Valeurs et principes éthiques en santé publique : une revue systématique.

CONTEXT: “Analytical frameworks” and “practical tools” referring extensively to values and principles have been developed since the 1990’s to provide guidance for public health decision makers and practitioners in ethical reasoning. OBJECTIVE: This study aimed at identifying the values and principles in public health ethics “frameworks” and “tools”, at classifying them by theme, and at characterizing them by questioning their meanings and articulations. METHOD: We conducted a systematic review according to PRISMA-S guidelines. It used 3 databases and gathered documents published during the last thirty years. This corpus was analyzed following a multidisciplinarily defined interpretive framework. RESULTS: We included 51 publications. More than a half was issued by North American organizations and 7 by European organizations. We identified 110 values and 153 principles referring to the themes of justice, autonomy, beneficence and non-maleficence, governance and evaluation of actions. LIMITATIONS: There are likely other unpublished frameworks and tools used by public health actors and decision makers. CONCLUSION: Although the most cited values and principles appear to correspond to several fundamental characteristics of public health, it is still early to talk about an ethics specific to public health.

Patient understanding of oral information: Self-assessment versus test/feedback.

OBJECTIVES: The primary objective of the study was to assess the agreement between the perceived and objectified comprehension levels of oral information received by patients during their preoperative consultation. METHODS: We conducted a prospective study in a surgical consultation service with patients who had scheduled prosthetic surgery. The study included 2 measurement phases, each of which involved an evaluation of the patient's perceived understanding and an evaluation of the understanding by a health professional (i.e., objective understanding). RESULTS: The study included 98 patients. Median (min-max) age was 67 (29-90) years. Depending on the item considered, the weighted kappa coefficient for agreement between perceived patient understanding and professional-objectified levels of understanding ranged from 0.05 to 0.42, suggesting low to moderate levels of agreement. In situations of disagreement, patients had higher self-ratings of understanding than practitioners' ratings for most items. CONCLUSION: Self and hetero-measurement permits the HP to see "how much the patient understands" and to clear up any important element of management both from the point of view of the patient's legal autonomy (self-determination and choice) and of his or her power to act (management of his or her illness). PRACTICE IMPLICATIONS: Asking patients if they have understood the information given is insufficient not only from both a medical care but also from a medico-legal point of view.

Ethical reflection support for potential organ donors' relatives: A narrative review.

BACKGROUND: Even in countries with an opt-out or presumed consent system, relatives have a considerable influence on the post-mortem organ harvesting decision. However, their reflection capacity may be compromised by grief, and they are, therefore, often prone to choose refusal as default option. Quite often, it results in late remorse and dissatisfaction. So, a high-quality reflection support seems critical to enable them to gain a stable position and a long-term peace of mind, and also avoid undue loss of potential grafts. In practice, recent studies have shown that the ethical aspects of reflection are rarely and often poorly discussed with relatives and that no or incomplete guidance is offered. No review of the literature is available to date, although it could be of value to improve the quality of the daily practice. OBJECTIVES: The objective was to review and synthesize the main concepts and approaches, theories and practices of ethical reflection support of the relatives or surrogates of potential post-mortem organ donors. RESEARCH DESIGN: A narrative review was performed in the medical, psychological and ethical fields using PubMed, PsycArticles and Web of Science databases (1980-2020). RESULTS: Out of 150 papers, 25 were finally retained. Four themes were drawn: the moral status of the potential post-mortem organ donor, the principlistic approach with its limits and critics, the narrative approach and the transcendental approach. DISCUSSION: This review suggests an extension of psychological support towards ethical reflection support. The process of helping relatives in their ethical exploration of post-mortem organ donation is psychologically and morally characterized. The need for specialized professionals educated and experienced both in clinical psychology and in health ethics to carry out this task is discussed. PRACTICAL IMPACT: This review could contribute to optimize the quality of the ethical reflection support by initiating an evolution from an empirical, partial and individual-dependent support to a more systematized, professionalized and exhaustive support.

