French hospital nurses' opinion about euthanasia and physician-assisted suicide: a national phone survey.

BACKGROUND: Hospital nurses are frequently the first care givers to receive a patient's request for euthanasia or physician-assisted suicide (PAS). In France, there is no consensus over which medical practices should be considered euthanasia, and this lack of consensus blurred the debate about euthanasia and PAS legalisation. This study aimed to investigate French hospital nurses' opinions towards both legalisations, including personal conceptions of euthanasia and working conditions and organisation. METHODS: A phone survey conducted among a random national sample of 1502 French hospital nurses. We studied factors associated with opinions towards euthanasia and PAS, including contextual factors related to hospital units with random-effects logistic models. RESULTS: Overall, 48% of nurses supported legalisation of euthanasia and 29%, of PAS. Religiosity, training in pallative care/pain management and feeling competent in end-of-life care were negatively correlated with support for legalisation of both euthanasia and PAS, while nurses working at night were more prone to support legalisation of both. The support for legalisation of euthanasia and PAS was also weaker in pain treatment/palliative care and intensive care units, and it was stronger in units not benefiting from interventions of charity/religious workers and in units with more nurses. CONCLUSIONS: Many French hospital nurses uphold the legalisation of euthanasia and PAS, but these nurses may be the least likely to perform what proponents of legalisation call "good" euthanasia. Improving professional knowledge of palliative care could improve the management of end-of-life situations and help to clarify the debate over euthanasia.

[Anhedonia and depressive symptomatology among HIV-infected patients with highly active antiretroviral therapies (ANRS-EN12-VESPA)]. / Anhédonie et dépression dans le contexte de l'infection par le VIH avec les multithérapies antirétrovirales (ANRS-EN12-VESPA).

INTRODUCTION: Anhedonia is defined as the loss of the capacity to feel pleasure and there is no consensus with its relationship with depressive symptomatology. Furthermore, no study has investigated the problematic of anhedonia in the context of HIV-infection, which concern a lot of patients with depressive symptoms. Depressive symptomatology presents a major challenge in the management of HIV-infection due to its central role in clinical progression. OBJECTIVE: This study aims to disentangle relationship between determinants of anhedonia, depression and anxiety in order to optimise mental management of HIV infection. METHOD: In 2003, a face-to-face survey (ANRS-EN12-VESPA) was conducted among patients selected in a random stratified sample of 102 French hospital departments delivering HIV care. Eligible respondents were HIV-infected outpatients, aged 18 or older living in France and diagnosed for at least six months. Among solicited patients, 2932 agreed to participate (response rate: 59%) and data about anhedonia, anxiety and depression are available for 1427 patients. The face-to-face gathered information on sociodemographic characteristics, such as education level, gender, partner, children, financial situation or housing and also psychosocial and sociobehavioural characteristics, such as drug use. Self-reported side effects of treatment were also available. ASSESSMENT TOOLS: Anxiety and depression were assessed using the hospital anxiety and depression (HAD) scale. Physical anhedonia was assessed using the French version of the Chapman scale. Three regression models were used to identify factors associated with anhedonia, anxiety and depression among demographic, psychosocial and clinical characteristics. RESULTS: Factors independently associated with anhedonia were older age (>50), lower education level, unemployment and men HIV contaminated by heterosexual relation or injecting drug use. Women, with lower education level, unemployment, without steady partner, with a detectable viral load and who reported side effect of HAART presented more frequently anxiety. Unemployment, uncomfortable housing, no social support from friends, self-reported side effect and lipodystrophy were independently associated with depression. CONCLUSION: Our results underline the multiplicity of factors associated with mental disorders related to depression. These results can be explained by the fact that the anxiety and anhedonia are two cardinal symptoms of depression. Determinants of anhedonia and anxiety reported in this study may provide the key to a more exact delineation of depressive disorders in the context of HIV infection in order to optimize long-term psychological follow up of concerned patients.

Suicide attempts among people living with HIV in France.

