[Palliative care for children in onco-hematology: Role of a specific home-care team]. / Soins palliatifs pédiatriques et fin de vie d'enfants suivis en onco-hématologie : place de l'hospitalisation à domicile.

BACKGROUND/OBJECTIVE: Our home-care unit (HCU) is specialized for pediatric cancer patients and has a strong palliative care activity. We believe that the introduction of home-care services can influence the place of palliative care and of death as well as the length of hospitalization. We aimed at describing characteristics and care course of patients treated in our HCU, and tried to identify some factors contributing to home care at the end of life. DESIGN/METHODS: We conducted a retrospective, observational, monocentric study about patients in pediatric onco-hematology, treated at least one day in our home-care unit, who died between July 1st 2013 and December 31st 2015. Statistical analysis was descriptive and analytic. RESULTS: A total of 74 patients known by our HCU died during study period. Eight were excluded. Forty-three out of 66 patients died at home. During the last 3 months of life, oncology patients have significantly less classical hospitalization, when compared to hematology patients. The implication of general physicians (GP) and nurses and information given to the family increase the possibility for home death. No significant association was found between ages at death, distance between home and hospital, other life conditions and place of death. CONCLUSIONS: Our HCU has a strong palliative care activity and a high rate of children dying at home. Good collaborations between our pediatric onco-hematology team and our HCU as well as between our HCU and caregivers optimize palliative care.

[Intravenous chemotherapy at home: A pediatric monocentric experience]. / Chimiothérapie intraveineuse à domicile en cancérologie pédiatrique : une expérience monocentrique.

INTRODUCTION: Our home care unit (HCU) developed the administration of IV chemotherapy at home for some pediatric oncologic patients. METHODS: We conducted a retrospective monocentric analysis, leading to identify patients with at least one sequence of chemotherapy at home in 2015. RESULTS: Two hundred and forty four sequences of home chemotherapy have been administered in 2015. We identified two situations for home IV chemotherapy. Pediatric oncologist of day hospital prescribes the sequence. The chemotherapy is delivered at hospital for the first day. HCU takes over for the next days at home. For a sequence replacing a conventional hospitalization, the attending physician examines the patient, and confirm the clinical validation. The pediatric oncologist of HCU checks lab exams, and prescribes the chemotherapy. For both situations, IV chemotherapy is prepared by our hospital pharmacy, delivers at home or at day hospital, and HCU team manages home material and organizes hospitalization. CONCLUSIONS: This kind of organization allows setting up home IV CT for more and more patients. It allows to limit daily hospitalization for some patients living far from the hospital, and whose therapies lead to several hospitalizations.

[Treating aplasia through home hospital care]. / Prise en charge d'une aplasie en hospitalisation à domicile.

Home care is developing for patients suffering from haematological-oncological pathologies. The nurses and the whole team of the home hospitalisation department of the Léon-Bérard Centre in Lyon are prepared to deal with aplasia. Depending on its seriousness, the patient may be hospitalised or treated at home.

[The "do-not-resuscitate order" in paediatric palliative home care: why should the emergency team be involved ?]. / L'anticipation de la non-réanimation en soins palliatifs pédiatrique à domicile : le Samu comme partenaire de soins ?

Major challenge in paediatric palliative home care is to anticipate management of future events. In our opinion, one of major approach is to avoid medical futility especially resuscitation attempts in terminally-ill children especially if home care will be organized. We therefore prospectively discussed with proxi what should be attempted (e.g. treat symptoms of pain or discomfort) and what should be avoided for the sake of the child. A crucial part of the discussion included anticipating non resuscitation of the terminally-ill child. We informed in writing local emergency unit coordinator on results of the discussion with care takers and suggested a procedure in case of an emergency call. To include the local emergency unit is now a standard in our paediatric oncology department since two situations may occur: 1) Parental panic while facing difficult terminal symptoms. We recommend that the local emergency unit coordinator dispatches an emergency team to the child's home in order to manage symptoms (seizures, pain, etc.) but avoid any futile resuscitation attempt. Parental decision to maintain the child at home should be re-evaluated regularly. 2) Parents who wish to stay at home as long as possible, refusing home-based death of their terminally-ill child. We recommend that the family doctor decides whether or not to refer the child to the hospital. Emergency team may be called upon based on the child's status and need for medicalised transport. Even if it should be rather rare that parents contact directly the emergency unit and not as usually the home care coordinator, such situation may occur and should be anticipated. Therefore, the anticipation of non-resuscitation recommendations is a key approach in paediatric palliative home care. This complex discussion should not be avoided as parental/medical panic may induce unrealistic requests for futile medical procedures.

