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

Integration and activity of hospital-based palliative care consultation teams: the INSIGHT multicentric cohort study

International audienceBackground: Hospital-based Palliative Care Consultation Teams (PCCTs) have a consulting role to specialist services at their request. Referral of patients is often late. Early palliative care in oncology has shown its effectiveness in improving quality of life, thereby questioning the “on request” model of PCCTs. Whether this evidence changed practice is unknown. This multicentre prospective cohort study aims to describe the activity and integration of PCCTs at the patient level. Methods: For consecutive patients newly referred to participating PCCTs, the team collected the following data: circumstances of first referral, problems identified, number of interventions, patient’s survival after first evaluation and place of death. Results: Seventeen PCCTs based in university hospitals in Paris area, recruited 744 newly referred adult patients, aged 72 ± 15 years, 52% males, and 504(68%) with cancer as primary diagnosis. After 6 months, 548(74%) had died. At first evaluation, 12% patients were outpatients, 88% were inpatients. Symptoms represented the main reasons for referral and problems identified; 79% of patients had altered performance status; 24% encountered the PCCT only once. Median survival (1st-3rd quartile) after first evaluation by the PCCT was 22 (5–82) days for overall patients, and respectively 31 (8–107) days and 9 (3–34) days for cancer versus noncancer patients (p < 0.0001). Place of death was acute care hospital for 51.7% patients, and home or Palliative Care Unit for 35%. Patients referred earlier died more often in PCU. Conclusion: The study provides original data showing a still late referral to the PCCTs in France. Cancer patients represent their predominant activity. The integrated palliative care model seems to emerge besides the “on request” model which originally characterised their missions

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

Aide à la décision de transfert ou non transfert en réanimation d’un patient atteint de cancer

Référentiel inter régional en soins oncologiques de support, AFSOS et Réseau Espace Santé - Cancer Rhône-Alpes (RRCRA), 201

Deferasirox in iron-overloaded patients with transfusion-dependent myelodysplastic syndromes: Results from the large 1-year EPIC study

The prospective 1-year EPIC study enrolled 341 patients with myelodysplastic syndromes (MDS); although baseline iron burden was >2500. ng/mL, ∼50% were chelation-naïve. Overall median serum ferritin decreased significantly at 1 year (p=0.002). Decreases occurred irrespective of whether patients were chelation-naïve or previously chelated; changes were dependent on dose adjustments and ongoing iron intake. Sustained reductions in labile plasma iron were observed. Discontinuation rate (48.7%) and adverse event profile were consistent with previously reported deferasirox data in MDS. Alanine aminotransferase levels decreased significantly; change correlated significantly with reduction in serum ferritin (p<0.0001). This large dataset prospectively confirms the efficacy and well characterizes the safety profile of deferasirox in MDS. © 2010 Elsevier Ltd