This study examined the prevalence and characteristics of attempted suicide among a representative sample of French Human Immunodeficiency virus (HIV) infected individuals. In 2003, a face-to-face survey was conducted among people living with HIV/AIDS (PLWHA) selected in a random, stratified sample of French hospital departments. Among solicited individuals, 2,932 agreed to participate and were asked if they had ever AS. Among the respondents, 23% had AS. Female gender, younger age, native French citizenship, reporting household financial difficulties, having been HIV-contaminated through homosexual contact or through injection drug use and suffering from lipodystrophy-related symptoms were all independently associated with AS. HIV-discrimination and the lack of social support from family remained independently associated with AS. Our findings indicate a high level of AS among PLWHA and emphasize the multiple roles of factors associated with living with HIV, together with sociodemographic factors. The results enable the possibility for vulnerable groups to be targeted for specific future interventions in order to prevent attempted suicide.

French district nurses' opinions towards euthanasia, involvement in end-of-life care and nurse patient relationship: a national phone survey.

OBJECTIVES: To assess French district nurses' opinions towards euthanasia and to study factors associated with these opinions, with emphasis on attitudes towards terminal patients. DESIGN AND SETTING: An anonymous telephone survey carried out in 2005 among a national random sample of French district nurses. PARTICIPANTS: District nurses currently delivering home care who have at least 1 year of professional experience. Of 803 district nurses contacted, 602 agreed to participate (response rate 75%). MAIN OUTCOME MEASURES: Opinion towards the legalisation of euthanasia (on a five-point Likert scale from "strongly agree" to "strongly disagree"), attitudes towards terminal patients (discussing end-of-life issues with them, considering they should be told their prognosis, valuing the role of advance directives and surrogates). RESULTS: Overall, 65% of the 602 nurses favoured legalising euthanasia. Regarding associated factors, this proportion was higher among those who discuss end-of-life issues with terminal patients (70%), who consider competent patients should always be told their prognosis (81%) and who value the role of advance directives and surrogates in end-of-life decision-making for incompetent patients (68% and 77% respectively). Women and older nurses were less likely to favour legalising euthanasia, as were those who believed in a god who masters their destiny. CONCLUSIONS: French nurses are more in favour of legalising euthanasia than French physicians; these two populations contrast greatly in the factors associated with this support. Further research is needed to investigate how and to what extent such attitudes may affect nursing practice and emotional well-being in the specific context of end-of-life home care.

[The relationship between the rigorous practice of sports and addictions: results from a survey in south-eastern France]. / Pratique sportive intensive et addictions: une enquête en région PACA.

This study aimed to assess the prevalence of cigarette, alcohol and cannabis consumption among top-ranked French student athletes aged between 16-24 years old, and to identify correlating factors. Overall, 837 athletes participated in the study (82% response rate). Among females, the amount and duration of sporting activity in which they were engaged on a weekly basis had a negative correlation to cigarette smoking and the occasional use of cannabis. Among males, however, a positive correlation of these factors was observed for cigarette smoking. Other determinants of alcohol, tobacco and cannabis use were the level of athletic competition and whether the athlete practiced a team sport (as opposed to an individual one), with some gender variations. Two major risk factors for young adult athletes were the existence of high psychological distress (for both sexes) and a lack of family support (particularly in the case of males). Further research is needed to investigate the specific motives to use so-called "recreational" drugs among young athletes engaging in high-level competition.

Management of HIV-related stigma and adherence to HAART: evidence from a large representative sample of outpatients attending French hospitals (ANRS-EN12-VESPA 2003).

This study investigated patterns of HIV disclosure to significant others (parents, siblings, children, other relatives, friends and colleagues) and describe them in terms of socio-demographic background and other characteristics, including experiences of AIDS-related discrimination. It also assessed the relationship between disclosure patterns and adherence to HAART. We used a cross-sectional survey conducted among a national representative sample of 2,932 HIV-infected people recruited in French hospitals. HIV disclosure patterns were both selective and cumulative: disclosure was more frequent for friends and siblings, while concealment prevailed concerning children, other relatives, and colleagues; but patients who disclosed their seropositivity to one significant other were also more likely to disclose it to other significant others. Patients reporting experiences of discrimination from sexual partners were less likely to be highly adherent, and we also found a significant relationship between uncontrolled disclosure and non-adherence. Patients who have opted for concealment probably consider non-adherence and uncontrolled disclosure as competing risks, but among them a significant minority loses on both counts. Counselling provided to HIV-infected people should not separate the adherence and disclosure issues, and adherence interventions should seek to help patients to manage concurrently disclosure/concealment of their seropositivity and its consequences.

