in an ICU from 2013 to 2016. PFCs held within 7 days after ICU admission and DTWs were verified by reviewing medical records and claims data. Comparisons were first made between patients with and without DTWs, and secondly, between DTW patients with and without PFCs within 7 days. Propensity score matching methods were used to examine the difference in costs between patients with and without DTWs and PFCs within 7 days.
RESULTS: Of the 579 patients included, those with DTWs (n = 73) had a longer ICU stay than those without (n = 506) (12.9 ± 7.1 vs. 8.4 ± 9.6 days, p < 0.001). The DTW patients were more likely to have a "do-not-resuscitate" order (p < 0.001) and PFCs within 7 days (p < 0.001) and had lower healthcare costs (USD 7358 ± 4116 vs. 8669 ± 9,535, p = 0.038). After matching, healthcare cost reduction for patients with DTWs, compared with those without DTWs, was USD 3467 [95% CI, 915-6019] (p < 0.001). Compared with DTW patients without PFCs within 7 days, the costs for DTW patients with PFCs within 7 days further reduced to USD 3042 [95%CI, 1358-4725] (p < 0.001).
CONCLUSIONS: Palliative family conferences held within 7 days after ICU admission with decisions to withdraw life-sustaining treatments significantly lowered healthcare costs.

Origine : PubMed

Withholding or withdrawing invasive interventions may not accelerate time to death among dying ICU patients

RAMAZZOTTI, Daniele ; CLARDY, Peter ; CELI, Leo Anthony ; STONE, David J. ; RUDIN, Robert S.
Plos one, 2019, vol.14, n°2, p. 1-9

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Thème : Ethique et déontologie. Cote : eD13.02

ARRET THERAPEUTIQUE ; ETHIQUE SOIN ; SOIN INTENSIF ; ESPERANCE VIE ; ADMISSION

BACKGROUND: Critically ill patients may die despite invasive intervention. In this study, we examine trends in the application of two such treatments over a decade, namely, endotracheal ventilation and vasopressors and inotropes administration, as well as the impact of these trends on survival durations in patients who die within a month of ICU admission.
METHODS: We considered observational data available from the MIMIC-III open-access ICU database and collected within a study period between year 2002 up to 2011. If a patient had multiple admissions to the ICU during the 30 days before death, only the first stay was analyzed, leading to a final set of 6,436 unique ICU admissions during the study period. We tested two hypotheses: (i) administration of invasive intervention during the ICU stay immediately preceding end-of-life would decrease over the study time period and (ii) time-to-death from ICU admission would also decrease, due to the decrease in invasive intervention administration. To investigate the latter hypothesis, we performed a subgroups analysis by considering patients with lowest and highest severity. To do so, we stratified the patients based on their SAPS I scores, and we considered patients within the first and the third tertiles of the score. We then assessed differences in trends within these groups between years 2002-05 vs. 2008-11.
RESULTS: Comparing the period 2002-2005 vs. 2008-2011, we found a reduction in endotracheal ventilation among patients who died within 30 days of ICU admission (120.8 vs. 68.5 hours for the lowest severity patients, p<0.001; 47.7 vs. 46.0 hours for the highest severity patients, p = 0.004). This is explained in part by an increase in the use of non-invasive ventilation. Comparing the period 2002-2005 vs. 2008-2011, we found a reduction in the use of vasopressors and inotropes among patients with the lowest severity who died within 30 days of ICU admission (41.8 vs. 36.2 hours, p<0.001) but not among those with the highest severity. Despite a reduction in the use of invasive interventions, we did not find a reduction in the time to death between 2002-2005 vs. 2008-2011 (7.8 days vs. 8.2 days for the lowest severity patients, p = 0.32; 2.1 days vs. 2.0 days for the highest severity patients, p = 0.74).
CONCLUSION: We found that the reduction in the use of invasive treatments over time in patients with very poor prognosis did not shorten the time-to-death. These findings may be useful for goals of care discussions.

Origine : PubMed

Delivery of end-of-life care in patients requesting withdrawal of a left ventricular assist device using intranasal opioids and benzodiazepines

WIENS, Evan J. ; PILKEY, Jana ; WONG, Jonathan K.
JOURNAL OF PALLIATIVE CARE, 12/02/2019, Pagination inconnue

Document en ligne

Thème : Médecine.

FIN VIE ; ARRET THERAPEUTIQUE ; ANALGESIQUE OPIOIDE ; VOIE NASALE ; DEMARCHE PALLIATIVE ; CARDIOLOGIE ; BENZODIAZEPINE ; METASTASE OSSEUSE ; ETUDE CAS

With the increasing prevalence of the left ventricular assist device (LVAD) in patients with end-stage cardiomyopathies, an increasing number of these patients are dying of noncardiac conditions. It is likely that the palliative care clinician will have an ever-increasing role in managing end of life for patients with LVADs, including discontinuation of LVAD support. There exists a paucity of literature describing strategies for effective delivery of palliative care in patients requesting discontinuation of LVAD therapy. Here, we present a case of a patient with metastatic cancer who requested LVAD discontinuation. Because of practical concerns and patient preference, the patient did not have intravenous (IV) access and medications requiring IV administration could not be used. Therefore, a strategy using intranasal midazolam and sufentanil was applied, the LVAD was deactivated, and the patient died comfortably. This case is, to our knowledge, the first to describe a strategy for delivery of palliative care in patients requesting discontinuation of LVAD support, particularly in the absence of IV access. Such a strategy may be applicable to patients wishing to die at home, and therefore allow greater latitude for patients and clinicians in their approach to the end of life.

Origine : SAGE Journals

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ACCOMPAGNEMENT ACHARNEMENT THERAPEUTIQUE ARRET THERAPEUTIQUE AUTONOMIE DECISION MEDICALE ETHIQUE EUTHANASIE FIN VIE FRANCE LOI PRISE DECISION REANIMATION SEDATION SUICIDE MEDICALEMENT ASSISTE TESTAMENT VIE

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