[Ethical stakes of psychosocial rehabilitation]

Psychosocial rehabilitation (PSR) is a therapeutic approach which aims to improve the overall functioning of people with severe mental disorders. We detail the principles of bioethics applied to care and seek to demonstrate how PSR meets the requirements of a humanistic psychiatry. The four fundamental principles of the ethics of care - autonomy, beneficence, non-maleficence and justice - are found in the practice of PSR. The practice and implementation of PSR is strongly encouraged in universal codes of ethics.

[Human rights and transgender surgery]

René Sève recalls that Contemporary Law in the Western World is based on autonomy of equal subjects, mutually recognizing the right to each carry out their own life project. The LGBTQIA+ person therefore exercises their ability to be their own species, according to Kirkegaard's word. It remains that "life project" also implies a constraint of stability and rationality. The author then shows, using Canadian and French statistical data, the difficulties of achieving this ideal for minors and, for adults, the other medical, paramedical and social conditions required. The rights of LGBT people cannot be considered independently of the physical and financial limits of the health system and therefore of the public debate on its priorities.

[Facilitators and barriers to shared decision-making in France in 2021: National survey in cancer]

INTRODUCTION

Shared-decision making (SDM) combines clinical expertise of the healthcare professional with patient's knowledge, values and preferences. This survey explores from a patient perspective, the implementation, facilitators and barriers of SDM in oncology in France in 2021.

PATIENTS AND METHODS

From August to October 2021, the digital platform Cancer contribution conducted an online survey relayed by 11 patient associations.

RESULTS

Out of 916 responses, 727 were analyzed: 394 from patients with hematological malignancies [HM], 185 with breast cancer [BC], 93 with other solid tumors [ST] and 55 with multiple cancers [MC]. Among the participants, 47.2 % reported that they participated in a decision about their health management, with a significant variation according to the pathology (BC 43.8 %, HM 41.1 %, ST 57 %, MC 60 %, P=0.01), and regardless of age and gender. Two-thirds felt comfortable with the shared decision-making process, in relation with the time allocated and the information provided, regardless of the pathology. In addition, emotions, uncertainty and lack of information are the main reasons quoted by patients to explain their lack of ease in making a decision related to their health.

CONCLUSIONS

In this survey, less than half of the patients declared that they have been enrolled in a SDM approach, this rate varying according to the type of solid tumor or hematological malignancy. This study shows that to improve the implementation of SDM in routine clinical practice in cancer, sufficient time and use of decision aids are needed.

The new Code of Ethics of the World Psychiatric Association: A fresh look at the ethical issues of the psychiatric profession

This article develops the WPA's new Code of Ethics that was developed in 2020. It succeeds the Declaration of Hawaii of 1977 and the Declaration of Madrid of 1996. The Code is divided into four sections that cover the practice of psychiatry in clinical practice, education, research and publication as well as public mental health. We will discuss the new ethical issues that this Code raises in parallel with the development of psychiatry and psychiatrists' role in society in recent years.

[Care counselling - Lessons learnt from an expert survey on the supply situation in the district of Lörrach]

BACKGROUND

There is a broad spectrum of care counselling offers. Various professional groups, each with different qualifications and objectives, carry out the counselling, and the accessibility and the service offers of the counselling centres vary greatly. The aim of this study was to develop recommendations for persons in need of care and their relatives in order to a) create more transparency and knowledge about the spectrum of care counselling for those in need of care and their relatives as well as the professionals in the field, and b) to optimize the structures of the heterogeneous spectrum of care counselling by means of a qualitative study with experts using the example of the district of Lörrach.

METHODS

Based on a systematic literature research, 21 semi-structured expert interviews of five different stakeholder groups (representatives of persons in need of care and their relatives, service providers, suppliers, county and municipalities, politicians) were analyzed. All interviews were digitally recorded and transcribed verbatim. Data analysis was conducted based on the structuring content analysis according to Kuckartz.