Vulnerability, unsafe sex and non-adherence to HAART: evidence from a large sample of French HIV/AIDS outpatients.

Current socio-behavioural research in HIV-infected people has tried to identify patients with "high-risk" profiles, i.e. who simultaneously exhibit non-adherence to highly active anti-retroviral therapy (HAART) and unsafe sex with serodiscordant partners. We challenged this approach by investigating the correlates of both behaviours, for homosexual men, heterosexual men and heterosexual women separately, among a representative sample of 4963 HIV-infected people in France. Variables introduced in the analysis dealt with patients' background and daily life, with a focus on situations of economic, social and personal vulnerability. Overall, 2932 patients agreed to participate, and 1809 were both receiving HAART and sexually active. Among heterosexual women, non-adherence and unsafe sex appeared as joint outcomes of similar situations of vulnerability. Among heterosexual men, these behaviours were weakly correlated and shared some predictors related to situations of vulnerability. Among homosexual men, non-adherence and unsafe sex were not correlated and had distinct determinants. Situations of vulnerability, the context and the motives of unsafe sex, as well as factors associated with non-adherence and unsafe sex varied greatly with gender and sexual preference. Theoretical models used for designing behavioural interventions should take into account this diversity.

[Collaboration between general practitioners and pharmacists in the management of patients on high-dosage buprenorphine treatment. Prescribers' practices]. / Collaboration entre médecins et pharmaciens pour le suivi des patients sous buprénorphine haut dosage. Pratiques des médecins prescripteurs.

OBJECTIVES: This paper examines the collaboration between general practitioners (GPs) and pharmacists in the outpatient management of patients on high-dosage buprenorphine (HDB) treatment. METHODS: A telephone survey of a sample of HDB prescribers in southeastern France questioned them about their knowledge, practices, and opinions about HDB treatment in October 2002; data from the national health insurance fund and the national statistics institute completed the study. Logistic regression was used to investigate factors associated with collaboration with pharmacists. GPs' practices were compared to assess their correlation, if any, with this collaboration. RESULTS: 345 GPs participated in the study. Only 54% reported collaborating with dispensing pharmacists in managing patients on HDB, despite official guidelines encouraging it. Collaboration was independently related to training in addiction treatment, a favorable opinion of maintenance treatment by GPs, long experience in HDB prescription, and participation in a specialized medical network. CONCLUSION: Implementation of recommendations on physician-pharmacist collaboration requires additional training in addiction medicine for GPs and the encouragement of their participation in medical networks. On the other hand, increasing the constraints on GPs may negatively affect patients' access to care.

Disclosure of prognosis to terminally ill patients: attitudes and practices among French physicians.

BACKGROUND: Disclosure of the prognosis to terminally ill patients is a strong prerequisite for integrating the physical, psychological, spiritual, and social aspects of end-of-life care. OBJECTIVE: This study aimed to assess French physicians' general attitudes and effective practices (with patients followed up to death recently) toward such disclosure. DESIGN/SUBJECTS: We used data from a cross-sectional survey conducted among a national sample of 917 French general practitioners, oncologists, and neurologists. RESULTS: A majority of respondents opted for prognosis disclosure only at patients' request, very few opted for systematic disclosure without patient's request, and a significant minority opted for systematic concealment. Concerning deceased patients described by respondents, 44.5% of competent patients were informed of prognosis by their physician, 27.3% were informed by someone else, 9.0% refused to be informed, and 19.2% were simply not informed. Concealment was more frequent for older patients, and physicians involved in a nongovernmental organization (NGO) for patients' support were more likely to disclose the prognosis, even without patient's request. CONCLUSIONS: Disclosure of the prognosis to terminally ill patients is still far from systematic in France. Further research is needed to better understand the motivations of French physicians' disclosure practices, which are probably culturally shaped.

[Doctors' opinions on palliative care: results from a French survey on physicians attitudes and practices]. / Deux points de vue des médecins sur les soins palliatifs.

