Chaque année, près de 150 000 personnes âgées institutionnalisées décèdent. Les conditions de fin de vie ont été améliorées avec le développement des soins palliatifs et la possibilité de faire intervenir des équipes spécialisées au sein des EHPAD. Cette étude a pour objectif de décrire l’intégration des soins palliatifs dans les parcours de fin de vie des résidents des EHPAD, au sein de la Métropole du Grand Nancy. Nous avons étudié de manière rétrospective l’ensemble des parcours de fin de vie de résidents de 8 EHPAD du Grand Nancy, dont les décès ont été constatés entre le 1er mars 2022 et le 31 mai 2022, soit 3 mois. À l’aide de questionnaires renseignés par notre équipe, les conditions de fin de vie ont été étudiées, y compris en milieu hospitalier grâce aux données disponibles dans les dossiers médicaux et administratifs des défunts. Il ressort de cette étude que 75 % des décès ont eu lieu en EHPAD et plus d’un quart des résidents décédés a bénéficié de l’intervention d’une équipe de soins palliatifs. Ces résultats sont encourageants et témoignent de l’intérêt que portent les EHPAD du Grand Nancy à la qualité de la fin de vie de leurs résidents. Par ailleurs, plusieurs transferts en milieu hospitalier ont eu lieu malgré un décès attendu, en raison de difficultés humaines et techniques au sein de l’EHPAD. L’anticipation de la fin de vie avec le recours plus précoce à des équipes de soins palliatifs semble être un levier important afin d’optimiser les parcours de soins des résidents institutionnalisés. Every year, nearly 150,000 institutionalized elderly people die. End-of-life conditions have been improved with the development of palliative care and the possibility of involving specialized teams within nursing homes. The objective of this study is to describe the integration of palliative care into the end-of-life paths of nursing home residents in the Grand Nancy Metropolitan. We studied retrospectively all the end-of-life paths of residents of 8 nursing homes in Grand Nancy, whose deaths were recorded between March 1, 2022 and May 31, 2022, therefore 3 months. With questionnaires provided by our team, end-of-life conditions were studied, including in hospitals thanks to the data available in the medical and administrative records of the deceased. This study showed that 75% of deaths occurred in nursing homes and more than a quarter of the residents who died benefited from the intervention of a palliative care team. These results are encouraging and testify to the interest of nursing homes in Greater Nancy in the quality of the end of life of their residents. Also, several transfers to hospitals took place despite an expected death, due to human and technical difficulties within the EHPAD. Anticipating the end of life with earlier use of palliative care teams seems to be an important lever to optimize the care pathways of institutionalized residents.

Objective. - Every year, nearly 150,000 institutionalized elderly people die. End-of-life condi-tions have been improved with the development of palliative care and the possibility of involving specialized teams within nursing homes. The objective of this study is to describe the integra-tion of palliative care into the end-of-life paths of nursing home residents in the Grand Nancy Metropolitan. Methodology. - We studied retrospectively all the end-of-life paths of residents of 8 nursing homes in Grand Nancy, whose deaths were recorded between March 1, 2022 and May 31, 2022, therefore 3 months. With questionnaires provided by our team, end-of-life conditions were studied, including in hospitals thanks to the data available in the medical and administrative records of the deceased. Results and discussion. - This study showed that 75% of deaths occurred in nursing homes and more than a quarter of the residents who died benefited from the intervention of a palliative care team. These results are encouraging and testify to the interest of nursing homes in Greater Nancy in the quality of the end of life of their residents. Also, several transfers to hospitals took place despite an expected death, due to human and technical difficulties within the EHPAD. Anticipating the end of life with earlier use of palliative care teams seems to be an important lever to optimize the care pathways of institutionalized residents. (C) 2022 Elsevier Masson SAS. All rights reserved.

L’anémie est un problème fréquent en médecine palliative. L’objectif de cette synthèse était de décrire les différentes données disponibles dans la littérature sur ce sujet afin d’aider les praticiens dans leurs prises en charge. Nous avons effectué une revue de la littérature internationale concernant l’anémie lors de situations palliatives. Nous avons détaillé certaines caractéristiques comme l’étiologie de l’anémie en situation palliative, les conséquences d’un traitement sur la qualité de vie ou sur le pronostic des patients. Nous avons également rappelé les différentes recommandations disponibles en France à ce sujet. Il existe peu de données disponibles dans la littérature concernant l’anémie chez les patients relevant de soins palliatifs. Les recommandations actuelles sont également limitées et parfois peu applicables dans des situations palliatives avancées. De nouvelles études sont nécessaires dans ce domaine, notamment sur l’utilisation des agents stimulants l’érythropoïèse et sur la correction des carences martiales et vitaminiques. Anaemia is a highly prevalent condition in palliative medicine. The objective of this abstract was to describe the data available in the literature on this subject in order to assist practitioners in treating their patients. We conducted a review of the international literature on anaemia in palliative care settings. We detailed certain characteristics such as the etiology of anaemia in palliative care situations or the impact of a treatment on patient quality of life or prognosis. We also reiterated the various recommendations available in France on this subject. Little data is available in the literature on anaemia in patients receiving palliative care. Current recommendations are also limited and sometimes have little applicability in advanced palliative situations. Further studies are needed in this area, particularly on the use of erythropoiesis-stimulating agents and the correction of iron and vitamin deficiencies.