[Blood transfusions at home or in the hospital? The preferences of cancer patients]. / Administration des transfusions sanguines à l'hôpital ou à domicile ? Le choix des patients atteints de cancer.

Home blood transfusion (HBT) is as safe and effective as hospital transfusion. If HBT can potentially cause anxiety, it can also improve patients' quality of life. The different factors influencing patients' preference for home or hospital are examined on the basis of a prospective study including 139 patients from the comprehensive cancer center of Lyon, and who received transfusions in the hospital outpatient department or at home between 2003 and 2004. A Probit model was used to identify the determinants of the choice of place of transfusion. The intensity of preference for this choice was assessed with the contingent valuation method. Of 139 patients included in the study, 97 chose HBT in the eventuality of a new transfusion. This preference was significantly related to a previous experiment of HBT and to the distance between patient's home and hospital. Mean willingness to pay was 60.9 euro for home and 47.3 euro for hospital transfusion. These results, in favour of HBT, are probably related to the strong involvement of physicians of the blood centre and their active collaboration with a high-level homecare network.

Oral moxifloxacin or intravenous ceftriaxone for the treatment of low-risk neutropenic fever in cancer patients suitable for early hospital discharge.

GOALS OF WORK: Patients with low-risk neutropenic fever as defined by the Multinational Association of Supportive Care in Cancer (MASCC) score might benefit from ambulatory treatment. Optimal management remains to be clearly defined, and new oral antibiotics need to be evaluated in this setting. MATERIALS AND METHODS: Cancer patients with febrile neutropenia and a favorable MASCC score were randomized between oral moxifloxacin and intravenous ceftriaxone. All were fit for early hospital discharge. The global success rate was related to the efficacy of monotherapy, as well as to the success of ambulatory monitoring. MAIN RESULTS: The trial was closed prematurely because of low accrual. Ninety-six patients were included (47 in the ceftriaxone arm and 49 in the moxifloxacin arm). A total of 65% were women, 30.2% had lymphoma, 34.4% had metastatic, and 35.4% had non-metastatic solid tumors. The success rates of home antibiotics were 73.9% and 79.2% for ceftriaxone and moxifloxacin, respectively. Seven patients were not discharged, and 14 required re-hospitalization. There were 17% of microbiologically documented infections that were, in most cases, susceptible to oral monotherapy. CONCLUSIONS: These results suggest that MASCC is a valid and useful tool to select patients for ambulatory treatments and that oral moxifloxacin monotherapy is safe and effective for the outpatient treatment of cancer patients with low-risk neutropenic fever.

[Organisational diagnosis of a home care-coordinating unit in oncology: which choices for the comprehensive cancer center of Lyon?]. / Diagnostic organisationnel d'un service hospitalier de coordination des soins à domicile en cancérologie. Quels choix stratégiques pour le Centre régional de lutte contre le cancer de Lyon?

Lyon comprehensive cancer center developed a home care-coordinating unit (HCCU) allowing a wide range of cancer care at home. We present the results of an organisational and strategical analysis of the unit, in relation with internal and external contexts. We describe the functioning of the unit, modelled from the daily follow-up of professionnels. Patient discharge is initiated by the oncologist at the inpatient clinic, at the day-hospital or at outpatient visit. After consent of the patient and relatives, the HCCU (nurses and medical oncologists) evaluates patient's needs, organises hospital discharge (contacts with community nurses and general practitioner, supply of medical appliances and drugs), and provides follow-up and counselling to patient and caregivers. The HCCU works in a challenging environment, with both partners and competitors. Within the hospital, it collaborates with all other units. Outside the hospital, partners are, besides patients themselves; general practitioners and community nurses home care agencies and network services, private medical appliance providers, and public health authorities. The unit might evolve towards formal home hospitalisation or community-hospital network. Collaboration of both structure closely associated with hospital could allow to provide continuous and graduated care by the same caregivers even if administrative structures change.

