Ethical issues encountered by French intensive care unit caregivers during the first COVID-19 outbreak.

PURPOSE: We aimed to describe the ethical issues encountered by health care workers during the first COVID-19 outbreak in French intensive care units (ICUs), and the factors associated with their emergence. METHODS: This descriptive multicentre survey study was conducted by distributing a questionnaire to 26 French ICUs, from 1 June to 1 October 2020. Physicians, residents, nurses, and orderlies who worked in an ICU during the first COVID-19 outbreak were included. Multiple logistic regression models were performed to identify the factors associated with ethical issues. RESULTS: Among the 4,670 questionnaires sent out, 1,188 responses were received, giving a participation rate of 25.4%. Overall, 953 participants (80.2%) reported experiencing issue(s) while caring for patients during the first COVID-19 outbreak. The most common issues encountered concerned the restriction of family visits in the ICU (91.7%) and the risk of contamination for health care workers (72.3%). Nurses and orderlies faced this latter issue more than physicians (adjusted odds ratio [ORa], 2.98; 95% confidence interval [CI], 1.87 to 4.76; P < 0.001 and ORa, 4.35; 95% CI, 2.08 to 9.12; P < 0.001, respectively). They also faced more the issue "act contrary to the patient's advance directives" (ORa, 4.59; 95% CI, 1.74 to 12.08; P < 0.01 and ORa, 10.65; 95% CI, 3.71 to 30.60; P < 0.001, respectively). A total of 1,132 (86.9%) respondents thought that ethics training should be better integrated into the initial training of health care workers. CONCLUSION: Eight out of ten responding French ICU health care workers experienced ethical issues during the first COVID-19 outbreak. Identifying these issues is a first step towards anticipating and managing such issues, particularly in the context of potential future health crises.

RéSUMé: OBJECTIF: Notre objectif était de décrire les enjeux éthiques rencontrés par les personnels de santé lors de la première éclosion de COVID-19 dans les unités de soins intensifs (USI) françaises, ainsi que les facteurs associés à leur apparition. MéTHODE: Cette enquête multicentrique descriptive a été réalisée en distribuant un questionnaire à 26 unités de soins intensifs françaises, du 1er juin au 1er octobre 2020. Les médecins, les internes, le personnel infirmier et les aides-soignant·es qui travaillaient dans une unité de soins intensifs pendant la première éclosion de COVID-19 ont été inclus·es. Des modèles de régression logistique multiple ont été réalisés pour identifier les facteurs associés aux questions éthiques. RéSULTATS: Parmi les 4670 questionnaires envoyés, 1188 réponses ont été reçues, soit un taux de participation de 25,4 %. Dans l'ensemble, 953 personnes participantes (80,2 %) ont déclaré avoir éprouvé un ou des problèmes alors qu'elles s'occupaient de patient·es lors de la première éclosion de COVID-19. Les problèmatiques les plus fréquemment rencontrées concernaient la restriction des visites des familles dans les USI (91,7 %) et le risque de contamination pour les personnels de la santé (72,3 %). Le personnel infirmier et les aides-soignant·es étaient davantage confronté·es à ce dernier problème que les médecins (rapport de cotes ajusté [RCa], 2,98; intervalle de confiance [IC] à 95 %, 1,87 à 4,76; P < 0,001 et RCa, 4.35; IC 95 %, 2,08 à 9,12; P < 0,001, respectivement), tout comme ils étaient davantage confrontées à la question d'« agir contrairement aux directives médicales anticipées du/de la patient·e ¼ (RCa, 4,59; IC 95 %, 1,74 à 12,08; P < 0,01 et RCa, 10,65; IC 95 %, 3,71 à 30,60; P < 0,001, respectivement). Au total, 1132 répondant·es (86,9 %) estimaient que la formation en éthique devrait être mieux intégrée à la formation initiale des personnels de santé. CONCLUSION: Huit travailleuses et travailleurs de santé français·es des soins intensifs sur dix ont été confronté·es à des problèmes éthiques lors de la première éclosion de COVID-19. L'identification de ces enjeux est une première étape vers leur anticipation et leur gestion, en particulier dans le contexte d'éventuelles crises sanitaires futures.

