Legalisation of euthanasia and assisted suicide: advanced cancer patient opinions - cross-sectional multicentre study

OBJECTIVES

The French government voted a new law in February 2016 called the Claeys-Leonetti Law, which established the right to deep and continuous sedation, confirmed the ban on euthanasia and ruled out physician-assisted suicide. The aim of this work was to gather the opinion of patients on continuous sedation and the legalisation of medical assistance in dying and to explore determinants associated with favourable and unfavourable opinions.

METHODS

This was a French national prospective multicentre study between 2016 and 2020.

RESULTS

331 patients with incurable cancer suffering from locally advanced or metastatic cancer in 14 palliative care units were interviewed. 48.6% of participants expressed a favourable opinion about physician-assisted suicide and 27.2% an unfavourable opinion about its legalisation. Regarding euthanasia, 52% of patients were in favour of its legalisation. In univariate analysis, the only factor determining opinion was belief in God.

CONCLUSIONS

While most healthy French people are in favour of legalising euthanasia, only half of palliative care patients expressed this opinion. Medical palliative care specialists were largely opposed to euthanasia. The only determining factor identified was a cultural factor that was independent of the other studied variables. This common factor was found in other studies conducted on cohorts from other countries. This study contributes to the knowledge and thinking about the impact of patients' personal beliefs and values regarding their opinions about euthanasia and assisted suicide.

TRIAL REGISTRATION NUMBER

NCT03664856.

Methadone and neuropathic cancer pain subcomponents: a prospective cohort pilot study

Forty per cent of cancer pain associate neuropathic and nociceptive pain simultaneously, and refractory pain affects 15% of cancer pain. Methadone is an effective opioid in treating nociceptive pain and could have an effect on neuropathic pain. Uncertainty remains on its effects on the different subcomponents of neuropathic pain.

OBJECTIVES

To identify which subcomponents of neuropathic cancer pain are addressed using methadone.

METHODS

An observational prospective cohort study of palliative care inpatients after rotation for refractory neuropathic cancer pain. Pain intensity was assessed weekly for 28 days, using a Visual Analogue Scale (VAS) and the Neuropathic Pain Symptom Inventory (NPSI).

RESULTS

Forty-eight patients were included and 17 completed the 28 days follow-up. VAS pain rating decreased by at least 20 mm in 47% of patients and the pain intensity was significantly lower at day 28 with 53% of patients with a VAS inferior to 4 (p<0.001). The pressure/squeezing component (NPSI score) decreased by more than 2 points in 50% of patients.A linear regression showed allodynia and pressure/squeezing were responsible for the largest part of the overall alleviation of pain (p=0.01).

CONCLUSIONS

Methadone could significantly improve neuropathic pain through a targeted effect of allodynia and its pressure/squeezing component.

Epidemiology of psychiatric disorders following cytoreductive surgeries plus hyperthermic intraperitoneal chemotherapy: a prospective cohort analysis

The peritoneal surface malignancy (PSM) is an advanced disease, the prognosis of which has been radically improved since the development of cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC). These procedures are associated with many complications. However, very few data are available regarding the psychiatric morbidities that might occur. The present study assessed the epidemiology of depressive mood and anxiety during the 6 months following the procedure. The analysis of a prospective cohort that included patients who underwent CRS with or without HIPEC between December 2016 and December 2019 was performed. A total of 115 patients were included. During the 6-months follow-up, the mean (SD) Hospital Anxiety and Depression Scale -D (HADS-D) score was 7.8 (48) and a significant increase compared with the pre-operative period (t(49) = - 4.36, p < 0.005) was found. Thirty-seven patients (32%) had a HADS-D score higher than 7. The incidence of a HADS-D score higher than 7 during the follow-up was 0.05 patient per patient-month. Anxiety and the overall mental disorders intensity scores also increased. The results showed an important increase of mental disorders and their intensity during the 6-months following a CRS with or without HIPEC.

Integrated Short-term Palliative Rehabilitation to improve quality of life and equitable care access in incurable cancer (INSPIRE): a multinational European research project

Background

Disability related to incurable cancer affects over a million Europeans each year and people with cancer rank loss of function among the most common unmet supportive care needs.

