Proactive and Ongoing Analysis and Management of Ethical Concerns in the Development, Evaluation, and Implementation of Smart Homes for Older Adults With Frailty.

Successful adoption and sustained use of smart home technology can support the aging in place of older adults with frailty. However, the expansion of this technology has been limited, particularly by a lack of ethical considerations surrounding its application. This can ultimately prevent older adults and members of their support ecosystems from benefiting from the technology. This paper has 2 aims in the effort to facilitate adoption and sustained use: to assert that proactive and ongoing analysis and management of ethical concerns are crucial to the successful development, evaluation, and implementation of smart homes for older adults with frailty and to present recommendations to create a framework, resources, and tools to manage ethical concerns with the collaboration of older adults; members of their support ecosystems; and the research, technical development, clinical, and industry communities. To support our assertion, we reviewed intersecting concepts from bioethics, specifically principlism and ethics of care, and from technology ethics that are salient to smart homes in the management of frailty in older adults. We focused on 6 conceptual domains that can lead to ethical tensions and of which proper analysis is essential: privacy and security, individual and relational autonomy, informed consent and supported decision-making, social inclusion and isolation, stigma and discrimination, and equity of access. To facilitate the proactive and ongoing analysis and management of ethical concerns, we recommended collaboration to develop a framework with 4 proposed elements: a set of conceptual domains as discussed in this paper, along with a tool consisting of reflective questions to guide ethical deliberation throughout the project phases; resources comprising strategies and guidance for the planning and reporting of ethical analysis throughout the project phases; training resources to support leadership, literacy, and competency in project teams for the analysis and management of ethical concerns; and training resources for older adults with frailty, their support ecosystems, and the public to support their awareness and participation in teams and ethical analysis processes. Older adults with frailty require nuanced consideration when incorporating technology into their care because of their complex health and social status and vulnerability. Smart homes may have a greater likelihood of accommodating users and their contexts with committed and comprehensive analysis, anticipation, and management of ethical concerns that reflect the unique circumstances of these users. Smart home technology may then achieve its desired individual, societal, and economic outcomes and serve as a solution to support health; well-being; and responsible, high-quality care.

Palliative Care Needs Assessment in the Population Living in Mayotte: SPMAYOTTE, a Qualitative Study Conducted with 62 Patients, Caregivers and Healthcare Professionals.

BACKGROUND/AIM: Mayotte is a French island in the Indian Ocean. There is no palliative care structure in this territory. The island and its population have specific characteristics: insularity, poverty, coexistence of modern and traditional medicine, importance of religion (Islam) and the presence of many foreigners without health insurance. The aim of this study is to determine the palliative care needs of the Mayotte population and propose the establishment of an appropriate service. METHODS: A qualitative study was conducted in Mayotte using interviews with patients and their caregivers, and focus groups were conducted with healthcare professionals involved in their care. Patients requiring palliative care were identified and recruited from the hospital or the patient's home by healthcare professionals. RESULTS: A total of 62 people participated in the study between May and June 2019. The needs expressed were analysed and then grouped into categories: access to medical care (especially at home), management of physical symptoms (analgesia) and psychological symptoms, organisation of care (coordination between healthcare professionals) and training of healthcare professionals (pain management, palliative care, interculturality and translation), taking into account cultural and religious aspects. Regarding the foreign population, the categories were: improving access to healthcare, access to the social protection system and daily living conditions (transport, food and accommodation). CONCLUSIONS: The specific needs of the population, assessed through the study, have led to an original proposal, which differs from the usual structures of palliative care in France.

Understanding why patients request euthanasia when it is illegal: a qualitative study in palliative care units on the personal and practical impact of euthanasia requests.

CONTEXT: Some patients in palliative care units request euthanasia regardless of legislation. Although studies have explored the reasons for these requests, little is known about the subjective, relational, and contextual repercussions for the patient. OBJECTIVES: The aim of this study is to understand the purpose of euthanasia requests from the patient's viewpoint and their personal and practical impact. METHODS: We conducted in-depth interviews with patients requesting euthanasia, their family members, and health care providers in 11 French palliative care units. A thematic analysis of the data was performed. RESULTS: In total, 18 patients were interviewed within 48 h of the request being made; 1 week later, 9 patients were interviewed again. Five main themes emerged: assuming the possibility of transgressing the forbidden, a call for unbearable suffering to be recognized, encouragement to change clinical practice, reclaiming a sense of freedom over medical constraints, and imagining a desirable future for oneself. CONCLUSIONS: A request for euthanasia appears to be a willful means to remove oneself from the impasse of an existence paralyzed by suffering. It creates a space for discussion, which promotes negotiation with patients on care practices and therapeutics, and strengthens patients' sense of autonomy. Investigating the relationship between the evolution of euthanasia requests within the palliative care setting could be beneficial. It is important to encourage health care professionals to adopt a readiness to listen by interacting with patients in a way that is not momentarily action-oriented but rather focused on proactive discussion.

