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Borghero G, Pierri V, Pili F, Muroni A, Ercoli T, Pateri MI, Pilotto S, Maccabeo A, Chiò A, Defazio G. Percutaneous gastrostomy, mechanical ventilation and survival in amyotrophic lateral sclerosis: an observational study in an incident cohort. Amyotroph Lateral Scler Frontotemporal Degener 2024; 25:563-569. [PMID: 38747354 DOI: 10.1080/21678421.2024.2351185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/24/2024] [Accepted: 04/29/2024] [Indexed: 07/25/2024]
Abstract
OBJECTIVE To analyze disease-modifying effects of percutaneous endoscopic gastrostomy (PEG) insertion for supporting nutrition, noninvasive ventilation (NIV), and tracheostomy-assisted ('invasive') ventilation (TIV) in amyotrophic lateral sclerosis (ALS). METHODS We retrospectively analyzed survival in a large population-based incident cohort that was prospectively followed up in our center. Analysis considered several known ALS-related prognostic variables. RESULTS In this population, PEG and NIV in multivariable analysis significantly correlated to survival as computed by disease onset to death/tracheostomy. NIV was associated with better survival while PEG was associated with reduced survival. Other independent prognostic factors were age at ALS onset, diagnostic delay, and flail arm/leg and pure upper motor neuron (PUMN) phenotypes. The length of survival after TIV was significantly associated with age at ALS onset (inverse correlation) whereas other variables did not. The length of survival after TIV correlated to age at ALS onset in such a way that each additional year of age at ALS onset decreased survival by about 0.7 months. Patients who underwent both TIV and NIV did not experience a better survival than those who underwent TIV alone. CONCLUSION The lack of effect of enteral nutrition on ALS survival probably reflected the timing of PEG insertion in patients with more severe disease. By contrast, patients who used mechanical ventilation had an increased overall survival compared with non-ventilated ones. The study also provided new information showing that the combined use of NIV and TIV did not may prolong ALS survival as compared to TIV alone.
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Affiliation(s)
- Giuseppe Borghero
- Institute of Neurology, Azienda Ospedaliero Universitaria di Cagliari, Italy
| | - Vincenzo Pierri
- Department of Medical Sciences and Public Health, University of Cagliari, Italy
| | - Francesca Pili
- Institute of Neurology, Azienda Ospedaliero Universitaria di Cagliari, Italy
| | - Antonella Muroni
- Institute of Neurology, Azienda Ospedaliero Universitaria di Cagliari, Italy
| | - Tommaso Ercoli
- Department of Medical Sciences and Public Health, University of Cagliari, Italy
| | - Maria Ida Pateri
- Department of Medical Sciences and Public Health, University of Cagliari, Italy
| | - Silvy Pilotto
- Department of Medical Sciences and Public Health, University of Cagliari, Italy
| | - Alessandra Maccabeo
- Department of Medical Sciences and Public Health, University of Cagliari, Italy
| | - Adriano Chiò
- Rita Levi Montalcini Department of Neurosciences, ALS Center, University of Turin, Turin, Italy, and
| | - Giovanni Defazio
- Institute of Neurology, Azienda Ospedaliero Universitaria di Cagliari, Italy
- Department of Translational Biomedicine and Neurosciences, University of Bari "Aldo Moro", Italy
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Grassano M, Koumantakis E, Manera U, Canosa A, Vasta R, Palumbo F, Fuda G, Salamone P, Marchese G, Casale F, Charrier L, Mora G, Moglia C, Calvo A, Chiò A. Giving Breath to Motor Neurons: Noninvasive Mechanical Ventilation Slows Disease Progression in Amyotrophic Lateral Sclerosis. Ann Neurol 2024; 95:817-822. [PMID: 38284771 DOI: 10.1002/ana.26875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 01/09/2024] [Accepted: 01/12/2024] [Indexed: 01/30/2024]
Abstract
OBJECTIVE Noninvasive mechanical ventilation (NIMV) improves amyotrophic lateral sclerosis (ALS) quality of life and survival. However, data about its effect on disease progression are still lacking. Here, we test whether NIMV use changed the rate of functional decline among ALS patients. METHODS In this retrospective observational study, we included 448 ALS patients followed up at the ALS Center in Turin, Italy, who underwent NIMV during the disease course. The primary outcome was the change in functional decline after NIMV initiation adjusting for covariates. Functional decline was based on the nonrespiratory items of the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R). RESULTS NIMV initiation resulted in a slower functional decline (mean improvement = 0.16 points per month, 95% confidence interval = 0.12-0.19, p < 0.001), with consistent effects observed