OBJECTIVE: To examine practitioners' opinions on palliative care. METHOD: Statistical analyses were carried out on data collected from 1000 physicians recruited to participate in a study on knowledge, attitudes and practices with respect to palliative care ("Palliative Care 2002"). A cluster analysis (CAH) was conducted based on responses to nine questions in order to identify homogeneous and contrasting profiles of opinions on palliative care. RESULTS: Two distinctly different categories of profiles emerged. The first one had a restrictive approach to palliative care (n = 387; 38.7%), while the second one supported its expansion (n = 613; 61.3%). CONCLUSION: A newly revised communication campaign which favoured and recognised palliative care could assist in the dissemination of related practices among physicians.

Factors associated with efavirenz discontinuation in a large community-based sample of patients.

Efavirenz (EFV) is a potent antiretroviral drug; its use may be limited, however, by psychiatric symptoms that require its discontinuation. We sought to identify the characteristics that placed patients at an elevated risk of discontinuation. Data for this cross-sectional study came from a self-administered questionnaire distributed by French AIDS community associations; it collected information about sociodemographic characteristics, addictive behaviours, treatment regimens, EFV history and depression. Patients remaining on EFV for more than six months were compared with those who stopped taking it. Of the 828 patients who completed the questionnaire, 175 had taken EFV for at least six months, and 152 had discontinued it (median months [IQR] of exposure=4[2-10]). Of these 327 patients (median age=42), 23% were women, 46% were unemployed, 38% had a steady sexual partner and 24% reported a history of multiple depressive episodes. Logistic regression showed that the factors independently associated with EFV discontinuation were female gender (OR[95%CI]=2.2[1.2-3.8]), unemployment (1.8[1.1-2.8]), a steady sexual partner (1.7[1-2.5]) and multiple episodes of depression (2.6[1.5-4.5]). Clinicians should keep in mind the neuropsychiatric risks of EFV during the first year, especially among patients with a history of multiple depressive episodes.

Opinions toward pain management and palliative care: comparison between HIV specialists and oncologists.

Despite the introduction of HAART, pain is still a common symptom in people living with HIV/AIDS. For these persons, pain management supplied by palliative care teams may support standard HIV care. This study compares opinions toward palliative care of 83 HIV specialists and 217 oncologists (French national survey: Palliative Care 2002). Data were collected by phone questionnaire. A cluster analysis was carried out in order to identify contrasted profiles of opinions toward palliative care. A logistic regression was performed to test the relationships between identified clusters and physicians' characteristics. With a two-cluster partition, we observed a profile corresponding to a restrictive conception of palliative care. Within this profile, physicians were more prone to consider that palliative care should be used only for terminally-ill patients, and only after all curative treatments have failed, with a restrained prescriptive power for physicians providing palliative care. This conception was associated with reluctance toward morphine analgesia. Once controlled for other physicians' characteristics, HIV specialists were more likely than oncologists to endorse this restrictive conception (OR=1.9, CI 95% [1.1; 3.3]). Thus French HIV specialists should be more informed about the utility of providing palliative care, even for patients who are not in terminal stage.

[Practice of trauma and emergency units in delivering care to youth who attempt suicide--experiences from Provence]. / Pratiques de prise en charge des jeunes suicidants en Provence-Alpes-Côte d'Azur.

Suicide attempts (SA) represent a significant public health problem and raise questions wih respect to the best, most appropriate methods for triage and the delivery of care. A prospective investigation to evaluate the quality of SA health care was carried out over a three month period within 18 hospitals having an emergency care unit. A total of 393 youth having attempted suicide were triaged and treated by these establishments during the period of the survey, with a large majority of them being girls (77%). Medicinal intoxication was the most often used method (85.1%). The criteria and regulations relating to the initial health care provided upon the patient's arrival were most followed, contrary to those concerning hospitalisation modalities and preparation for release following treatment. Factors explaining the implementation of these criteria were related to the type of emergency unit, the presence of a mental disorder and the duration of the patient's hospitalisation. These results show that several aspects of health care provided to young suicide attempters should be improved in Provence.

Socio-economic conditions, health status and employment among persons living with HIV/AIDS in France in 2001.