Added value of functional neuroimaging to assess decision-making capacity of older adults with neurocognitive disorders: protocol for a prospective, monocentric, single-arm study (IMAGISION).

INTRODUCTION: Assessment of decision-making capacity (DMC) is essential in daily life as well as for defining a person-centred care plan. Nevertheless, in ageing, especially if signs of dementia appear, it becomes difficult to assess decision-making ability and raises ethical questions. Currently, the assessment of DMC is based on the clinician's evaluation, completed by neuropsychological tests. Functional MRI (fMRI) could bring added value to the diagnosis of DMC in difficult situations. METHODS AND ANALYSIS: IMAGISION is a prospective, monocentric, single-arm study evaluating fMRI compared with clinical assessment of DMC. The study will begin during Fall 2021 and should be completed by Spring 2023. Participants will be recruited from a memory clinic where they will come for an assessment of their cognitive abilities due to decision-making needs to support ageing in place. They will be older people over 70 years of age, living at home, presenting with a diagnosis of mild dementia, and no exclusion criteria of MRI. They will be clinically assessed by a geriatrician on their DMC, based on the neuropsychological tests usually performed. Participants will then perform a behavioural task in fMRI (Balloon Analogue Risk Task) to analyse the activation areas. Additional semistructured interviews will be conducted to explore real life implications. The main analysis will study concordance/discordance between the clinical classification and the activation of fMRI regions of interest. Reclassification as 'capable', based on fMRI, of patients for whom clinical diagnosis is 'questionable' will be considered as a diagnostic gain. ETHICS AND DISSEMINATION: IMAGISION has been authorised by a research ethics board (Comité de Protection des Personnes, Bordeaux, II) in France, in accordance with French legislation on interventional biomedical research, under the reference IDRCB number 2019-A00863-54, since 30 September 2020. Participants will sign an informed consent form. The results of the study will be presented in international peer-reviewed scientific journals, international scientific conferences and public lectures. TRIAL REGISTRATION NUMBER: NCT03931148.

Recherche sur la fin de vie, la nécessité d'un consensus : premiers résultats.

During the past 15 years, in France, like in many European countries, the attention paid to patients at the end of their lives has continued to grow. But in the meantime, only a few researchers have managed to collect reliable data on End-of-Life Care and to implement scientific studies describing the reality of these situations. This difficulty is due in particular to the lack of a recognized and operational definition of the end of life.Our objective is to explore the possibility of achieving consensus around a definition based on the isolated elements in the literature.A Delphi consensus approach has been conducted. A “Delphi” approach allows consensus to be achieved without the influence of leadership effects.The population of this study is the group of care providers who are members of the Société Française d’Accompagnement et de Soins Palliatifs (SFAP), whether they are professionals or volunteers. An electronic survey asked for the degree of approval of individuals for each of the proposed definitions on a Lickert scale. The first round of Delphi was proposed at the end of 2019 among palliative care actors. 1463 people responded to this questionnaire in one month. Two types of definition seem to dominate the other proposals. The first is related to an estimate of life expectancy: life expectancy of less than 15 days and less than one month. The second emerging definition is related to the evolution of a pathology: based on the fact of being in advanced or terminal phase of an incurable pathology.These results confirm that the end-of-life period can be seen from two points of view, the first in relation to the time left to live and the other in relation of the terminal phase of the disease which calls for a less clearly defined time.These two definitions are based on different approaches, one temporal and the other disease-centered. An alternative definition emerges from this study and will be tested in the second round of Delphi.

Quelle démarche méthodologique afin d'aboutir à une offre pertinente de soins palliatifs à Mayotte ?