[Ethical issues surrounding death in pre-hospital medicine]. / Enjeux et éthique face à la mort en médecine préhospitalière.

Mobile emergency and resuscitation teams are confronted with death on a daily basis. In the home, the management of a death is complex. It raises ethical questions and sometimes destabilizes personal or collective values. Our single-center qualitative survey, conducted over a one-month period (2022), questioned 64/154 caregivers about the moral burden and challenges of such situations. The consequences of operational experience are discussed: time, fatigue, emotions and training. The quality of presence is an alternative to the success or failure of cardiac arrest care at home.

Poor results after pyrocarbon interpositional shoulder arthroplasty.

BACKGROUND: This study aimed to describe the clinical outcomes and complications of 10 cases of pyrocarbon interposition shoulder arthroplasty (PISA). METHODS: The clinical and radiographic records of 10 patients who underwent PISA using the InSpyre shoulder prosthesis (Tornier-Wright) between July 2012 and March 2017 were reviewed. The mean age at surgery was 55 years. Surgical indications included patients aged <60 years with Walch type B glenoid glenohumeral osteoarthritis (n = 7), avascular necrosis (AVN) of the humeral head (n = 1), or secondary severe glenohumeral osteoarthritis with axillary nerve dysfunction (n = 2). Outcomes of interest were postoperative complications and need for revision surgery, preoperative and postoperative patient-reported outcomes (Constant score [CS] and Subjective Shoulder Value [SSV]), and range of motion. The radiographic characteristics of the implants were evaluated. RESULTS: Among the 10 patients, 5 underwent revision to reverse shoulder arthroplasty during the study period owing to poor clinical outcomes based on the CS and SSV. All 5 revised patients had Walch type B glenoid morphology at the time of the index procedure. The mean time to revision surgery in this subset of patients was 60 months. The remaining 5 patients who did not undergo any revision procedure had significant improvement in mean CS and SSV from 30-65 points and 32%-87%, respectively, but at a shorter duration of follow-up of 35 months. CONCLUSION: High clinical failure rate and poor results at mean 5-year follow-up were found in younger PISA patients with baseline Walch B glenohumeral osteoarthritis. We would caution against use of PISA in this challenging patient population. PISA yielded more favorable short-term outcomes in patients with humeral-sided deformity or severe secondary glenohumeral osteoarthritis with axillary nerve dysfunction; however, longevity of the implant in this population remains unclear.

Poor Involvement of General Practitioners in Decisions of Withholding or Withdrawing Life-Sustaining Treatment in Emergency Departments.

BACKGROUND: Decisions of withholding or withdrawing life-sustaining treatment are frequent in emergency departments (ED) and patients are often unable to communicate their wishes concerning end of life desires. OBJECTIVE: To evaluate the participation of general practitioners (GPs) during the decision-making process of withholding or withdrawing life-sustaining treatments in ED. DESIGN: Prospective observational multicenter study. PATIENTS: We included patients for whom a decision of withdrawing or withholding life-sustaining treatments was made in ED. For each patient, we enrolled one general practitioner. MAIN MEASURES: GPs were interviewed about their perception of end of life patient's management and the communication with ED and families. KEY RESULTS: There were 109 potential patient participants. We obtained answers from 54 (49.5%) of the patient's associated GPs. Only 4 (7.4%) GPs were involved during the decision-making process of withholding or withdrawing life-sustaining treatments. Among GPs, 29 (53.7%) were contacted by family after the decision, most often to talk about their difficult experience with the decision. A majority (94%) believed their involvements in these decisions were important and 68% wished to "always" participate in end of life decisions despite the fact that they usually don't participate in these decisions. Finally, 66% of GPs believed that management of end of life in the emergency department was a failure and should be anticipated. CONCLUSIONS: GPs would like to be more involved and barriers to GP involvement need to be overcome. We do not have any outcome data to suggest that routine involvement of GPs in all end of life patients improves their outcomes. Moreover, it requires major system and process-based changes to involve all primary care physicians in ED decision-making. NIH TRIAL REGISTRY NUMBER: NCT02844972.

