La spécialité de la réanimation est une discipline jeune, née dans les années 1950, la dénomination de médecine intensive-réanimation pour les services médicaux étant récente. Elle est marquée par des évolutions techniques incessantes, tout en étant soumise à de fortes demandes sociétales. Symbolisant à la fois la performance et la toute-puissance médicales aux yeux du public, cette spécialité soulève de nombreuses questions éthiques parmi les patients, leurs proches et parmi les professionnels.
La réalité d'une clinique confrontant quotidiennement à la vie, la survie et la mort conduit les professionnels de ces services à s'ouvrir à d'autres disciplines pour préserver le sens du soin et son humanité. Les auteurs font le point sur ces enjeux contemporains en s'appuyant sur leur expertise en tant que réanimateurs polyvalents ou spécialisés, soignants, ou psychologues cliniciens. Ils approchent ces questions en croisant les regards sur le vécu émotionnel et psychique des professionnels, celui des patients ou celui des familles.
Une grande variété de situations sont abordées, reflétant la réalité des services, depuis la greffe et la dialyse, le vécu de conscience altérée, l'état de coma, de réveil, à la mort cérébrale ou au don d'organe.
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BACKGROUND: Expert communication skills are essential for the delivery of effective palliative care across the domains of care. However, few health care providers receive formal communication training. To promote communication education for interdisciplinary palliative care teams, a train-the-trainer course for interdisciplinary hospital-based palliative care teams was developed to prepare them to teach other health care professionals communication skills. Course Design: The curriculum was organized by the eight domains of the National Consensus Project Guidelines for Quality Palliative Care and provided communication skills training for California-based teams. The two-day train-the-trainer course included skill-building exercises and interactive discussions to assist participants in integrating communication skills building into their clinical settings. Using a goal-directed method of teaching, faculty assisted teams in developing three institutional goals for providing palliative care communication training to other health care professionals. Evaluation of the course included immediate postcourse evaluation and follow-up evaluation at six and nine months.
RESULTS: The first statewide interdisciplinary communication training took place in January 2018 with 26 palliative care teams consisting of primarily nurses, followed by social workers, chaplains, and physicians. The 46 course participants' postcourse evaluations demonstrated high satisfaction with the course. On a scale of 1 to 5 (1 = lowest), the course met participants' expectations and objectives (4.8). The teams' precourse goals focused on (1) staff education, training, and mentorship, and (2) institution-wide system changes.
CONCLUSION: Palliative care interdisciplinary teams can incorporate communication skills into their practice and provide communication skills training to their institutions.
Delivering comprehensive end-of-life care to dying patients must involve addressing physical symptoms and psychosocial concerns. Care pathways have been introduced to support health care teams in delivering this care. This retrospective chart review explores the contributions of the Spiritual Care Team in the care of dying patients. They offer a range of interventions which include supportive care, religious and spiritual support. This study was one step towards appreciating the contributions of the Spiritual Care Team.
La décision partagée est celle que le patient prend avec son médecin. Lorsqu’il ne peut plus exprimer sa volonté, la décision est prise par ce dernier à l’issue d’une procédure collégiale. Au sein de ce dispositif, les directives anticipées sont consultées et le témoignage de la personne de confiance pris en compte, à défaut celui des proches. Complétée par la concertation au sein de l’équipe de soins, la procédure constitue une démarche partagée sur le plan de la réflexion et de la responsabilité éthique.
Les mots "soins palliatifs" génèrent de nombreuses émotions pour le patient à qui le diagnostic est posé. Quand il n’y a plus rien à faire, tout reste à construire… Tout reste à "écrire", à "dire", à "vivre". L’accompagnement en soins palliatifs prend sens lorsqu’il s’inscrit dans une dynamique pluridisciplinaire. La musicothérapie vient donc prendre place dans ce travail d’équipe. Après avoir rencontré le patient lors d’un bilan psychomusical, le musicothérapeute pourra donc proposer un accompagnement personnalisé et adapté aux besoins et aux possibilités de celui-ci. Dans cet article, nous avons fait le choix de vous présenter deux techniques de musicothérapie réceptive, que nous développons dans nos pratiques cliniques en pédiatrie et en gériatrie.
