Prise en charge des accès douloureux paroxystiques en fin de vie (d'une évaluation des pratiques professionnelles aux perspectives en Médecine Générale)

LE KREMLIN-B.- PARIS 11-BU Méd (940432101) / SudocSudocFranceF

Assessing the implementation and effectiveness of early integrated palliative care in long-term care facilities in France: an interventional mixed-methods study protocol

Abstract Background Majority of residents in long-term care facilities (LTCF) have limited and delayed access to palliative care even though many suffer from incurable chronic illnesses that will likely require the provision of palliative care. We present the study protocol of “PADI-Palli”, an intervention aims to advance early integrated palliative care into standard care delivered in LTCF. This study will assess the effectiveness of early integrated palliative care on palliative care accessibility for older persons in LTCF, and identify the key factors for the successful implementation of early integrated palliative care and its sustainability in the LTCF context. Methods This multicentre interventional study utilises a pragmatic research design with a convergent parallel mixed-methods approach. The qualitative study will use a case study design and the quantitative study will use a stepped wedge cluster randomised trial. In total, 21 participating LTCF from three French regions will be randomly allocated to one of seven clusters. The clusters will cross over from the usual care to the active intervention condition over the course of the study. The primary outcome relates to the accurate identification of palliative care needs and early access to palliative care for LTCF residents. Secondary outcomes are quality of care, quality of life for residents and their families, and quality of life at work for professionals. Measurements will be performed before and after the intervention. Implementation and evaluation of PADI-Palli intervention is grounded in the Consolidated Framework for Implementation Research. Discussion Existing evidence demonstrates that early integrated palliative care in cancer care leads to a significant improvement in patient outcomes and processes of care. Little is known, however, about early integrated palliative care in the context of LTCF for older persons. This study has the potential to fill this gap in the literature by providing evidence on the effectiveness of early integrated palliative care for older persons in LTCF. Moreover, this study will provide a better understanding of the relevant contextual elements that facilitate or hinder early integrated palliative care implementation and transferability. If proven effective, this intervention can be scaled to other care settings in which older persons require palliative care. Trial registration ClinicalTrials.gov ID: NCT04708002; National registration: ID-RCB number: 2020-A01832-37

Patients’, family caregivers’, and professionals’ perspectives on quality of palliative care: A qualitative study

International audienceBACKGROUND:The quality of palliative care is the foremost preoccupation of clinicians, decision-makers, and managers as well as patients and families. Major input from healthcare professionals is required to develop indicators for the quality of palliative care, but the involvement of patients and families is also recognized as essential, even though this is rarely achieved in practice.AIM:The objectives of this study were to identify (1) convergences and divergences in the points of view of different stakeholders (patients, families, healthcare professionals) relative to key elements of the quality of palliative care and (2) avenues for refining existing indicators of quality of palliative care.DESIGN:Cross-sectional qualitative study.SETTING/PARTICIPANTS:There were six settings: two hospital-based palliative care units, one hospice, and three other medical units where a mobile palliative care team intervene. Semi-structured interviews were conducted among 61 patients, families, healthcare professionals, and managers.RESULTS:Four major dimensions of quality of care are deemed critical by patients, their families, and professionals: comprehensive support for the patients themselves, clinical management, involvement of families, and care for the imminently dying person and death. Differences exist between various stakeholders regarding perceptions of some dimensions of quality of care. Avenues for improving current quality of care indicators are identified.CONCLUSION:Our study results can be used to refine or develop quality indicators that truly mirror the points of view of patients and their families and of healthcare professionals

Utilisation du Midazolam et sédation en soins palliatifs: quel paradoxe entre pratique soignante et sens du soins?