across various demographic factors, including sex, age at diagnosis, and disease duration before NIMV initiation. This finding was replicated using the PRO-ACT (Pooled Resource Open-Access ALS Clinical Trials) dataset. The favorable impact of NIMV on ALSFRS-R progression was evident independently of disease stages. Notably, NIMV benefits were not dose-dependent but were particularly prominent for nighttime respiratory support. INTERPRETATION NIMV significantly influences the rate of motor progression in ALS, and this effect is not determined by the nonlinearity of ALSFRS-R trajectory. The functional decline slowed following NIMV initiation, independently of the site of disease onset or disease severity at the time of NIMV initiation. Our findings underscore the importance of timely NIMV initiation for all ALS patients and highlight the need to consider NIMV-induced slowing of disease progression when evaluating clinical trial outcomes. ANN NEUROL 2024;95:817-822.
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Affiliation(s)
- Maurizio Grassano
- "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Emanuele Koumantakis
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
- Post Graduate School of Medical Statistics, University of Turin, Turin, Italy
| | - Umberto Manera
- "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
- Neurologia 1U, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Antonio Canosa
- "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
- Neurologia 1U, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Rosario Vasta
- "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Francesca Palumbo
- "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Giuseppe Fuda
- "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Paolina Salamone
- "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Giulia Marchese
- "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Federico Casale
- "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Lorena Charrier
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Gabriele Mora
- "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Cristina Moglia
- "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
- Neurologia 1U, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Andrea Calvo
- "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
- Neurologia 1U, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Adriano Chiò
- "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
- Neurologia 1U, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
- Institute of Cognitive Sciences and Technologies, National Council of Research, Rome, Italy
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Moglia C, Palumbo F, Veronese S, Calvo A. Withdrawal of mechanical ventilation in amyotrophic lateral sclerosis patients: a multicenter Italian survey. Neurol Sci 2023; 44:4349-4357. [PMID: 37418099 PMCID: PMC10641048 DOI: 10.1007/s10072-023-06905-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/08/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Law 219/2017 was approved in Italy in December 2017, after a years-long debate on the autonomy of healthcare choices. This Law, for the first time in Italian legislation, guarantees the patient's right to request for withdrawal of life-sustaining treatments, including mechanical ventilation (MV). OBJECTIVE To investigate the current status of MV withdrawal in amyotrophic lateral sclerosis (ALS) patients in Italy and to assess the impact of Law 219/2017 on this practice. METHODS We conducted a Web-based survey, addressed to Italian neurologists with expertise in ALS care, and members of the Motor Neuron Disease Study Group of the Italian Society of Neurology. RESULTS Out of 40 ALS Italian centers, 34 (85.0%) responded to the survey. Law 219/2017 was followed by an increasing trend in MV withdrawals, and a significant increase of neurologists involved in this procedure (p 0.004). However, variations across Italian ALS centers were observed, regarding the inconsistent involvement of community health services and palliative care (PC) services, and the intervention and composition of the multidisciplinary team. CONCLUSIONS Law 219/2017 has had a positive impact on the practice of MV withdrawal in ALS patients in Italy. The recent growing public attention on end-of-life care choices, along with the cultural and social changes in Italy, requires further regulatory frameworks that strengthen tools for self-determination, increased investment of resources in community and PC health services, and practical recommendations and guidelines for health workers involved.
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Affiliation(s)
- Cristina Moglia
- "Rita Levi Montalcini", Department of Neuroscience, ALS Centre, University of Turin, Turin, Italy.
