[Withholding or withdrawing life-sustaining treatments in acute oncology situations: History and regulatory aspects in France]. / La « Limitation et/ou arrêt des thérapeutiques ¼ (LAT) en oncologie face à une situation aigüe : historique et aspects réglementaires en France.

The management of oncology patients, especially hospitalized patients, can lead to almost daily discussions regarding therapeutic limitations. Here, we review the history and propose a summary of the texts framing the notion of "withholding and withdrawing life-sustaining treatment" in oncology practice in France. This decision is regulated by the Claeys-Léonetti Law of February 2, 2016 recommending a collegial discussion and its documentation in the medical record. The decision to withhold or withdraw life-sustaining treatments is the subject of discussion between the patient, his physicians and his family and may take place at any time during his management. The work of intensive-care physicians provides many useful recommendations for acute oncology situations, however articles specific for oncology practice are scarce; this is a topic that oncologists must take up.

Early Routine Upper Gastrointestinal Contrast Study Following Bariatric Surgery: an Indispensable Postoperative Care or a Medicolegal Heritage?

Concerns still exist regarding the role of early routine upper gastrointestinal contrast study (UGI) after bariatric procedures for detection of early complications. We reviewed our database to identify patients who underwent laparoscopic primary or redo surgery (previously placement of adjustable gastric banding), between January 2012 and December 2017. All the patients underwent UGI within 48 h after surgery. Among 1094 patients, early UGI was abnormal in 5 patients: in 4 cases a leak (one false positive) and in one case stenosis (one true positive) were suspected. In this clinical setting, five leaks were observed and required surgical re-exploration: 3 correctly identified and 2 not detected at UGI. Overall, 3 patients developed anastomotic stenosis. Our data suggest that early routine UGI after bariatric procedures has limited utility.

Should doctors provide futile medical treatment if patients or their proxies are prepared to pay for it?

Ethically and legally doctors are not obliged to provide futile treatment to patients, even if the patient or their proxies are prepared to pay for it. However, it may be justified where such treatment is harmless and has a placebo effect. In deciding about a request for futile treatment, doctors should be guided by the ethical principles of patient autonomy, beneficence, non-maleficence and justice. Guidelines are provided to assist doctors in making such decisions. Where futile treatment is withdrawn or refused, palliative care must always be offered. If it isdecided to withdraw or refuse treatment, the patient or their proxy should be given the opportunity to contact another practitioner or institution that may be prepared to offer such treatment.

[The suitability of therapeutic effort: An end-of-life strategy]. / Adecuación del esfuerzo terapéutico, una estrategia al final de la vida.

End-of-life treatment and attention to the needs of relatives are not adequate for several reasons: Society denies or hides the death; it is very difficult to predict it accurately; treatment is frequently fragmented between different specialists, and there is insufficient palliative medicine training, including communication skills. There are frequent conflicts with decisions made at the end of life, particularly the suitability of therapeutic effort. The attitude of professionals on the adequacy of therapeutic effort is not homogenous, and varies depending on the specialty, experience, and beliefs. Many doctors are still afraid of inconveniencing patients. Primary care is in a privileged position to approach the life and values of our patients and their families, and not just the disease, which makes it the right place to guide and advise the patient on the preparation and registration of living wills.

[Advance directives in Italy: a goal not yet reached but already passed?]. / Direttive anticipate in Italia: un obiettivo non ancora raggiunto ma già superato?

The advance directives (ADs) have been adopted in many countries to defend patients' autonomy. In Italy, in the past, this topic gave rise to a heated debate involving philosophers, theologians, and politicians. In 2009, the government presented a bill of law on ADs firmly criticized from a scientific, moral and juridical point of view because the bill's content is against the principles of Italian Constitution, Italian Code of Medical Ethics, Oviedo Convention, and official statements of many scientific societies. Although the bill has passed the Low Chamber it lies, even since, in the Senate, lacking in regard any agreement among the political parties. The purpose of this article is to highlight that, in our country, patients, relatives and doctors deserve a law not only related to the specific topic of ADs, but - as in other European countries (Germany, Spain, France, UK) - aimed to deal with the complex issue of end of life care as a whole. This law should take into account the sound evidence existing in regard to the four fundamental principles supporting the best scientific and ethical approaches to the end of life issues: shared decision making process between doctors and patients/relatives; rejection of dying process marked by the suffering; withholding/withdrawing futile treatments together with palliative sedation as two crucial contributions to suppress the patient suffering and pain; clear-cut difference between these clinical/ethical options and euthanasia. At the same time, this law should be able to provide physicians with a legal coverage to make all the clinical and ethical decisions more and more complex because of the continuous evolution of medical science on one hand, and the impressive development of biotechnology on the other hand.

Futility in Chronic Anorexia Nervosa: A Concept Whose Time Has Not Yet Come.

Comparatively little scholarly attention has been given to the question of futility in chronic psychiatric disorders, with the exception of a small body of work on so-called end-stage anorexia nervosa (AN). A review of this literature provides the background for a critical examination of whether the concept of futility has any clinically meaningful, ethically justifiable, and legally defensible application to AN. In this article, the arguments for and against futility judgments in AN are analyzed with special emphasis on determinations of capacity in this serious mental illness. Parallels between the futility disputes in medical and psychiatric disorders, where applicable, will be drawn to further illuminate whether or not the concept that continued psychiatric treatment for AN is ever truly futile.

