Charles-Henri Rapin

Euthanasia and physician-assisted suicide: a view from an EAPC Ethics Task Force

In 1991, a debate at the European Parliament on euthanasia stimulated discussion at all levels in Europe. Subsequently, the Board of Directors of the EAPC organised a working session together with two experts to help them clarify the position the organisation should adopt towards euthanasia. The experts collaborated with the Board of Directors on a document and in 1994 the EAPC produced a first statement, Regarding euthanasia, published in the official journal of the EAPC – the European Journal of Palliative Care . In February 2001, the EAPC Board asked an expert group to form an Ethics Task Force to review the subject and advise the organisation accordingly.

Reasons for dissatisfaction: a survey of relatives of intensive care patients who died

OBJECTIVE To describe the reasons for eventual dissatisfaction among the families of patients who died in the intensive care unit (ICU), regarding both the assistance offered during the patients stay in the hospital and the information received from the medical staff. DESIGN Cross-sectional descriptive study, which was conducted after a survey using a questionnaire. SETTING Interdisciplinary ICU (n = 8 beds) at San Giovanni Hospital in Bellinzona (CH). SUBJECTS Three-hundred ninety families of patients who died in the ICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A postal questionnaire (n = 43 questions) was sent to the families of 390 patients who died in the ICU during 8 yrs (1981 to 1989). The results referred to 123 replies: a) 82.6% of the respondents expressed no criticism of the patients hospital stay; b) 90% considered the patients treatment was adequate; c) 17% felt that the information received concerning diagnosis was insufficient or unclear; and d) 30% (particularly close relatives and those relatives who were informed of the death by telephone and not in person) expressed dissatisfaction regarding the information received on the cause of death. CONCLUSIONS Our survey found that the relatives of patients who died were most dissatisfied with the care received according to: a) the type of death (e.g., sudden death vs. death preceded by a gradual deterioration in the patients condition); and b) the manner in which the relatives were notified of the death (in person vs. by telephone). The personal characteristics of the people interviewed, such as gender and the closeness of their relationship to the deceased, also seem to have some bearing on the opinions expressed. A high percentage of respondents were satisfied with the treatment received by their dying relative and the information conveyed by caregivers. Nevertheless, the dissatisfaction expressed by some respondents indicates a need for improvement, especially in communicating information to the relatives of these patients.

Elevated Serum Vitamin B12 Levels Associated With CRP as a Predictive Factor of Mortality in Palliative Care Cancer Patients: A Prospective Study Over Five Years

The relationship between vitamin B12 levels and survival was studied in a group of 161 terminally ill cancer patients who were recruited consecutively between 1988 and 1989. Their average age was 74.7 years. The length of survival decreased with the increase in serum vitamin B12 levels (P = 0.0015, Cox model). In multivariate analyses, C-reactive protein (CRP) was the most important prognostic factor in this population, and vitamin B12 provided information independent of CRP in predicting survival. These data indicate that an elevated serum vitamin B12 level is a predictive factor for mortality in patients with cancer, independent of CRP or other factors. Multiplying it by the CRP makes it possible to create a new, easy-to-use prognostic index, which can distinguish different levels of mortality risk at three months.

Evaluation of the Age-Adjusted Incidence of Hip Fractures Between Urban and Rural Areas: The Difference Is Not Related to the Prevalence of Institutions for the Elderly

Abstract: As many as 40% of hip fractures occur in institutions for the elderly. Several studies have demonstrated a higher age-adjusted incidence of hip fractures in urban areas compared with rural areas. To assess whether this difference could be due to a preferential location of institutions for the elderly in urban areas, we compared the incidence of hip fractures over a 5-year period in urban versus rural areas, as defined according to the population density (urban >15 inhabitants/ha2). We then determined the age-adjusted incidence of hip fractures in institutional-dwelling elderly and home-dwelling elderly. Hip fracture incidence was 100.0/100 000 (150.5 in women and 43.8 in men) in urban areas, and 71.0/100 000 (107.2 in women and 32.8 in men) in rural areas (p<0.001). When only those patients living in their own homes were analyzed, the incidence was 66.7/100 000 (94.6 in women and 35.7 in men) in urban regions and 36.8/100 000 (49.6 in women and 23.4 in men) in rural areas (p<0.001), a difference of even greater magnitude than when both home-dwelling and institutional-dwelling residents were considered together. In a logistic regression model including age class, gender, urban or rural areas and institutionalization for inhabitants 65 years of age and older, urban residents have a 31% significantly (p<0.001) higher incidence of hip fracture compared with rural residents; women have a 79% significantly (p<0.001) higher incidence of hip fracture compared with men; and institutional-dwelling elderly have a 351% significantly (p<0.001) higher incidence of hip fracture compared with home-dwelling elderly. These results confirm the existence of a higher age-adjusted incidence of hip fractures in urban compared with rural areas. Since this difference is increased when patients living at home were analyzed separately, it indicates that the difference between urban and rural areas is not due to a preferential urban location of institutions for the elderly.

Refrigerator content and hospital admission in old people.

We assessed whether the refrigerator contents of elderly people could be related to subsequent admission to hospital. 132 patients aged over 65 years had a thorough assessment of their refrigerator contents and the numbers and dates of admission were recorded. Elderly people with empty refrigerators were more frequently admitted (p=0.032) in the month after assessment and three times sooner than those who did not have empty refrigerators (34 vs 100 days, p=0.002).

