[Diagnosis disclosure in geriatric oncology]

The disclosure of a cancer diagnosis in an elderly person is often difficult. It can be impacted by sensory or cognitive disorders, a depressive condition, or by the presence of family members. It is important to take account of a disease which is sometimes at an advanced stage, reduced life expectancy and obvious frailty. The disclosure should always be made whatever the clinical situation, but always with an adapted, honest and step-by-step process.

Improvement of decision-making criteria for the care of elderly cancer patients by general practitioners (Lorraine, France)

Objective

The objective of this study was to identify changes in the decision-making criteria of general practitioners (GPs) concerning the care of elderly cancer patients after 1 year of corrective measures for care practices in the Lorraine region, France.

Materials and methods

In 2014, a postal mail questionnaire was sent to all GPs in the Lorraine region. This questionnaire was designed to identify GPs’ decision-making criteria. It was based on the results of a literature review and on existing guidelines. During 1 year, corrective measures were implemented to improve practices, especially training sessions for physicians and production of specific tools, including a guide to the accepted ideas in geriatric oncology. In 2015, the same questionnaire was resent to all GPs to compare the answers.

Results

In 2014, 430 questionnaires were returned out of 2,048 sent, and in 2015, 378 questionnaires were returned out of 2,066 sent. Our results show for the first time that there exists a significant difference in the overall decision criteria between the two survey periods. This difference mainly concerns criteria related to the cancerous diseases. Physicians tend to consider the principal decision criteria to be less important after the training period. GPs express the importance of accessibility to specialists for additional advice in both 2014 and 2015; the distance between the patient’s home and an adapted care facility and the interval before care begins are viewed as similarly important.

Conclusion

Training and information sessions for physicians remain the most important tool for improving care practices. Such training strategies are more effective when carried out at the geographical scale at which the cancer professionals practice, allowing them to exploit their local organizational structure. The analysis of our data makes it possible to further integrate the patient into the care path, which remains a public health issue in terms of cost and organization.

Decision making affecting care of older people with cancer: a comparison between general practitioners and oncologists in Lorraine

The main objective of this study is to identify the decision criteria of general practitioners and oncologists in the management of older patients with cancer in Lorraine. The secondary objectives are to identify the difficulties encountered and to propose solutions to improve health path of these patients. 2,995 post mail questionnaires were sent to all general practitioners and oncologists in Lorraine. Some decision criteria differ between general practitioners and oncologists: civilian age and accessibility to a specialized advice for general practitioners; type of cancer, nutritional status, application of best practice recommendations, and multidisciplinary discussion for oncologists. The main difficulties reported are organizational and relate to time interval before specific care beginning, accessibility to a medical specialist, and post-diagnosis such link between primary care and hospital. General practitioners and oncologists mainly agree with the difficulties encountered and the solutions to find, even if some decision criteria differences are highlighted. The training of professionals remains the major lever for improvement of medical practices.

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.

Withdrawal of Artificial Nutrition

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.