Objectives

To test the clinical and cost-effectiveness of an integrated short-term palliative rehabilitation intervention, to optimise function and quality of life in people affected by incurable cancer.

Design

This is a multinational, parallel group, randomised, controlled, assessor blind, superiority trial.

Methods

The INSPIRE consortium brings together leaders in palliative care, oncology and rehabilitation from partner organisations across Europe, with complementary expertise in health service research, trials of complex interventions, mixed-method evaluations, statistics and economics. Partnership with leading European civil society organisations ensures citizen engagement and dissemination at the highest level. We will conduct a multinational randomised controlled trial across five European countries, recruiting participants to assess the effectiveness of palliative rehabilitation for people with incurable cancer on the primary outcome - quality of life - and secondary outcomes including disability, symptom burden and goal attainment. To support trial conduct and enhance analysis of trial data, we will also conduct: comparative analysis of current integration of rehabilitation across oncology and palliative care services; mixed-method evaluations of equity and inclusivity, processes and implementation for the intervention, at patient, health service and health system levels. Finally, we will conduct an evidence synthesis, incorporating INSPIRE findings, and a Delphi consensus to develop an international framework for palliative rehabilitation practice and policy, incorporating indicators, core interventions, outcomes and integration methods.

Scientific contribution

If positive, the trial could produce a scalable and equitable intervention to improve function and quality of life in people with incurable cancer and reduce the burden of care for their families. It could also upskill the practitioners involved and motivate future research questions. The intervention could be adapted and integrated into different health systems using existing staff and services, with little or no additional cost.

Legalised active assistance in dying: palliative care stakeholders' national e-consultation

OBJECTIVES

There is a growing debate surrounding the legalisation of medical assistance in dying (MAID). MAID is currently prohibited by the French law; however, the debate has recently been reinvigorated in France. This study aims to collect opinions of palliative care stakeholders (PCS) regarding the legalisation of MAID and to identify the factors associated with their opinions.

METHODS

We performed a transversal survey between 26 June 2021 and 25 July 2021, on PCS who were on the French national scientific society for palliative care. Participants were invited by email.

RESULTS

1439 PCS took part and expressed an opinion about the legalisation of MAID. 1053 (69.7%) were against the legalisation of MAID. When forced to choose which option should be privileged if the law had to change, 3.7% favoured euthanasia, 10.1% favoured assisted suicide with provision of lethal drug by a professional, 27.5% favoured assisted suicide with prescription of a lethal drug and 29.5% favoured assisted suicide with provision of a lethal drug by an association. The opinion regarding legalisation of MAID was statistically different depending on the participant profession (p<0.001) and when comparing clinical and non-clinical positions (p<0.001). A quarter of participants (26.7%) believe that legalising MAID might lead them to change their current position.

CONCLUSIONS

Overall, French palliative care professionals are against a modification of the current legal framework for legalising MAID but some might change their current position if a law was voted. This might destabilise the PCS demography that is already worrying.

Palliative care from the perspective of cancer physicians: a qualitative semistructured interviews study

OBJECTIVE

Integrated palliative care for populations with cancer is now highly recommended. However, numerous physicians working in cancer care are still reluctant to refer patients to specialist palliative care teams. This study explores their perceptions of palliative care and factors influencing reasons to refer to specialist palliative care.

METHODS

We used a qualitative methodology based on semistructured interviews with physicians working in cancer care, in two tertiary hospitals and one comprehensive cancer centre with access to a specialist palliative care team. Forty-six physicians were invited and 18 interviews were performed until data saturation. Participants were mainly men, licensed in cancer care, 37.9 years old on average and had 13 years of professional experience. The length of interviews was on average 34 min (SD=3). Analysis was performed accordingly with the thematic analysis.

RESULTS

The data analysis found four themes: symptom management as a trigger, psychosocial support, mediation provided by interventions, and the association with terminal care or death. Palliative care integrated interventions were mainly perceived as holistic approaches that offered symptom management expertise and time. They were valued for helping in consolidating decision-making from a different or external perspective, or an 'outside look'. Several barriers were identified, often due to the confusion between terminal care and palliative care. This was further highlighted by the avoidance of the words 'palliative care', which were associated with death.

CONCLUSIONS

National policies for promoting palliative care seemed to have failed in switching oncologists' perception of palliative care, which they still consider as terminal care.

