End-of-life medical decisions in France: a death certificate follow-up survey 5 years after the 2005 act of parliament on patients’ rights and end of life

UNLABELLED BACKGROUND The "Patients' Rights and End of Life Care" Act came into force in France in 2005. It allows withholding/withdrawal of life-support treatment, and intensified use of medications that may hasten death through a double effect, as long as hastening death is not the purpose of the decision. It also specifies the requirements of the decision-making process. This study assesses the situation by examining the frequency of end-of-life decisions by patients' and physicians' characteristics, and describes the decision-making processes. METHODS We conducted a nationwide retrospective study of a random sample of adult patients who died in December 2009. Questionnaires were mailed to the physicians who certified/attended these deaths. Cases were weighted to adjust for response rate bias. Bivariate analyses and logistic regressions were performed for each decision. RESULTS Of all deaths, 16.9% were sudden deaths with no information about end of life, 12.2% followed a decision to do everything possible to prolong life, and 47.7% followed at least one medical decision that may certainly or probably hasten death: withholding (14.6%) or withdrawal (4.2%) of treatments, intensified use of opioids and/or benzodiazepines (28.1%), use of medications to deliberately hasten death (i.e. not legally authorized) (0.8%), at the patient's request (0.2%) or not (0.6%). All other variables held constant, cause of death, patient's age, doctor's age and specialty, and place of death, influenced the frequencies of decisions. When a decision was made, 20% of the persons concerned were considered to be competent. The decision was discussed with the patient if competent in 40% (everything done) to 86% (intensification of alleviation of symptoms) of cases. Legal requirements regarding decision-making for incompetent patients were frequently not complied with. CONCLUSIONS This study shows that end-of-life medical decisions are common in France. Most are in compliance with the 2005 law (similar to some other European countries). Nonetheless, the study revealed cases where not all legal obligations were met or where the decision was totally illegal. There is still a lot to be done through medical education and population awareness-raising to ensure that the decision-making process is compatible with current legislation, the physician's duty of care and the patient's rights

Les personnes dépendantes en France : Evolution et prise en charge

Using the microsimulation model Destinie, we project the number of elderly disabled people by 2040 in France. Transition probabilities between three different states of disability (non-dependent, moderately dependent, severely dependent) are estimated based on data from the HID survey, a two-wave panel. Results are very sensitive to our assumptions regarding the average duration of disability. In our central scenario, in which life expectancy with disability at age 60 remains stable, 1.2 million elderly people would suffer from disability in 2040, a 50% increase compared to 2000. The average age of the disabled elderly would increase markedly, from 78 to 82 years for men, and from 83 to 87.7 years for women. The share of severely dependent elderly people would remain stable, at 41% of the total number of disabled elderly. Microsimulation also allows for a longitudinal approach. We follow individuals from generations 1940 to 1954, from their 60th birthday to their death. Women are more affected by old-age disability than men: among the individuals living beyond age 60, 52% of women and 29% of men would experience at least one year in dependency. Because of the fall in fertility and the increasing number of divorces, the average number of potential caregivers (spouse and children) will tend to decrease over the next 40 years, from 2.8 to 2.3 for men and from 2.2 to 2.0 for women. The number of disabled people without spouse nor valid child would increase from 125,000 today to 165,000 in 2040. With unchanged legislation, the annual public expenditures related to Apa (Allocation personnalisée d’autonomie, the disability allowance targeted toward elderly people) would increase from 3.5 to 4 billion euros (in constant prices) in 2040. This moderate evolution is due to the assumption of a price-indexed schedule: the maximum value of the benefit would remain stable in constant prices, and the share of this maximum value actually paid to beneficiaries would decline over time. Indeed, this share depends on household resources; even though pensions are themselves price-indexed, their average level will increase significantly due to the renewal of cohorts of pensioners. Results are markedly different if we assume an indexation of Apa on wages. Such an assumption takes a better account of likely changes in costs of caregiving to disabled people: it would lead to an annual public cost of about 10.2 billion euros in 2040

