Ethical and Clinical Aspects of Intensive Care Unit Admission in Patients with Hematological Malignancies: Guidelines of the Ethics Commission of the French Society of Hematology

Admission of patients with hematological malignancies to intensive care unit (ICU) raises recurrent ethical issues for both hematological and intensivist teams. The decision of transfer to ICU has major consequences for end of life care for patients and their relatives. It also impacts organizational human and economic aspects for the ICU and global health policy. In light of the recent advances in hematology and critical care medicine, a wide multidisciplinary debate has been conducted resulting in guidelines approved by consensus by both disciplines. The main aspects developed were (i) clarification of the clinical situations that could lead to a transfer to ICU taking into account the severity criteria of both hematological malignancy and clinical distress, (ii) understanding the process of decision-making in a context of regular interdisciplinary concertation involving the patient and his relatives, (iii) organization of a collegial concertation at the time of the initial decision of transfer to ICU and throughout and beyond the stay in ICU. The aim of this work is to propose suggestions to strengthen the collaboration between the different teams involved, to facilitate the daily decision-making process, and to allow improvement of clinical practice

« A la recherche d’une juste anticipation : éloge de la patience »

International audienc

« A la recherche d’une juste anticipation : éloge de la patience »

International audienc

Recommandations pour la mise en place de staffs pluriprofessionnels (SPP) dans les services de soins

International audienceThe context and constraints of modern medicine (hospital beds and caregivers’ reductions, ambulatory shift, new therapeutic approaches, integration of supportive care…) combined with new societal and Health system changes (ageing population, chronic diseases, new requirements of the patients…) redefine the orientations of care and question professional practices. The participative approach (PA) as a model of team organization proposes solutions involving the skills of the various interacting caregivers and experimental knowledge and consideration of patient needs. The multi-professional staff (MPS) is a collaborative tool of this participative approach that federates a team around a health or care project personalized from the crosschecked eyes of care professionals and from a shared decision-making process. Its objective is to combine the improvement of quality of care with quality of life at work. It requires a transversal mindset of teams, intrinsic values and specific characteristics. Its organization is simple but requires some rules and we will develop the main steps to success. This article, which is the result of a joint reflection and experience of health professionals, shows the principles and wants to demonstrate the weakness of MPS. The interest of the French National Cancer Institute for this collaborative tool is an asset for further work in the perspective of generalization of MPS for all patients with chronic disease and not only for patients at palliative phase.Le contexte et les contraintes de la médecine moderne (réduction des lits d’hospitalisation, virage ambulatoire, diminution du nombre de soignants, nouvelles thérapies, intégration des soins de support…) conjointement aux nouvelles données sociétales et des systèmes de santé (vieillissement de la population, maladies chroniques, exigences nouvelles des personnes malades…) redéfinissent les champs du soin et interrogent les pratiques professionnelles. La démarche participative en tant que modèle d’organisation du travail en équipe propose des solutions faisant intervenir aussi bien les compétences des divers professionnels de santé en interaction, que les savoirs expérientiels et la prise en compte des préférences des personnes malades. Le staff pluriprofessionnel est un outil de la démarche participative, qui fédère une équipe autour d’un projet de soin ou de santé individualisé à partir des regards croisés des professionnels du soin et des prises de décision partagées. Son objectif est d’allier l’amélioration de la qualité du soin à celle de la qualité de vie au travail. Il requiert un état d’esprit transversal, des valeurs intrinsèques et des caractéristiques spécifiques . Son organisation est simple mais obéit à quelques règles. Nous en développerons les principales étapes. Cet article, issu d’une réflexion commune de professionnels de santé, vient démontrer ses principes et sa faisabilité. L’intérêt manifesté par l’INCa pour cet outil est un atout de poids pour la suite de ce travail dans l’optique d’une généralisation des staffs pluriprofessionnel pour tous les patients atteints d’une pathologie chronique et pas seulement pour les patients en situation palliative

Nutritional advice in older patients at risk of malnutrition during treatment for chemotherapy: a two-year randomized controlled trial.

We tested the effect of dietary advice dedicated to increase intake in older patients at risk for malnutrition during chemotherapy, versus usual care, on one-year mortality.We conducted a multicentre, open-label interventional, stratified (centre), parallel randomised controlled trial, with a 1∶1 ratio, with two-year follow-up. Patients were aged 70 years or older treated with chemotherapy for solid tumour and at risk of malnutrition (MNA, Mini Nutritional Assessment 17-23.5). Intervention consisted of diet counselling with the aim of achieving an energy intake of 30 kCal/kg body weight/d and 1.2 g protein/kg/d, by face-to-face discussion targeting the main nutritional symptoms, compared to usual care. Interviews were performed 6 times during the chemotherapy sessions for 3 to 6 months. The primary endpoint was 1-year mortality and secondary endpoints were 2-year mortality, toxicities and chemotherapy outcomes.Between April 2007 and March 2010 we randomised 341 patients and 336 were analysed: mean (standard deviation) age of 78.0 y (4·9), 51.2% male, mean MNA 20.2 (2.1). Distribution of cancer types was similar in the two groups; the most frequent were colon (22.4%), lymphoma (14.9%), lung (10.4%), and pancreas (17.0%). Both groups increased their dietary intake, but to a larger extent with intervention (p<0.01). At the second visit, the energy target was achieved in 57 (40.4%) patients and the protein target in 66 (46.8%) with the intervention compared respectively to 13 (13.5%) and 20 (20.8%) in the controls. Death occurred during the first year in 143 patients (42.56%), without difference according to the intervention (p = 0.79). No difference in nutritional status changes was found. Response to chemotherapy was also similar between the groups.Early dietary counselling was efficient in increasing intake but had no beneficial effect on mortality or secondary outcomes. Cancer cachexia antianabolism may explain this lack of effect.ClinicalTrials.gov NCT00459589