A Hospital-Based Committee of Moral Philosophy to Revive Ethics.

The Méditerranée Infection Foundation's primary goal is supporting a research hospital for the treatment of infectious diseases in Marseille. The main objective of this innovative center is to understand the mechanisms of contagion and face them. The Foundation will include a committee on moral philosophy that will accompany and supervise biomedical research. This is not a conventional ethics committee, frequently giving rise to a board's bureaucratic excesses, which might slow down creative biomedical clinical research without necessarily restricting abuses. Moral philosophy, however, can handle contemporary biomedical issues. In all its diversity, this discipline is able to enrich the debate on medical issues, thanks to many philosophical currents such as deontological ethics and consequentialism. The purpose of this committee is therefore to advance reflection on the bioethical issues encountered in biomedical research in infectious diseases, while respecting the precepts of moral philosophy.

How do physicians perceive quality of life? Ethical questioning in neonatology.

BACKGROUND: The outcome of very preterm infants is marked by the development of complications that can have an impact on the quality of life of the children and their families. The concept of quality of life and its evaluation in the long term raise semantic and ethical problems for French physicians in perinatal care. Our reflection aims to gain a better understanding of the representations surrounding quality of life in neonatal medicine. DISCUSSION: If French physicians hesitate to face this concept (through self-interest and apprehension), it is because the debate has become more complex. Formerly, the dilemma was between respect for life versus quality of life. Today, although this dilemma is still with us, the questions raised by French physicians show us that autonomy is given increasing importance. The equation to be solved now contains three variables: respect for life, well-being, autonomy. So we find ourselves between three positions and no longer two: respect for life (the ethics of conviction), quality of life based on autonomy (rationalist and secular deontologism), and quality of life based on the differential between well-being and suffering (utilitarianism). A solution could lie in consequentialism, which integrates the consequences for future generations in terms of both safeguarding of autonomy and quality of life, and puts the sacredness of life in second place but without sacrificing it. By evaluating their future quality of life, we can better respond to the needs of these children.

[From the "screen" society to concern for future generations]. / De la société du "tout à l'écran" au souci des générations futures.

The youth of today is evolving in an unprecedented sociocultural context marked by the rapid development of new virtual technologies. Young people are constantly looking at screens, big and small, tactile and digital, which have invaded their social sphere. Connected, logged on, overstimulated, the new generation lives surrounded by reactivity and electronic interactions. It is adults' responsibility to expand the range of their cultural and outdoor activities in order to avoid the risk of their capacity for personal expression wasting away.

Metacognition: towards a new approach to quality of life.

PURPOSE: Recent studies have demonstrated that various diseases states (e.g., schizophrenia, Alzheimer's disease) and events (e.g., a stroke) alter a person's perception of their physical and mental status. Most often this involves alterations in a person's metacognitive capabilities, and this can question the conceptual model of quality of life (QoL) based on a "perspectivist" approach. METHODS: Using the example of schizophrenia, we applied a philosophical model, developed by Griffin, to deal with this potential threat to the validity of QoL assessment. RESULTS: Patients with schizophrenia are at risk for being impaired in their ability to assess their QoL. We hypothesise that metacognition (i.e., the ability to attribute mental states in terms of beliefs and goals to one's self and others) is a formal condition to assess QoL. This particular skill is important because self-reflection is necessary for making a qualitative judgment. A link between this psychological concept and the philosophical concept of reflexivity may be established. We propose a conceptual approach to QoL that takes into account the patient's reflexivity. This approach is derived from Griffin's theory based on the list of "prudential values" and the satisfaction of the informed desires of the individual. CONCLUSION: The ability of patients to evaluate and value their life should be considered to enrich the concept of QoL. The approach derived from Griffin's theory might constitute a new avenue for QoL research.

