Aider les étudiants en médecine à approcher la mort [Helping medical students to approach death].

A project recently launched by the Faculty of biology and medicine of Lausanne introduces the approach of facing death during both the dissection and the course of clinical activities. Existential questions relating to mortality are bound to arise sooner or later during the course of the study. For the sake of humanized clinical practice, these questions must be confronted. In response to a request by a student association, an accompanying curriculum with active student's contribution through encounters with death in anatomy and clinical situations was created in Lausanne. Students will benefit from this new program throughout their curriculum. This program is the first of its kind in Switzerland.

Chemotherapy in patients with advanced pancreatic cancer: too close to death?

PURPOSE: We evaluated the attitude in using chemotherapy near the end of life in advanced pancreatic adenocarcinoma (PAC). Clinical and laboratory parameters recorded at last chemotherapy administration were analyzed, in order to identify risk factors for imminent death. METHODS: Retrospective analysis of patients who underwent at least one line of palliative chemotherapy was made. Data concerning chemotherapy (regimens, lines, and date of last administration) were collected. Clinical and laboratory factors recorded at last chemotherapy administration were: performance status, presence of ascites, hemoglobin, white blood cell (WBC), platelets, total bilirubin, albumin, LDH, C-reactive protein (C-rp), and Ca 19.9. RESULTS: We analyzed 231 patients: males/females, 53/47 %; metastatic/locally advanced disease, 80/20 %; and median age, 66 years (range 32-85). All patients died due to disease progression. Median overall survival was 6.1 months (95 % CI 5.1-7.2). At the last chemotherapy delivery, performance status was 0-1 in 37 % and 2 in 63 %. Fifty-nine percent of patients received one chemotherapy line, while 32, 8, and 1 % had second-, third-, and fourth line, respectively. The interval between last chemotherapy administration and death was <4 weeks in 24 %, ≥4-12 in 47 %, and >12 in 29 %. Median survival from last chemotherapy to death was 7.5 weeks (95 % CI 6.7-8.4). In a univariate analysis, ascites, elevated WBC, bilirubin, LDH, C-rp and Ca 19.9, and reduced albumin were found to predict shorter survival; however, none of them remained significant in a multivariate analysis. CONCLUSIONS: A significant proportion of patients with advanced PAC received chemotherapy within the last month of life. The clinical and laboratory parameters recorded at last chemotherapy delivery did not predict shorter survival.

Erforschung und Antworten auf den vorzeitigen Todeswunsch eines Patienten mit einer schweren fortgeschrittenen Krankheit [Exploring and Responding to a Wish to Hasten Death of a patient with Advanced Illness].

It is not uncommon for patients with an advanced disease to express a desire to their physician to hasten their death. Recent studies show that the motivation of such a desire is multifactorial and multidimensional, including depression, physical, psycho-social and spiritual suffering, fears about the process of dying and/or misunderstandings about the options for end-of-life care. The objective of this paper is to propose to the physician how to explore the dimensions of this request and some elements to answer it.

Désir de mort, désir de vie et fin de vie [Desire to die, desire to live at the end of life]

Since a couple of years, physicians are confronted with an increasing request of end of life patients asking for a dying facilitated process. The reasons for this are multiple and complex. Existential suffering, increased by depression, a feeling of loss of meaning or dignity and/or being a burden, seems to be a significant factor. Social isolation and physical symptoms seem to be only contributory. The identification of "protecting elements" such as spiritual well-being or a preserved sense of dignity offers new opportunities for care. Providing a space for dialogue by exploring the patient's expectations and fears, his knowledge of care options available at the end of life, his own resources and difficulties frequently contribute to decrease suffering.

Compétences en soins patiatifs : que faut-il savoir faire en tant que médecin [Competencies in palliative care : what should the physicians be able to do?]

Palliative patients (patients with progressive incurable illnesses) have a number of needs, early and late in their illness trajectories. This article highlights some of the most important competencies required by physicians to address these needs. They cover a broad spectrum of domains and include pain and symptom management, communication, disclosure, prognostication, and psychological, social and spiritual needs. All physicians, generalists and specialists alike, should possess the basic competencies but should also recognize that some patients, especially those not responding to initial strategies, require timely referrals to specialized palliative care teams.

'Do not attempt resuscitation' and 'cardiopulmonary resuscitation' in an inpatient setting: factors influencing physicians' decisions in Switzerland.