- Azienda Ospedaliero-Universitaria Città Della Salute e Della Scienza Di Torino, Turin, Italy.
| | - Francesca Palumbo
- "Rita Levi Montalcini", Department of Neuroscience, ALS Centre, University of Turin, Turin, Italy
| | | | - Andrea Calvo
- "Rita Levi Montalcini", Department of Neuroscience, ALS Centre, University of Turin, Turin, Italy
- Azienda Ospedaliero-Universitaria Città Della Salute e Della Scienza Di Torino, Turin, Italy
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Theme 09 - Clinical Trials and Trial Design. Amyotroph Lateral Scler Frontotemporal Degener 2023; 24:209-229. [PMID: 37966326 DOI: 10.1080/21678421.2023.2260201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
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White S, O'Cathain A, Halliday V, Croot L, McDermott CJ. Factors influencing decisions people with motor neuron disease make about gastrostomy placement and ventilation: A qualitative evidence synthesis. Health Expect 2023; 26:1418-1435. [PMID: 37254833 PMCID: PMC10349261 DOI: 10.1111/hex.13786] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 05/15/2023] [Accepted: 05/18/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND People with motor neuron disease (pwMND) are routinely offered gastrostomy feeding tube placement and (non-invasive and invasive) ventilation to manage the functional decline associated with the disease. This study aimed to synthesise the findings from the qualitative literature to understand how individual, clinical team and organisational factors influence pwMND decisions about these interventions. METHODS The study design was guided by the enhancing transparency in reporting the synthesis of qualitative research (ENTREC) statement. The search of five bibliography databases and an extensive supplementary search strategy identified 27 papers that included qualitative accounts of pwMND, caregivers and healthcare professionals' (HCPs) experiences of making decisions about gastrostomy and ventilation. The findings from each study were included in a thematic synthesis. FINDINGS Making decisions about interventions is an emotional rather than simply a functional issue for pwMND. The interventions can signal an end to normality, and increasing dependence, where pwMND consider the balance between quality of life and extending survival. Interactions with multiple HCPs and caregivers can influence the process of decision-making and the decisions made. These interactions contribute to the autonomy pwMND are able to exert during decision-making. HCPs can both promote and threaten pwMND perceived agency over decisions through how they approach discussions about these interventions. Though there is uncertainty over the timing of interventions, pwMND who agree to interventions report reaching a tipping point where they accept the need for change. CONCLUSION Discussion of gastrostomy and ventilation options generate an emotional response in pwMND. Decisions are the consequence of interactions with multiple external agents, including HCPs treading a complex ethical path when trying to improve health outcomes while respecting pwMND right to autonomy. Future decision support interventions that address the emotional response and seek to support autonomy have the potential to enable pwMND to make informed and timely decisions about gastrostomy placement and ventilation. PATIENT OR PUBLIC CONTRIBUTION The lead author collaborated with several patient and participant involvement (PPI) groups with regards to the conceptualisation and design of this project. Decisions that have been influenced by discussions with multiple PPI panels include widening the scope of decisions about ventilation in addition to gastrostomy placement and the perceptions of all stakeholders involved (i.e., pwMND, caregivers and HCPs).