Continuous Deep Sedation Until Death of Children at the End of Life: French Physicians' Opinions.

Objectives: To evaluate physicians' opinions concerning continuous deep sedation until death (CDSUD) and implementation of Claeys-Leonetti; a law intended to be applicable to all patients, but without a specific framework for children thus giving rise to ethically and legally complex situations. The secondary objective was to identify if physicians' characteristics could influence their opinions. Study Design: This was a national, multicenter, noninterventional cross-sectional survey from January 30, 2020, until March 1, 2020. The target population consisted of French physicians involved in children's end-of-life situations. The validated questionnaire explored respondents' characteristics and their opinions on four hypothetical pediatric clinical cases. Results: Analysis was conducted on 391 respondents. The oncological situation was more easily recognized as end of life compared with the neurological pathology (77% vs. 40.4%). Dependence on mechanical ventilation was another major factor influencing physicians in identifying end-of-life situations. Physicians clearly recognized the difference in intention between CDSUD and euthanasia. They accepted to implement CDSUD more easily in newborns. The withdrawal of artificial nutrition and hydration gave rise to divergent opinions. Respondents were in favor of adolescents' decision-making autonomy and their access to drafting advance directives. The child's best interest prevailed in case of objection by parents, except in situations outside the law's framework or in cases of disagreement within the health care team. Conclusion: Results of our study showed differences in the interpretation of the law concerning the CDSUD application framework and provide elements for reflection, which may ultimately contribute to the development of specific guidelines in CDSUD in children at the end of life.

Quality of life assessment in preterm children: physicians' knowledge, attitude, belief, practice--a KABP study.

BACKGROUND: The sequelae of extremely preterm birth have an impact on the quality of life (QoL) of these children. Standardized assessment of their QoL is rarely done in France. The aim of this study is to examine among all the types of physicians involved in the management of children born extremely preterm, their knowledge, use in routine practice and expectations concerning QoL assessment of these children using standardized questionnaires. METHODS: Prospective survey among heads of obstetric, neonatal medicine and paediatric neurology departments, by means of questionnaires. Two qualitative methods were used: focus groups and Delphi method. RESULTS: Seventy-eight physicians participated (obstetricians 24%, neonatologists 58%, paediatric neurologists 18%). The physicians considered QoL a relevant concept which they assessed subjectively. They expressed a need for information on methods of assessment. An ideal QoL questionnaire was described. Expectations regarding availability of QoL data were expressed from a medical, family and societal perspective. The impact of QoL measurement on the ethical aspect of decision-making was approached, in particular the potential impact of this tool on the decision made. Expectations were found to differ between specialties. CONCLUSION: This original study reports the perspective of experts on taking into consideration the QoL of children born extremely preterm. This is a subjective notion that is difficult to implement and which may influence therapeutic choices.

Preterm children quality of life evaluation: a qualitative study to approach physicians' perception.

BACKGROUND: While data for preterm children health-related quality of life are available, there are little data on the perception of health-related quality of life evaluation by physicians who manage preterm children, or its use in real life and decision making. The aim of this qualitative study is to highlight among physicians, themes of reflection about health-related quality of life in extremely preterm children (less than 28 weeks' gestation). METHODS: Focus groups at a French University Hospital with physicians who manage extremely preterm children: obstetricians, intensive care physicians, neonatal physicians and paediatric neurologists. The focus groups allowed the participants to discuss (drawing on their personal experience), three principal topics regarding the health-related quality of life of preterm children: representation, expectations in daily practice and evaluation method. RESULTS: We included fourteen participants in the three focus groups. Many themes emerged from the focus groups: approaches for defining health-related quality of life and difficulties of utilization, the role that health-related quality of life should have in the system of care, the problem of standards and evidence-based decision making. Physicians had difficulties with taking positions regarding this concept. There were no differences by gender, age or seniority, but points of view varied by specialty and type of practice. Physicians who had longer specialized care for extremely preterm children were more sensitive to the impact of preterm complications on health-related quality of life. CONCLUSIONS: This study provides preliminary results about physicians' perspective on the health-related quality of life of extremely preterm children. The themes emerged from the focus groups are classically described in other domains but not all in so clear a way (definition, interests and limits, ethical reflection). This approach was never developed in the field of prematurity with well-knowed consequences on quality of life. These results require to be confirmed on a larger representative sample. The themes and questions of this broad opinion survey will rest on the information issued from our preliminary interviews.

