Palliative care integration and end-of-life care intensity for patients with NSCLC.

BACKGROUND: Non-small cell lung cancer (NSCLC) without oncogenic driver mutations is considered to have a poor prognosis, although recent therapeutic progress. This study aims to assess the real-life integration of palliative care (PC) and the intensity of end-of-life (EOL) care for this population. METHODS: This was an observational cohort study of decedent patients from metastatic NSCLC without oncogenic driver mutations over the period 01/2018 to 12/2022, treated in first line with immunotherapy +/- chemotherapy. We analysed PC integration and aggressiveness criteria of EOL care in the last month before death: systemic anti-cancer treatment administration, emergency room visits, intensive care unit admission, hospitalization, hospitalization duration > 14 days, and hospital death. RESULTS: Among 149 patients, 75 (50 %) met the PC team at least once, and the median time from the first encounter to death was 2.3 months. In the last month before death, at least one criterion of aggressive EOL care was present for 97 patients (70 %). For patients with PC use < 30 days and for patients with PC use < 90 days before death, there were significant changes: increase in the frequency of systemic anti-cancer treatment (respectively 51.1 % vs 20 %; p < 0.001 and 58.7 % vs 6.2 %; p < 0.001); decrease in hospitalization lasting > 14 days (respectively 30 % vs 7 %; p = 0.001 and 36 % vs 6.2 %; p = 0.018) and in death hospitalisation (respectively 66 % and 18 %; p < 0.001 and 58.7 % and 10.3 %; p < 0.001). After adjusting for the factors tested, patients with no PC or late PC use in the last month before death or in the last three month before death, the odds ratio (OR) remained significantly greater than 1 (respectively OR = 3.97 [1.70; 9.98]; p = 0.001 and OR = 23.1 [5.21-177.0], p < 0.0001). CONCLUSION: PC is still insufficiently integrated for patients with NSCL cancer. Cancer centres should monitor key indicators such as PC use and aggressiveness criteria of EOL care.

[Medical decision in a very elderly patient: a case report of application of the Leonetti law in emergency medicine]. / Décision médicale chez la personne très âgée: à propos d'un cas d'application de la loi Leonetti en médecine d'urgence.

Advanced care decision in emergency medicine is difficult for the elderly. How to be fair, avoiding an unreasonable obstinacy? Based on the case of very old person, we show how an optimal management can be decided in accordance with the spirit of the law.

[Observatory of the elderly over 80 years supported by the mobile emergency and resuscitation service]. / Observatoire du sujet âgé de plus de 80 ans pris en charge en urgence par le service mobile d'urgence et de réanimation.

Emergency medical services (EMS) received an increasing number of calls for patients aged 80 and older. The goal of the present study was to evaluate outcome and functional dependence of patients aged 80 and older who EMS managed in the prehospital theater. This prospective study was conducted over 1 year (September 2007-August 2008), all consecutive patients aged 80 and older managed by a medical team during the study period were included. Characteristics of patients, including previous health status and functional dependence, were recorded on-the scene by the attending physician. Three-month mortality was recorded, as well as ADL score. Data are expressed as mean values±standard deviations, medians and interquartile ranges (IQRs), and percentages and compared using univariate and multivariate analysis. P<0.05 was considered the threshold for significance. Five hundred twenty-three patients were included. Mean age was 86 ± 5. Median ADL index was 2 (IQR 0-9), and 63% of patients were living at home. At 3 months, the survival rate was 66% (n=273) and the proportion of patients living at home was 64% (P=0.9), the median ADL index of survivors was 2 (IQR 0-8) vs 1 (IQR 0-6) initially for this subpopulation, P=0.01. Our study confirms utility and efficacy of full access of elderly persons to advanced life support especially for self-patients and not restricted based on aging per se. The development and daily use of tools for rapid assessment of autonomy should enable practitioners to innovate and thus, adapt their management.

[Prehospital management by EMS of a potential non-heart-beating donor]. / Prise en charge par le Smur d'un patient en arrêt cardiaque en vue d'un prélèvement d'organe à coeur arrêté

After their prehospital management by EMS system and on-scene declaration of death, some patients are potential non-heart-beating donors. We report the case of refractory cardiac arrest, transferred to the hospital assisted by chest compression device. Time factor might be an important brake on prehospital recruitment. Future networks should attempt to shorten the time intervals.

A quality control programme for acute myocardial infarction management in out-of-hospital critical care medicine.

This study, conducted over two time periods, aimed to evaluate the effectiveness of the diffusion of data, implementation of correctives measures and updated protocols in reducing time to reperfusion in acute myocardial infarction (AMI) management in the out-of-hospital setting. Mean (SD) time to hospital admission and to arterial puncture improved (58 (13) vs 67 (18) min, p = 0.03; and 82 (16) vs 95 (29) min, p = 0.02). The study, performed according to quality control programme methodology, showed that the chronology of AMI management could be improved by appropriate interventions and monitoring of intervention times.

[Survey on the use of mannitol in prehospital care in Paris area]. / Enquête sur l'utilisation du mannitol en réanimation préhospitalière en Ile-de-France.

OBJECTIVE: To evaluate the use of mannitol in prehospital care in Paris area. STUDY DESIGN: Survey using telephone interviews. METHODS: Emergency physicians on duty in the 37 emergency departments in charge of prehospital care in Paris area were called by one investigator. They were asked to answer a questionnaire about their own use of mannitol in the prehospital setting. RESULTS: Ninety-six questionnaires were recorded. Physicians were anaesthesiologists (9%) or emergency physicians (87%). In three departments, mannitol was not available in the ambulances. Thirty-five per cent (n = 34) reported no use of mannitol and 17% (n = 16) just once. Fourteen physicians (15%) did not want to use it. The reasons for not using mannitol were lack of knowledge about efficacy for five, need for previous brain imaging for seven or neurosurgeon's agreement before using mannitol for three. For those who had already used mannitol or were ready to use it, the main indication was increased intracranial pressure with clinical signs of brain herniation after severe brain injury for 92% of physicians. Thirty-one % reported not knowing the dose of mannitol, 33% having a memorandum immediately available and among those who answered the question, 63% gave a value compatible with guidelines. CONCLUSION: A significant percentage of physicians tacking part in the French prehospital care system, do not follow published guidelines on the use of mannitol. Actions improving implementation of those guidelines should be supported.