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Affiliation(s)
- Sean White
- Neurosciences Department, Faculty of Medicine Dentistry and HealthThe University of SheffieldSheffieldUK
| | - Alicia O'Cathain
- School of Health and Related Research (ScHARR)The University of SheffieldSheffieldUK
| | - Vanessa Halliday
- School of Health and Related Research (ScHARR)The University of SheffieldSheffieldUK
| | - Liz Croot
- School of Health and Related Research (ScHARR)The University of SheffieldSheffieldUK
| | - Christopher J. McDermott
- Neurosciences Department, Faculty of Medicine Dentistry and HealthThe University of SheffieldSheffieldUK
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Manera U, Grassano M, Matteoni E, Bombaci A, Vasta R, Palumbo F, Torrieri MC, Cugnasco P, Moglia C, Canosa A, Chiò A, Calvo A. Serum chloride as a respiratory failure marker in amyotrophic lateral sclerosis. Front Aging Neurosci 2023; 15:1188827. [PMID: 37293667 PMCID: PMC10244551 DOI: 10.3389/fnagi.2023.1188827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 04/24/2023] [Indexed: 06/10/2023] Open
Abstract
Respiratory failure is the most common cause of death in patients with amyotrophic lateral sclerosis (ALS) and occurs with great variability among patients according to different phenotypic features. Early predictors of respiratory failure in ALS are important to start non-invasive ventilation (NIV). Venous serum chloride values correlate with carbonate (HCO3-) blood levels and reflect metabolic compensation of respiratory acidosis. Despite its wide availability and low cost, few data on serum chloride as a prognostic marker exist in ALS literature. In the present study, we evaluated serum chloride values at diagnosis as prognostic biomarkers for overall survival and NIV adaptation in a retrospective center-based cohort of ALS patients. We collected all ALS patients with serum chloride assessment at diagnosis, identified through the Piemonte and Valle d'Aosta Register for ALS, evaluating the correlations among serum chloride, clinical features, and other serum biomarkers. Thereafter, time-to-event analysis was modeled to predict overall survival and NIV start. We found a significant correlation between serum chloride and inflammatory status markers, serum sodium, forced vital capacity (FVC), ALS functional rating scale-revised (ALSFRS-R) item 10 and 11, age at diagnosis, and weight loss. Time-to-event analysis confirmed both in univariate analysis and after multiple confounders' adjustment that serum chloride value at diagnosis significantly influenced survival and time to NIV start. According to our analysis, based on a large ALS cohort, we found that serum chloride analyzed at diagnosis is a low-cost marker of impending respiratory decompensation. In our opinion, it should be added among the serum prognostic biomarkers that are able to stratify patients into different prognostic categories even when performed in the early phases of the disease.
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Affiliation(s)
- Umberto Manera
- “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Turin, Italy
- SC Neurologia 1U, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Maurizio Grassano
- “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Turin, Italy
| | - Enrico Matteoni
- “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Turin, Italy
| | - Alessandro Bombaci
- “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Turin, Italy
| | - Rosario Vasta
- “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Turin, Italy
| | - Francesca Palumbo
- “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Turin, Italy
| | - Maria Claudia Torrieri
- Neurology Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Paolo Cugnasco
- “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Turin, Italy
| | - Cristina Moglia
- “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Turin, Italy
- SC Neurologia 1U, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Antonio Canosa
- “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Turin, Italy
- SC Neurologia 1U, AOU Città della Salute e della Scienza di Torino, Turin, Italy
- Institute of Cognitive Sciences and Technologies, Rome, Italy
| | - Adriano Chiò
- “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Turin, Italy
- SC Neurologia 1U, AOU Città della Salute e della Scienza di Torino, Turin, Italy
- Institute of Cognitive Sciences and Technologies, Rome, Italy
| | - Andrea Calvo
- “Rita Levi Montalcini” Department of Neuroscience, University of Turin, Turin, Italy
- SC Neurologia 1U, AOU Città della Salute e della Scienza di Torino, Turin, Italy
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Pateri MI, Pilotto S, Borghero G, Pili F, Pierri V, Ercoli T, Gigante AF, Muroni A, Defazio G. Increasing prevalence 2015-2019 of amyotrophic lateral sclerosis in Sardinia, Italy. Neurol Sci 2023:10.1007/s10072-023-06753-5. [PMID: 36964314 DOI: 10.1007/s10072-023-06753-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/12/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND While amyotrophic lateral sclerosis (ALS) incidence has increased during the last decades, structured evidence on increased prevalence is lacking. After reporting a significant yearly increase of ALS incidence over a 10-year period, we checked for increased prevalence in Southern Sardinia over a quinquennium. METHODS ALS patients (El Escorial Criteria) recruited from the study area and followed at ALS Centre, University of Cagliari, were included. Prevalence was computed for January 1, 2015 and January 1, 2019 and was calculated for the overall ALS population as well as for tracheostomized and non-tracheostomized patients. RESULTS We observed a non-significant trend for greater ALS prevalence in 2019 than in 2015 (18.31 per 100,000 vs. 15.26 per 100,000; rate ratio: 1.83, p = 0.01). By contrast, a significantly raising 2015 to 2019 ALS prevalence was observed in tracheostomized patients. No significant difference could be detected in non-tracheostomized. CONCLUSIONS We provided the highest prevalence rate to date reported in the worldwide literature, and also showed a non-significant raising ALS prevalence in the Sardinian population over a quinquennium. The trend in raising ALS prevalence was likely due to extended survival due to invasive interventions.