OBJECTIVE: The department of Mayotte is lagging far behind in terms of access to palliative care. We present the methodological approach for assessing the palliative care needs of the population, which led us to make a proposal for a care offer adapted to the local context. METHOD: The main principles of a public health methodology for health needs assessment were followed. The researchers carried out an overall analysis of the situation based on several axes: bibliographical research, collection of quantitative data, qualitative study, interviews with local experts and institutional decision-makers. A summary report of the results was presented to those working in the field at the end of the study in order to support proposals for the creation of a suitable palliative care offer. RESULTS: In view of the paucity of epidemiological data, the qualitative study was decisive in assessing needs. Exchanges with institutional decision-makers enabled a deeper understanding of local specificities and improved the relationship between local actors leading to the emergence of a co-construction process. In December 2019, a palliative care offer resulting from the study’s proposals was funded. CONCLUSION: Our methodology was based on regular exchanges in the field and enabled us to encourage the emergence of a decisive element for the success of the project: the support of carers and institutional decision-makers. This co-construction between the partners allowed interactivity between the different categories of actors involved and reinforced the quality of the work and the emergence of a collective intelligence (study SP Mayotte).

Neural Activation in Risky Decision-Making Tasks in Healthy Older Adults: A Meta-Analysis of fMRI Data.

Decision making is a complex cognitive phenomenon commonly used in everyday life. Studies have shown differences in behavioral strategies in risky decision-making tasks over the course of aging. The development of functional neuroimaging has gradually allowed the exploration of the neurofunctional bases of these behaviors. The purpose of our study was to carry out a meta-analysis on the neural networks underlying risky decision making in healthy older adults. Following the PRISMA guidelines, we systematically searched for fMRI studies of decision making in older adults using risky decision-making tasks. To perform the quantitative meta-analysis, we used the revised version of the activation likelihood estimation (ALE) algorithm. A total of 620 references were selected for initial screening. Among these, five studies with a total of 98 cognitively normal older participants (mean age: 69.5 years) were included. The meta-analysis yielded two clusters. Main activations were found in the right insula, bilateral dorsolateral prefrontal cortex (dlPFC) and left orbitofrontal cortex (OFC). Despite the limited number of studies included, our meta-analysis highlights the crucial involvement of circuits associated with both emotion regulation and the decision to act. However, in contrast to the literature on young adults, our results indicate a different pattern of hemispheric lateralization in older participants. These activations can be used as a minimum pattern of activation in the risky decision-making tasks of healthy older subjects.

[Influence of COVID-19 on issues relating to end of life and the support of patients]. / Influence de la Covid-19 sur les questions relatives à la fin de vie et à l'accompagnement.

The covid-19 epidemic and the resulting lockdown measures have undoubtedly led people who are ill, as well as those at risk of becoming ill, to contemplate the notions of risk, uncertainty and death. What effects has this confrontation with the question of death had and what impact will it continue to have on the palliative care approach and the decisions to withhold and withdraw treatment in certain circumstances?

Platelet transfusions in haematologic malignancies in the last six months of life.

BACKGROUND AND OBJECTIVES: Practices in end-of-life platelet transfusions in haematologic malignancies are variable. Our aim was to describe the platelet transfusion burden and parameters linked to this indication in such a setting and thereby contribute to defining optimal practices. MATERIALS AND METHODS: From July 2015 to December 2016, all consecutive deceased adult patients with a haematologic malignancy receiving a platelet transfusion in the last 6 months of their life from the Etablissement Français du Sang Bourgogne Franche-Comté were included retrospectively. The outcome criteria were changes in the number of platelet transfusions, percent platelet recovery, platelet transfusion interval, reported bleeding with its grade and recipient adverse events in the last 6 months of life. RESULTS: Among the 1125 patients monitored, 119 were included in our study. Bleeding prophylaxis (versus treatment) was the reason for 55% of transfusions. 18% of platelet concentrates (n = 1999) were transfused during the last two weeks of life. As death approached, the transfusion and haemorrhage burden increased (P < 0·0001 in both cases), whereas platelet recovery and transfusion interval decreased (P = 0·02 in both cases). Recipient adverse events were rare (0·6%) and of minor severity. CONCLUSION: In end-of-life transfused patients with haematologic malignancies, approaching death is associated with an increased number of platelet transfusions and bleeding events, while platelet recovery and transfusion intervals are reduced. Such findings, together with further evaluations, may contribute to informing best practices for these patients.