La prise en charge d’un patient en fin de vie à son domicile demande une réflexion pluridisciplinaire de tous les intervenants. L’information de la personne et de ses proches ainsi que la prise en compte de tous les aspects de l’accompagnement doivent mener à des prises de décision collégiales. La prise en charge est alors globale autour d’un projet de soins concerté.
BACKGROUND: Palliative care programs in the United States are becoming more integrated with oncology outpatient practices.
OBJECTIVES: This article offers a condensed review of available literature on the usefulness of palliative care in the oncology clinic setting and a case study to illustrate these ideas.
METHODS: Literature was reviewed related to the successes and failures of providing an embedded palliative care team in an oncology clinic and its role and effectiveness as part of a collaborative interprofessional team for patients with cancer.
FINDINGS: The incorporation of palliative care into outpatient oncology clinics presented a reduction in symptom burden, financial burden, and emergency department visits for symptom management. Palliative care also facilitates increased communication between patients and providers to ensure that care meets patients' wishes.
La tension entre les valeurs en conflit peut faire naître des désaccords au sein de l’équipe de soins. Face à un choix crucial, grave et irréversible, la déontologie n’est plus suffisante : elle doit être assortie d’une réunion d’éthique ad hoc. La délibération collégiale repose sur un “contrat moral” entre les membres de l’équipe qui s’engagent à respecter les principes de l’éthique et les règles de l’éthique de discussion, en tant que repères communément partagés.
Ce n’est que depuis 2008 que les soins palliatifs pédiatriques sont clairement évoqués en France. Ils sont définis comme des soins allant de la période anténatale jusqu’à 19 ans, dès que l’enfant est atteint d’une maladie qui limite ou menace sa durée de vie. De nombreuses infirmières peuvent, au cours de leur carrière, y être confrontées en établissement sanitaire ou médico-social. Ils nécessitent une prise en charge pluridisciplinaire et une coordination de tous les professionnels de santé concernés par la prise en charge.
BACKGROUND: The aim of this study was to evaluate the implementation process of a multidisciplinary approach for potential organ donors in the emergency department (ED) in order to incorporate organ donation into their end-of-life care plans.
METHODS: A new multidisciplinary approach was implemented in six hospitals in the Netherlands between January 2016 and January 2018. The approach was introduced during staff meetings in the ED, Intensive Care Unit (ICU) and neurology department. When patients with a devastating brain injury (DBI) had a futile prognosis in the ED, without contra indications for organ donation, an ICU admission was considered. Every ICU admission to incorporate organ donation into end-of-life care was systematically evaluated with the involved physicians using a standardized questionnaire.
RESULTS: In total, 55 potential organ donors were admitted to the ICU to incorporate organ donation into end-of-life care. Twenty-seven families consented to donation and 20 successful organ donations were performed. Twenty-nine percent of the total pool of organ donors in these hospitals were admitted to the ICU for organ donation.
CONCLUSIONS: Patients with a DBI and futile medical prognosis in the ED are an important proportion of the total number of donors. The implementation of a multidisciplinary approach is feasible and could lead to better identification of potential donors in the ED.
INTRODUCTION: Terminal bleeding, a distressing symptom experience for patients, caregivers, and health professionals, occurs in a subset of patients in the palliative care setting. Terminal bleeding is often thought of as a large-volume catastrophically fatal event, but it can also occur for a longer period of time and still be the precipitating event for a patient's death.
CASE REPORT: We present the case of terminal bleeding in an 87-year-old patient with angiosarcoma, a rare aggressive vascular neoplasm that can occur anywhere in the body but tend to occur more frequently in the head and neck.
DISCUSSION: The patient's advanced age and aggressive disease presented challenges in managing the symptoms and precluded many of the conventional recommended interventions to manage bleeding.
CONCLUSION: This case report speaks to the need for multidisciplinary planning that takes prognosis, performance status, previous therapies, and patient preferences into account when caring for patients with advanced cancer.