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Affiliation(s)
- Maria Ida Pateri
- Institute of Neurology, University Hospital of Cagliari, Cagliari, Italy
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Silvy Pilotto
- Institute of Neurology, University Hospital of Cagliari, Cagliari, Italy.
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
| | - Giuseppe Borghero
- Institute of Neurology, University Hospital of Cagliari, Cagliari, Italy
| | - Francesca Pili
- Institute of Neurology, University Hospital of Cagliari, Cagliari, Italy
| | - Vincenzo Pierri
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Tommaso Ercoli
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | | | - Antonella Muroni
- Institute of Neurology, University Hospital of Cagliari, Cagliari, Italy
| | - Giovanni Defazio
- Institute of Neurology, University Hospital of Cagliari, Cagliari, Italy
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Amyotrophic Lateral Sclerosis Centre, University of Cagliari, Cagliari, Italy
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Oliver D, Baker I, Borasio GD, Cras P, Faull C, Hepgul N, Lorenzl S, Stockdale C, de Visser M, Vanopdenbosch L, Voltz R, Veronese S. The involvement of palliative care with neurology – a comparison of UK, Switzerland and Italy. Amyotroph Lateral Scler Frontotemporal Degener 2022; 24:256-262. [PMID: 36288469 DOI: 10.1080/21678421.2022.2136993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVES To ascertain the involvement of palliative care with neurology services in the care of people with amyotrophic lateral sclerosis (ALS) in the United Kingdom, Italy and Switzerland, in particular the collaboration with and referral from neurology, the involvement in multidisciplinary team care and in the respiratory support of ALS patients. METHODS In 2019, two online surveys were undertaken of palliative care specialists, using specialist groups of the European Academy of Neurology, European Association of Palliative Care and the Association of Palliative Medicine for Great Britain and Ireland. RESULTS The respondents were specialist palliative care professionals, predominantly senior doctors, involved in the care of people with ALS. As the numbers of respondents from many countries were in single figures the analysis was restricted to the United Kingdom, Italy and Switzerland. The time of involvement varied, with early involvement commonest in the UK. Barriers to referral included neurologists not referring and financial issues, particularly in Switzerland. The reluctance of patients and families to see palliative care services was reported as less than 20% in all countries. Respondents were often involved in the care of people receiving noninvasive ventilation (NIV), in all countries. and with tracheostomy ventilation (TV), particularly in Italy. CONCLUSIONS Palliative care services are often involved in the care of people with ALS, but the extent and timing of involvement varies. The use of clinical guidelines and education on palliative care for neurology services may encourage collaboration, for the benefit of people with ALS and their families.
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Affiliation(s)
- David Oliver
- Tizard Centre, University of Kent, Canterbury, United Kingdom
| | - Idris Baker
- Morriston Hospital, Swansea, Wales, United Kingdom
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Patrick Cras
- Department of Neurology, Antwerp University, Antwerpen, Belgium
| | | | - Nilay Hepgul
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College, London, United Kingdom
| | - Stefan Lorenzl
- Institute of Nursing Sciences and Practice, Paracelsus Medical University, Salzburg, Austria
| | | | - Marianne de Visser
- Department of Neurology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | | | - Raymond Voltz
- Department of Palliative Medicine, University Hospital, Cologne, Germany
| | - Simone Veronese
- Department of Research in Palliative Care, Fondazione FARO, Turin, Italy
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