Morphinofobia: the situation among the general population and health care professionals in North-Eastern Portugal

BackgroundMorphinofobia among the general population (GP) and among health care professionals (HP) is not without danger for the patients: it may lead to the inappropriate management of debilitating pain. The aim of our study was to explore among GP and HP the representation and attitudes concerning the use of morphine in health care.MethodsA cross-sectional study was done among 412 HP (physicians and nurses) of the 4 hospitals and 10 community health centers of Beira Interior (Portugal)and among 193 persons of the GP randomly selected in public places. Opinions were collected through a translated self-administered questionnaire.ResultsA significant difference of opinion exists among GP and HP about the use of morphine. The word morphine first suggests drug to GP (36,2%) and analgesia to HP (32,9%.). The reasons for not using morphine most frequently cited are: for GP morphine use means advanced disease (56%), risk of addiction (50%), legal requirements (49,7%); for HP it means legal risks (56,3%) and adverse side effects of morphine such as somnolence - sedation (30,5%) The socio-demographic situation was correlated with the opinions about the use of morphine.ConclusionsFalse beliefs about the use of morphine exist among the studied groups. There seems to be a need for developing information campaigns on pain management and the use of morphine targeting. Better training and more information of HP might also be needed.

Role of the physiotherapist in palliative care

Physiotherapists, whether trained in intensive care or internal medicine, must be attentive to patients at the end of their lives. Palliative-care physiotherapy requires basic training in rehabilitation techniques; the integration of a rehabilitation professional in a caregivers team; a profound communication with the patient, leading to an effective accompaniment and direct response to the patients needs; and recognition of the patients functional needs. The involvement of the physiotherapist can extend to the very end of life. In a series of 56 geriatric patients (35 suffering from cancer, 21 from other pathologic conditions) who died at the Center of Continuous Care, 44 (79%) had a treatment of respiratory physiotherapy until their last 24 hr.

Douleurs et conflits : Approche comparative et implications pour la qualité des soins en fin de vie

Are conflicts to an organization what pain is to an organism?OBJECTIVES: To explore the similarities and the differences between pain and conflicts in palliative care settings, and to better understand the potential importance of conflicts in end of life quality of care.METHODS: Comparative and reflective methods focusing on how conflicts and pain are taken care of in health structures.RESULTS: Pain and conflicts present numerous similarities such as identity, typology, prevalence, warning function, economic and social costs, denial, occultation and hurdles to appropriate management. Differences also exist regarding pain – there are prevention programs on local and international levels; there are specific research and training programs; and there is also some social visibility. This does not yet exist on a larger scale regarding conflicts.CONCLUSION: Decision makers at clinical and public health levels should probably push to label conflicts as indicators of quality of care and develop appropriate health policy programs.

P044 Observatoire genevois de la fragilité et de la sous-alimentation ?

Introduction et but de l’etude Les personnes âgees qui se fracturent l’extremite proximale du femur dans des conditions banales (chute de leur hauteur), souffrent de sous–alimentation dans pres de 80 % des cas. Cette sous-alimentation, par manque d’apports, est surtout proteoenergetique. Plus de la moitie des personnes âgees qui se fracturent vivent chez elles, a domicile, les autres en institutions. La sous–alimentation precede la chute et la fracture de l’os fragilise. Nous proposons de retenir la fracture de l’extremite proximale du femur comme un indicateur de fragilite, de precarite et de carences nutritionnelles des personnes âgees. Pour intervenir aupres des personnes âgees dans nos communautes, il faut determiner les regions ou les zones socio-sanitaires ou il y a le plus grand nombre de fractures vivant a domicile, ou il y a la plus grande incidence et ou la moyenne d’âge des fractures est la plus basse : c’est l’objectif d’un observatoire des fractures de hanche, en particulier quand nos moyens d’intervention sont limites. Un observatoire des fractures de hanche permet aussi de mesurer l’effet des interventions de promotion de la sante, de prevention et de prise en soin ; nous devons pouvoir mesurer les effets sur le nombre, sur l’incidence et sur l’âge moyen des patientes et des patients fractures. L’observatoire genevois de la fracture de la hanche, initie en 2001, couvre maintenant une decennie de donnees retrospectives. Materiel et methodes Recolte des 4 000 domiciles des personnes âgees victimes de fracture du col du femur a Geneve entre 1991 et 2000. Resultats Les premiers resultats issus de l’observatoire mettent en evidence, pour les personnes residant dans leur domicile prive, un risque accru de fracture de la hanche et un âge de survenu de la fracture plus precoce en ville par rapport a la campagne. En affinant ce resultat, nous avons identifie des quartiers a Geneve ou l’incidence est plus forte et la moyenne d’âge des fractures plus basse par rapport a d’autres quartiers (ceci avec controle des effets d’âge et de sexe). Ces differences s’expliquent en partie par le revenu median des quartiers. L’observatoire genevois de la fracture de la hanche apporte donc ici sa contribution selon laquelle le niveau social d’un quartier influence a Geneve la sante de ses habitants. Les quartiers ainsi identifies devraient pouvoir beneficier en priorite d’actions preventives. Des cartes de la region ont ete etablies selon le sexe pour l’incidence et l’âge moyen au moment de la fracture. Conclusions Nous souhaitons poursuivre ce projet en continuant le recueil de donnees epidemiologiques et en evaluant les effets, sur le risque de fracture et sur l’âge de survenue de la fracture, d’interventions de promotion nutritionnelle, de prevention et de prise en soin.