Withholding or withdrawing treatment and palliative treatment hastening death: the real reason why doctors are not held legally liable for murder.

Doctors who hasten the termination of the lives of their patients by withholding or withdrawing treatment or prescribing a potentially fatal palliative dose of medication satisfy the elements of intention and causation of a charge of murder against them. However, the courts have held that, for policy reasons based on 'society's legal convictions', such conduct is not unlawful if the patient consented to it or medical treatment would be futile or palliative treatment may hasten death. Doctors are not held liable for murder because society regards their omissions or acts as lawful--not because they did not have the intention in law to kill or did not cause the death of their patients.

[The significance of quality of life--an ethical approach]. / Die Bedeutung von Lebensqualität--aus ethischer Perspektive.

Quality of life is highly appreciated as an evaluation criterion and a goal of interventions in medicine, but it is insufficiently applied. There is no unanimous definition of "quality of life". From a philosophical point of view, subjectivistic concepts can be differentiated from objectivistic ones. In medicine there are the three concepts of general, health-related and disease-specific quality of life. In this paper it is argued that a general and subjectivistic account of quality of life is of prevailing ethical significance, due to patient orientation and patient autonomy reasons. The normative function of quality of life should be given much more consideration by the responsible players in clinical research, healthcare and allocation decisions within the healthcare system.

Does regional variation impact decision-making in the management and palliation of pancreatic head adenocarcinoma? Results from an international survey.

BACKGROUND: Management and palliation of pancreatic head adenocarcinoma is challenging. End-of-life decision-making is a variable process involving multiple factors. METHODS: We conducted a qualitative, physician-based, 40-question international survey characterizing the impact of medical, religious, social, training and system factors on care. RESULTS: A total of 258 international clinicians completed the survey. Respondents were typically fellowship-trained (78%), with a mean of 16 years' experience in a university-affiliated (93%) hepato-pancreato-biliary group (96%) practice. Most (91%) believed resection is potentially curative. Most patients were discussed preoperatively by multidisciplinary teams (94%) and medical assessment clinics (68%), but rarely critical care (21%). Intraoperative surgical palliation included double bypass or no intervention for locally advanced nonresectable tumours (41% and 49% v. 14% and 85%, respectively, for patients with hepatic metastases). Postoperative admission to the intensive care unit was frequent (58%). Severe postoperative complications were often treated with aggressive cardiopulmonary resuscitation, intubation and critical care (96%), with no defined time points for futility (74%). Admitting surgeons guided most end-of-life decisions (97%). Formal medical futility laws were rarely available (26%). Insurance status did not alter treatment (97%) or palliation (95%) in non-universal care regions. Clinician experience, regional culture and training background impacted treatment (all p < 0.05). CONCLUSION: Despite remarkable overall agreement, geographic and training differences are evident in the treatment and palliation of pancreatic head adenocarcinoma.

CONTEXTE: Le traitement et les soins palliatifs pour l'adénocarcinome de la tête du pancréas sont complexes. Les décisions de fin de vie reposent sur un processus hautement variable qui dépend de multiples facteurs. MÉTHODES: Nous avons administré à des médecins un sondage international qualitatif à 40 questions afin de caractériser l'impact sur les soins exercé par différents facteurs, notamment médicaux, religieux, sociaux, relatifs à la formation et systémiques. RÉSULTATS: En tout, 258 cliniciens ont participé à ce sondage international. Les participants étaient en général des spécialistes (78%), cumulaient en moyenne 16 ans d'expérience dans le domaine hépatopancréatobiliaire (96%) au sein d'un groupe affilié à une université (93%). La plupart (91%) ont dit croire que la résection est potentiellement curative. La majorité des cas faisaient l'objet de discussions préopératoires par des équipes multidisciplinaires (94%) et en clinique d'évaluation médicale (68%), mais rarement par une équipe de soins intensifs (21%). Les soins palliatifs chirurgicaux peropératoires incluaient la double dérivation ou la non intervention en présence de tumeurs non résécables localement avancées (41% et 49% c. 14% et 85%, respectivement, chez les patients porteurs de métastases hépatiques). L'admission postopératoire aux soins intensifs a eacute;té fréquente (58%). Les complications postopératoires graves étaient souvent traitées par réanimation cardiorespiratoire énergique, intubation et soins intensifs (96 %), sans critères chronologiques de futilité définis (74 %). C'est aux chirurgiens traitants que revenait la plupart des décisions de fin de vie (97 %). Peu avaient accès à des consignes formelles au sujet de la futilité des interventions médicales (26 %). La couverture d'assurance n'a modifié ni le traitement (97%) ni les soins palliatifs (95%) dans les régions où les soins n'étaient pas universels. L'expérience des médecins, la culture régionale et la formation de base ont eu un impact sur le traitement (toutes, p < 0,05). CONCLUSION: Malgré une concordance remarquable, des différences géographiques et des différences liées à la formation ont eu un impact sur le traitement et les soins palliatifs pour l'adénocarcinome de la tête du pancréas.