Learning from informed consent litigation to improve practices: A systematic review.

OBJECTIVE: To describe the reasons that lead judges to qualify malpractice as a lack of information, then rule in favour or not of the health professional (HP). METHODS: We conducted a systematic review of case law relating to the breach of disclosure obligations over a ten-year period from 2010 to 2020. We used 3 legal databases: Légifrance, Dalloz and Lexis 360, all identified as the most exhaustive. RESULTS: Of the 514 law cases included: judges found malpractice owing to lack of information in 377 (73.3%) cases. Among the latter, malpractices were lack of risk information (N = 257, 68.2%), lack of proof of information (N = 243, 64.5%) and/or lack of information on therapeutic alternatives (N = 49, 13.0%). These malpractices resulted in a conviction of the HP in 268 (71.1%) of the cases. CONCLUSION: Case law is an important source of information for improving the quality of HP, lawyers, and judges' practices. PRACTICE IMPLICATIONS: This review suggests that.

Characteristics of parental decision-making for children with advanced cancer who are offered enrollment in early-phase clinical trials: A systematic review.

Limited research is available on parental decision-making regarding their children's participation in pediatric phase I oncology trials compared with the adult population. The objectives of this review were to describe: (1) the process of parental decision-making in this situation; (2) the optimal communication features physicians need when proposing inclusion in such trials; and (3) the place of the child/adolescent in the assent process. Thirty relevant studies meeting inclusion criteria were identified by searching five computerized databases (PubMed, Web of Science, Cairn, Psychinfo, EM Premium). Parental decision-making is a complex process based on hopeful expectations, multiple family considerations and the child's previous cancer experience. It is highly impacted by the quality of physicians' communication. A therapeutic alliance along with an empathetic attitude and a timely delivery of accurate information is essential. Due weight should be given to the voice of children or adolescents and their optimal level of involvement may be discussed depending on their age and maturity. They should be given age-adapted information in order to empower them to be rightfully and meaningfully involved in early-phase research. This review highlights the main gaps and necessary remedial actions to support an optimal patient care management in this situation. Physicians' training in communication, structured interdisciplinary teamwork and early integration of palliative care are three key challenges which need to be implemented to actively engage in optimization strategies which would improve patient care and family support when offering enrollment in a phase I trial.

Human papillomavirus vaccination coverage, policies, and practical implementation across Europe.

BACKGROUND: Our objectives were to describe Human Papillomavirus vaccination coverage rates (HPV-VCR), policies, and practical steps for programme implementation that may be linked to high uptake in the population targeted by routine programmes across 30 European Union/European Economic Area Member States and Switzerland. METHODS: Information from institutional websites and from articles indexed in Medline between 01/2006 and 01/2017 was reviewed and extracted using a standardised form. In 12/2017, a cross-sectional survey was administered to national experts, in order to update the compiled information. RESULTS: Data were available in 31 countries, and validated by national experts in 28 of them. National vaccination programmes targeted girls 9-15 years of age in 30 countries and boys in 11 countries. HPV-VCR in girls was monitored in 25 countries: VCR was reported ≥71%(high) in ten countries, 51-70% in seven, 31-50% in four, and ≤30%(very low) in four. In high VCR countries, HPV vaccination was mainly delivered through school health services, and invitation and reminders to attend for vaccination were used. In areas with very low VCR, vaccination tended to be opportunistic and no reminders were used. CONCLUSION: According to our findings, school delivery within structured vaccination programmes and the use of reminders tended to be associated with highest HPV-VCR.

Practices, organisation, and regulatory aspects in advising on antibiotic prescription: the international ESCMID AntibioLegalMap survey.

