Collectif Doloplus : déjà vingt-cinq ans au service de la douleur des plus âgés.

Collectif Doloplus: twenty-five years supporting the fight against pain in the elderly. Speech and communication disorders among the elderly can be an obstacle in the detection and evaluation of pain. In these conditions, the Doloplus and Algoplus (heteroassessment) behavioural scales should be used. This article provides an overview of the guidelines for using these two scales and the role each has in daily practice. It also shows the impact a high-quality evaluative approach can have on the care provided.

[Specificity of pain assessment in the aged]. / Spécificités de l'évaluation de la douleur chez les personnes âgées.

Pain is frequent in older subjects but remains under diagnosed and treated. Systematic evaluation of pain is recent and the assessment tools, although well known, are only occasionally used. The main progress in the evaluation of pain in the elderly is the concept of behavioral assessment. Two assessment scales have been designed for people with communication disorders: the DOLOPLUS and the ECPA. Every carer should be skilled in the use of at least one auto and one hetero assessment scale to recognize and treat pain in the older subjects.

An Algorithm for Neuropathic Pain Management in Older People.

Neuropathic pain frequently affects older people, who generally also have several comorbidities. Elderly patients are often poly-medicated, which increases the risk of drug-drug interactions. These patients, especially those with cognitive problems, may also have restricted communication skills, making pain evaluation difficult and pain treatment challenging. Clinicians and other healthcare providers need a decisional algorithm to optimize the recognition and management of neuropathic pain. We present a decisional algorithm developed by a multidisciplinary group of experts, which focuses on pain assessment and therapeutic options for the management of neuropathic pain, particularly in the elderly. The algorithm involves four main steps: (1) detection, (2) evaluation, (3) treatment, and (4) re-evaluation. The detection of neuropathic pain is an essential step in ensuring successful management. The extent of the impact of the neuropathic pain is then assessed, generally with self-report scales, except in patients with communication difficulties who can be assessed using behavioral scales. The management of neuropathic pain frequently requires combination treatments, and recommended treatments should be prescribed with caution in these elderly patients, taking into consideration their comorbidities and potential drug-drug interactions and adverse events. This algorithm can be used in the management of neuropathic pain in the elderly to ensure timely and adequate treatment by a multidisciplinary team.

Withdrawal of artificial nutrition: influence of prior experience on the perception of caregivers.

CONTEXT: In spite of the existence of clinical guidelines and a legal framework in France, the withdrawal of artificial nutrition (AN) in palliative care remains a difficult situation for caregivers who are confronted with this reality. OBJECTIVES: To describe the perception of caregivers on the withdrawal of AN and to compare this perception between caregivers who have already been confronted with this situation and those who have not. METHODS: Cross-sectional survey questionnaire of nurses and nurses' aides (n = 274) working in medicine, surgery, and palliative care departments of a regional hospital. RESULTS: Of the caregivers, 59.5% declared having been confronted with the withdrawal of AN in their professional practice. This was associated with a better perception by these caregivers even if their knowledge on the criteria to be considered in the decision was not significantly modified. CONCLUSION: The coherence of the withdrawal of AN with the personal beliefs of the caregivers, already high in the absence of being confronted with this practice, is better among caregivers who have been confronted with this situation. The lack of information perceived by caregivers should prompt us to develop additional training on the withdrawal of AN, its objectives, and its clinical consequences.

Caregivers Confronted With the Withdrawal of Artificial Nutrition at the End of Life: Prevalence of and Reasons for Experienced Difficulties.

BACKGROUND: Withdrawing artificial nutrition in palliative care is an issue that often leads to ethical dilemmas among health care providers, despite clinical guidelines. OBJECTIVES: To describe the experience of health care providers confronted with the withdrawing of artificial nutrition at the end of life and identifying the factors related to the level of ethical dilemmas. METHODS: Cross-sectional survey questionnaire of all the nurses and nurses' aides working in medicine, surgery, and palliative care departments of a regional hospital and who have already been confronted with the withdrawal of artificial nutrition. RESULTS: Of 818 questionnaires sent, 274 were returned (response rate 33.5%); 60% (163) of the care providers who responded were involved in withdrawing artificial nutrition at the end of life. Among these, 42 (25.8%) had always or often been affected with ethical dilemmas, and 97 (60%) responded that withdrawing artificial nutrition had always or often been preceded by a multidisciplinary discussion. Items significantly associated with a high level of ethical dilemmas were (1) existence of differences in opinion within the health care team, (2) lack of information regarding the indication of the withdrawal of artificial nutrition, (3) feeling uncomfortable with the patient and his or her relatives, (4) guilt, (5) feeling of abandonment of care, and (6) uneasiness. CONCLUSION: Health care providers seem to have a lack of information and consensus regarding the withdrawal of artificial nutrition at the end of life. The ethical dimension of withdrawing artificial nutrition in palliative care has a strong impact on care providers, regardless of the circumstances of the withdrawal.

[Principle of double effect and sedation for intractable distress: reflexion on survival in sedated patients]. / Théorie du double effet et sédation pour détresse en phase terminale : réflexion autour de la survie des patients sédatés.

The effect of sedation for intractable distress on survival in terminally ill patients is a debated question. For certain people, this would limit the physician's intervention to the detriment of symptom alleviation for patients. The principle of double effect is traditionally used to overcome this ethical conflict. Studies conducted between 1990 and 2009 fail to show that the death of patients undergoing sedation for intractable distress is hastened. Some authors conclude that sedation does not hasten death and claim that principle of double effect is unnecessary in this debate. In our view, caution is required in the interpretation of studies results and absence of evidence of sedation effects on survival cannot be considered as an evidence of absence of sedation effects on survival. Furthermore, we consider obtaining a definitive answer as impossible in the future, as the required cannot be conducted for ethical reasons. Caution, we think, is necessary, especially as sedation is sometimes used with explicit intention of hastening the end of life. Physician's intention, key point of the principle of double effect, comes back into the foreground of ethical debate on sedation for intractable distress. Far from limiting the physician's action, the principle of double effect, which requires us to clarify our intentions, should allow us to make the distinction between sedation for intractable distress and euthanasia.

[Place and characteristics of patients older than 85 managed by mobile palliative care team; a retrospective study]. / Place et caractéristiques des patients âgés de 85 ans et plus suivis en équipe mobile de soins palliatifs ; étude rétrospective.

The objectives of this study was to specify the place of the patients older than 85 in the activity of the Mobile health unit of the Hospital of Metz-Thionville, to determine their characteristics and to show possible care differences as compared with younger patients. This is a retrospective study concerning all the patients seen by the Mobile health unit in 2006 and 2007. The patients older than 85 represent 11% of the 652 patients followed by the Unit and 7.8% of the 2.436 consultations on the study period. The older patients have a WHO mean score significantly higher and a Karnofsky mean score significantly lower than the younger subjects. Their survival rate tends to be lower but not significantly. Cancers are less frequent in older patients and they have fewer consultations than younger ones. The older patients present fewer communication problems and less often pain than the younger patients. The prescriptions of non-opioid and opioid analgesics, steroïds or antiepileptic drugs (used as analgesics) are less frequent in the older patients. The results of this study showed some specificities of palliative care in the older patients: we observed a great variety of pathologies and a lower frequency of cancers than in younger patients, various places of care, difficulties to evaluate the symptoms or to treat them due to communication problems especially. If these specificities are real, they do not seem to have important repercussions on following since the group of the patients older than 85 and the one of the younger patients differ only little in terms of survival rate or mean number of consultations.