RESULTS

Nine main categories emerged from 21 experts' transcripts. The findings from four main categories relating to the criterion of transparency are shown below as examples. The experts report on numerous obstacles that they recognize for persons in need of care and their relatives in order to be able to take advantage of care counselling in a highly complex health care system. For people with no background knowledge of the health care system, the current care counselling structure is not transparent, and it is almost impossible to differentiate between the various care counselling services, some of which have different tasks to fulfil. The basic topic-specific advisory structure is characterized by multiple uncoordinated structures, also with regard to care, which makes it difficult even for professionals to gain an overview and orientation towards a targeted use of the counselling services for those seeking advice, such as persons in need of care and their relatives. The experts reaffirm the importance of creative ideas and different channels, taking into account generational differences and different information behaviour among those seeking advice, in order to increase the provision of information and the visibility of care counselling services. Low-threshold, citizen-oriented, regional and barrier-free access to information must be set up for persons in need of care and their relatives. At the district level, a central platform should be established primarily aimed at professional users which many want to be located at the care support center or, for example, at the district office where all threads come together and which includes all care counselling services and their areas of activity.

DISCUSSION AND CONCLUSION

Overall, the study results reveal numerous systemic weaknesses in the spectrum of care counselling services and in the care system, which in this study were limited to the regional research field and considered from the perspective of care management. The analysis of the results highlights the importance of optimizing the structural quality of care counselling. A need to reform social legislation and, above all, long-term care insurance (Eleventh Book of the Social Code), can be derived from the interview analysis and should be further investigated in a nationwide survey.

[Opioids substitution therapy: A respect for the dignity of the human person]

The Opioid substitution treatment (OST) has been highly argumentative in ways that raise important ethical issues. The stigma in treating opioid addiction continues to be a major barrier to effective management plan. It prevents individuals from seeking treatment and is associated with poor mental and physical health. OST are considered to improve outcomes in opioid dependency. They are legitimate therapeutic options because they comply with the four principles of bioethics: autonomy, no maleficence, beneficence and justice. OST plan should conceived in a way that outcomes only giving a medication to the patient. It has many ethical aspects that should be valued: fairness, respect and solidarity. However, OST may be misused or diverted, resulting in negative treatment outcomes, here comes the important role of the multidisciplinary treatment plan to contain and prevent from misuse. We will be discussing in this paper the ethical aspect of the OST and the values that should be promoted, in order to cherish and enhance the dignity of the human being, by replacing a deadly disease with a chronic one giving the patient a chance to lead a normal life.

[Transition to adulthood: An essential period in the follow up of young patients]

In recent decades, follow-up of cancer survivors has taken on its full meaning with the gradual improvement in the survival of children and adolescents with cancer. This follow-up is associated specially for adolescents with a multitude of transitions: the transition from therapeutic management to the monitoring for possible relapse, the transition into long-term follow-up after childhood cancer, the transition from a pediatric system to an adult care system. If this transition can be perceived as difficult by patients, it gives young people the opportunity to access more autonomous follow-up and support in becoming an adult. Supporting the transition should make caregivers attentive to this time of consolidation of adolescence, favorable to the emergence of a sense of stable, mature identity that guarantees a certain autonomy. This is a key to a successful transition limiting breakdown of care and promoting "the work of the disease". The double contribution of adult and pediatric oncology provides support tailored to these psychic and societal issues. AYA teams can actively participate in this process by facilitating the acculturation of pediatric and adult care teams to the specificity of this group, thus allowing a continuum of care.

[Cardiac rehabilitation in elderly patient]

According to "OMS" we are old at age 65. Because of the ageing population (life expectancy has increased in Europe) and medical progress, more and more old patients are addressed to cardiac rehabilitation centers. Ageing is a physiological process which varies between individuals, and in the same person organ ageing also differs. Old patient has usually several pathological diseases. Because old patient has restricted functional reserve, acute illness could get him closer to the decompensation area. Complications are more frequent in ageing people, and often need a specific initial treatment which delays rehabilitation. Rehabilitation program of old non-disabled patient is not different from that addressed to youngers. The main objective for dependent people is to restore the ability to perform activities of daily living. Correction of vascular risk factors and therapeutic education are also valuable in elderly. For patients with difficulty to remember or to understand instructions, family help is valuable when possible. The benefit of the rehabilitation in the elderly is demonstrated by several studies.