OBJECTIVE: Healthcare organizations are expanding community-based serious illness care programs to deliver care for homebound patients. Programs typically focus on home-based primary care or home-based palliative care, yet this population may require both services. We developed and evaluated a primary and palliative care program serving seriously ill older adults, called the Reaching Out to Enhance the Health of Adults in Their Communities and Homes (REACH) program. Our objective was to determine the impact of the REACH program on healthcare utilization and the patient care experience.
DESIGN: Case study using medical record review and telephone interviews.
SETTING: Home-based serious illness care program in central North Carolina.
PARTICIPANTS: Patients enrolled in the REACH program from August 2014 to March 2016 (n = 159).
INTERVENTION: Home-based primary and palliative care delivered by an interdisciplinary team for seriously ill older adults.
MEASUREMENTS: Structured medical record review including demographics, health and functional status, and acute hospitalization and emergency department (ED) visits in the 12 months preceding and following initiation of the REACH program. A convenience sample of participants completed telephone interviews that measured the quality-of-care experience and quality of communication.
RESULTS: REACH patients had a 43% reduction in hospital visits and a 25% reduction in ED visits. Participants in telephone interviews reported a high-quality care experience and very good quality of communication with REACH providers.
CONCLUSION: A care model that integrates home-based primary care and palliative care has the potential to reduce health service utilization and enhance the care experience for older patients with serious illness.
Objective: Healthcare professionals who work in palliative care units face stressful life events on a daily basis, most notably death. For this reason, these professionals must be equipped with the necessary protective resources to help them cope with professional and personal burnout. Despite the well-recognized importance of the construct "meaning of work," the role of this construct and its relationship with other variables is not well-understood. Our objective is to develop and evaluate a model that examines the mediating role of the meaning of work in a multidisciplinary group of palliative care professionals. Using this model, we sought to assess the relationships between meaning of work, perceived stress, personal protective factors (optimism, self-esteem, life satisfaction, personal growth, subjective vitality), and sociodemographic variables.
Method: Professionals (n = 189) from a wide range of disciplines (physicians, psychologists, nurses, social workers, nursing assistants, physical therapists, and chaplains) working in palliative care units at hospitals in Madrid and the Balearic Islands were recruited. Sociodemographic variables were collected and recorded. The following questionnaires were administered: Meaning of Work Questionnaire, Perceived Stress Questionnaire, Life Orientation Test-Revised, Satisfaction with Life Scale, Subjective Vitality Scale, Rosenberg Self-Esteem Scale, and the Personal Growth Scale.
Result: The explanatory value of the model was high, explaining 49.5% of the variance of life satisfaction, 43% of subjective vitality, and 36% of personal growth. The main findings of this study were as follow: (1) meaning of work and perceived stress were negatively correlated; (2) optimism and self-esteem mediated the effect of stress on the meaning attached to work among palliative care professionals; (3) the meaning of work mediated the effect of stress on subjective vitality, personal growth, and life satisfaction; and (4) vitality and personal growth directly influenced life satisfaction.
Significance of results: The proposed model showed a high explanatory value for the meaning professionals give to their work and also for perceived stress, personal protective factors, and sociodemographic variables. Our findings could have highly relevant practical implications for designing programs to promote the psychological well-being of healthcare professionals.
BACKGROUND: Paramedics may be involved in the care of patients experiencing a health crisis associated with palliative care. However, little is known about the paramedic's role in the care of these patients.
AIM: To describe the incidence and nature of cases attended by paramedics and the care provided where the reason for attendance was associated with a history of palliative care.
DESIGN: This is a retrospective cohort study.
SETTING/PARTICIPANTS: Adult patients (aged >17 years) attended by paramedics in the Australian state of Victoria between 1 July 2015 and 30 June 2016 where terms associated with palliative care or end of life were recorded in the patient care record. Secondary transfers including inter-hospital transport cases were excluded.
