Subcutaneous administration of paracetamol-Good local tolerability in palliative care patients: An observational study.

BACKGROUND: The subcutaneous route is widely used in both palliative care and geriatrics. Numerous compounds are administered by this route, including paracetamol. However, there is no recommendation on which to base this latter practice and, in the absence of published evidence, nothing is known regarding its local tolerability in palliative care patients. AIM: The main objective of this study was to assess the local tolerability of paracetamol when administered subcutaneously for analgesic or antipyretic purposes in patients hospitalized in the palliative care unit. The secondary objective was to identify the factors favoring the occurrence of local adverse events. DESIGN: This is a prospective multicenter observational study (NCT02884609). PARTICIPANTS: Study conducted in 160 patients hospitalized in the palliative care units of three hospitals in metropolitan France from 2014 to 2017. RESULTS: Of the 160 patients, 44 (28%) presented at least one non-serious local adverse event (edema in 29, erythema in 5, pain in 15, hematoma in 2, pruritus in 1, and local heat in 2). No serious adverse events were observed. Factors associated with the occurrence of local adverse events were younger age, administration in the arm and thorax, and a high number of daily administrations. CONCLUSION: This first ever study carried out on this subject reveals that subcutaneous administration of paracetamol in palliative care patients was well tolerated locally.

Withdrawal of artificial nutrition: influence of prior experience on the perception of caregivers.

CONTEXT: In spite of the existence of clinical guidelines and a legal framework in France, the withdrawal of artificial nutrition (AN) in palliative care remains a difficult situation for caregivers who are confronted with this reality. OBJECTIVES: To describe the perception of caregivers on the withdrawal of AN and to compare this perception between caregivers who have already been confronted with this situation and those who have not. METHODS: Cross-sectional survey questionnaire of nurses and nurses' aides (n = 274) working in medicine, surgery, and palliative care departments of a regional hospital. RESULTS: Of the caregivers, 59.5% declared having been confronted with the withdrawal of AN in their professional practice. This was associated with a better perception by these caregivers even if their knowledge on the criteria to be considered in the decision was not significantly modified. CONCLUSION: The coherence of the withdrawal of AN with the personal beliefs of the caregivers, already high in the absence of being confronted with this practice, is better among caregivers who have been confronted with this situation. The lack of information perceived by caregivers should prompt us to develop additional training on the withdrawal of AN, its objectives, and its clinical consequences.

Caregivers Confronted With the Withdrawal of Artificial Nutrition at the End of Life: Prevalence of and Reasons for Experienced Difficulties.

BACKGROUND: Withdrawing artificial nutrition in palliative care is an issue that often leads to ethical dilemmas among health care providers, despite clinical guidelines. OBJECTIVES: To describe the experience of health care providers confronted with the withdrawing of artificial nutrition at the end of life and identifying the factors related to the level of ethical dilemmas. METHODS: Cross-sectional survey questionnaire of all the nurses and nurses' aides working in medicine, surgery, and palliative care departments of a regional hospital and who have already been confronted with the withdrawal of artificial nutrition. RESULTS: Of 818 questionnaires sent, 274 were returned (response rate 33.5%); 60% (163) of the care providers who responded were involved in withdrawing artificial nutrition at the end of life. Among these, 42 (25.8%) had always or often been affected with ethical dilemmas, and 97 (60%) responded that withdrawing artificial nutrition had always or often been preceded by a multidisciplinary discussion. Items significantly associated with a high level of ethical dilemmas were (1) existence of differences in opinion within the health care team, (2) lack of information regarding the indication of the withdrawal of artificial nutrition, (3) feeling uncomfortable with the patient and his or her relatives, (4) guilt, (5) feeling of abandonment of care, and (6) uneasiness. CONCLUSION: Health care providers seem to have a lack of information and consensus regarding the withdrawal of artificial nutrition at the end of life. The ethical dimension of withdrawing artificial nutrition in palliative care has a strong impact on care providers, regardless of the circumstances of the withdrawal.

[Intervention of mobile palliative care team on nursing homes: retrospective study]. / Intervention d'une équipe mobile de soins palliatifs en établissement hébergeant des personnes âgées dépendantes: étude rétrospective.

