mercredi 5 février 2020 

14h10 - 15h10


 
Forum 1

Ethique famille

MODÉRATEUR(S) :  Olivier LESIEUR (La Rochelle), Mathieu SÉRIE (Nouméa)  
  

End-of-life management strategies the opinion of Tunisian intensivists in the Vincent lambert's case

Orateur(s) :   Meriem FATNASSI (Tunis, TUNISIE) 

Auteur(s) :  Hela MAAMOURI (Tunis)   Nassereddine FOUDHAILI (Tunis, TUNISIE)   Nozha BRAHMI (Tunis)  

14h10 - 14h18
Durée de la présentation : 5 min
Durée de la discussion : 3 min


Abstract : 
End-of-life management strategies the opinion of Tunisian intensivists in the Vincent lambert's case

Introduction / Rationale :
Decision-making at the end of life is a very difficult situation frequently encountered by Intensivists. The media debate over the case of Vincent Lambert focused on issue related to the end-of-life management strategies. This study aims to discover the opinion of Tunisian physicians in different hospitals..

Méthodes / Patients and Methods :
We have realized a questionnaire composed of 17 items. Sixty intensivists participated to our study. They have different status in intensive care and anesthesia: 10 professors, 26 senior doctors and 24 interns.

Résultats / Results :
We collected 60 opinions. 96.6 % of intensivists had taken care patients in vegetative state and 88.1 % (n=52) agreed with the fact that patients in vegetative coma are eligible to limiting or even stopping health care. 50.8% were against active limiting care. It was on account of humanitarian believes in 62.1 % of cases and religious convictions in 20.7 %. The other causes were moral, legal and ethic. 83.9% thought that the health care limiting is not prohibited by Islamic religion. Furthermore, 79.3% approved passive limiting care et 83.1% were against euthanasia in Tunisia. In pratice, 72.9% have used deep sedation as palliative care. In fact, the common methods of care limiting were: not using catecholamines in 94.9%, stopping enteral and parenteral nutrition in 88.1% and administration of deep sedation while maintaining the intubation in 62.7%. Most of them (96.6 %) recognized that Vincent lambert's affair raised the problem of end-of-life management. 59.3 % agreed with the medical and the partner decision. 56.1 % found that the lawsuit initiated by parents to human rights was disproportionate and that media influenced negatively the matter. Finally, the majority of doctors suggested that advance directives may help in those situations.

Discussion / Discussion :


Conclusion / Conclusion :
The end of life management remains a subject of controversy. Advance directives and formulated laws such as Leonetti law can be helpful.
 

IMPACT OF A VISUAL SUPPORT DEDICATED TO PROGNOSIS OF PATIENTS ON SYMPTOMS OF STRESS OF FAMILY MEMBERS

Orateur(s) :   Pascal BEURET (Roanne) 

Auteur(s) :  Gabrielle BURELLI (Roanne)   Arthur VINCENT (Roanne)   Jeremy MALLARD (Roanne)   Sarah MEFFRE (Roanne)   Alizee MAAREK (Roanne)   Sixtine BONNET (Roanne)   Jerome MOREL (Saint Etienne)  

14h18 - 14h26
Durée de la présentation : 5 min
Durée de la discussion : 3 min


Abstract : 
IMPACT OF A VISUAL SUPPORT DEDICATED TO PROGNOSIS OF PATIENTS ON SYMPTOMS OF STRESS OF FAMILY MEMBERS

Introduction / Rationale :
Family members commonly have inaccurate expectations of patient’s prognosis. Adding to classic oral information a visual support, depicting day by day the evolution of the condition of the patient, improves the concordance in prognosis estimate between physicians and family members. The objective of this study was to evaluate the impact of this support on symptoms of anxiety/depression of family members.

Méthodes / Patients and Methods :
We conducted a bi-center prospective before-after study, all consecutive patients admitted in the two ICUs were eligible. In the period before (3 months) family members received classic oral information; in the period after (3 months) in addition to classic oral information the visual support (figure 1) was available for family members in the patient’s room since the day of admission until discharge from ICU. At day 5 and 90 from admission, symptoms of anxiety/depression of referent family member were evaluated by Hospital anxiety and depression scale score (HADS).

