Contribution of collegial support meetings (CSM) in the management of complex situations of patients with advanced cancer.

PURPOSE: Collegial support meetings (CSM) have been set up in the Gustave Roussy Cancer Center for inpatients whose complex care requires a multi-professional approach involving many participants: oncologists but also health-caregivers, a member of the palliative care team, an intensivist, and a psychologist. This study is aimed at describing the role of this newly multidisciplinary meeting implemented in a French Comprehensive Cancer Center. METHODS: Each week, the health-caregivers decide which situations should be examined, depending on the difficulty of a case. The discussion goes on to include the goal of treatment, the intensity of care, ethical and psychosocial issues, and the patient's life plan. Finally, to obtain feedback from the teams, a survey has been distributed to assess the interest in the CSM. RESULTS: In 2020, 114 inpatients were involved, and 91% were in an advanced palliative situation. During the CSMs, 55% of the discussions focused on whether to continue specific cancer treatment-29% about whether to continue invasive medical care-50% about optimizing supportive care. We estimate that between 65 and 75% of CSMs influenced further decisions. Death occurred during the hospitalization for 35% of the patients that were discussed. The lapse of time between last chemotherapy and death was 24 days (IQR, 28.5). CSMs were well received, since 80% of the teams find these meetings useful. CONCLUSIONS: CSMs reach conclusions for medical and nursing staff involved, in order to improve the management of inpatients with cancer in advanced palliative situation and to define the better goals of care.

Decisions about treatment with targeted therapies in a palliative care unit: A case series.

BACKGROUND: Early palliative care integration into the oncologic treatment pattern is recognized and strongly recommended to anticipate end-of-life issues and avoid disproportionate care. Targeted therapies (TTs), with their very rapid onset of action and relatively good tolerance, may have an effect on cancer-related symptoms, which could be beneficial in the context of palliative care. METHODS: Data were extracted from a cohort of all patients hospitalized in an acute palliative care unit between 03.04.2019 and 07.04.2020. Data for all consecutive patients for which a decision on a TT was made during hospitalization were retrospectively analyzed. RESULTS: Forty-two patients were identified. Thirty-one patients were currently receiving TT on admission. For 19/31 (61.3%) patients, the treatment was discontinued. The remaining 12 patients had TT after discharge from the palliative care unit (continuation of the same TT or modification of the TT during the stay), with an average duration of 208 days and an average of 46 days between the last TT and death. TT was introduced or reintroduced in 7 patients of the 11 patients hospitalized without treatment at admission. In this group, the average duration of treatment was 28 days, with an average of 28 days between the last TT and death. Five of the patients who received re-challenged TT experienced a subjective improvement of their symptom. SIGNIFICANCE OF RESULTS: TT was discontinued in the majority of our patients. However, in some cases, the treatment was maintained because it was effective on cancer-related symptoms even at the end of life. However, this should not overshadow the palliative process. The continuation or introduction of a specific oncological treatment requires close cooperation between oncologists and palliative care physicians and an honest and clear explanation to patients and their families.

Development of a Decision-Aid Form (DAF) for the stratification of care in a French comprehensive cancer center, a tool to support identification of care goals.

BACKGROUND: For cancer patients, life-threatening complications may be difficult to anticipate, which can lead to complex medical decision-making processes. Since 2015, the Gustave Roussy Cancer Center has used a Decision-Aid Form (DAF), which contains an estimated gradation of care in cases where patients' conditions worsen. In this study, we assessed the acceptability of the DAF and the predictive value of the proposed stratification of care with regard to care delivered and patient's outcomes. METHODS: During a 5-month period, all patients who had been transferred from Site 1 to Site 2 of the hospital were prospectively included. RESULTS: A DAF was completed for 89.3% of the 206 patients included. Planned stratification of care was indicated in nearly all cases. The involvement of the palliative care team was indicated in only 29% of the DAF. The value of the WHO/ECOG Performance Status (PS) was limited. Finally, the field "information for patients and relatives" was infrequently completed. Although the possibility of transfer to the Intensive Care Unit was proposed for two-thirds of the patients, 76% of the 35 patients experiencing an acute event received only medical or palliative care. Overall, the level of therapeutic commitment suggested by the DAF was most often revised towards less aggressive care. CONCLUSIONS: The results of our study suggest that implementing an advanced stratification record is possible in a French cultural setting. To achieve complete cultural acceptance, our large integrated institutional program continues to play a key role in anticipating intent, tracing and sharing information with patients and their relatives.

