[Limitations of active therapeutic and palliative care in chronic respiratory disease]

The issue of intensive and palliative care in patients with chronic disease frequently arises. This review aims to describe the prognostic factors of chronic respiratory diseases in stable and in acute situations in order to improve the management of these complex situations. The various laws on patients' rights provide a legal framework and define the concept of unreasonable obstinacy. For patients with chronic obstructive pulmonary disease, the most robust decision factors are good knowledge of the respiratory disease, the comorbidities, the history of previous exacerbations and patient preferences. In the case of idiopathic pulmonary fibrosis, it is necessary to know if there is a prospect of transplantation and to assess the reversibility of the respiratory distress. In the case of amyotrophic lateral sclerosis, treatment decisions depend on the presence of advance directives about the use of intubation and tracheostomy. For lung cancer patients, general condition, cancer history and the tumor treatment plan are important factors. A multidisciplinary discussion that takes into account the patient's medical history, wishes and the current state of knowledge permits the taking of a coherent decision.

The ETHICA study (part I): elderly's thoughts about intensive care unit admission for life-sustaining treatments

PURPOSE

To assess preferences among individuals aged ≥80 years for a future hypothetical critical illness requiring life-sustaining treatments.

METHODS

Observational cohort study of consecutive community-dwelling elderly individuals previously hospitalised in medical or surgical wards and of volunteers residing in nursing homes or assisted-living facilities. The participants were interviewed at their place of residence after viewing films of scenarios involving the use of non-invasive mechanical ventilation (NIV), invasive mechanical ventilation (IMV), and renal replacement therapy after a period of invasive mechanical ventilation (RRT after IMV). Demographic, clinical, and quality-of-life data were collected. Participants chose among four responses regarding life-sustaining treatments: consent, refusal, no opinion, and letting the physicians decide.

RESULTS

The sample size was 115 and the response rate 87 %. Mean participant age was 84.8 ± 3.5 years, 68 % were female, and 81 % and 71 % were independent for instrumental activities and activities of daily living, respectively. Refusal rates among the elderly were 27 % for NIV, 43 % for IMV, and 63 % for RRT (after IMV). Demographic characteristics associated with refusal were married status for NIV [relative risk (RR), 2.9; 95 % confidence interval (95 %CI), 1.5-5.8; p = 0.002] and female gender for IMV (RR, 2.4; 95 %CI, 1.2-4.5; p = 0.01) and RRT (after IMV) (RR, 2.7; 95 %CI, 1.4-5.2; p = 0.004). Quality of life was associated with choices regarding all three life-sustaining treatments.

CONCLUSIONS

Independent elderly individuals were rather reluctant to accept life-sustaining treatments, especially IMV and RRT (after IMV). Their quality of life was among the determinants of their choices.

Evaluation of supportive care needs: Comparison between patients and physicians’ perception

e20649

Background: In order to optimize supportive care for cancer patients, we proposed them to fill a short questionnaire evaluating their potential complaints and we evaluated the concordance of their answers with the perception of their referent physician. Methods: Patients seen in consultation in an oncology unit were proposed to answer anonymously to 7 questions designed to identify potential social, psychological, nutritional problems or uncontrolled pain. Their physician answered to a similar questionnaire. Physicians were blinded to patients’ answers. Results: 155 patients accepted to complete the questionnaire. Median age was 60 yrs [21–85], 45% of patients were in metastatic setting. 70% of patients reported at least one problem, especially in the field of potential social problems (35%) or sleep disorders (25%). Concordance between patients and physicians was high for psychological support need (81%) or nutritional problems (87%) but was lower for social problems (62%) or uncontrolled pain (69%). Physicians tended to underestimate patients’ problems and missed social issues for 30% of patients or sleep disorders for 18% of patients. On the contrary and surprisingly, physicians overestimate patients’ complaints about uncontrolled pain (underestimation in 9% of cases but overestimation in 20% of cases for the item). Conclusions: Discordance between physicians and patients’ perception of supportive care needs emphasizes the importance of extending the use of screening tolls in daily practice.

No significant financial relationships to disclose.