Introduction. Anaemia is a common problem in palliative care patients. It can be responsible for many uncomfortable symptoms such as asthenia, dyspnoea and pain. The purpose of this study was to analyse the management of anaemia by physicians from mobile palliative care teams and palliative care units. Method. An observational, declarative and descriptive study was conducted between September and December 2017, based on an electronic questionnaire sent to physicians from mobile palliative care teams and palliative care units in mainland France. Data was collected regarding indications, the choice of treatment, the method of surveillance and the use of standards. Results. We collected answers from 140 physicians. Of these, 87% were only treating anaemia in palliative care patients presenting symptoms, and 95% did not use any standard. The symptoms that led more often to anaemia being treated were dyspnoea and asthenia. The first-line treatment used by 95% of responders was a transfusion of packed red blood cells, primarily for reasons of speed and efficacy. Conclusions. The majority of physicians who responded to our questionnaire stated that they did not use anaemia management standards, but that the practices they used were in line with the small number of recommendations and data available on the subject. Further studies are needed on this topic and more specifically on the use of erythropoiesis-stimulating agents and the correction of vitamin and iron deficiencies. (C) 2020 Elsevier Masson SAS. All rights reserved.

Limits and levers to the implementation of the palliative approach in the Nursing Home. The main objective was to identify the limits or levers to the implementation of the palliative approach in the Nursing Homes (NH). It is an ancillary study. We conducted a qualitative study by semi-directed interviews with Coordinator Physicians in NH in Lorraine. Data collection started in January 2018 and was ended in June 2018. The verbatims were analyzed by grounded theory. The analysis highlighted structural and cyclical constraints specific to the NH, such as the lack of medical and nurse permanence and the Limited material and personal resources. The study showed that the hospital based NH have the possibility to free themselves of these Limits. Awareness-raising and the training of caregivers have been identified as major levers in palliative care. Conversely the lack of training appeared as an obstacle. The intervention of the Hospital at Home Team and the Mobile Palliative Care Team is described as an essential support. The analysis showed that the organization and cooperation of the various actors is a major issue for the implementation of the palliative approach. The Trusted Person and Advance Directives devices are poorly used and do not support the palliative approach in NH. Thus, most of the Limits identified in the survey are the structural constraints and the lack of training. The main Lever that needs to be developed seems to be the training in palliative care and the proper use of different toots created to circumvent structural constraints. (C) 2020 Elsevier Masson SAS. All rights reserved.

The aim of this study was to understand on which arguments the end-of-life decisions in neonatal reanimation were taken. The study was a qualitative study by semi-guided individual interview with a thematic analysis. The components entering the discussions are numerous. There is sometimes confusion in intentionality. Decisions taken for end-of-life in neonatal reanimation often seem difficult especially in half-tone clinical pictures. (C) 2019 Elsevier Masson SAS. All rights reserved.

The aim of the study was to describe the practices of French obstetricians in the choice of parents to poursue the pregnancy after the announcement of a fetal pathology of particular gravity, not curable. The study was a descriptive study, transversal and national by anonymous electronics questionnaires. The majority of obstetricians do not have specific training in palliative or ethical care and does not have a protocol framing these clinical situations of palliative care but consider this document useful. Obstetricians have an important place in these situations, and even if an awareness seems to be emerging, much remains to be done. (C) 2019 Elsevier Masson SAS. All rights reserved.

By evolving since the 1980s, modern neonatology significantly reduced the morbidity and mortality of pre-term newborns. This evolution exposes new questioning situations by saving life but with sometimes heavy sequels. The neonatologists' medical practices evolved from "end of life decision-making" to accompaniment of the patient and his family in a palliative care perspective. This evolution was impacted by multiple recommendations from the French national consultative ethics committee (No. 63, 65 and 121) that spoked firstly of "euthanasia exception" and later of grave transgression. The committee was influenced by the results from two studies, EPIPAGE 1 and 2, which showed an amelioration of morbidity and mortality of pre-term newborns, for all terms on the last decades. This evolution was also due to new laws in France: first in 2002 relative to patients' rights and the quality of healthcare system, then in 2005 relative to patients' rights and the end of life. However, some difficult situations persist, particularly when withdrawing artificial nutrition and hydration. The body of a child dying of undernutrition seems to be an unbearable sight for caregivers and families. Some authors legitimate a systematic "terminal sedation" together with the withdrawal of nutrition and hydration to "limit suffering". Others speak of "fixing a reanimation mistake" for children alive thanks to reanimation. They think they can "undo" things and by this way they differentiate a "natural" life and an "artificial" life. All of this prompts us to conduct a study to understand the argumentation of end of life decision in neonatal reanimation. (C) 2019 Elsevier Masson SAS. All rights reserved.