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Zusammenfassung. Aufgrund der demografischen Entwicklung gewinnt die Rehabilitation Betagter an Bedeutung. Im Vergleich zum jüngeren Patienten sind beim betagten Patienten die Autonomie und die Handlungsfähigkeit in Alltagssituationen meist rascher bedroht, die soziale Partizipation fragiler, und somit die Gefahr der Vereinsamung prinzipiell grösser. Die Kommunikation mit dem Umfeld spielt eine grössere Rolle. Das Risiko für Komplikationen ist hoch; andererseits äussern betagte Patienten in der Regel weniger Angst vor dem Tod als vor einem völligen Verlust der Selbständigkeit und davor, ihren Angehörigen «zur Last zu fallen». Auch betagte Patienten profitieren von organspezifischen Rehabilitationsmassnahmen auf dem Niveau der Alltagsfunktionalität und sozialen Partizipation, wie dies exemplarisch für die Neurorehabilitation nach Schlagfanfall gezeigt wurde. Die geriatrische Rehabilitation fokussiert spezifisch auf die Bedürfnisse Betagter, die durch Multimorbidität, Vulnerabilität oder Gebrechlichkeit (Frailty) charakterisiert sind. Sie ist als interprofessioneller Prozess aufgebaut, der polymodal körperliche, psychische und soziale Aspekte systematisch erfasst und mit dem Patienten und seinem Umfeld ein individuell adaptiertes Ziel erarbeitet. Zentral sind die Aspekte Mobilität, Selbsthilfefähigkeit, Ernährung, Kognition, Stimmung, Kontinenz und soziale Situation. Ein Tragpfeiler ist dabei eine altersadaptierte, proteinreiche Ernährung. Ärztlicherseits wird es – gerade bei der Rehabilitation Betagter – hilfreich sein, die Kompetenzen aus verschiedenen Fachrichtungen synergistisch zu nutzen. Unter der Vorstellung einer optimalen Betreuung und Beratung gerade in den Kompetenzfeldern Mobilität, Kognition und Ernährung kann eine Co-Betreuung ein zukunftsfähiges Modell sein. Im Hinblick auf die rehabilitative Prognose dürfte «Alter» im Sinne der Anzahl bisheriger Lebensjahre eine überschätzte Prognosevariable sein. «Höheres Alter» kann hingegen als Surrogatmarker für Komorbiditäten gelten, die mit zunehmendem Lebensalter an Häufigkeit zunehmen. Unter diesen Gesichtspunkten ist es unbedingt zu vermeiden, dass betagte Patienten rein auf Grund ihrer bereits verbrachten Lebensjahre weniger häufig als Jüngere die Chance einer rehabilitativen Behandlung erhalten.

[Why and how to promote decision-making autonomy of cancer patients?]

Involvement of patients in decision-making about their health has been promoted nationally and internationally since several years. Despite this, patient (and their relatives) participation remains insufficient and one of the objectives of the current French national cancer policy (Plan cancer 2014-2019) is to give everyone the possibility to play an active role in the management of their care. This overview focuses on decision-making autonomy of cancer patients through two main questions: why and how to promote it? After a brief review of the decision-making models described in the literature in the past decades insisting on the major role of the decisional context and the dynamic character of this context, this article presents a selection of published works which aimed to respond to those 2 questions.

[Treatment of extra-articular distal radius fractures in active elderly patients]

Extra-articular distal radius fractures in active elderly patients are common and predominantly affect females. The high number of patients lost to follow-up compromises the evaluation of outcomes. Treatment aims to control the comminution and allow fast recovery of pre-injury activity levels. Fixation with volar locking plates is the gold standard. The role of bone substitutes in this type of injury is unclear.

[Ethics and ritual circumcision]

Circumcision dates back to ancient times, nowadays, this ritual is practiced mainly in the context of Jewish and Muslim religions. The purpose of this article is to give urologists elements of reflection on the act according to the ethical principles of autonomy, beneficence, non-maleficence and justice. According to a Kantian vision, priority should be given to the respect and wishes of the individuals. In contrast, for the utilitarian theory, circumcision can be justified by a contribution to the happiness of the majority of community members at the expense of a given few. In the event of a request for ritual circumcision, urologists find themselves in the middle, uncomfortable for some, questioning the ethics of its meaning. The main pitfall for the surgeon remains in respecting the child's autonomy.