French Swiss physicians' attitude toward palliative sedation: Influence of prognosis and type of suffering.

OBJECTIVE: Palliative sedation is a last resort medical act aimed at relieving intolerable suffering induced by intractable symptoms in patients at the end-of-life. This act is generally accepted as being medically indicated under certain circumstances. A controversy remains in the literature as to its ethical validity. There is a certain vagueness in the literature regarding the legitimacy of palliative sedation in cases of non-physical refractory symptoms, especially "existential suffering." This pilot study aims to measure the influence of two independent variables (short/long prognosis and physical/existential suffering) on the physicians' attitudes toward palliative sedation (dependent variable). METHODS: We used a 2 × 2 experimental design as described by Blondeau et al. Four clinical vignettes were developed (vignette 1: short prognosis/existential suffering; vignette 2: long prognosis/existential suffering; vignette 3: short prognosis/physical suffering; vignette 4: long prognosis/physical suffering). Each vignette presented a terminally ill patient with a summary description of his physical and psychological condition, medication, and family situation. The respondents' attitude towards sedation was assessed with a six-point Likert scale. A total of 240 vignettes were sent to selected Swiss physicians. RESULTS: 74 vignettes were completed (36%). The means scores for attitudes were 2.62 ± 2.06 (v1), 1.88 ± 1.54 (v2), 4.54 ± 1.67 (v3), and 4.75 ± 1.71 (v4). General linear model analyses indicated that only the type of suffering had a significant impact on the attitude towards sedation (F = 33.92, df = 1, p = 0.000). Significance of the results: The French Swiss physicians' attitude toward palliative sedation is more favorable in case of physical suffering than in existential suffering. These results are in line with those found in the study of Blondeau et al. with Canadian physicians and will be discussed in light of the arguments given by physicians to explain their decisions.

Comprehensive assessment of patients in palliative care: a descriptive study utilizing the INTERMED.

Documentation in palliative care is often restricted to medical and sociodemographic information, and the assessment of physical and psychological symptoms or the quality of life. In order to overcome the lack of comprehensive information, we have evaluated the utility of the INTERMED-a biopsychosocial assessment method to document integrated information of patients' needs-in 82 consecutive patients for whom a palliative care consultation was requested. Results confirm the biopsychosocial heterogeneity of the sample, and the importance of integrated information to clinical, scientific, educational, and health care policy agendas. The INTERMED could become a useful method to tailor interdisciplinary interventions based on comprehensive patient needs assessment.

Neurodevelopmental outcome and school performance of very-low-birth-weight infants at 8 years of age.

The neurodevelopmental outcome and school performance of 50 appropriate for gestational age (AGA) and 33 small for gestational age (SGA) very-low-birth-weight (VLBW) infants, compared to a control group (41 Term infants) were assessed at 8 years of age. The incidence of major handicaps among AGA and SGA/VLBW infants respectively, was 16% and 6%. No major handicap was found in the control group. The incidence of neurodevelopmental abnormalities (NDA) among AGA's (40%) and SGA's (57.6%) compared with the control group (31.7%) was found to be significantly higher. School failure occurred more frequently among VLBW infants (22.9%) and was related in children with NDA--and more particularly among AGA's--to the presence of language disorders or associated NDA. Evaluation of the consequences of NDA and school problems for later academic and professional achievement now requires further follow-up studies.

Neurodevelopmental abnormalities in preschool children with high perinatal risk. Prognostic value and consequences on education at 8 years of age.

Two groups of 41 children with high perinatal risk were studied. All children of the study group (SG) had neurodevelopmental abnormalities (NDA) at the age of 5 years, without major handicap. The control group (CG) consisted of 41 children matched for sex, neonatal pathology, birthweight, gestational age and socioeconomic status, without NDA at 5 years. In the SG 85.4% of the children had persistent NDA at school age. In the CG 36.6% of the children presented NDA, but less severe than those of the SG. The SG children had more often associated NDA than those of the CG. The outcome of NDA diagnosed at preschool age and the results of psychometric tests are described. Associated NDA or a borderline IQ, with emotional and behavioral problems, have a gloomy school prognosis. 46.3% of the children in the SG had major schooling problems and 12.2% of children in the CG. These results show the possibility to detect children at risk of school achievement problems before school entrance; they might be useful in counselling and preventing behavioral and educational difficulties.

High risk appropriate for gestational age (AGA) and small for gestational age (SGA) preterm infants. Neurological handicap and developmental abnormalities at five years of age.

Outcome at five years of age of 110 high risk AGA, 71 high risk SGA preterm infants with similar birth weight and 102 term control infants was studied. Mean IQ in the 3 groups was not statistically different. Major handicaps were found in 16.3% of the AGA and in 8.5% of the SGA preterms. There was no major handicap among the controls. Minor neurodevelopmental abnormalities were present in 25.6% of AGA, 28.2% of SGA and 19.6% of controls. The types of neurodevelopmental handicaps were different in the 3 groups and generally more severe in the AGA group. All the major handicaps among AGA preterms were found in children with severe neonatal complications. In the SGA preterm group, only 1/3 of the major handicaps can be related to perinatal complications. Affective and behavior disorders were probably related in some way to neurodevelopmental achievement. This study showed that preterm infants with GA less than or equal to 32 weeks are more at risk than more mature SGA preterms with similar birth weight.