PURPOSE: Giving advice about antibiotic prescription through dedicated consultations is a cornerstone of antibiotic stewardship programmes. Our objective was to explore practices, organisation, and regulatory requirements related to antibiotic advising. METHODS: We performed an international, exploratory, Internet-based, cross-sectional survey targeting infectious diseases and clinical microbiology specialists. It was disseminated through ESCMID and ESGAP networks. RESULTS: Answers from 830 participants (74 countries, 77% of participants from Europe) were collected. Consultations were mostly given on demand (81%, 619/764), while unsolicited consultations targeting specific conditions (e.g., positive blood culture) were less frequent (66%, 501/764). Consultations usually included indications on diagnostic work-up and follow-up (> 79%). Curbside consultations (i.e., without examining the patient) were reported by 82% (598/733) of respondents, mainly by phone (89%, 531/598). The referring physician was considered authorised not to follow the advice by 57% (383/676). Direct consultations (i.e., after examining the patient) were recorded in the medical file more frequently than curbside consultations (69%, 472/689 vs 35%, 206/592). Concerning legal liability, the majority of respondents considered that it is shared between the adviser and the referring physician, who, however, is considered primarily responsible. The advisers' liability was considered to be lower in cases of curbside and unrecorded consultations. Significant inter-countries and intra-country variability were identified, suggesting that the setting markedly influenced practices. CONCLUSION: Significant variability exists in the practice of antibiotic advising. This concerns both the organisation of care and how advisers perceive regulatory requirements. These elements must be taken into account when implementing antibiotic stewardship programmes and when training stewards.

French Society of Cardiology guidelines on exercise tests (part 2): Indications for exercise tests in cardiac diseases.

The exercise test is performed routinely in cardiology; its main indication is the diagnosis of myocardial ischemia, evaluated along with the subject's pretest probability and cardiovascular risk level. Other criteria, such as analysis of repolarization, must be taken into consideration during the interpretation of an exercise test, to improve its predictive value. An exercise test is also indicated for many other cardiac diseases (e.g. rhythm and conduction disorders, severe asymptomatic aortic stenosis, hypertrophic cardiomyopathy, peripheral artery disease, hypertension). Moreover, an exercise test may be indicated for specific populations (women, the elderly, patients with diabetes mellitus, patients in a preoperative context, asymptomatic patients and patients with congenital heart defects). Some cardiac diseases (such as chronic heart failure or arterial pulmonary hypertension) require a cardiopulmonary exercise test. Finally, an exercise test or a cardiopulmonary exercise test is indicated to prescribe a cardiac rehabilitation programme, adapted to the patient.

[Elaboration of prevention norms: Need for ethical reflection]. / Élaboration des normes de prévention : une réflexion éthique nécessaire.

INTRODUCTION: Public health tries to modify existing social norms by setting up strategies to promote the emergence of norms that are more adapted to the objectives of good health and well-being. Prevention policies and the corresponding interventions concern health behaviours and are designed to modify the individual's habits, and contribute to defining new ways of being, acting and living. Prevention therefore involves numerous personal, cultural, social and collective values. An ethical reflection concerning the meaning, rationale and justice of these actions is therefore essential. The objective of this study is to characterize the ethical reflection at the time of creation of public health norms. METHODS: A narrative review, based on the Web of Science database covering journals of the various disciplines concerned, was conducted to address this issue. RESULTS: Thirty-four publications were selected, illustrating the numerous definitions and types of norms used in public health intervention strategies. Many stakeholders are involved in the creation of public health norms specialists, opinion leaders, and social stakeholders. Finally, although some publications stress that the use of prevention norms raises a number of ethical issues, no publication refers to the presence of a structured ethical reflection as part of this process. CONCLUSION: Ethical reflection is an essential part of prevention interventions and tools. What is the best way of achieving the best results? How to resolve conflicts of interests? These issues must be addressed when developing policies or programmes and can more effectively guide public health strategies and help to improve their acceptability and efficacy in populations.

French Society of Cardiology guidelines on exercise tests (part 1): Methods and interpretation.