Investigation of opposition to diagnostic or therapeutic procedures in older people hospitalized in acute geriatric services: the OPTAH pilot study protocol.

BACKGROUND: Shared decision-making is a process that involves collaborative discussions between a patient and a care team to ensure informed healthcare decisions. This process becomes more complex when the older person's decision-making capacities are affected. In these situations, surrogate decision-making processes are used to define a person-centered care plan. Despite these processes, the implementation of the care plan defined in the best interest of the patient may nevertheless be rejected by the patient, particularly in cases of neurocognitive disorders or delirium. This concept of opposition and/or refusal is frequently used in research. This is not yet well understood in the medical literature, and there is a lack of consensus on its definition. We, therefore, explored this concept by defining opposition to diagnostic or therapeutic proposals. METHOD: Our pilot study protocol is based on a mixed methodology (epidemiological and qualitative research) to quantify this phenomenon, validate the proposed definition, and explore its core elements. Opposition and refusal of care will be quantified, and semi-structured interviews will be conducted with patients, their relatives, and referring carers. Multidisciplinary meetings that will be associated with these situations will also be observed and analyzed. Methodological approaches that can be used to explore opposition and refusal of care in a scientific, reproducible framework are presented. This methodology considers the specificities of the geriatric, polypathological population with neurocognitive disorders. DISCUSSION: Opposition and refusal of care are key concepts in clinical research on ethics, particularly in the geriatric field. These concepts are frequently mentioned in studies involving older patients but have not been specifically defined or studied. This study would undoubtedly lead to greater awareness among professional caregivers and relatives of the significance of such opposition, and more respectful interactions in these complex hospitalization cases. TRIAL REGISTRATION: ClinicalTrial.gov, NCT03373838 . Registered on 14 December 2017.

[Study of representations of end-of-life platelet transfusion by its protagonists: Patients, nurses and hematologic oncologists]. / Étude des représentations de la transfusion plaquettaire en fin de vie par ses acteurs : patients, infirmiers et médecins d'hématologie.

INTRODUCTION: End-of-life platelet transfusion practice in onco-hematology is subjective and depends on representations shared by patients, nurses and hematologists. This study aims to describe these representations of platelet transfusion in a context of a severe and advanced hematologic malignancy through the social representation of its protagonists. METHODS: A qualitative study, using the associative network method and including three groups of 15 participants (patients with an advanced hematologic malignancy, regularly transfused in platelet concentrates; nurses and hematologic oncologists) from four hematology centers was conducted between February and April 2019. Analysis was carried out using IraMuTeQ software. RESULTS: Patients expect platelet transfusion to have a direct beneficial impact on their health and highlight human relations. Nurses aim at the patient's well-being, in his or her individuality, and at respecting the transfusion protocol. Physicians seek to relieve symptoms by taking into account a multitude of decision-making factors. The textual clustering method, nuances those previous results and individualizes four different orientations, independent of groups: dependency, singularity, subjectivity and neutrality. DISCUSSION: The perception of the social representations related to platelet transfusion at the end-of-life should make it possible to adapt the discourse to the preferred orientation of the speaker and could be an asset in goals of care discussion with patients as well as with teams in charge of palliative care.

[Does the written press give a fair account of a complex medical question: «the Vincent Lambert case¼?] / La presse écrite rend-elle compte d'une façon juste d'une question médicale complexe : « le cas Vincent Lambert ¼ ?

Does the written press give a fair account of a complex medical question: "The Vincent Lambert Case"? We have studid press articles referring to Mr. Vincent Lambert's situation from 2013 to 2017. Analysis using a reading grid (including 7 questions) of press articles from four French daily newspapers (Libération, Le Monde, Le Figaro and La Croix) and a specialized medical news site (Agence de presse médicale) so that they can build their own opinion. 341 articles were analyzed (61 articles from Libération, 65 articles from Le Monde, 86 articles from Le Figaro, 82 articles from La Croix, 47 articles from the APM), writing a chronology of the main facts of the patient's history from 2013 to 2017 in order to have benchmarks to estimate the accuracy of the information reported in the various articles. Articles are rarely fully explicit. Inadequate expressions ("passive euthanasia", "end-of-life procedure") are used in the majority of newspapers. Some articles present the facts in a partisan way and contribute to mask the complexity of the patient's situation. Court decisions are often shortened and therefore simplified, which does not help the reader to understand the situation in an informed way. Reflective benchmarks are sometimes found in the various newspapers from 2013 to 2016. From 2016 onwards, we notice that the articles are shorter and that they no longer give any reference points for reflection. The daily written press in its current format does not seem to be able to help the general public to obtain accurate information on complex issues involving broad areas of reflection. The difficulty of the journalist's work in addressing this type of questioning comes partly from the constraints of brevity that are often imposed on them on the one hand and from the constant evolution of the information itself on the other.

