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Objectives: Palliative care is a basic human right for all patients suffering from progressive and excruciating pain, limitations in daily activities as well as requiring constant care. The development of palliative care is always associated with the physical, psychological, social and spiritual care quality level and requires continuous evaluation by the care-receiving patients. This study aimed to determine the psychometric properties of the patients’ perspective of the quality of palliative care scale. Materials and Methods: This methodological study was conducted on 500 patients with chronic diseases admitted to the hospitals affiliated in Golestan University of Medical Sciences, between 2019 and 2020. Participants were selected through stratified sampling through proportional allocation as well as considering the bed occupancy rate in the two referral hospitals of the university. According to Wild approach, we translated the original version of the scale the patients’ perspectives of the quality of the palliative care scale with 35 items and eight subscales. Using exploratory and confirmatory factor analysis, the psychometric properties of the scale (i.e., initial reliability and face, content, convergent and construct validities) were assessed. The reliability of the scale was calculated by applying Cronbach’s alpha coefficient, McDonald’s omega coefficient and the Intraclass correlation coefficient (ICC). SPSS-16 and AMOS-24 software programs were used to analyse the data. Results: Three items were omitted after assessing the initial reliability of the translated version of the perspectives of the quality of the palliative care scale using adjusted Cronbach’s alpha. The qualitative face validity and impact score of the remaining items of the scale were confirmed by the target group. Meanwhile, a panel of experts confirmed the content validity ratio and content validity index. Convergent validity was approved by calculating the average variance extracted >0.5. Performing EFA led to the extraction of 7 subscales with 32 items. CFA and goodness of fit indices such as GFI = 0.98, CFI = 0.91, RMSEA = 0.048 and GFI = 0.97 confirmed the construct model by omitting three items. Hence, the Persian version of the patient’s perspective of the quality of palliative care scale was finalised, including seven subscales with 29 items. ICC of >0.7 represented good reliability. Moreover, Cronbach’s alpha and McDonald’s omega coefficient confirmed the internal consistency of the scale. Conclusion: Based on the findings of this study, the Persian version of the patients’ perspective of the quality of palliative care scale is introduced as a valid and reliable scale. It can accurately indicate and predict the meticulous quality of such care in hospitalised patients and can be used in the cure and care assessments in the health system.

International audience; ObjectivesWhilst euthanasia and assisted suicide are forbidden by French Law, patients at the end of their life, hospitalized in Palliative Care Units (PCU) sometimes express such requests. The “DESA study” focused on the expression of patients’ requests for euthanasia and assisted suicide, i.e. how patients worded their wishes. The aim is to identify, from the “raw wording” of these requests, their common features, specificities and evolution.Patients/materials and methodsThis qualitative study took place in 11 French PCU during one year. It included adult patients who had made an explicit request for euthanasia or physician-assisted suicide to a health professional. According to the principles of grounded theory, semi-structured interviews were conducted within 48 hours of the initial request (D0), and then a week after this request (D7).ResultsEighteen Patients were initially interviewed. Only 9 were interviewed at D7. At D0, the initial request is a request for euthanasia. This request is expressing physical and psychological suffering, trauma and representations of death. At D7, we observe a semantic change: the request is less explicit and requires less intervention by a third party. It remains centred on death without suffering.ConclusionHealthcare providers need to actively listen to the request being made to be able to understand the meaning of the words and their function. It is their nuance, variety and evolution that help to better identify patients’ needs.

Background Whilst euthanasia and assisted suicide are forbidden by French Law, patients at the end of life, hospitalized in Palliative Care Units, sometimes express the Wish to Hasten their Death. Few Studies have analyzed the formulation of these patient requests in interviews and the associated death-related representations. The DESA study analyzed the expression of patients’ requests, focusing on the terms and how patients worded their wishes. The aim is to identify from the “raw wording” of the patients’ requests, the means of expressing them in all its singularity and evolution. Methods This is a qualitative study that took place in 11 French Palliative care Units during on year and included adult patients who had made an explicit request (euthanasia or physician assisted suicide) to a health care provider. Semi-structured interviews were conducted within 48 hours of the initial request (D0), then a week later (D7). Results At DO, the initial request is a request for euthanasia and it calls a third person urgently. This request is related to physical and psychological suffering, trauma and representations of death. At D7, we observe a semantic change; the request is less explicit and requires less intervention by a third party. The quest remains that of a death without suffering. Conclusions These patients express themselves easily on their request and listening is necessary to be able to hear the meaning of the words but also their functions. It is their nuance, variety and evolution that help to understand what the requirements mean. Trial registration number : ClinicalTrials.gov Identifier: NCT02845817