Introduction:Palliative care practice confronts us with the dilemma of «equitable care», namely: when to treat, by what means and, above all, when to stop.The issue of artificial nutrition is the perfect example.The present study was conducted to identify the arguments used by the Mobile Palliative Care Team to discuss the introduction or withdrawal of artificial nutrition and compare these arguments according to the advice given. Methods:A descriptive, historical cohort-type epidemiological study was carried out on all medical files of patients followed by the mobile team of the Metz-Thionville Regional Hospital in 2013 and for whom a discussion had taken place regarding artificial nutrition. Results:The most commonly mentioned arguments were general patient condition (68.4% of cases), estimated life expectancy (67.3%) and the palliative nature of care management (55.1%).Advice for the withdrawal or withholding of artificial nutrition formulated by the mobile team was followed in 75.9% of cases while the advice for the introduction or continuation of artificial nutrition was followed in 93.3%. Conclusion:The decision to withdraw or pursue artificial nutrition is based on a body of arguments and a multidisciplinary evaluation with discussion encompassing an ethical dimension involving the patient and his/her relatives.

Background: The subcutaneous route is widely used in both palliative care and geriatrics. Numerous compounds are administered by this route, including paracetamol. However, there is no recommendation on which to base this latter practice and, in the absence of published evidence, nothing is known regarding its local tolerability in palliative care patients. Aim: The main objective of this study was to assess the local tolerability of paracetamol when administered subcutaneously for analgesic or antipyretic purposes in patients hospitalized in the palliative care unit. The secondary objective was to identify the factors favoring the occurrence of local adverse events. Design: This is a prospective multicenter observational study (NCT02884609). Participants: Study conducted in 160 patients hospitalized in the palliative care units of three hospitals in metropolitan France from 2014 to 2017. Results: Of the 160 patients, 44 (28%) presented at least one non-serious local adverse event (edema in 29, erythema in 5, pain in 15, hematoma in 2, pruritus in 1, and local heat in 2). No serious adverse events were observed. Factors associated with the occurrence of local adverse events were younger age, administration in the arm and thorax, and a high number of daily administrations. Conclusion: This first ever study carried out on this subject reveals that subcutaneous administration of paracetamol in palliative care patients was well tolerated locally.

Introduction - Refractory pain to treatment is a problem in palliative care. In this situation it's possible to undertake a deep and continuous sedation until death using midazolam. We propose here a case of a patient for who an analgesic-sedation was undertake with ketamine due to a refractory pain alternatively to a sedation with midazolam. Case presentation. - A patient 60 years old, estimated weight 60 Kg, receiving medical care for a diffuse large B cell lymphoma. Due to apparition of carcinomatous meningitis with tetraplegia and a profound alteration of general state the patient switch to palliative care. After entering palliative care unit the patient's state will rapidly worsen with an augmentation of refractory neuropathic pains. In accordance with the patient and her family it's decide to undertake sedation. Sedation was conduct with ketamine starting by 100 mg per day growing to 150 mg per day in ten days. This sedation with ketamine allowed the patient some calms moments of consciousness in a crucial part of her life permitting her to talk with her family. Discussion. - In this case we could see that an analgesic-sedation with ketamine did not cause major or uncomfortable side effect for the patient. It allowed to overcome an inextricable situation and offered time to the patient and her family, which couldn't have been done with midazolam. Conclusion. - Analgesic sedation with ketamine seems to be an interesting alternative to midazolam in refractory pain. Also this is necessary to study this practice precisely by rigorous clinical study. (C) 2018 Elsevier Masson SAS. All rights reserved.

Introduction. Developmental coordination disorder (DCD) is a complex disease poorly known. It is responsible for backwardness in the development and acquisition of motor coordination and gesture among 6% of children. Objective. Examine the place of general practitioner's (GP) place in the diagnosis management of children with this disorder. Method. We conducted a descriptive study on medical records of the historical cohort of children with non-verbal learning disabilities. It was monitored in 2011 and 2012 at the regional reference center for learning disabilities. We led complementary survey though telephone interview with GPs. Results. On average the diagnosis management involved 6.6 health professionals and lasted 4.2 years. It was triggered mainly by teachers (60%) and parents (25.8%). The GP's intervention was found in 38.3% of medical records, with an average rank equal to 3.9. Despite of the knowledge of the learning disorder in 98% of cases, GP's didn't seem to be implicated in the diagnosis management. It was due to a lack of collaboration and information sharing between health professionals. Conclusion. GP is not involved in the first line in the diagnostic management of children DCD. The diagnostic delay is long. The absence of guideline and the saturation of reference centers justify the need for a primary care network deployed in 2013 in Lorraine.