BACKGROUND: Interventions of mobile palliative care teams in nursing homes have been the subject special consideration, however very little data are available on this subject. OBJECTIVES: To determine the proportion of patients followed and consultations conducted in nursing homes for the dependent elderly by a mobile palliative care team, to describe the patients followed and to analyze the various aspects of this intervention. METHOD: Retrospective study on the interventions carried out by a mobile palliative care team in nursing homes between January 1st and December 31st, 2012. RESULTS: The interventions in nursing homes targeted, 7.2% of the followed patients and represented 8.7% of the total activity of the mobile team. Intervention requests were made primarily by the family physician. The followed patients were mostly women (63%), with a mean age of 84 years, presenting non-cancerous diseases (78.2%), and had an average of 4.4 consultations. Half of the patients died during follow-up. Three quarters of the patients presented pain, neuro-psychological symptoms and verbal communication disorders. Four out of ten patients met with the occupational therapist and one of ten, the psychologist. DISCUSSION: The activity of mobile palliative care teams remains marginal, although steadily (on the rise. The collected data illustrate the specificity of geriatric palliative care, while certain characteristics inherent to nursing homes require establishing appropriate therapy proposals. CONCLUSION: Although quantitatively limited, the activity of mobile palliative care teams in nursing homes appears important as these interventions are likely meet the needs of both patients and staff in addition to enabling patients in palliative care to remain at their current place of residence.

[Management of opioid maintenance treatments when analgesic treatments are required]. / Gestion des traitements de substitution aux opiacés lorsqu'un antalgique est indiqué

Opioid maintenance treatments (OMT) reduce illicit opiate use and its associated risks. They are often prescribed on a long-term basis. Physiological changes induced by long-term OMT may cause hyperalgesia and cross-tolerance to opioid agonists, which suggests that the dosage of analgesic treatment should be modified in cases of acute pain, especially when an opioid-based analgesia is required. When treatment with analgesics is necessary, OMT must be maintained, except in exceptional cases. If a split-dosing schedule is temporarily employed during OMT, the daily dosage should not be increased for analgesic purposes. Analgesic treatment must be managed differently in case of treatment with buprenorphine or methadone. With buprenorphine, non-opioid analgesics should be introduced first, if possible. If this strategy is inefficient or contraindicated, a temporary or definitive switch to methadone should be considered. In the case of methadone-based OMT, opioid analgesics should be added directly and the dosage should be adapted according to the level of pain reported by the patient.

[Place and characteristics of patients older than 85 managed by mobile palliative care team; a retrospective study]. / Place et caractéristiques des patients âgés de 85 ans et plus suivis en équipe mobile de soins palliatifs ; étude rétrospective.

The objectives of this study was to specify the place of the patients older than 85 in the activity of the Mobile health unit of the Hospital of Metz-Thionville, to determine their characteristics and to show possible care differences as compared with younger patients. This is a retrospective study concerning all the patients seen by the Mobile health unit in 2006 and 2007. The patients older than 85 represent 11% of the 652 patients followed by the Unit and 7.8% of the 2.436 consultations on the study period. The older patients have a WHO mean score significantly higher and a Karnofsky mean score significantly lower than the younger subjects. Their survival rate tends to be lower but not significantly. Cancers are less frequent in older patients and they have fewer consultations than younger ones. The older patients present fewer communication problems and less often pain than the younger patients. The prescriptions of non-opioid and opioid analgesics, steroïds or antiepileptic drugs (used as analgesics) are less frequent in the older patients. The results of this study showed some specificities of palliative care in the older patients: we observed a great variety of pathologies and a lower frequency of cancers than in younger patients, various places of care, difficulties to evaluate the symptoms or to treat them due to communication problems especially. If these specificities are real, they do not seem to have important repercussions on following since the group of the patients older than 85 and the one of the younger patients differ only little in terms of survival rate or mean number of consultations.

[Principle of double effect and sedation for intractable distress: reflexion on survival in sedated patients]. / Théorie du double effet et sédation pour détresse en phase terminale : réflexion autour de la survie des patients sédatés.

The effect of sedation for intractable distress on survival in terminally ill patients is a debated question. For certain people, this would limit the physician's intervention to the detriment of symptom alleviation for patients. The principle of double effect is traditionally used to overcome this ethical conflict. Studies conducted between 1990 and 2009 fail to show that the death of patients undergoing sedation for intractable distress is hastened. Some authors conclude that sedation does not hasten death and claim that principle of double effect is unnecessary in this debate. In our view, caution is required in the interpretation of studies results and absence of evidence of sedation effects on survival cannot be considered as an evidence of absence of sedation effects on survival. Furthermore, we consider obtaining a definitive answer as impossible in the future, as the required cannot be conducted for ethical reasons. Caution, we think, is necessary, especially as sedation is sometimes used with explicit intention of hastening the end of life. Physician's intention, key point of the principle of double effect, comes back into the foreground of ethical debate on sedation for intractable distress. Far from limiting the physician's action, the principle of double effect, which requires us to clarify our intentions, should allow us to make the distinction between sedation for intractable distress and euthanasia.