Résultats / Results :
140 patients and their referent family members were included (77 in period before and 63 after). Characteristics of patients of the two groups were similar regarding age, reason for admission, SAPS II at admission and SOFA score at day 5. Also characteristics of referent family members were comparable in terms of age, sex ratio, type of relationship with the patient and number of visits since admission. At day 5 total HAD score was 17 [9-25] in the group before without the support and 15 [10-22] in the group after with the support (p = 0.43).The prevalence of symptoms of anxiety (HAD-A score > 7) and depression (HAD-D score > 7) was similar in the two groups (respectively 66.2% and 49.4% in the group before, and 68.3% and 36.5% in the group after (NS). At day 90 total HAD score was 11 in the group before [7-16] and 9 [5-16] in the group after (p = 0.38). By multivariate analysis the following factors were significantly associated with total HAD score > 12 at day 5: age of patient (OR 0.98 [0.96-0.999]), number of visits of referent (OR 2.72 [1.09-6.76]) and previous or current treatment of referent for anxiety or depression (OR 2.76 [1.08-7.06]).

Discussion / Discussion :


Conclusion / Conclusion :
In this study the use of a visual support dedicated to prognosis of patients did’nt modify the level of stress of family members.
 

Sedation practice and discomfort during withdrawal of mechanical ventilation in critically ill patients at End-of-Life: a post-hoc analysis of a multicenter study

Orateur(s) :   René ROBERT (Poitiers) 

Auteur(s) :  Amélie LE GOUGE (Tours)   Jean REIGNIER (Nantes)  

14h26 - 14h34
Durée de la présentation : 5 min
Durée de la discussion : 3 min


Abstract : 
Sedation practice and discomfort during withdrawal of mechanical ventilation in critically ill patients at End-of-Life: a post-hoc analysis of a multicenter study

Introduction / Rationale :
The use of sedation and opioids at the end of life is a topic of considerable ethical debate. Incidence of discomfort during the end-of-life of ICU patients and impact of sedation on discomfort are poorly known.

Méthodes / Patients and Methods :
Post-hoc analysis of an observational prospective multicenter study comparing terminal weaning vs. immediate extubation for end-of-life in ICU patients, aimed at assessing the incidence of discomfort events according to levels of sedation. Discomforts including gasps, significant bronchial obstruction or high behavioral pain scale score, were prospectively assessed by nurses from mechanical ventilation withdrawal until death. Level of sedation was assessed using the Richmond Agitation Sedation Scale (RASS).

Résultats / Results :
Among the 450 patients included in the original study, 226 (50 %) experienced discomfort after mechanical ventilation withdrawal. Patients with discomfort received lower doses of midazolam and equivalent morphine, and less frequently had deep sedation (RASS -5) than patients without discomfort (59% vs 79%, p<0•001). After multivariate logistic regression, immediate extubation was the only factor associated with discomfort whereas deep sedation and administrations of vasoactive drugs were two factors independently associated with no discomfort. Death occurred less rapidly in patient with discomfort than in those without discomfort (7•3 hours [1•9-25•0] vs 1•6 [0•3-6•0], P < 0•0001) (Figure). Long-term evaluation of psychological disorders in family members of dead patients did not differ between those with discomfort and the others.

Discussion / Discussion :
Despite the theoretically expected anticipatory titrated doses of opioids and benzodiazepines to alleviate any discomfort after withdrawal of mechanical ventilation, half of the patients did not receive sedation or opiate when the decision to withdraw mechanical ventilation was taken.
A major point that could interfere with the continuous deep sedation practice until death is the fear of potentially hastening death, and there is much controversy regarding its proper use in end-of-life care.

Conclusion / Conclusion :
Discomfort was frequent during end-of-life of ICU patients and was mainly associated with terminal extubation and less profound sedation.
 

Post-death meeting for relatives of ICU deceased patients: a way to alleviate grief symptoms?

Orateur(s) :   Thibault DEKEYSER (Béthune) 

Auteur(s) :  Dominique MALACRINO (62408, Béthune)   Caroline SEJOURNE (62408, Béthune)   Marie-Christine DUFOSSEZ (62408, Béthune)   Mehdi MARZOUK (62408, Béthune)   Imen RAHMANI (62408, Béthune)   Laura LSTIBUREK (62408, Béthune)   Christophe VINSONNEAU (62408, Béthune)  

14h34 - 14h42
Durée de la présentation : 5 min
Durée de la discussion : 3 min


Abstract : 
Post-death meeting for relatives of ICU deceased patients: a way to alleviate grief symptoms?