What is the effectiveness and safety of mirtazapine versus escitalopram in alleviating cancer-associated poly-symptomatology (the MIR-P study)? A mixed-method randomized controlled trial protocol

BACKGROUND

Advanced cancer patients often experience multiple symptoms at a same time. This might lead to polypharmacy and increase adverse events representing major threats to the quality of health care, especially in palliative care situations. Mirtazapine, an antidepressant agent, has been suggested as a potential relevant drug to alleviate multiple cancer-related symptoms at a same time. Therefore, the present study aims to assess the effectiveness of mirtazapine in alleviating multiple symptoms at a same time in advanced cancer patients suffering from a major depressive episode compared to a group receiving escitalopram, another antidepressant agent.

METHODS

Multicentre, prospective, randomized, controlled trial in 12 palliative care services in France. The study will be based on a mixed-method methodology using parallel groups, of oral mirtazapine compared with oral escitalopram, with a 56 day follow-up. The primary outcome will be an improvement of the Global health Status (issued from the EORTC-QLQ-C30) on day 56. 418 participants will be clinically followed-up on day 7 and 56 and will have a telephonic assessment on days 14 and 28. A sub-sample of participants will be invited to take part in semi-structured qualitative interviews at baseline and day 56. For the qualitative part, purposeful sampling will be used.

DISCUSSION

This study will provide evidence for the pharmaceutics management of poly-symptomatology in advanced cancer patients. This could lead to important changes in the management of those patients by using a single molecule to alleviate multiple symptoms at a same time, potentially improving medication adherence, symptoms' control, and reducing the risk of medications adverse events.

TRIAL REGISTRATION

Trial registration: NCT04763135 . Registered 18 March 2021.

Art therapy and social function in palliative care patients: a mixed-method pilot study

OBJECTIVES

To evaluate the influence of art therapy in reducing palliative symptoms, on social availability and on perceptions of aesthetics in hospitalised palliative care patients. The secondary objective was to evaluate its influence on bereaved families.

METHODS

A mixed-method quasi-experimental before and after study comprising a follow-up postal survey of bereaved families. All patients who were keen to have art therapy sessions were eligible. We used patient-reported outcome scales 5 min before and after the session. The Edmonton Symptom Assessment Scale has been used for pain, anxiety, well-being, fatigue and depression. Ten-point visual analogue scales were used for social availability, lack of desire and wishes, and perceptions of aesthetics based on the Beautiful-Well-Good model. A postal survey was sent to bereaved families. Correlations and data mining analyses were performed.

RESULTS

In all, 24 patients were recruited for a total of 53 art therapy sessions analysed. Seven families completed the survey. Art therapy significantly reduced the assessed symptoms and overall symptom distress by 54.4% (p <0.001, d = 1.08). It also decreased the feeling of social unavailability (-59%, d = 0.67) and the lack of desire and wishes (-60%, d=0.86). The analysis of the family questionnaires indicates the positive effects regarding support, artwork and feelings during illness and grief.

CONCLUSION

Our results suggest an overall improvement in the symptoms experienced and social functioning of palliative patients. Based on our findings, we propose a model for the potential mechanism of action of art therapy.

Duration of palliative care involvement and immunotherapy treatment near the end of life among patients with cancer who died in-hospital

BACKGROUND

Immune checkpoint inhibitors (ICIs) have revolutionised cancer treatment, but their use near the end of life in patients with advanced cancer is poorly documented. This study investigated the association between administration of ICI therapy in the last month of life and the duration of involvement of the palliative care (PC) team, among patients with advanced cancer who died in-hospital.

METHODS

In a retrospective, multicentre study, we included all patients who died in 2018 of melanoma, head and neck carcinoma, non-small cell lung cancer or urothelial or renal cancer, in 2 teaching hospitals and one community hospital in France. The primary outcome was the association between ICI therapy in the last month of life and duration of involvement of the PC team in patient management.

RESULTS

Among 350 patients included, 133 (38%) received anti-cancer treatment in the last month of life, including 71/133 (53%) who received ICIs. A total of 207 patients (59%) received palliative care, only 127 (36%) 30 days before death. There was a significant association between ongoing ICI therapy in the last month of life and shorter duration of PC management (p = 0.04). Receiving ICI therapy in the last month of life was associated with an increased risk of late PC initiation by multivariate regression analysis (hazard ratio 1.668; 95% CI 1.022-2.722).

