Surgical patient advocacy: role and value in surgery.

Patient advocacy may be necessary during medical care in the home or office as well as during hospitalization in either private or public sector care. Patients may choose a relative, a close friend or a physician as their patient advocate. The patient advocate may provide physical assistance and usually accompanies the patient throughout the course of disease. By agreeing to the presence of a patient advocate during visits, the patient implicitly acknowledges that confidentiality may be breached. Patient advocates may be particularly useful for the patient in case of severe disease or poor prognosis. The advocate becomes an intermediary contact and, at the same time, provides educational, relational and psychological support for the patient. The patient advocate should be consulted when the patient is incapable of making his own decisions. The patient advocate is supposed to be able to express the wishes of the patient, when the latter is incapable of doing so. The patient should therefore choose someone who, in his judgment, is competent to voice the patient's opinion for him. When the patient advocate remains at the patient's side at the end of life, whether in the hospital or at the patient's home, the advocate can benefit from "family solidarity leave" and obtain a daily stipend if this interrupts his or her professional activity.

[Is there still a future for the French "Perruche" jurisprudence?]. / La jurisprudence Perruche a-t-elle encore un avenir?

Since March 1, 2010, French citizens have a new procedure for defending their rights: the Priority preliminary ruling on the issue of constitutionality (QPC). During a trial, any citizen may request that the Constitutional Council be seized if he/she considers that a provision of a law applicable is inconsistent with the Constitution. One of the first QPCs was released regarding the Perruche antijurisprudence provision. The decision of the Supreme Court (Cour de Cassation) on November 17, 2000 had granted the child Nicolas Perruche the right to financial compensation for the material costs related to his physical disability as a result of congenital rubella. In response, Article 1 of the law of March 4, 2002 was passed in order to prohibit the compensation of a child "solely because of his/her birth". Since this law was enacted, only the moral injury of the parents can be indemnified in a case like that of Nicolas Perruche. Over time, the application of this article of the law of March 4, 2002 has become the subject of a heated debate. In the QPC decision of June 11, 2010, the Constitutional Council found the "Perruche antijurisprudence" provision to be consistent with the Constitution, except for the transitional provisions. Thus, it is assumed that the "Perruche antijurisprudence" provision applies to all children born after the entry into force of the law, i.e., as of March 7, 2002. In addition, the Perruche jurisprudence prevails for all claims filed before March 7, 2002. The issue of the cases for which legal action was taken after March 7, 2002 for a child born before March 7, 2002 remains debated. The current debate is whether the implementation of the law of March 4, 2002 should be extended or not to instances subsequent to March 7, 2002 for births prior to that date. In the present state of jurisprudence, the Court of Appeals answers negatively and applies the Perruche jurisprudence to all children born before March 7, 2002, regardless of the date by which the claims were filed.

10 years of controversy, twists and turns in the Perruche wrongful life claim: compensation for children born with a disability in France.

Since March 1st, 2010, French citizens have been able to call on a new legal procedure for defending their rights: the priority preliminary ruling on issues of constitutionality (question prioritaire de constitutionnalité, QPC). If, during a trial, a citizen considers that a provision of the applicable law is inconsistent with the Constitution of the French Republic, he/she may request that the matter be referred to the Constitutional Council. One ofthe first QPCs concerned legislation related to the Perruche jurisprudence. In a ruling on November 17th, 2000, the French Supreme Court of Appeal had granted the child Nicolas Perruche the right to financial compensation for the material costs related to his physical disability (caused by congenital rubella). In response, Article 1 of the Patients' Rights and Quality of Care Act (passed on March 4th, 2002) prohibited the award of compensation to a child "just because he/she has been born [with a disability]", i.e. in "wrongful life" claims. Since the enactment of the Act, compensation in a case like Perruche may only be awarded to cover the parents' psychological suffering, rather than the child's status at birth. The application of this "anti-wrongful life claim" legislation has since been subject of heated debate. In a QPC ruling on June 11th, 2010, the Constitutional Council found that Article 1 of the Patients' Rights and Quality of Care Act was (with the exception of its transitional provisions) indeed consistent with the Constitution of the French Republic.

A French hospital sentenced for unreasonable obstinacy.