OBJECTIVE: To determine the prevalence of cardiopulmonary resuscitation (CPR) and do-not-attempt-resuscitation (DNAR) orders, to define factors associated with CPR/DNAR orders and to explore how physicians make and document these decisions. METHODS: We prospectively reviewed CPR/DNAR forms of 1,446 patients admitted to the General Internal Medicine Department of the Geneva University Hospitals, a tertiary-care teaching hospital in Switzerland. We additionally administered a face-to-face survey to residents in charge of 206 patients including DNAR and CPR orders, with or without patient inclusion. RESULTS: 21.2% of the patients had a DNAR order, 61.7% a CPR order and 17.1% had neither. The two main factors associated with DNAR orders were a worse prognosis and/or a worse quality of life. Others factors were an older age, cancer and psychiatric diagnoses, and the absence of decision-making capacity. Residents gave four major justifications for DNAR orders: important comorbid conditions (34%), the patients' or their family's resuscitation preferences (18%), the patients' age (14.2%), and the absence of decision-making capacity (8%). Residents who wrote DNAR orders were more experienced. In many of the DNAR or CPR forms (19.8 and 16%, respectively), the order was written using a variety of formulations. For 24% of the residents, the distinction between the resuscitation order and the care objective was not clear. 38% of the residents found the resuscitation form useful. CONCLUSION: Patients' prognosis and quality of life were the two main independent factors associated with CPR/DNAR orders. However, in the majority of cases, residents evaluated prognosis only intuitively, and quality of life without involving the patients. The distinction between CPR/DNAR orders and the care objectives was not always clear. Specific training regarding CPR/DNAR orders is necessary to improve the CPR/DNAR decision process used by physicians.

Assistance au suicide en hôpital de soins aigus: sommes-nous prêts [Physician-assisted suicide in university hospital: are we ready?]

Assisting people to commit suicide has generated a passionate public debate. In exceptional situations, access to this support can be granted to the demanders in a hospital environment. So did the CHUV and the academic hospitals of Geneva draw up a procedure permitting, in principle, the access to an assistance to commit suicide. Two recent clinical situations experienced in the CHUV's Service of internal medicine have created a lot of discussions, doubts and revealed, sometimes, divergent positions. By the light of this clinical cases, we wished to share the perspective of the internist in charge of the ethician, of the chaplain, of the medical director, of the psychiatrist and of the palliative care responsible. Theses complex situations illustrate the deep ambivalence felt by the clinicians confronted to situations which require a multidisciplinary approach.

Gender differences in HIV progression to AIDS and death in industrialized countries: slower disease progression following HIV seroconversion in women.

To evaluate sex differences in human immunodeficiency virus (HIV) disease progression before (pre-1997) and after (1997-2006) introduction of highly active antiretroviral therapy, the authors used data from a collaboration of 23 HIV seroconverter cohort studies from Europe, Australia, and Canada restricted to the 6,923 seroconverters infected through injecting drug use and sex between men and women. Within a competing risk framework, they used Cox proportional hazards models allowing for late entry to evaluate sex differences in time from HIV seroconversion to death, to acquired immunodeficiency syndrome (AIDS), and to each first AIDS-defining disease and death without AIDS. While no significant sex differences were found before 1997, from 1997 onward, women had a lower risk of AIDS (adjusted cumulative relative risk (aCRR) = 0.76, 95% confidence interval (CI): 0.63, 0.90) and death (adjusted hazard ratio = 0.68, 95% CI: 0.56, 0.82) than men did. Compared with men, women also had lower risks of AIDS dementia complex (aCRR = 0.23, 95% CI: 0.07, 0.74), tuberculosis (aCRR = 0.60, 95% CI: 0.39, 0.92), Kaposi's sarcoma (aCRR = 0.27, 95% CI: 0.07, 0.99), lymphomas (aCRR = 0.47, 95% CI: 0.23, 0.96), and death without AIDS (aCRR = 0.74, 95% CI: 0.56, 0.98). Sex differences in HIV disease progression have become larger and statistically significant in the era of highly active antiretroviral therapy, supporting a stronger impact of health interventions among women.

Assessing the wish to die in elderly people.

Background: The wish to die has mainly been studied in terminally- ill young adults. In elderly persons, factors associated with the wish to die are likely to differ from those observed in younger people. Since the most frequently used scale -"The Schedule ofAttitudes Toward Hastened Death" (SAHD, Rosenfeld et al., 2000)- was previously used in terminally ill cancer or AIDS patients, its use in elderly people suffering from multiple comorbidities is problematic. The objectives of this study were 1) to adapt the SAHD for use in elderly people, 2) to develop a new instrument to assess patients' attitudes towards death 3) to test the relevance/acceptability of these instruments. Methods:An adapted version of the SAHD to the elderly population (SAHD-OLD) was obtained by analyzing all items of the instrument instrument in an interdisciplinary group of experts in geriatric care. Items were modified according to their relevance in elderly population. An instrument to assess patients' attitudes towards death was built on previous qualitative work performed by Schroepfer. These 2 instruments were subjected to cognitive testing in a convenience sample of 11 community-dwelling people (median age = 82 years; range 76-91). Results: The SAHD-OLD was obtained by modifying those items addressing palliative care issues (eg. irreversible consequences of stopping treatment) and systematically replacing "illness/disease" by "health problems". We expressed in statements the 6 categories identified by Schroepfer, and created instructions asking respondents to describe their current attitude towards death (Adapted Schroepfer). During cognitive testing, our sample assessed the SAHD-OLD and the Adapted Schroepfer as relevant for elderly people. Respondents judged these 2 instruments acceptable and appreciated the direct manner in which they addressed end of life issues. The opportunity to speak openly on this topic was welcomed. Conclusions: The SAHD-OLD and the Adapted Schroepfer seem promising instruments to assess the wish to die in elderly people suffering from multiple comorbidities. Preliminary results show good comprehension, high relevance and acceptability. Psychometric properties of the SAHD-OLD are currently being tested in a large sample of patients.