Using targeted therapies at the end of life.

The prescription of chemotherapy during the last weeks of a patient's life is a recognised criterion of decreasing quality of life but also survival. Targeted therapies have a particular efficiency and tolerance profile raising the question of their use in a palliative setting. Two patients were treated for a melanoma, at terminal stage, with poor efficiency of the symptomatic treatments. We introduced targeted therapies, which was previous treatments used in both patients.The evolution and benefits of the treatment was very different in our two patients and make us discuss the interest of targeted therapies in an end-of-life context and propose criteria for their maintenance or introduction in this indication. This discussion requires close collaboration between oncologists and palliative physicians and a very clear information given to patients and their relatives.

Ethical issues related to the COVID-19 pandemic in patients with cancer: experience and organisations in a French comprehensive cancer centre.

BACKGROUND: The COVID-19 pandemic has aggressively reached the most vulnerable, not only the elderly but also patients with chronic conditions such as cancer. In this study, we present the outlines of ethical thinking and the measures implemented to try to respect our basic values of care, in the specific environment of an oncology hospital. METHODS: Our ethics committee created an ethical watch system based on 24/7 shifts to assist practitioners in their daily decisions. We discuss the challenges faced by patients with cancer during the pandemic, such as access to critical care and ethical dilemmas in the context of resource scarcity, as well as the issue of isolation of patients. We also debate the restrictions in access to oncology care in a health context strongly 'prioritised' against COVID-19. RESULTS: In all areas of an ethical dilemma, either for sorting out access to critical care or for the dramatic consequences of prolonged isolation of patients, our common thread was our attempt to protect, whenever possible, the principles of deontological ethics by strictly resisting utilitarian pressure. Respecting democratic health decision-making processes is a cornerstone of ethically relevant decisions, including in the context of a sanitary crisis. CONCLUSION: The role of an ethics committee related to real-life situations includes not only a reflexive perspective in respect of fundamental principles, but also the help to enlighten and resolve ethical dilemmas in complex clinical situations. This ethical watch team assists physicians in decision-making, promoting the supportive and palliative dimension of care with a holistic approach.

[What place for an Ethics committee in a comprehensive cancer centre? For an ethics embodied in real life]. / Quelle place pour un comité d'éthique dans un Centre de lutte contre le cancer ? Pour une éthique incarnée.

The Ethics committee of Gustave Roussy cancer center is devoted to both reflection and action. The group has 40 members, professionals, patients and outside experts. These meet in plenary meetings or in specific working sessions and intervene at the request of any professional faced with ethical questions in the care. This Ethics Committee has voluntarily a double vocation: on one hand, a reflective group on major issues of ethics in health and its involvement in hospital life; on the other hand, a working group embedded in the daily lives of the care. The themes addressed at the meetings (plenary sessions, annual meetings) include shared-decision making, advance directives, refusal of care, religious aspects, or biomedical research… Daily activity centered on the care revolves around several times a week meetings, in various services, "Supportive Collegial Meetings" such as proposed in the 3rd French Cancer Plan; these include nursing staff members, oncologists, intensive and palliative care specialists, psychologist, around difficult medical and/or ethical situations. In case of situation requiring an urgent discussion, a referral to the Ethics Committee brings together within 24hours four to five members of the Committee and the care team. Moreover, the Ethics Committee helped develop Aid to Decision making Form upon care gradation for hospitalized cancer patients. Through these interventions on a daily basis, assistance of professionals, reflexive vocation or even delivery of training, the Ethics Committee contributes to an acculturation around anticipation and collegiality in the care. Its double polarity aims to reconcile "philosophical time' for the ethics process, and the connection with the routine issues raised by patients, their families and caregivers.