On 2 June 2009, the Nimes administrative court condemned the Hospital of Orange (France) for unreasonable obstinacy after neonatal resuscitation. On 14 December 2002, an apparently stillborn child was resuscitated after approximately 30 minutes of foetal distress. Cardiac activity was recovered, but the child has since suffered from severe disabilities. The court did not find any fault committed by the hospital regarding maternal care. However, the hospital was sentenced to compensate for the injuries caused by unreasonable obstinacy. According to the court, the medical team should have taken into account the harmful neurological consequences of prolonged foetal distress. The court did not condemn the act of resuscitation itself, but its excessive length. This court ruling serves as a basis for reflection regarding the limits by which unreasonable obstinacy should be set.

Sudden death caused by aortic dissection in a patient with polycystic kidney disease.

A 43-year-old man presented at the emergency medical unit with chest pain. The results of a clinical examination were normal, apart from sternum pain (without radiation) on palpation. The patient had no respiratory problems and the pain was relieved by paracetamol. The electrocardiogram, laboratory tests and chest X-ray were normal. However, the man was found dead the next morning. In the autopsy, we noted the presence of haemopericardium, aortic dissection (starting from the vessel's origin and extended to the aortic arch and on through the diaphragm), polycystic kidney disease and liver cysts. In adult autosomal dominant polycystic kidney disease (ADPKD) patients, the main causes of death are ruptured intracerebral aneurysms, coronary artery disease, congestive heart failure, valvular heart disease and ruptured abdominal aortic aneurysms. Aortic dissection is considered to be rare cause of sudden death in ADPKD sufferers. ADPKD can have serious consequences for the vascular system. The families of confirmed ADPKD sufferers must be informed and screened as early as possible, in order to prevent renal and cardiovascular complications.

Victims of assault: a Europe-wide review of procedures for evaluating the seriousness of injuries.

In France, victims of assault receive a medical certificate describing their injuries. This certificate must fulfil certain criteria because it plays a major role in the subsequent judicial proceedings--notably the establishment of a period of 'total incapacity for work', which determines the court in which the case will be heard. Determination of the duration of this period of incapacity is complex. We decided to review medical examination procedures for victims of assault in a number of other European countries (England and Wales, Belgium, Germany, Switzerland and Spain). Our study revealed that only in France do physicians have to make a quantitative assessment of injuries, which is supposed to reflect the extent of the injuries and the intensity of the violence--despite the difficulties this may pose. We discuss the relevance of this quantitative assessment.

Total ankle arthroplasty in France.

OBJECTIVES: After more than 10 years' experience in France, the French Foot Surgery Association (Association française de chirurgie du pied [AFCP]) presents an update on mobile-bearing ankle prostheses, based on a multicenter study. META-ANALYSIS - BIOMECHANICS - ASSESSMENT AND INDICATIONS: A preliminary comparative meta-analysis of the literature studies on ankle and prosthesis biomechanics, reviews validated indications and contra-indications, and details clinical and radiological outcomes assessment protocols. PROFESSIONAL SURVEY: Sixty-three surgeons (95% AFCP members) answered a professional online survey, by email or regular post: 70% performed total ankle replacement (TAR), 39% of them at least two per year and 16% more than 10 per year, resulting in 317 TARs per year or 50% of the French activity and 312 arthrodeses per year or 17% of the French activity - which gave the survey considerable power. In 2004-2005, 46% of the TARs implanted were AES, 38% Salto and 9% Hintegra. GAIT ANALYSIS FOLLOWING TAR: This study included two series of patients (15 in Brussels and six in Paris) with laboratory gait analysis preoperatively and at 6 months' and 1 year's FU. Following TAR, speed, cadence and strides increased and mean total work approximated normal values. These two independent studies quantified the advantages of TAR over arthrodesis. MULTICENTER STUDY: This retrospective study had a minimum follow-up of 1 year. Results were not distinguished between the four types of prosthesis (approved by the French Healthcare Agency [HAS]) involved. Inclusion criteria for operators were: AFCP membership, and experience of more than 20 prostheses of a given type. Twelve out of 15 centers responded and undertook to include continuous series. Data were centralized on a dedicated anonymous online site. Five hundred and ninety-two TARs (388 Salto, 173 AES, 22 Hintegra, nine Star) in 555 patients (mean age, 56.4 years; range 17-84 yrs) were included. Indications were post-traumatic arthritis (48%), arthritis associated with laxity (15%), inflammatory arthropathy (20%), primitive arthritis (9%), prosthetic revision (2%), and miscellaneous (5%). Sixty-one percent of operations included associated procedures: 208 Achilles lengthenings, 45 subtalar arthrodeses, nine calcaneal osteotomies and 45 lateral ligament reconstructions. Complications comprised 53 malleolar fractures, and 39 cutaneous and seven infections (9%). At a mean 37 months' FU, 87.5% of patients were satisfied or very satisfied; mean functional score was 82.1/100; radiographic mobility, 23.2 degrees ; and total SF 36 score (on the Short Form Health Survey), 66. X-ray found stable anchorage in 98% of cases, cysts in 15%, and calcification in 4%. REVISION FOR FAILURE: Overall cumulated survivorship was 88% at 71 months: 22 patients underwent arthrodesis (61% satisfied), and 10 implant replacement (50% satisfied). CONCLUSION: This multioperator, multi-implant series of 592 patients confirmed literature data. Prospective follow-up of the cohorts managed in these expert centers is essential, in order to make available long-term data.