Introduction / Rationale :
Introduction: Bereavement in Intensive Care Unit (ICU) is associated with psychiatric disorders on relatives called Post-Intensive Care Syndrome Family (PICS-F). No isolated intervention (such as condolence letter) has shown a positive effect on these disorders, despite a well acceptance by relatives. We thought that a more integrated bereavement program should be considered. The goal of this study is to evaluate a combined psychologist-physician post-death meeting (PDM) in a bereavement program to evaluate needs and adhesion of relatives, and the effect on symptom of anxiety and depression.

Méthodes / Patients and Methods :
Patients and Methods: Monocentric, prospective study focused on relatives of patient admitted > 48h and deceased in ICU. During patient’s stay, relatives’ presence was allowed on a 24h-basis and they could meet a clinician psychologist. Formal meeting between relatives and the staff was realized at patient’s admission and after important decision-making treatment. Two weeks after patient’s death, the psychologist called relatives to offer emotional support and to invite to a PDM. PDM occurs three weeks after patient’s death with the psychologist and the physician in charge of the patient. The objectives of the meeting were to provide emotional support, to answer medical question, and to detect symptoms of anxiety and/or depression with the Hospital Anxiety and Depression Scale (HADS). We hypothesized that PMD would be able to alleviate PICS-F at 3 months. We aimed to enroll 70 families to detect a 20% lowering of HADS.

Résultats / Results :
Results: The rate of PDM acceptance was lower than expected. After 53 inclusions, only 12 relatives accepted the PDM, whereas the phone call was well perceived (86 %). Main association with acceptance of PMD was a short duration of ICU stay (4.3 days [2 – 5.3] vs 7.3 days [3,7 – 10.9] P=0,027) and ICU admission for acute respiratory failure (66.7% vs 19.5%, P=0,003) (Table 1). We found no relation between the number of in ICU meeting (psychologist of medical staff) and PMD acceptance. For relatives who accept PMD we found a high proportion of symptom of anxiety and depression (92% and 83%) with a HADS at 28.5 [22 – 34.5] (Median, IQR). No evaluation was performed at 3 months.

Discussion / Discussion :


Conclusion / Conclusion :
Conclusion: Post death contact appears well perceived by relatives but PMD quite useless. This result may be explained by the inclusion of only late death (> 48 h) where psychologist and medical staff had the opportunity to support relatives. Further study should focus on early death (< 48 h).
 

The pediatric intensivist’s position when confronted to parents opposed to termination of life-sustaining treatments on their child

Orateur(s) :   Delphine BROWN (Paris) 

Auteur(s) :  Marcel louis VIALLARD (Paris)   Laure DE SAINT-BLANQUAT (Paris)   Agathe BÉRANGER (Paris)   Lucie DERAUGLAUDRE     (Paris)   Marion GREGNON     (Paris)   Sylvain RENOLLEAU (Paris)   Marie france MAMZER     (Paris)   Dupic LAURENT (Paris)  

14h42 - 14h50
Durée de la présentation : 5 min
Durée de la discussion : 3 min


Abstract : 
The pediatric intensivist’s position when confronted to parents opposed to termination of life-sustaining treatments on their child

Introduction / Rationale :
Pediatric intensivists frequently question themselves on the issue of limitation or termination of life-sustaining treatments (LLST) carried out on children. Such a decision comes under the Claeys-Leonetti Law which forbids doctors from applying unreasonable treatment However, every so often, parents oppose themselves to a collegial LLST decision that the medical and paramedical team had taken. Such cases can even end up in Court. In order to sort out this problem, this study focused on the factors that underlie the disagreement and the solution brought forward by pediatricians whenever parents demand to persue treatments although considered as unreasonable obstinacy.

Méthodes / Patients and Methods :
We carried out a qualitative study involving three multipurpose pediatric critical care unit . All pediatricians operating within these units were contacted. Those who volonteered were met individually for a semi-directed interview. Every interview was recorded and entitled to a complete hand-written retranscription. The interviews were analysed following the phenomenological interpretive analysis method and were subject to dual listing.