To investigate employment levels and identify barriers to work among persons living with HIV/AIDS in France in 2001, we conducted a cross-sectional study among HIV-infected patients seen in the hospital outpatient clinics of the two French regions most affected: Ile-de-France (IDF) and Provence-Alpes-Côte-d'Azur (PACA). Of the 840 outpatients included in the study, 58.8% in IDF and 46.8% in PACA were currently employed, and 28.1 and 47.8%, respectively, were receiving disability benefits. Among unemployed patients, 32.1% in IDF and 29.6% in PACA reported that they planned to (re)enter the workforce. Current and planned employment status were associated with characteristics indicative of the patients' social and demographic situation before the HIV diagnosis (region of residence, educational level, HIV transmission group, age, nationality) and with their health status at the interview (HIV progression, HCV co-infection). Receiving disability benefits was negatively associated with plans to return to work. HIV-related discrimination at work was reported by 11.9% of the patients in IDF and 9.2% in PACA, and was not associated with occupational status. Thus, social interventions should seek to prevent patients, particularly the most socially vulnerable, from leaving their jobs at acute stages of their illness and should promote (re)entry into the workforce among unemployed patients.

Evaluation of buprenorphine maintenance treatment in a French cohort of HIV-infected injecting drug users.

BACKGROUND: Buprenorphine was approved in France for treating opiate dependence in July 1995 and can be prescribed by general practitioners (GPs). Most studies assessing buprenorphine maintenance treatment (BMT) outcomes have taken place in GP settings. An evaluation of BMT outcomes in patients already followed for their HIV-infection could supply additional information about the changes in addictive practices in a non-GP setting. METHODS: We assessed BMT discontinuations and the course of self-reported addictive behaviours and characteristics associated with buprenorphine-injection misuse in 114 HIV-infected patients on BMT who were followed in a hospital-based outpatient department. RESULTS: The continuous series of follow-up visits at which these 114 patients reported regular buprenorphine prescriptions accounted for 237.5 person-years of observation, i.e. 475 follow-up visits. Of the 114 patients on BMT, 43% continued BMT throughout the follow-up, 40% stopped it, and results for 17% were not available either because they did not answer the self-administered questionnaire (5%) or because they were lost to follow-up (12%). Addictive behaviours declined but buprenorphine injection misuse remained stable. Depression measured by the CESD score (RR=1.04 95%CI [1.01-1.06]), cocaine use (RR=2.48 95%CI [1.31-4.68]) and alcohol consumption exceeding 4 alcohol units (AU) per day (RR=2.29, 95%CI [1.17-4.46]) were independently associated with buprenorphine injection misuse among stabilised BMT patients. CONCLUSIONS: Despite the reduction in drug injection after starting BMT, buprenorphine injection misuse mainly involves patients with characteristics of severe addiction. Better monitoring of the illicit drug use patterns of patients on BMT may suggest new medical strategies for GPs to improve BMT outcomes.

Hospitalization for depressive syndrome in a cohort of HIV-infected patients contaminated through injecting drug use: MANIF 2000 cohort, France, 1995-1999.

The objective of this study was to estimate the relative impact of hospitalization for depressive syndrome (DS) on all causes of hospitalization and characterize individuals more likely to experience hospitalization for DS in the French cohort study, Manif 2000, of patients HIV infected through injection drug use. We selected all patients followed-up to the 24-month visit (C24) who missed no more than one visit. Using medical records, dates and causes of hospitalizations, were collected retrospectively. A Poisson regression model based on generalized estimating equations was used to identify factors associated with hospitalization for DS. During the study period, 223 hospitalizations were recorded for 120 of the 335 selected patients. DS was the second reason for hospitalization after infections, accounting for 14.3% of the total number of hospitalizations. DS was reported in 32 hospitalizations and involved 24 patients, five of them being hospitalized more than once for the same cause. Factors independently associated with hospitalization for DS were history of multiple incarceration (RR = 2.1, 95% CI: 1.0-4.7), polydrug use (RR = 2.6, 95% CI: 1.1 -5.9) and lack of stable relationship (RR = 4.2, 95% CI: 1.6- 11. 1). In the HAART era, DS represents an important cause of hospitalization of HIV-infected injecting drug users, mainly concerning patients presenting no stable relationship and signs of social instability. Scheduled psychiatric consultations for these patients would permit us to identify those for whom major depression might lead to hospitalization and provide them with timely and appropriate care.