Is there such a thing as Latin bioethics?

This paper reflects on the presumption that there are distinct ethical differences between the supposedly 'Anglo-Saxon liberal' and 'Latin (Southern European) paternalist' ethical traditions. The predominance of the bioethical paradigm (principalism) is measured by a comparative analysis of regional moral opinion reflected in nation-state health laws. By looking at the way the ethico-legal concept figures into various national ordinances, we attempt to ascertain the extent and nature of variation (if any) between localities by exploring the understanding and application of principalism's keystone: patient autonomy.

Ethical issues on pregnancy termination: impact of new imaging modalities.

OBJECTIVE: To explicate the ontological statuses of both the fetus and neonate as a basis for clinical ethical judgments about the obligations of both physicians and pregnant women to protect the life and health of both the fetus and the neonate. METHODS: Despite drastic changes in perinatology, there is still a legal separation between fetuses and neonates. Neonatal status remains specific because of the prohibition of 'transgressing human life'. Nevertheless, the concept of a 'prenatal human being' recently emerged. While new technologies blur the fetus/neonate borderline, why is it still legal in many European countries to terminate a fetal life in the late stages of pregnancy? One might even support the idea that what is authorized before birth should also be after, thereby 'fetalizing' neonates. RESULTS: The 'personalistic' approach is against this 'fetalization', considering that terminating a neonate life is 'transgressive'. The 'utilitarian' model considers we cannot decide what is good for someone else, which justifies terminating the life of neonates who are not persons yet. A phenomenological view supports the ontological difference on our perceptions, differing whether we observe ultrasound fetal images or real neonatal pictures. CONCLUSION: This does not mean the weight of fetal images should be underestimated.

[Health system reforms, economic constraints and ethical and legal values]. / Réformes du système de santé, contraintes économiques et valeurs éthiques, déontologiques et juridiques.

Health system and hospital reforms have led to important and on-going legislative, structural and organizational changes. Is there any logic at work within the health system and hospitals that could call into question the principle of solidarity, the secular values of ethics that govern the texts of law and ethics? In order to respond, we compared our experiences to a review of the professional and scientific literature from 1992 to 2010. Over the course of the past eighteen years, health system organization was subjected to variations and significant tensions. These variations are witnesses to a paradigm shift: although a step towards the regionalization of the health system integrating the choice of public health priorities, consultation and participatory democracy has been implemented, nevertheless the system was then re-oriented towards the trend of returning to centralization on the basis of uniting economics, technical modernization and contracting. This change of doctrine may undermine the social mission of hospitals and the principle of solidarity. Progress, the aging population and financial constraints would force policy-makers to steer the health system towards more centralized control. Hospitals, health professionals and users may feel torn within a system that tends to simplify and minimize what is becoming increasingly complex and global. Benchmarks on values, ethics and law for the hospitals, healthcare professionals and users are questioned. These are important elements to consider when the law on the reform of hospitals, patients, health care and territories and regional health agencies is implemented.

[Dignity and freedom: towards an insoluble contradiction?]. / Dignité et liberté: vers une contradiction insoluble?