La presse écrite rend-elle compte d'une façon juste d'une question médicale complexe : « Le Cas Vincent Lambert ¼ ? Nous avons analysé des articles de presse faisant référence à « l'affaire Vincent Lambert ¼ parus de 2013 à 2017 pour comprendre la façon dont la presse quotidienne française grand public relate les questions médicales complexes à forte tonalité éthique et interroger sa capacité à informer avec justesse ses lecteurs pour qu'ils puissent se construire leur propre opinion. À l'aide d'une grille de lecture (comportant 7 questions), 341 articles de presse de 4 quotidiens français (Libération, Le Monde, Le Figaro et La Croix) et d'un site de dépêches médicales spécialisées (Agence de presse médicale) ont été analysés. Les articles apparaissent rarement entièrement explicites. Des expressions inadaptées (« euthanasie passive ¼, « procédure de fin de vie ¼) sont utilisées dans la majorité des journaux. Certains articles exposent les faits de manière partisane et participent à maquiller la complexité de la situation du patient. Les décisions de justice sont souvent raccourcies et donc simplifiées, ce qui n'aide pas le lecteur à saisir la situation de manière éclairée. Des repères réflexifs sont parfois retrouvés dans les différents journaux de 2013 à 2016. À partir de 2016, on remarque que les articles sont plus courts et ne donnent plus aucun repère de réflexion. De nos jours, la presse écrite n'est probablement plus le premier vecteur d'information choisi par le citoyen. Les articles des titres de presse étudiés dans leur format actuel ne sont peut-être pas le meilleur moyen d'aider le grand public à s'informer de manière juste sur des questions complexes englobant de vastes champs de réflexion. La difficulté du travail du journaliste pour aborder ce type de questionnement vient en partie des contraintes de brièveté qui leur sont souvent imposées d'une part, et de l'évolution constante de l'information elle-même d'autre part.

COVID-19 outbreak: organisation of a geriatric assessment and coordination unit. A French example.

Older people are particularly affected by the COVID-19 outbreak because of their vulnerability as well as the complexity of health organisations, particularly in the often-compartmentalised interactions between community, hospital and nursing home actors. In this endemic situation, with massive flows of patients requiring holistic management including specific and intensive care, the appropriate assessment of each patient's level of care and the organisation of specific networks is essential. To that end, we propose here a territorial organisation of health care, favouring communication between all actors. This organisation of care is based on three key points: To use the basis of territorial organisation of health by facilitating the link between hospital settings and geriatric sectors at the regional level.To connect private, medico-social and hospital actors through a dedicated centralised unit for evaluation, geriatric coordination of care and decision support. A geriatrician coordinates this multidisciplinary unit. It includes an emergency room doctor, a supervisor from the medical regulation centre (Centre 15), an infectious disease physician, a medical hygienist and a palliative care specialist.To organise an ad hoc follow-up channel, including the necessary resources for the different levels of care required, according to the resources of the territorial network, and the creation of a specific COVID geriatric palliative care service. This organisation meets the urgent health needs of all stakeholders, facilitating its deployment and allows the sustainable implementation of a coordinated geriatric management dynamic between the stakeholders on the territory.

How does decisional capacity evolve with normal cognitive aging: systematic review of the literature.