Les personnes dépendantes en France : Evolution et prise en charge

Using the microsimulation model Destinie, we project the number of elderly disabled people by 2040 in France. Transition probabilities between three different states of disability (non-dependent, moderately dependent, severely dependent) are estimated based on data from the HID survey, a two-wave panel. Results are very sensitive to our assumptions regarding the average duration of disability. In our central scenario, in which life expectancy with disability at age 60 remains stable, 1.2 million elderly people would suffer from disability in 2040, a 50% increase compared to 2000. The average age of the disabled elderly would increase markedly, from 78 to 82 years for men, and from 83 to 87.7 years for women. The share of severely dependent elderly people would remain stable, at 41% of the total number of disabled elderly. Microsimulation also allows for a longitudinal approach. We follow individuals from generations 1940 to 1954, from their 60th birthday to their death. Women are more affected by old-age disability than men: among the individuals living beyond age 60, 52% of women and 29% of men would experience at least one year in dependency. Because of the fall in fertility and the increasing number of divorces, the average number of potential caregivers (spouse and children) will tend to decrease over the next 40 years, from 2.8 to 2.3 for men and from 2.2 to 2.0 for women. The number of disabled people without spouse nor valid child would increase from 125,000 today to 165,000 in 2040. With unchanged legislation, the annual public expenditures related to Apa (Allocation personnalisée d’autonomie, the disability allowance targeted toward elderly people) would increase from 3.5 to 4 billion euros (in constant prices) in 2040. This moderate evolution is due to the assumption of a price-indexed schedule: the maximum value of the benefit would remain stable in constant prices, and the share of this maximum value actually paid to beneficiaries would decline over time. Indeed, this share depends on household resources; even though pensions are themselves price-indexed, their average level will increase significantly due to the renewal of cohorts of pensioners. Results are markedly different if we assume an indexation of Apa on wages. Such an assumption takes a better account of likely changes in costs of caregiving to disabled people: it would lead to an annual public cost of about 10.2 billion euros in 2040

A new scoring system for the diagnosis of BRCA1/2 associated breast-ovarian cancer predisposition.

International audienceCriteria have been proposed for genetic testing of breast and ovarian cancer susceptibility genes BRCA1 and BRCA2. Using simulations, this study evaluates the efficiency (sensitivity, positive predictive value [PPV] and specificity) of the various criteria used in France. The efficiency of the criteria published in 1998, which are largely used, is not optimal. We show that some extensions of these criteria provide an increase in sensitivity with a low decrease in specificity and PPV. The study shows that scoring systems (Manchester, Eisinger) have similar efficiency that may be improved. In this aim, we propose a new scoring system that takes into account unaffected individuals and kinship coefficients between family members. This system increases sensitivity without affecting PPV and specificity. Finally, we propose a two-step procedure with a large screening by the physician for recommending genetic counselling, followed by a more stringent selection by the geneticist for prescribing genetic testing. This procedure would result in an increase of genetic counselling activity but would allow the identification of almost 80% of mutation carriers among affected individuals, with a mutation detection rate of 15% and a specificity of 88%

CT-based semi-automatic quantification of vertebral fracture restoration

Minimally invasive surgeries aiming to restore fractured vertebral body are increasing; therefore, our goals were to create a 3D vertebra reconstruction process and design clinical indices to assess the vertebral restoration in terms of heights, angles and volumes. Based on computed tomography (CT)-scan of the vertebral spine, a 3D reconstruction method as well as relevant clinical indices were developed. First, a vertebra initial solution requiring 5 min of manual adjustments is built. Then an image processing algorithm places this solution in the CT-scan images volume to adjust the model's nodes. On the vertebral body's anterior and posterior parts, nine robust heights, volume and endplate angle measurement methods were developed. These parameters were evaluated by reproducibility and accuracy studies. The vertebral body reconstruction accuracy was 1.0 mm; heights and volume accuracy were, respectively, 1.2 and 179 mm3. In conclusion, a 3D vertebra reconstruction process requiring little user time was proposed as well as 3D clinical indices assessing fractured and restored vertebra

Four-Generation Families in France

The number of centenarians, and their multiplication, can obviously not be taken as pure measures of mortality and mortality decline. But they are figures that capture one's imagination. In the same way, the indicator Sophie Pennec proposes here conjures up an image of family photos where four or five generations are seated together. How frequent are such situations today, and how frequent will they be tomorrow? How many women will be helping out with their grandchildren while also taking care of their parents

Pourquoi et comment compter?

Compter, comprendre, prévoir, tels sont les objectifs du démographe qui dispose d'un outillage performant mais jamais totalement satisfaisant. C'est parce que l'objet même de ses recherches échappe sans arrêt à l'investigation, du fait de la difficulté à le définir