RESULTS: A total of 4348 cases met inclusion criteria. Median age was 74 years (interquartile range 64–83). The most common paramedic assessments were ‘respiratory’ (20.1%), ‘pain’ (15.8%) and ‘deceased’ (7.9%); 74.4% (n = 3237) were transported, with the most common destination being a hospital (99.5%, n = 3221). Of those with pain as the primary impression, 359 (53.9%) received an analgesic, morphine, fentanyl or methoxyflurane, and 356 (99.2%) were transported following analgesic administration. Resuscitation was attempted in 98 (29.1%) of the 337 cases coded as cardiac arrest. Among non-transported cases, there were 105 (9.6%) cases where paramedics re-attended the patient within 24 h of the previous attendance.
CONCLUSION: Paramedics have a significant role in caring for patients receiving palliative care. These results should inform the design of integrated systems of care that involve ambulance services in the planning and delivery of community-based palliative care.
Palliative care has a very important role in the care of patients with motor neurone disease and their families. There is increasing emphasis on the multidisciplinary assessment and support of patients within guidelines, supported by research. This includes the telling of the diagnosis, the assessment and management of symptoms, consideration of interventions, such as gastrostomy and ventilatory support, and care at the end of life. The aim of palliative care is to enable patients, and their families, to maintain as good a quality of life as possible and helping to ensure a peaceful death.
Requests for hastened death and suicidal ideation may be more prevalent in populations approaching the end of life. Often these wishes and thoughts occur in the context of concurrent psychiatric disorders and emotional suffering. We discuss the case of a veteran with terminal lung cancer and comorbid psychiatric illness who attempted suicide while under the care of an inpatient interdisciplinary hospice team and describe our team's response to this suicide attempt. We review risk factors for suicidality at end of life, challenges of distinguishing desire for hastened death from suicidality, and the ethics of resuscitation of a dying patient after a suicide attempt.
BACKGROUND: Palliative radiation therapists (PRTs) have been integrated in varying capacities into outpatient palliative radiation therapy (RT) services across Canada for over 2 decades. At our institution, PRTs have developed an essential role over 11 years within a palliative radiation oncology (PRO) clinic that focuses on integrating symptom management with radiation oncology assessment for palliative RT. PRTs have had direct clinical, technical, research, and administrative involvement as the clinic evolved from a pilot in 2007 supporting one half-day per week to the current model of five full clinical days.
METHODS: Using collaborative reflection, we explored the PRTs' experience and insight. Twelve PRTs who contributed to the PRO clinic for varying lengths of time from 2007 through to 2016 were invited to participate in the development of a collective expression of the PRT experience. Seven PRTs consented to completing an electronic survey consisting of fifteen open-ended questions regarding individual roles and perspectives relating to our PRO clinic. Survey answers were enhanced by semistructured interviews when needed for clarification. Responses were contextualized within the operational changes to our multidisciplinary clinical model, from pilot to integrated service.
RESULTS/DISCUSSION: Five respondents answered all of the questions. From the narratives, PRT roles and responsibilities were outlined and their insights and reflections included to contextualize clinical changes. Four phases of the clinic were identified and elucidated. Beginning in January 2007, three PRTs staffed a multidisciplinary clinical pilot one half-day per week for single-fraction, symptomatic bone metastases. The clinic has now evolved through various iterations to the current model with four PRTs sharing a "navigator" role with two registered nurses five full clinic days per week. The range of PRT experiences, responsibilities, and challenges encountered reflected specific clinical and operational conditions.
CONCLUSION: As our clinical service model evolved from short-term pilot to fully integrated departmental service, so did the PRT role. PRTs contributing to RT as part of a multidisciplinary model support and advance nontraditional involvement in the holistic care of patients with advanced cancer.
Music is one of the things in my life that has most reliably gotten me into and kept me out of trouble. Having played in bands for decades, I see parallels with the practice of medicine. As a hospitalist and a palliative care pediatrician, I would like to apply lessons from music to consider how general palliative care (provided by all clinicians) and specialty palliative care (provided by board-certified physicians) can work together in harmony. Music (like medicine) thrives through collaboration, benefits from specialized knowledge, and begs to be shared.
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