[Terminal care of patients by the general practitioner and the specialist. Results of a French survey "Attitudes and practices in palliative treatment--2002"]. / Prise en charge des malades en fin de vie en médecine générale et spécialisée. Résultats de l'enquête française "Attitudes et pratiques face aux soins palliatifs-2002".

OBJECTIVE: Assess the attitude of the practitioners with regard to the management of patients at the end of their lives, depending on the physician/patient communication and treatment of pain. Method Statistical analysis of the data collected among 1,000 practitioners recruited for a survey on knowledge, attitudes and practices regarding palliative care in 2002. RESULTS: The practitioners who felt "ill at ease" in the management of patients at the end of their life often had a poor opinion regarding morphine and did not systematically their patients of the therapeutic aims. CONCLUSION: Greater awareness by the practitioners of palliative care would help to improve the quality of care supplied to terminally ill patients.

[Causes of hospitalization and death in the MANIF 2000 cohort, composed of HIV-infected patients contaminated by intravenous drug use, 1995-1999]. / Motifs d'hospitalisation et mortalité dans la cohorte MANIF 2000, composée de sujets infectés par le VIH et contaminés par usage de drogues en intraveineux, 1995-1999.

OBJECTIVE: To describe the causes of hospitalization and mortality among the MANIF 2000 cohort study, composed of HIV-infected patients contaminated through intravenous drug use. METHOD: Data collection with a standardized questionnaires with clinical, biological, therapeutic and psycho-sociologic data on inclusion and every six months. Dates and causes of hospitalization and death were collected retrospectively by nurses from the hospital clinical records. Comparison were made using the chi(2) or Mann-Whitney tests with 5% significance threshold. RESULTS: The MANIF 2000 cohort study included, between October 1995 and June 1998, 467 patients with a median age of 33 years, 30% of whom were women. On inclusion, 42.2% were still injecting drugs (half of them were on substitution therapy), 10.5% had stopped injections of drugs, 32% exhibited more than 500CD4/mm(3) and 55.7% had not taken antiretroviral treatment. As of December 31(st) 1999, 21 patients had died, i.e. a mortality rate of 19% persons/years of follow-up (10-fold greater than that expected in the general population). Less than 5 deaths were due to HIV (n=4). Suicides and liver disease each represented the same number of deaths. Out of the 335 patients not having missed more than one follow-up throughout the 24 month period, 120 had been hospitalized at least once (n=223 hospitalizations), i.e., a hospitalization rate of 2.8 per 100 persons/month of follow-up. A quarter of hospitalizations were due to benign infections or stage B or C pathologies according to the 1993 classification of HIV infections and one hospitalization out of 5 was due to psychiatric problems (in majority depressive syndromes). Other predominant causes were worsening of general state of health, trauma, problems related to alcohol consumption, drugs abuse or hepatic decompensation. CONCLUSION: HIV-infected patients contaminated by intravenous drug use represent a particular population that cumulates many risk factors and which requires careful monitoring of co-morbidities such as hepatic and psychiatric diseases in order to avoid premature death.

The prescription of opioid analgesics to terminal cancer patients: impact of physicians' general attitudes and contextual factors.

OBJECTIVE: This study aimed to examine factors associated with the prescription of opioid analgesics to terminal cancer patients, including physicians' general attitudes toward morphine and contextual factors. METHODS: A survey was conducted among a sample of French general practitioners (GPs) and oncologists. Respondents were asked to describe the last three terminally ill patients they had followed up to death. RESULTS: Overall, 526 GPs and oncologists (global response rate: 57%) described 1,082 cancer patients, among whom 85.4% received opioid analgesics. Among other significant predictors (patient age, cancer type, family assistance), this prescription was less frequent for female patients followed by male physicians (OR = 0.53), and more frequent for patients followed by physicians trained in palliative care (OR = 2.70). On the other hand, physicians' attitudes toward morphine were not associated with prescription of morphine and other opioid analgesics. SIGNIFICANCE OF RESULTS: Although nonprescription of opioid analgesics is only a crude proxy measure for undertreatment of cancer pain, our findings suggest the need to develop training in palliative care in order to standardize practices among GPs and specialists. Our results also highlight the necessity to study pain assessment as an interaction between the physician and the patient, and to consider patients' and physicians' respective genders as a key variable within this interaction.