Conclusion de l'étude: - La sédation provoque une souffrance psychologique et morale chez les soignants qui s’interrogent sur ce qu’ils font- La sédation remet en question la compétence soignante dans ses actions- Le travail en équipe est la condition pour réduire cette incertitudeDécrire les expériences et explorer les perceptions de l’usage du Midazolam et de la pratique de la sédation . Comprendre les représentations de la sédation et leur impact sur les pratiques de soin. méthodes de recueil des données:Focusgroups, Récits cliniques, Observations participantesDeux méthodes d’analyse des données: analyse thématique des verbatim, analyse lexical

Palliative sedation challenging the professional competency of health care providers and staff: a qualitative focus group and personal written narrative study

Abstract Background Despite recent advances in palliative medicine, sedating a terminally ill patient is regarded as an indispensable treatment to manage unbearable suffering. With the prospect of widespread use of palliative sedation, the feelings and representations of health care providers and staff (carers) regarding sedation must be carefully explored if we are to gain a better understanding of its impact and potential pitfalls. The objective of the study was to provide a comprehensive description of the opinions of carers about the use of sedation practices in palliative care units (PCU), which have become a focus of public attention following changes in legislation. Methods Data were collected using a qualitative study involving multi-professional focus groups with health care providers and staff as well as personal narratives written by physicians and paramedical staff. A total of 35 medical and paramedical providers volunteered to participate in focus group discussions in three Palliative Care Units in two French hospitals and to write personal narratives. Results Health care provider and staff opinions had to do with their professional stance and competencies when using midazolam and practicing sedation in palliative care. They expressed uncertainty regarding three aspects of the comprehensive care: biomedical rigour of diagnosis and therapeutics, quality of the patient/provider relationship and care to be provided. Focusing on the sedative effect of midazolam and continuous sedation until death, the interviewed health care providers examined the basics of their professional competency as well as the key role played by the health care team in terms of providing support and minimizing workplace suffering. Nurses were subject to the greatest misgivings about their work when they were called upon to sedate patients. Conclusions The uncertainty experienced by the carers with regard to the medical, psychosocial and ethical justification for sedation is a source of psychological burden and moral distress, and it has proved to be a major source of suffering in the workplace. Lastly, the study shows the uncertainty can have the positive effect of prompting the care team to devise ways to deal with it

Utilisation du Midazolam et sédation en soins palliatifs: quel paradoxe entre pratique soignante et sens du soins?

Conclusion de l'étude: - La sédation provoque une souffrance psychologique et morale chez les soignants qui s’interrogent sur ce qu’ils font- La sédation remet en question la compétence soignante dans ses actions- Le travail en équipe est la condition pour réduire cette incertitudeDécrire les expériences et explorer les perceptions de l’usage du Midazolam et de la pratique de la sédation . Comprendre les représentations de la sédation et leur impact sur les pratiques de soin. méthodes de recueil des données:Focusgroups, Récits cliniques, Observations participantesDeux méthodes d’analyse des données: analyse thématique des verbatim, analyse lexical

In situ and laboratory non-additive litter mixture effect on C dynamics of Sphagnum rubellum and Molinia caerulea litters

International audiencePurposeThe accumulation of carbon in peatlands originates from the slow rate of Sphagnum litter decomposition. Vegetation shifts can alter the Sphagnum decomposition rate through a litter mixture effect. This is rarely studied in peatlands. In a site colonised by vascular plants, we examined the effect of mixing litters of Sphagnum species with those of Molinia caerulea and Betula spp. on litter carbon (C) dynamics. We tested that water content and pH may explain the potential non-additive litter mixing effect.Materials and methodsLitter bags with Sphagnum cuspidatum or Sphagnum rubellum and M. caerulea or Betula spp. were placed in situ, in a Sphagnum decomposing environment and retrieved after 1 year of incubation. In the laboratory, the specific interaction between S. rubellum and M. caerulea was investigated. Solid, soluble and gaseous forms of C were studied in addition to the fluorescence of the dissolved organic matter (FDOM).Results and discussionLaboratory and field experiments showed that there is a non-additive effect of mixing S. rubellum and M. caerulea litter on C dynamics. The analyses of FDOM suggested a relatively higher living biomass in the laboratory-measured mixture than in the expected one. The in situ S. rubellum moist environment could stimulate the decomposition of M. caerulea that experiences much drier conditions in its native environment. In the laboratory experiment, M. caerulea were kept moist, and no significant difference in water content between the measured and expected mixture was found. Also, pH decreased in the measured mixture, ruling out any direct effect on microbial activity.ConclusionsThe non-additive mixture effect observed in the laboratory may be triggered by an increase of the microbial biomass. This increase was not explained by direct moisture or a pH effect. The suggested hypothesis that a lower pH could affect the availability of labile organic substrate through increased organic matter (OM) hydrolysis and thus stimulate microbial growth has to be further studied