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Dorsemans AC, Coarelli G, Heinzmann A, Verdon B, De Luca M, Petit E, Pierron L, Levy-Soussan M, Durr A, Gargiulo M, Ewenczyk C. End-of-Life Discussions With Patients and Caregivers Affected By Neurogenetic Diseases. Neurol Clin Pract 2023; 13:e200199. [PMID: 37854177 PMCID: PMC10581072 DOI: 10.1212/cpj.0000000000200199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 09/06/2023] [Indexed: 10/20/2023]
Abstract
Background and Objectives No effective cure is available for neurogenetic diseases such as Huntington disease, spinocerebellar ataxias, and Friedreich ataxia, all of which cause progressive motor, cognitive, and psychiatric symptoms leading, in the long term, to severe communication (among other) impairments. In end-of-life situations, advanced directives (indications formulated by the patient about end-of-life choices) are one decision-making resource for relatives, caregivers, and health care professionals. Given the slowly progressive nature of these diseases, the related disabilities, and their hereditary component, patients, caregivers, and neurologists are often at a loss concerning the right course of action to take. Our study's aim was to explore patients' and caregivers' perceptions, needs, and expectations around anticipated end-of-life discussions and advanced directives. Methods DIRAGENE is an observational, cross-sectional, mixed-methods study with a patient-centered component and a primary caregiver-centered component. Observations include disease severity, psychosocial, and emotional scales; in-house questionnaires; and semidirected interviews. Results We included 124 participants, of which 81 were patients and 43 primary caregivers. Only 16% of the participants knew specifically about advanced directives and 7% had written documents vs 30% and 18% in the general French population, respectively, adjusted for age. Qualitative analysis of the interviews with 15 couples showed notable dissimilarities in ideas about advanced directives between patients and caregivers and that the underlying pathology, severity, and inheritability are less relevant factors regarding end-of-life discussions than age, environment, prior experiences with death, and history of family illness. Most patients (95%) and caregivers (98%) found that participating in the study was helpful in bringing awareness to end-of-life issues, wished to prioritize discussing them with loved ones, and requested assistance in managing them throughout the course of the disease. Discussion Being affected by severe neurogenetic diseases does not seem to prompt individuals to give much thought to end-of-life planning. However, patients and caregivers welcome comprehensive information and expect progressive support from trained health care professionals in having such discussions. Routine integration of these conversations into medical management through a holistic and adapted approach will benefit patients with illnesses with unfavorable long-term prognoses.
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Affiliation(s)
- Anne-Claire Dorsemans
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Giulia Coarelli
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Anna Heinzmann
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Benoit Verdon
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Manuella De Luca
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Elodie Petit
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Lucie Pierron
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Michèle Levy-Soussan
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Alexandra Durr
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Marcela Gargiulo
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Claire Ewenczyk
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
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Giabicani M, Arditty L, Mamzer MF, Fournel I, Ecarnot F, Meunier-Beillard N, Bruneel F, Weiss E, Spranzi M, Rigaud JP, Quenot JP. Team-family conflicts over end-of-life decisions in ICU: A survey of French physicians' beliefs. PLoS One 2023; 18:e0284756. [PMID: 37098023 PMCID: PMC10128920 DOI: 10.1371/journal.pone.0284756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/08/2023] [Indexed: 04/26/2023] Open
Abstract
INTRODUCTION Conflicts between relatives and physicians may arise when decisions are being made about limiting life-sustaining therapies (LST). The aim of this study was to describe the motives for, and management of team-family conflicts surrounding LST limitation decisions in French adult ICUs. METHODS Between June and October 2021, French ICU physicians were invited to answer a questionnaire. The development of the questionnaire followed a validated methodology with the collaboration of consultants in clinical ethics, a sociologist, a statistician and ICU clinicians. RESULTS Among 186 physicians contacted, 160 (86%) answered all the questions. Conflicts over LST limitation decisions were mainly related to requests by relatives to continue treatments considered to be unreasonably obstinate by ICU physicians. The absence of advance directives, a lack of communication, a multitude of relatives, and religious or cultural issues were frequently mentioned as factors contributing to conflicts. Iterative interviews with relatives and proposal of psychological support were the most widely used tools in attempting to resolve conflict, while the intervention of a palliative care team, a local ethics resource or the hospital mediator were rarely solicited. In most cases, the decision was suspended at least temporarily. Possible consequences include stress and psychological exhaustion among caregivers. Improving communication and anticipation by knowing the patient's wishes would help avoid these conflicts. CONCLUSION Team-family conflicts during LST limitation decisions are mainly related to requests from relatives to continue treatments deemed unreasonable by physicians. Reflection on the role of relatives in the decision-making process seems essential for the future.
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Affiliation(s)
- Mikhael Giabicani
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, and Université Paris Cité, Paris, France
- Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Inserm, Laboratoire ETREs, Paris, France
| | - Laure Arditty
- Service de Réanimation, Centre Hospitalier Intercommunal des Alpes du Sud, Gap, France
| | - Marie-France Mamzer
- Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Inserm, Laboratoire ETREs, Paris, France
- Unité Fonctionnelle d'Ethique Médicale, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Isabelle Fournel
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besançon, Besançon, France
- EA3920, Université de Bourgogne-Franche Comté, Besançon, France
| | - Nicolas Meunier-Beillard
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- DRCI, USMR, CHU Dijon Bourgogne, Dijon, France
| | - Fabrice Bruneel
- Intensive Care Unit, Versailles Hospital Center, Le Chesnay, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, and Université Paris Cité, Paris, France
| | - Marta Spranzi
- Center for Clinical Ethics, AP-HP, Paris and Université de Versailles Saint-Quentin en Yvelines, Versailles, France
| | - Jean-Philippe Rigaud
- Service de Médecine Intensive Réanimation, CH de Dieppe, Dieppe, France
- Espace de Réflexion Éthique de Normandie, CHU de Caen, Caen, France
| | - Jean-Pierre Quenot
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France
- Equipe Lipness, Centre de Recherche INSERM UMR1231 et LabEx LipSTIC, Université de Bourgogne-Franche Comté, Dijon, France
- Espace de Réflexion Éthique Bourgogne Franche-Comté (EREBFC), Dijon, France
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