[Intensive care anaesthesia practice in the prison environment. Can a prisoner benefit from ambulatory anaesthesia]. / Pratique de l'anesthésie réanimation en milieu pénitentiaire. Un détenu peut-il bénéficier d'une anesthésie ambulatoire ?

Ambulatory anaesthesia is an anesthesia allowing the return of the patient home the same day. Even if the ambulatory hospitalization can, in theory, be applied to a prisoner as to every patient, caution is essential in such approach. Every anaesthetist reanimator doctor practicing in public hospitals may give care to patient prisoners while he is far from dominating all features of the prison world and while he must put down his therapeutic indications. The ambulatory anaesthesia in prison environment does not guarantee full security for the patient. Procedures could be set up between hospital complexes, caretakers practicing within penal middle (Unit of Consultation and Ambulatory Care [UCAC]) the prison service and hospital, the prefecture, to identify possible ambulatory interventions for a patient prisoner and to set up all guarantees of patient follow-up care in his return in prison environment. The development of interregional secure hospital units (ISHU) within teaching hospitals, allows an easier realization of interventions to the prisoners, but exists only in seven teaching hospitals in France.

[Dead children born: Current regulation, inscription to registry office differs]. / Décès périnatal : réglementation actuelle, inscription à l'état civil et devenir du corps.

From a juridical point of view, in France, we become a "person" only when we are born "living" and "viable". These two criteria are necessary, but the threshold of viability is not defined by the law. The general education of registry office leaned on a circular fixing a << threshold of viability >> itself based on a recommendation of the Worldwide Organization of Health (WHO). The fetus was considered as viable after a term of twenty-two weeks of amenorrhea or if it had a weight over or equal to 500 grammes. The inscription to Registry office differs, as well as the taking care of the body of the child, depending on whether he was born living, viable and living and not viable, dead and viable, or dead and not viable. In France, the civil officer established an act of child declared lifeless when the child was born living but not viable or when the child is death - born but viable. However, parents of not viable and born dead children, often close to the threshold of viability, also liked to acquire an act of lifeless child, to be able to organize funeral has child lifeless and to inscribe it in their family record book. The act of child declared lifeless allows to inscribe the child on the family record book if the parents wish and give to the families the delay of ten days to claim the body. By judgment of February 6th, 2008, the Supreme Court of appeal cancelled rulings where the threshold had been kept to refuse the deliverance of an act of lifeless child. Her Supreme court of appeal considers that law does not impose de threshold from which the recognition of the status of lifeless child would be possible. Since the decrees of August, 2008, there is no border anymore of minimum of term or weight. Consequently, the lifeless born children after an unprompted delivery or a medical break, the pregnancy can be inscribed on the civil record. On the other hand, it is not possible for the precocious wrong coat and the termination of pregnancy.

[Obstructive lung diseases in a French prison: results of systematic screening]. / Dépistage de l'asthme et de la bronchopneumopathie obstructive à la maison d'arrêt d'Amiens: étude préliminaire transversale.

BACKGROUND: French prisoners have health problems that have been inadequately treated before imprisonment. This population has insufficient access to the healthcare system. Addictive behaviours, particularly smoking, are widespread. The aim of the study is to evaluate the prevalence of airflow limitation by using a primary care screening method adapted for the correctional facility and its inmates. METHOD: The screening of airflow limitation using a mobile spirometer is carried out in inmates consulting the primary care unit (UCSA) of Amiens prison. Patients consulting the UCSA between 16 August and 17 October 2006 and providing their consent are included in the study. The criteria for exclusion are: a counter-indication for spirometry, poor compliance with the effort of forced expiry after eight efforts, as well as refusal to take part in the study. The descriptive statistical analysis includes all of the quantitative and qualitative variables. RESULTS: Among the 210 patients included in the sample, only five patients refused to take part in the study. Their mean age was 37 (range: 16-65) and 90% were men. Ninety percent of this population were active smokers. Sixty percent of these smokers would like to quit. The spirometry detected 11% undiagnosed airflow limitation: 11 prisoners suffered from chronic obstructive lung disease and 13 prisoners suffered from asthma. DISCUSSION: Given the relative youth and high risk nature of these diagnosed patients, the potential for the long or short term aggravation, and a growing recognition of the seriousness of exposure to tobacco, the authors suggest that the systematic screening of inmates for airflow limitation may be used to assist in detecting serious health issues. Along with new French antismoking legislation, this screening may enable primary care workers to better reduce smoking habits in prisons.