The exercise test is still a key examination in cardiology, used for the diagnosis of myocardial ischemia, as well as for the clinical evaluation of other heart diseases. The cardiopulmonary exercise test can further define functional capacity and prognosis for any given cardiac pathology. These new guidelines focus on methods, interpretation and indications for an exercise test or cardiopulmonary exercise test, as summarized below. The safety rules associated with the exercise test must be strictly observed. Interpretation of exercise tests and cardiopulmonary exercise tests must be multivariable. Functional capacity is a strong predictor of all-cause mortality and cardiovascular events. Chest pain, ST-segment changes and an abnormal ST/heart rate index constitute the first findings in favor of myocardial ischemia, mostly related to significant coronary artery disease. Chronotropic incompetence, abnormal heart rate recovery, QRS changes (such as enlargement or axial deviations) and the use of scores (based on the presence of various risk factors) must also be considered in exercise test interpretation for a coronary artery disease diagnosis. Arrhythmias or conduction disorders arising during the exercise test must be considered in the assessment of prognosis, in addition to a decrease or low increase in blood pressure during the exercise phase. When performing a cardiopulmonary exercise test, peak oxygen uptake and the volume of expired gas/carbon dioxide output slope are the two main variables used to evaluate prognosis.

Improvement of decision-making criteria for the care of elderly cancer patients by general practitioners (Lorraine, France).

OBJECTIVE: The objective of this study was to identify changes in the decision-making criteria of general practitioners (GPs) concerning the care of elderly cancer patients after 1 year of corrective measures for care practices in the Lorraine region, France. MATERIALS AND METHODS: In 2014, a postal mail questionnaire was sent to all GPs in the Lorraine region. This questionnaire was designed to identify GPs' decision-making criteria. It was based on the results of a literature review and on existing guidelines. During 1 year, corrective measures were implemented to improve practices, especially training sessions for physicians and production of specific tools, including a guide to the accepted ideas in geriatric oncology. In 2015, the same questionnaire was resent to all GPs to compare the answers. RESULTS: In 2014, 430 questionnaires were returned out of 2,048 sent, and in 2015, 378 questionnaires were returned out of 2,066 sent. Our results show for the first time that there exists a significant difference in the overall decision criteria between the two survey periods. This difference mainly concerns criteria related to the cancerous diseases. Physicians tend to consider the principal decision criteria to be less important after the training period. GPs express the importance of accessibility to specialists for additional advice in both 2014 and 2015; the distance between the patient's home and an adapted care facility and the interval before care begins are viewed as similarly important. CONCLUSION: Training and information sessions for physicians remain the most important tool for improving care practices. Such training strategies are more effective when carried out at the geographical scale at which the cancer professionals practice, allowing them to exploit their local organizational structure. The analysis of our data makes it possible to further integrate the patient into the care path, which remains a public health issue in terms of cost and organization.

Decision making affecting care of older people with cancer: a comparison between general practitioners and oncologists in Lorraine.

The main objective of this study is to identify the decision criteria of general practitioners and oncologists in the management of older patients with cancer in Lorraine. The secondary objectives are to identify the difficulties encountered and to propose solutions to improve health path of these patients. 2,995 post mail questionnaires were sent to all general practitioners and oncologists in Lorraine. Some decision criteria differ between general practitioners and oncologists: civilian age and accessibility to a specialized advice for general practitioners; type of cancer, nutritional status, application of best practice recommendations, and multidisciplinary discussion for oncologists. The main difficulties reported are organizational and relate to time interval before specific care beginning, accessibility to a medical specialist, and post-diagnosis such link between primary care and hospital. General practitioners and oncologists mainly agree with the difficulties encountered and the solutions to find, even if some decision criteria differences are highlighted. The training of professionals remains the major lever for improvement of medical practices.

[Complexity: concept and challenges for public health interventions]. / La complexité : concept et enjeux pour les interventions de santé publique.