CONCLUSION

ICI therapy is frequently used close to the end of life in patients with advanced cancer. Innovative new anti-cancer treatments should not delay PC referral. Improved collaboration between PC and oncological teams is needed to address this issue.

Knowledge and use of prognostic scales by oncologists and palliative care physicians in adult patients with advanced cancer: A national survey (ONCOPRONO study)

BACKGROUND

Prognostic scales exist to estimate patient survival in advanced cancer. However, there are no studies evaluating their use and practice. The objective of this study was to evaluate in a nationwide study the proportion of oncologists and palliative care physicians who had knowledge of these scales.

METHODS

A descriptive, national, cross-sectional study was conducted via an online questionnaire to oncologists and palliative care physicians across France.

RESULTS

Palliative care physicians had better knowledge of the scales than oncologists (42.3% (n = 74) vs. 27.8% (n = 33), p = 0.015). The Palliative Performance Status (PPS) and Pronopall Scale were the best-known (51.4% (n = 55) and 65.4% (n = 70), respectively) and the most widely used (35% (n = 28) and 60% (n = 48), respectively). Improved training in the use of these scales was requested by 85.4% (n = 251) of participants, while 72.8% (n = 214) reported that they did not use them at all. Limited training and lack of consensus on which scale to use were cited as the main obstacles to use.

CONCLUSION

This is the first national study on the use of prognostic scales in advanced cancer. Our findings highlight a need to improve training in these scales and to reach a consensus on scale selection.

Identification of factors associated with aggressive end-of-life antitumour treatment: retrospective study of 1282 patients with cancer

OBJECTIVE

Antitumour treatment in the last 2 weeks of death (ATT-W2) and a new regimen of ATT within 30 days of death (NATT-M1) are considered as aggressive end-of-life (EOL) care. We aimed to assess factors associated with inappropriate use of antitumour treatment (ATT) at EOL.

METHODS

Data of patients with cancer who died in 2013, 2015, 2017 and 2019 in a single for-profit cancer centre were retrospectively analysed. ATT was divided into chemotherapy (CT), oral targeted therapy (OTT), hormonotherapy and immunotherapy (IMT).

RESULTS

A total of 1282 patients were included. NATT-M1 was given to 197 (15.37%) patients, and 167 (13.03%) had an ATT-W2. Patients with a performance status of <2 and treated with CT had more both ATT- W2 (OR=2.45, 95% CI 1.65 to 3.65, and OR=10.29, 95% CI 4.70 to 22.6, respectively) and NATT-M1 (OR=2.01, 95% CI 1.40 to 2.90, and OR=8.41, 95% CI 4.46 to 15.86). Predictive factors of a higher rate of ATT-W2 were treatment with OTT (OR=19.08, 95% CI 7.12 to 51.07), follow-up by a medical oncologist (OR=1.49, 95% CI 1.03 to 2.17), miscellaneous cancer (OR=3.50, 95% CI 1.13 to 10.85) and length of hospital stay before death of <13 days (OR=1.92, 95% CI 1.32 to 2.79). Urinary tract and male genital cancers received less ATT-W2 (OR=0.38, 95% CI 0.16 to 0.89, and OR=0.40, 95% CI 0.16 to 0.99) and patients treated by IMT or with age <69 years more NATT-M1 (OR=19.21, 95% CI 7.55 to 48.8, and OR=1.69, 95% CI 1.20 to 2.37). Patients followed up by the palliative care team (PCT) had fewer ATT-W2 and NATT-M1 (OR=0.49, 95% CI 0.35 to 0.71, and OR=0.42, 95% CI 0.30 to 0.58).

CONCLUSIONS

Most recent ATT and access to a PCT follow-up are the two most important potentially modifiable factors associated with aggressive EOL in patients with cancer. Early integrated palliative oncology care could help to decrease futile ATT at EOL.

What is the evidence for mirtazapine in treating cancer-related symptomatology? A systematic review

PURPOSE

Cancer patients often experience multiple distressing symptoms which are challenging to manage. It would therefore be helpful to find a treatment that alleviates more than one symptom, to avoid polypharmacy: mirtazapine has been used in several studies for this purpose. The objective of this study was to assess the effectiveness and safety of mirtazapine in alleviating one or more frequently encountered cancer-related symptoms.