[Is the person of trust a reliable witness in case of organ removal from a deceased person for donation purposes?]. / La personne de confiance est-elle un témoin fiable en cas de possibilité de prélèvement d'organe sur personne décédée en vue d'un don?

OBJECTIVES: All adults (people over the age of 18) can assign a person of trust and this person can be a parent, a partner or the treating doctor. Following the introduction of the 4(th) March 2002 law, this third party is now within the doctor-patient relationship. The aim of this study is to find out who is appointed as a person of trust by patients notably concerning the level of education or medical knowledge of these people. We have equally put the person of trust to the test within the realms that they would be questioned regarding organ donation from the deceased. PATIENTS AND METHODS: The included subjects were adults admitted to hospital for surgical procedures or medical biopsies that were not deemed life threatening. The data collection was done by doctors from the legal medicine department at the university hospital of Amiens over a period of 18 months. With the permission of the patient and his or her person of trust, a one-to-one discussion was held. Statistical analysis took place focusing on all the variables together and is shown by comparing the patient group versus the person of trust group. The significance threshold returned was 0.05. RESULTS: A total of 125 patients-persons of trust couples were interviewed. The patients and their person of trust were not different in terms of age, social status, occupational groups and education. However, a person of trust is more often a woman (64%) against 50% of patients. A person of trust more often lives as a couple than the patients. Concerning organ donation, over half of the people questioned were for donation but only a third of patients had already discussed the subject with their person of trust. The persons of trust bring in 40% of cases a response that is not concordant in the position of the patient. DISCUSSION: The creation of a person of trust due to the law of 4(th) March 2002 brings about the opportunity for the patient to take on an approach, with the doctors, of having somebody that can advise them. Yet in this study, there is no significant evidence of a difference between the level of education of patients and that of their person of trust, or a difference in the distribution of the socio-professional categories, or specific choices for the GP. The person of trust can be used to wait on behalf of the patient whilst he or she is not able to do so. Even if the patient feels that the person of trust has come first over other close friends or relatives, the persons of trust assume this role with difficulty. Since its creation, the person of trust was presented as a response to social demand; however, it seems that patients are not sufficiently informed when it comes to the possibilities that are on offer to them.

[The genetic fingerprints file in France: between security and freedom]. / Les fichiers des empreintes génétiques en France: entre sécurité et liberté.

In France, the French National File Automated with Genetic fingerprints (FNAEG) is a bank automated by genetic data which is used in penal domain. It facilitates search of the authors of malpractices, or the missing people. Since 1998, it has enabled to resolve numerous criminal cases. An extension of the field of application has been observed. It is a confidential register which is subjected to numerous controls. Nevertheless, private character of the data and its functioning (criminal character of the refusal of taking, periods of answer, and problem of data's conservation) explain the important contesting of associations worried about the respect of personal freedoms.

[Tuberculosis vaccination programs: where are we?]. / Comment en est-on arrivé à suspendre l'obligation vaccinale du BCG ?

The incidence of tuberculosis strongly dropped since the obligation of declaration and the vaccination generalized in the middle of the 20(th) century. Many countries suspended the obligatory character of vaccination, preferring to reserve it to populations at risk. France had preserved obligatory generalized vaccination, using an intradermal injection whose realization is difficult and produced many side effects. Since 2004, different opinions to the installation of a vaccination reserved to the populations at risk are favorable, in particular, those originating in a country with strong tuberculosis endemia. These opinions also recommend to reinforce the tracking of the subjects reached of tuberculosis. Mrs Roselyne Bachelot, Minister of Health, announced on July 11, 2007 the suspension of the obligatory character of the BCG from the child and the teenager with the profit of a strong recommendation of vaccination of the children most exposed to tuberculosis as of the first month of life. In parallel, a national programme of fight against tuberculosis 2007-2009 is launched.