Résultats / Results :
16 pediatricians out of 30 took part in the study. 8/16 claimed they would increase treatments or carry out cardiopulmonary resuscitation acts if asked to do so by parents, even if this went against the initial collegial decision. 8/16 claimed they would persue treatments although not beyond the current level. 2/16 said they would oppose themselves to parents concerning blood transfusion for comfort reasons.
Several key factors were identified as leading a doctor to the non-application of a LLST decision : the certainty regarding the child’s death on a short or mid-term basis (16/16), the litigiousness risk (14/16), the apprehension of mediatic pressure (14/16), the fear of a violent reaction from parents (13/16), other self-interest positions within the medical team (12/16), empathy towards parents (11/16), the uncertainty concerning the neurological prognosis (5/16), the lapse of time needed to fully accept the application in force of a decision (5/16). 12 pediatricians out of 16 admitted their own-suffering when confronted to the situation.

Discussion / Discussion :


Conclusion / Conclusion :
This study points out that pediatricians tend to follow parents’ position when confronted to parental opposition. In such situations, pediatricians go against their own decision in order to safeguard the parental alliance even if it leads to unreasonable obstinacy, thus conflicting with medical deontological Code obligations.
 

ADVANCE DIRECTIVES : A GENERAL OVERVIEW.

Orateur(s) :   Meriem FATNASSI (Tunis, TUNISIE) 

Auteur(s) :  Ameni ABIDI (Tunis, TUNISIE)   Hela MAAMOURI (Tunis)   Takoua KHZOURI (Tunis)   Nozha BRAHMI (Tunis)  

14h50 - 14h58
Durée de la présentation : 5 min
Durée de la discussion : 3 min


Abstract : 
ADVANCE DIRECTIVES : A GENERAL OVERVIEW.

Introduction / Rationale :
End-of-life management strategies are clearly a worldwide highly topical issue of major importance that intensivists have to deal with on a daily basis. Advance directives may be the solution sought to guide physicians to take such difficult decisions. Yet, health care directives are not legislated in Tunisia. The objective of this project was to draw a general descriptive overview to assess patients’ wishes in Tunisia.

Méthodes / Patients and Methods :
Data were collected from a 39-item-questionnaire based on the French Intensive Care Society’s form for advance directives which was filled by 101 people of general population in Tunisia, including doctors and paramedics, from May to mid-September 2019. All people included were 18 or older and well informed of the form’s utility.

Résultats / Results :
A total of 101 participants were included. The mean age was 34.6±13.5 years with extremes of 18 and 76 and a sex ratio of 1.7. Fourty-one (36.6 %) were either doctors or nurses and 3 (3%) did suffer from a severe medical condition. Among all the participants, 30 (29.7%) thought that end-of-life decisions were up to the doctor. For the rest, they willingly chose to be hospitalized in an ICU, to undergo cardiopulmonary rescuscitation and to have ventilation support with orotracheal intubation or tracheostomy respectively in 63 (87.5 %), 60 (83.3%) and 67 (93.1%) of the cases. Only 4 (5.6%) refused temporary dialysis. When asked about sequelae they can live with, participants accepted hemiplegia in 63.9% and paraplegia in58.3% of the cases. On the contrary, 68 (94.4%) refused to live in permanent coma and 55 (79.9%) disagreed to undergo tracheostomy and ventilation for life. Moreover, 31 (43.1%) found that serious un aesthetic sequelae was a fatal consequence they could not survive. As well, only 7 (9.7 %) consented to live with deep intellectual deficiency. Regarding palliative care, 53 (73.6%) participants wished to be profoundly sedated until death, 65 (90.3%) prefered to die home over 2(2.8%) in hospital. Sixty-two (84.9%) desired to see a representative of their religion. Furthermore, 65 (89%) were for organ donnation. Gender, being a health care professional and age under 30 versus equal or over30 were not significant in dependent factors (p>0.05).

Discussion / Discussion :


Conclusion / Conclusion :
It is our duty as health care professionals to spread advance directives awareness and education. Nevertheless, the law should keep the pace with ethics evolution.