Introduction: Since 2000, the notion of "complex interventions" has been emerging in the health research field. "Complex interventions" and "complexity" are commonly used terms, but they are generally not defined. Conceptual ambiguities persist concerning the notion of complexity. The objective of this exploratory review is to characterize the notion of complexity: What is complexity? Where does this notion come from and what does it cover? What are the consequences of complexity in the health field?Methods: To clarify the concept of complexity, a narrative review was conducted in the fields of humanities and social science, managerial economics, psychology and healthcare.Results: The concept of complexity, that can be attributed to Edgar Morin, has been the subject of appropriations, adaptations, and operations in multiple areas. Complexity consists of understanding the factors influencing individual decisions. In the field of healthcare, the concept of complexity is used more pragmatically and is defined by objective characteristics of interventions (defined as complex) or their contexts for the practical purposes of evaluation.Discussion: The notions of complexity and complex interventions have implications for researchers and users of the results of research. In particular, the notion of complexity is designed to provide a better understanding of the mechanism of effectiveness of interventions, support transferability and use by actors and decision-makers.

Female plastic surgery patients prefer mirror-reversed photographs of themselves: A prospective study.

INTRODUCTION: The use of a patient's image in plastic surgery is common today. Thus, plastic surgeons should master the use of the image and be aware of the implications of the patients' perception of themselves. The mere-exposure effect is a psychological phenomenon in which a person tends to rate things more positively merely because (s)he is familiar with them. Faces are asymmetric, so faces in photos are different from those observed in mirrors. The main objective of this study was to assess whether patients within a plastic surgery population, particularly those undergoing facial aesthetic surgery, preferred standard photographs or mirror-reversed photographs of themselves. METHOD: A prospective study was conducted in a plastic surgery department, which included women who were admitted to the hospital the day before their procedures. The patients were separated into the following two groups: Group 1 was composed of patients who were undergoing facial aesthetic surgeries, and Group 2 consisted of other patients who presented to the plastic surgery department for surgery. The patients were required to rate their appreciation of their own faces and to choose between standard and mirror-reversed photos of themselves. RESULTS: A total of 214 patients participated. The median age was 47.9 years (interquartile range (IQR): 36.4-60.6), and the median face appreciation was 5 (IQR: 5-7). The preference for the mirror-reversed photograph was significantly different from chance (p < 0.001, binomial (214, 156, 0.5)); 73% of the patients preferred the mirror-reversed photographs. The proportions of patients who preferred the mirror-reversed photograph differed significantly (p = 0.047) between Groups 1 (84%) and 2 (70%). CONCLUSION: Plastic surgery patients have a significant preference for mirror-reversed photographs of themselves over standard photographs. This preference is even more pronounced among patients who are undergoing facial aesthetic surgery. LEVEL OF EVIDENCE: III.

Perception of therapeutic patient education in heart failure by healthcare providers.

BACKGROUND: Care provider support for therapeutic patient education (TPE), its results and relationships with patients are factors in the setting up and sustainability of this practice. AIM: With a view to understanding the factors determining TPE care provider participation and favouring its development, the aim of this study was to describe the perception healthcare providers have of TPE in heart failure. METHODS: A national survey by self-administered questionnaire was performed in 2013 in 61 Observatoire de l'INsuffisance cardiaque (ODIN; Heart Failure Observatory) centres participating in the I-CARE programme. The cardiologist in charge of each centre received five questionnaires: one for him/herself and four for other healthcare providers working with him/her. RESULTS: We received 116 responses out of the 305 questionnaires sent (38.0%). Almost all of the responders stated that the patients were more observant after TPE sessions (91.4%). According to the responders, patients were better informed thanks to TPE (53.9%); they stated that TPE had changed their relationships with patients (81.9%); they also felt that they were educating the patient's close family/friends at the same time as the patients (86.2%). CONCLUSION: The survey showed that TPE improves care relationships. Healthcare providers recognize that they have been working differently since the programme was set up, and want the patient's close family/friends to be involved in treatment.