Dignity is a distinctive trait that our culture has chosen to attach to the individual. Dignity is an unconditional value and the prerogative of man. It goes without saying for us today that whatever his worldly status, his age, his sex, the colour of his skin, his state of health, etc, a man possesses dignity. However, from the point of view of history, nothing seems less spontaneous than to attribute to all men equal dignity. The idea of an ontological dignity, a dignity rooted in the depths of the human being, is the fruit of a long, laborious history which bears the mark of Judeo-Christian culture, of the philosophy of the age of Enlightenment, and of the international legal clauses that followed the atrocities committed during the second world war. Yet the semantic inflation of the concept, henceforth omnipresent in texts of law, society debates or ethical recommendations, threatens to make it sink into insignificance. Instead of enriching the argument, it becomes a pretext for not having to argue. A concept with an imprecise content, dignity has become through time a sort of magic word which, in the name of ethics, makes it possible to defend any position and the contrary. Thus the dignity argument makes it possible to justify the depenalising of euthanasia (it would be an attempt on the dignity of a being if he was refused the right to put an end to a life which is nothing but suffering) and its condemning (it would be an insult to a man's dignity if the only answer to his appeal for moral support was the administration of a lethal substance). Confused with the exercising of freedom or the quality of life, dignity has a regrettable tendency to cease to define an unconditional value; it has become a malleable, fluctuating property, sometimes even considered as related to living conditions or the state of physical and mental breakdown.

A cross-sectional analysis of patient care pathways and profiles in a dental emergency department.

INTRODUCTION: Hospital dental emergency (DE) departments are assumed to improve access to emergency care. Patients use these facilities at night and during weekends, mainly because private care is not available at these times. However, motivation for using hospital care during office hours remain unclear. This study aimed to investigate the characteristics and care pathways of patients consulting a DE department during office hours and to identify the profiles of DE department users. METHODS: A descriptive cross-sectional study was performed in the DE department of La Timone Hospital (Marseille, France). Structured interviews were conducted with 150 patients. The interview guide explored sociodemographic data, dental care behaviour, characteristics of the emergency visit, care pathway and follow-up. Descriptive statistics and a multiple correspondence analysis were used for statistical analysis of the data collected. RESULTS: The main motivation for seeking care was pain (76%), and 59.3% of the patients attended the DE department as a first intention. The main reasons for coming to the hospital were trust in hospital practitioners (42%) and convenience of care accessibility (40.1%). Two contrasting profiles of patients were identified: young patients with a low income (regular users of DE departments, seeking acute pain relief); and elderly patients (infrequent users of DE departments, seeking follow-up care). CONCLUSION: This study highlighted that hospitals can be a primary pathway to DE care even though private care may be available. However, serious limitations regarding the continuity of care in the hospital exist, regardless of patient profile.

Symptoms of anxiety and depression in relatives after decisions of withholding and withdrawing life-sustaining treatments in emergency departments.

OBJECTIVE: The aim of our study was to assess anxiety and depression in patients' relatives after a decision of withholding and withdrawing life-sustaining treatments. METHODS: We conducted a prospective observational multicenter study in three university hospitals' emergency departments. The Hospital Anxiety and Depression Scale (HADS) was assessed on the relatives of patients admitted in emergency departments 3 days and 21 days after the decision of withholding or withdrawing life-sustaining treatments. RESULTS: Among the 109 patients with a decision of withholding or withdrawing life-sustaining treatments, 88 relatives were included and 74 (67, 8%) completed the 21-day follow up. Among those, 14 (18.9%) and 13 (17.6%) displayed symptoms of anxiety and depression at 3 days, respectively. After 21 days, symptoms anxiety and depression were still present in the same way for nine (12.2%) of the relatives. The median total HADS score was 13.5 [interquartile range (IQR): 8-16] at 3 days and 10 [IQR: 5-17] at 21 days. The symptoms of depression at 21 days were more frequent for the relatives of patients who died at 21 days (P = 0.03). CONCLUSION: We found symptoms of anxiety and depression in relatives after decisions of withholding and withdrawing life-sustaining treatments in emergency departments, which persist at 21 days. Further studies are needed to support these results and to search the relatives at risk to develop these symptoms.