PURPOSE: Aging is associated with increased needs related to complex decisions, particularly in medical and social issues. However, the complexity of decision-making involves many neurological functions and structures which are potentially altered by cognitive aging. METHODOLOGY: A systematic review was conducted in accordance with PRISMA guidelines to examine changes in decision-making occurring in normal cognitive aging. The keywords "decision making" and "normal aging" were used to find the clinical studies and literature reviews focused on these changes. RESULTS: A total of 97 articles were considered in the review, and ultimately 40 articles were selected, including 30 studies and 10 literature reviews. The data from these studies were of uneven quality and too disparate to allow meta-analysis according to PRISMA criteria. Nevertheless, a key result of the analysis is the decrease of processing speed with aging. In ambiguous decision-making situations, the alteration of the ventromedial system is associated with changes in motivation profiles. These changes can be compensated by experience. However, difficulties arise for older adults in the case of one-off decisions, which are very common in the medical or medico-social domains. CONCLUSIONS: Cognitive aging is associated with a slowdown in processing speed of decision-making, especially in ambiguous situations. However, decision-making processes which are based on experience and cases in which sufficient time is available are less affected by aging. These results highlight the relativity of decision-making capacities in cognitive aging.

Impact on Health-Related Quality of Life of Parenteral Nutrition for Patients with Advanced Cancer Cachexia: Results from a Randomized Controlled Trial.

BACKGROUND: Malnutrition worsens health-related quality of life (HRQoL) and the prognosis of patients with advanced cancer. This study aimed to assess the clinical benefits of parenteral nutrition (PN) over oral feeding (OF) for patients with advanced cancer cachexia and without intestinal impairment. MATERIAL AND METHODS: In this prospective multicentric randomized controlled study, patients with advanced cancer and malnutrition were randomly assigned to optimized nutritional care with or without supplemental PN. Zelen's method was used for randomization to facilitate inclusions. Nutritional and performance status and HRQoL using the European Organization for Research and Treatment of Cancer QLQ-C15-PAL questionnaire were evaluated at baseline and monthly until death. Primary endpoint was HRQoL deterioration-free survival (DFS) defined as a definitive deterioration of ≥10 points compared with baseline, or death. RESULTS: Among the 148 randomized patients, 48 patients were in the experimental arm with PN, 63 patients were in the control arm with OF only, and 37 patients were not included because of early withdrawal or refused consent. In an intent to treat analysis, there was no difference in HRQoL DFS between the PN arm or OF arm for the three targeted dimensions: global health (hazard ratio [HR], 1.31; 95% confidence interval [CI], 0.88-1.94; p = .18), physical functioning (HR, 1.58; 95% CI, 1.06-2.35; p = .024), and fatigue (HR, 1.19; 95% CI, 0.80-1.77; p = .40); there was a negative trend for overall survival among patients in the PN arm. In as treated analysis, serious adverse events (mainly infectious) were more frequent in the PN arm than in the OF arm (p = .01). CONCLUSION: PN improved neither HRQoL nor survival and induced more serious adverse events than OF among patients with advanced cancer and malnutrition. Clinical trial identification number. NCT02151214 IMPLICATIONS FOR PRACTICE: This clinical trial showed that parenteral nutrition improved neither quality of life nor survival and generated more serious adverse events than oral feeding only among patients with advanced cancer cachexia and no intestinal impairment. Parenteral nutrition should not be prescribed for patients with advanced cancer, cachexia, and no intestinal failure when life expectancy is shorter than 3 months. Further studies are needed to assess the useful period with a potential benefit of artificial nutrition for patients with advanced cancer.

Impact du dispositif Lisp sur le déploiement de la culture et de la démarche palliatives.

INTRODUCTION: Access to palliative care is a right recognized in France since 1999. Various care systems are present in the field of palliative care, and in particular the Identified Palliative Care Beds (LISP), which aim to promote the deployment of the palliative culture and approach in care services regularly confronted with palliative situations and whose organizational reference framework is mentioned in DHOS/O2/2008/99 of 25 March 2008. Although the system is widely deployed in hospitals, there is still some uncertainty about the actual functioning of LISPs and the impact of the system on these initial objectives. The LISP study thus proposes to question the contribution of LISPs to the deployment of culture and palliative care in healthcare services. METHOD: The investigation method used for this qualitative survey is based on semi-directive interviews in 6 establishments in the Bourgogne Franche Comté region. RESULTS: At the end of our study, we note that in half of the services surveyed, the system has clearly contributed to the gradual emergence of a palliative culture and approach. CONCLUSION: A number of measures necessary for its efficiency are emerging, which could give rise to avenues of reflection articulated in 3 axes: making the system less abstract, in particular by identifying LISPs at the level of services and strengthening the information transmitted with regard to the system, developing support by EMSPs, and questioning the means to be allocated to enable efficient operation.