Background. - Though ethical dilemma is common in neonatal practice, it is only recently subject to scientific research. Objectives. - We aimed to describe neonatologists' practices in end of life decision-making processes and in palliative care, and their practical implementation in NICU. Methods. - This cross-sectional prospective study was performed by an online survey. Pediatricians from French level III maternity wards were selected. Data collected concerned the general characteristics of the participants as well as their personal awareness of palliative reflection. Five clinical cases explored processes of discussion and decision in palliative care, as well as their implementation. Results. - Seventy-one practitioners responded on 65 level III NICUs. Ten percent were trained in palliative medicine and 17% had this project. The palliative care team was invited in less than a third of the multidisciplinary meetings, although most responders acknowledged its usefulness in accompanying children, their families or caregivers. Parents' weight in the final decision was important for the responders but less than that of doctors. It concerned parents' vision on disability. For palliative care in the delivery room, 13% did not use any medication. Others mostly used the umbilical vein. Midwives more often took responsibility of palliative care in the delivery rooms. Conclusions. - Neonatologists expert in palliative care are still too few in level III centers. Palliative teams are not yet involved in patient's regular care. Practices in palliative care in France are still quite dependent on the center, especially regarding medications. This study underlines the importance of interventions training neonatologists in the field of palliative medicine. (c) 2017 Elsevier Masson SAS. All rights reserved.

Background - Assessment of 20 months of work collaboration between intensive care unit (ICU) and mobile palliative care teams within the collegial group discussions prior to withholding or withdrawing treatments decisions defined in the Act of 22 April 2005.Objectives. - The research was designed: (1) to describe and to analyse the characteristics of patients receiving palliative care from mobile palliative care team; (2) to compare them with the other patients hospitalized in the ICU; (3) to describe the collaboration between mobile palliative care team and intensive care unit on withholding or withdrawing treatments.Method. - This was a single-centre retrospective study conducted in the intensive care unit of Metz-Thionville hospital; we enrolled all patients admitted in the ICU between January 1st, 2011 and December 31, 2012.Results. - The mobile palliative care team met 2.9% of 1256 patients admitted in the ICU during the study period. Patients met by the mobile palliative care team were significantly older, in a more serious condition at admission and hospitalized longer compared to the rest of patients admitted in the ICU. The collection of the patient's will was possible for 47.2% of them. Further to the intervention of the mobile palliative care team, it was decide to withdraw or withhold the treatment of 91.7% of the patients.Conclusion. - Mobile palliative care teams, although not seeming a classic interlocutor for the ICU, can play an important role by participating in the preliminary discussions to with holding or withdrawing treatments and by helping to support patients and their relatives. (C) 2015 Elsevier Masson SAS. All rights reserved.

Introduction : La Dyspraxie est un trouble complexe qui reste peu connu, responsable d'un retard dans le developpement et l'acquisition de la coordination motrice et du geste chez 6% des enfants. Nous avons etudie la place du medecin generaliste dans le parcours diagnostique de l'enfant dyspraxique.Methode : Une etude epidemiologique descriptive a ete menee sur une cohorte historique de dossiers d'enfants, ayant un trouble non verbal des apprentissages, suivi en 2011 et 2012 au centre referent pour les troubles des apprentissages en Lorraine. Une etude complementaire, a ete realisee par entretiens telephoniques aupres des medecins generalistes des enfants. Le recrutement a ete facilite par une neuropediatre et l'analyse des donnees, permise avec l'aide d'un epidemiologiste du CHU de Nancy, en utilisant le logiciel SAS® 9.3.Resultats : En moyenne, les parcours diagnostiques comptaient 6,6 intervenants et duraient 4,2 ans. Le medecin generaliste intervenait dans 38.3% des parcours avec un rang moyen d'intervention egal a 3,9. Dans 98% des cas, les medecins generalistes objectivaient des Troubles des Apprentissages (TDA) chez leurs jeunes patients, mais dans 77,6% des cas, la part dyspraxique n'etait pas suspectee. Parmi les medecins generalistes interroges, 72,9% s'estimaient familiers avec la dyspraxie et 40%, estimaient la connaitre de facon « succincte », « vague », « a peu pres » ou « incertaine ». Conclusion : Le medecin generaliste n'est pas sollicite en premiere ligne. Il pourrait etreinteressant, de plus sensibiliser les medecins generalistes, sur les signes precoces d'anomalies du developpement non verbal de l'enfant