[Prospective study on the quality of care and quality of life in advanced cancer patients treated at home or in hospital: intermediate analysis of the Trapado study]. / Etude prospective de qualité des soins et de qualité de vie chez des patients cancéreux en phase palliative, en hospitalisation ou à domicile: analyse intermédiaire de l'étude Trapado.

The preferences of advanced cancer patients and the impact of cancer management on relatives remain partly unknown. We present the preliminary results of a prospective study evaluating quality of care (QC), quality of life (QoL) and family impact (FI) in advanced cancer patients treated at home or in hospital, depending on their own choice. QC is evaluated using STAS questionnaire, and QoL and symptom control using EORTC QLQ-C30, Spielberger questionnaire and VAS for pain evaluation. FI is evaluated using GHQ28 and semi-structured interviews conducted at days 0, 15, 30, then monthly until death. Intermediate analysis of 52 patients (100 expected) of whom 63 % had chosen home care, 26 % in-hospital care. Actual assignment is home care: 56 %, in-hospital care: 44 %. Place of death is home: 15 %, hospital: 85 %. In the QC study, the two symptoms most frequently rated by nurses are anxiety and pain, in either group. Patient information and communication are also similar in both groups. The QoL and symptom study shows that patients also rate pain as frequent (84 %) but moderate (mean VAS score 2.5/10). However, the most frequent symptom is fatigue (100 %). Anxiety is rated higher at hospital, as well as FI (anxiety, insomnia, social dysfunction and global score). Palliative care research is sometimes difficult but feasible. In this study, most patients prefer home care. Anxiety and FI seem lower at home. However, re-hospitalisations just before death are frequent and death generally occurs in hospital.

Factors predicting home death for terminally ill cancer patients receiving hospital-based home care: the Lyon comprehensive cancer center experience.

This study aimed to determine factors favoring home death for cancer patients in a context of coordinated home care. A retrospective study was conducted among patients followed up by the home care coordinating unit of the cancer center of Lyon. The main endpoint was place of death. Univariate analysis included general characteristics (age, gender, rural or urban residence, disease), Karnofsky Index (KI), type of care at referral (chemotherapy, palliative care, or other supportive care), and coordinating medical oncologist (MCO) home visits. Significant factors were used in a logistic regression analysis. Of 250 patients, 90 (36%) had home death. Low KI and MCO home visit were correlated with home death (odds ratio, respectively, 2.1 and 3.1). These results indicate that health care support favors home death. A hospital-based home care unit is effective for bridging the gap between community and hospital. MCO home visits offer concrete support to health care professionals, patients, and relatives.

Economic evaluation of antineoplasic chemotherapy administered at home or in hospitals.

OBJECTIVES: Comparative economic evaluations of chemotherapy administered in hospital day-care units or in the home are relatively scarce. Furthermore, most existing evaluations do not include methodologic studies. This study seeks to compare the costs of anticancer chemotherapy with hospital at-home care versus a hospital day-care unit in the Rhône-Alpes region of France. METHODS: This study is based on a randomized controlled crossover trial that included 42 patients, to whom chemotherapy courses were alternatively given in both settings. All cost categories were taken into account according to microcosting methods. A detailed assessment was performed on coordination and health care in both structures (marginal costs and average costs), from the viewpoint of society. RESULTS: The marginal cost for one chemotherapy administration was significantly higher with hospital at-home care than in the hospital day-care unit ($232.5 vs. $157, p < .0001). Conversely, the average cost was significantly lower with home care than at the hospital ($252.6 vs. $277.3, p = .0002). CONCLUSIONS: The results show that the interest of developing home care in anticancer chemotherapy is questionable regarding costs. In the French healthcare system, where there is a surplus of hospital beds, marginal costs seem to be more relevant indicators in most cases than average costs.