[How to take up an expertise for medical liability in anaesthesiology?]. / Comment gérer une expertise en responsabilité en anesthésie réanimation ?

Search for responsibility in medicine became everyday. Anaesthetists are particularly exposed and will be, several times, confronted to it during their career. They have to have knowledge of some necessary elements to get to grips with expertise. Expertise can be asked by a penal jurisdiction. In that case, the anaesthetist can be directly and personally implicationed. When expertise is asked by a civil jurisdiction, it concerns anaesthetists, whichever the (liberal or employee of private). Expertise during administrative procedures concern hospital's anaesthetists. It is important to organize a preparatory meeting in any expertise. Praticians must collect together the complete medical file to establish the most exactly possible, chronology of facts. The anaesthetist can be accompanied by medical consultant appointed by the insurance companies and a lawyer. But he does not have to content with be represented by them. Presence in expertise is essential; praticians can so give evidence of their good faith and answer the expert's questions. Vagueness or doubt are never favorable to pratician. It is also, a responsible and respectful behavior toward the patient.

[Is it necessary to found an exemption from the medical secrecy concerning the health of politicians?]. / Faut-il instaurer une dérogation au secret médical concernant l'état de santé des hommes politiques?

In its book " The great secrecy", Dr. Gübler revealed that President of French Republic, Franpois Mitterrand, had lied on his cancer as of his accession with the capacity. 1981 to 1994, Dr. Gübler was the personal doctor of the President of French Republic, deceased on January 8, 1996. The great secrecy was diffused on January 17, 1996. French Justice ordered the interruption of its diffusion on January 18, 1996. The recourse led to a compensation for family of President. However, the European Court of the Humans Right (CEDH), May 18, 2004, condemned France retaining that the general and absolute character medical secrecy could not attack the freedom of expression and to the right to knowledge by the Nation of the truth on health of its former President of Republic. The CEDH however approves initial prohibition but not the maintenance of this prohibition, 9 months later. The great secrecy remained interdict in France until 2004 and was republished at the beginning of 2005. Dr Gübler was condemned for violation of medical secrecy and was erased Order of the doctors, decision confirmed by the Council of State. This story started again the medical, legal and political debate around the medical secrecy concerning politicians. In September 2005, President of French Republic, Jacques Chirac, was hospitalized after a cerebral vascular accident. Communicate were regularly published on its health, but questions were asked concerning medical activity under these conditions.

[Suing the surgeon: what are procedures? How to conduct an assessment?]. / Mise en cause du chirurgien: quelles sont les procédures? Comment gérer une expertise?

Surgeons are particularly exposed to lawsuits. Most will be threatened or confronted with litigation several times during their career. The surgeon can be held directly and personally liable during a penal procedure. Civil jurisdictions oversee expert evaluation in cases involving self-employed and salaried surgeons in private practice. An administrative structure for expert evaluation is set up for surgeons working in the public sector. The law of March 4, 2002 has set up a new structure with commissions for reconciliation and compensation of medical accidents (CRCI); these apply to all surgeons. It is essential that the practitioner prepare himself fully, studying both the patient dossier and the pertinent medical literature in order to participate in an expert evaluation under the best circumstances and to justify the diagnostic and therapeutic measures taken. The surgeon may be accompanied by legal counsel and an expert medical witness, but he should not abdicate all responsibility for testimony to them; he, as the treating physician, has the fullest knowledge of the medical case and can best respond to the expert's interrogation. This behavior also demonstrates both responsibility and respect to the patient and his family.

[The death certificate: how to draft and why?]. / Le certificat de décès: comment le remplir et pourquoi?

The death certificate must be established within 24 hours following the death and handed to the mayor. The obligation to place in the coffin immediately is planned by a defined list of contagious diseases. Medicolegal obstacle must be ticked if there is a doubt on the cause of death. In order to look into the causes of the death, swabs can be asked by the physician. It is a medical or scientific autopsy to look into the causes of the death apart from a juridical procedure. The presence of a battery prosthesis (pacemaker) must be specified, so that it can be removed by a physician or a thanatopractionner before the placing in the coffin. Death certificate is passed on by the city hall to Insee, which updates the identification national register of physical people. Inserm receives anonymous data of the causes of death allowing to establish the mortality national statistics. In the absence of medicolegal obstacle or obligation to place in the coffin immediately, funeral operations can begin: preservation care, body transport, placing in the coffin and finally burial or cremation.