Death caused by cardioinhibitory reflex cardiac arrest--a systematic review of cases.

Forensic pathologists often refer to the cardioinhibitory reflex cardiac arrest (CiRCA) following short neck trauma as a mechanism of death. We sought via a systematic review of the literature to identify circumstances under which carotid bifurcation stimulation could lead to death. Two independent reviewers selected case studies or reports from Medline, ISI Web of Knowledge, and Embase. Circumstances and contributory factors were extracted for each case. From the available data, authors independently assessed whether CiRCA was highly probable (no alternative explanation possible), probable (alternative explanation possible), or unlikely (alternative explanation highly probable). A narrative approach was used to define circumstances in which CiRCA remained possible. From the 48 published cases evoking CiRCA as a possible cause of death between 1881 and 2009, 28 were most likely to result of other mechanism of death (i.e., cerebral hypoxia due to carotid compression, mechanical asphyxia, myocardial infarction). CiRCA remained possible for 20 cases (including five based on anecdotal evidence only) with only one case with no alternative explanation other than CiRCA. Our findings support the presumption that reflex cardiac arrhythmia due to carotid bifurcation stimulation cannot provoke death alone. Actual state of knowledge suggests CiRCA might be contributory to death in the presence of drug abuse and/or cardiac pathology, often associated with physical and/or mental excitation.

In-situ revascularisation for secondary aorto-enteric fistulae: the success of silver-coated Dacron is closely linked to a suitable bowel repair.

OBJECTIVES: The purpose of this study was to assess short- and mid-term results of in-situ revascularisation (ISR) using silver-coated Dacron prostheses and bowel repair for management of secondary aorto-enteric fistulae (SAEF). DESIGN: Single-centre retrospective chart review. MATERIAL AND METHODS: This study includes all the patients treated by ISR using silver-coated Dacron for SAEF between 2006 and 2010. Primary end points were mortality and survival rates. Secondary end points were reinfection-free survival and secondary patency rates. RESULTS: Eighteen male patients with SAEF with a median age of 64 years were operated by ISR using silver-coated Dacron during the study period without operative death. The 30-day mortality was 22% and the in-hospital mortality rate was 39%. Indeed, during hospitalisation, a duodenal leak was observed in four patients including three who died. Four others patients died due to multi-system organ failure. Median follow-up was 16 months (range 1-66). The survival rate at 12 months was 55%. One duodenal leak was observed leading to death. The reinfection-free survival and the secondary patency rates at 12 months were 60% and 89%, respectively. CONCLUSION: In-situ revascularisation with silver-coated Dacron provides acceptable results in terms of mortality. This treatment may be useful for simple vascular reconstruction and allow greater attention to bowel repair that is a determinant in short- and mid-term survival.

Freedom of choice of specialist physicians is important to Swiss resident: a cross-sectional study.

QUESTION UNDER STUDY: To assess how important the possibility to choose specialist physicians is for Swiss residents and to determine which variables are associated with this opinion. METHODS: This cross-sectional study used data from the 2007 Swiss population-based health survey and included 13,642 non-institutionalised adults who responded to the telephone and paper questionnaires. The dependent variable included answers to the question "How important is it for you to be able to choose the specialist you would like to visit?" Independent variables included socio-demographics, health and past year healthcare use measures. Crude and adjusted logistic regressions for the importance of being able to choose specialist physicians were performed, accounting for the survey design. RESULTS: 45% of participants found it very important to be able to choose the specialist physician they wanted to visit. The answers "rather important", "rather not important" and "not important" were reported by 28%, 20% and 7% of respondents. Women, individuals in middle/high executive position, those with an ordinary insurance scheme, those reporting ≥2 chronic conditions or poorer subjective health, or those who had had ≥2 outpatient visits in the preceding year were more likely to find this choice very important. CONCLUSIONS: In 2007, almost half of all Swiss residents found it very important to be able to choose his/her specialist physician. The further development of physician networks or other chronic disease management initiatives in Switzerland, towards integrated care, need to pay attention to the freedom of choice of specialist physicians that Swiss residents value. Future surveys should provide information on access and consultations with specialist physicians.