METHODS

Systematic review of clinical trials in English or French. Eight databases were searched. Included studies assessed the effectiveness of mirtazapine in alleviating one or more frequently encountered cancer-related symptoms. Comparator and validated assessment tools were required. Studies were independently appraised by two investigators before data synthesis.

RESULTS

The search yielded 1898 references, from which we identified 12 relevant articles evaluating highly heterogeneous outcomes. These were two randomised-controlled (RCTs), three non-randomised controlled, and seven non-randomised non-controlled trials. In total, 392 participants were included and 185 were in RCTs. No study assessed the effectiveness of mirtazapine in alleviating symptoms at the same time, but some considered more than one symptom. Overall, the data was of poor quality, limited by small sample size and bias. However, mirtazapine showed effectiveness in treating depression, anxiety, sleep disorders, emesis and neuropathic pain. Across all studies, mirtazapine is safe to use, with drowsiness and dizziness the most common side-effects.

CONCLUSION

Study design and small sample sizes limit the ability to interpret results. Trials to assess the impact of mirtazapine or other medicines in alleviating multiple symptoms would be valuable.

Quality of end-of-life care in the emergency department

Objective

To assess appropriateness of end-of-life treatments provided to actively dying patients attending the emergency department of a primary care hospital.

Methods

Retrospective cohort study of patients who died in the emergency department of a French primary care hospital between January 2014 and January 2017. The deceased were identified through the admissions register. Then, electronic medical records were screened for bio-demographic data, data relative to decisions to withhold or withdraw treatments, to diagnosis and to the care provided. Patients were clustered into two categories, actively dying or non-actively dying, using clinical opinion based on their medical records. Appropriateness of care was appraised following French guidelines.

Results

One hundred and forty-six deaths were recorded. Actively dying patients mostly suffered from vascular conditions (29.4%). When compared to the overall sample, they were more likely to have decisions to withhold or withdraw treatments (OR = 5.3 [1.56; 20.7], p-value = 0.003), to have strong opioids (OR = 5.32 [2.1; 13.9], p-value <0.0001), hypnotics (OR = 2.6 [0.95; 8.39], p-value = 0.05), and scopolamine (OR = 2.5 [1.1; 6.13], p-value = 0.03). Moreover, they were less likely to have unbeneficial treatments in terminal conditions, such as resuscitation care (OR = 0.06 [0.001; 0.52], p = 0.002) and antibiotics (OR = 0.42 [0.19; 0.92], p-value = 0.022). There were no differences in rate of hydration, venous access and use of tracheal aspirations.

Conclusions

Overall, actively dying patients were appropriately supported. However, several issues regarding hydration management, drug administration routes, and broncho-pulmonary secretions management remain to be addressed.

Nursing home hospital transfers in the terminally ill: night shift nurses matter!

BACKGROUND

French demographic projection expects an increasing number of older, dependent patients in the next few years. A large proportion of this population lives in nursing homes and their transfer to hospitals at the end of life is an ongoing issue.

OBJECTIVE

This study explored the factors influencing the transfer of patients living in nursing homes to hospital at the end of life.

DESIGN

We used a mixed-methods questionnaire developed by an expert group and assessing different characteristics of the nursing homes.

PARTICIPANTS

All the nursing homes in the Rhône-Alpes area (n=680) were surveyed.

RESULTS

We obtained 466 (68%) answers. We found that a palliative care programme was present in 336 (72%) nursing homes. The majority had a coordinating physician 428 (82%) and a mean number of 6 nurses for 83 beds, with 83 (18%) having a night shift nurse. There was a mean number of 19 deaths per nursing home during the recorded year. The main cause of death was dementia (41%), cancer-related death (13%). Death occurred mostly in the nursing home (14 74%). Night shift nurse attendance was significantly associated with the place of death: 27 deaths occurred in nursing homes with a night shift nurse versus 12 in those without one (p<0001).

CONCLUSIONS

The location of the death of frail elderly patients is a major health issue that needs to be addressed. Our results suggests that the presence of a night shift nurse decreases the number of emergency transfers and deaths in the hospital.