Background Grieving relatives can suffer from numerous consequences like anxiety, depression, post-traumatic stress disorder (PTSD) symptoms, and prolonged grief. This study aims to assess the psychological consequences of grieving relatives after patients’ death in French palliative care units and their needs for support. Methods This is a prospective observational multicenter mixed study. Relatives of adult patients with a neoplasia expected to be hospitalized more than 72 h in a palliative care unit for end-of-life issues will be included within 48 h after patient admission. End-of-life issues are defined by the physician at patient admission. Relatives who are not able to have a phone call at 6-months are excluded. The primary outcome is the incidence of prolonged grief reaction defined by an ICG (Inventory Complicate Grief) > 25 (0 best-76 worst) at 6 months after patient’ death. Prespecified secondary outcomes are the risk factors of prolonged grief, anxiety and depression symptoms between day 3 and day 5 and at 6 months after patients’ death based on an Hospital Anxiety and Depression score (range 0–42) > 8 for each subscale (minimal clinically important difference: 2.5), post-traumatic stress disorder symptoms 6 months after patient’ death based on the Impact of Events Scale questionnaire (0 best-88 worst) score > 22, experience of relatives during palliative care based on the Fami-Life questionnaire, specifically built for the study. Between 6 and 12 months after the patient’s death, a phone interview with relatives with prolonged grief reactions will be planned by a psychologist to understand the complex system of grief. It will be analyzed with the Interpretative Phenomenological Analysis. We planned to enroll 500 patients and their close relatives assuming a 25% prolonged grief rate and a 6-month follow-up available in 60% of relatives. Discussion This study will be the first to report the psychological consequences of French relatives after a loss of a loved one in palliative care units. Evaluating relatives’ experiences can provide instrumental insights for means of improving support for relatives and evaluation of bereavement programs. Trial registration NCT03748225 registered on 11/19/2018. Recruiting patients.

When and how to provide a palliative sedation in terminally ill patients? With the introduction in the French law of sedatives practices, the professionals in palliative care are obliged to define the concepts, to name the difference kinds of sedations, to elaborate guidelines for good practice. French society of palliative care has worked to clarify the vocabulary, and to differentiate palliative sedations to their duration, their depth and the patient's consent (typology SEDAPALL). Its guidelines of 2010 have been updated in the form of three reference sheets in conjunction with a continuous deep sedation until death: how to estimate that the vital prognosis is short term? How to evaluate the refractory suffering? What are the guidelines for the pharmacological administration? The French National Authority for Health has produced a guide titled "How to realise a continuous deep sedation until death?" The present paper highlights some fundamental points of necessary steps: listening, understanding and analysing the suffering; the collegiate procedure - multi professional deliberative process, the pharmacological administration.Quand et comment mettre en place une sédation à visée palliative en fin de vie ? L’introduction dans la loi des pratiques sédatives a obligé les professionnels de soins palliatifs à définir les concepts, nommer les différentes formes de sédations, élaborer des guides de bonne pratique. La Société française d’accompagnement et de soins palliatifs s’est efforcée de clarifier le vocabulaire et de différencier les pratiques sédatives à visée palliative selon leur durée, leur profondeur et le consentement du patient (typologie SEDAPALL). Elle a actualisé ses recommandations de 2010 sous forme de trois fiches repères en lien avec une sédation profonde et continue maintenue jusqu’au décès : Comment apprécier qu’un pronostic vital est engagé à court terme ? Comment évaluer le caractère réfractaire d’une souffrance ? Quels repères pour une mise en oeuvre médicamenteuse ? La Haute Autorité de santé élabore un guide intitulé Comment mettre en oeuvre une sédation profonde et continue jusqu’au décès ? Le présent article reprend quelques points fondamentaux des étapes incontournables : l’écoute, la compréhension et l’analyse de la souffrance, la procédure collégiale – processus délibératif pluriprofessionnel, la mise en oeuvre pharmacologique.

International audience; Context: Relatives of patients receiving palliative care are at risk for psychological and physical distress, and their perception of quality of care can influence patients' quality of life. Objectives: The purpose of this study was to develop and validate the QUALI-PALLI-FAM questionnaire (QUAlity of PALLIative car from FAMilies' perspective) to measure families' perception of and satisfaction with palliative care. Methods: An exploratory factor analysis was conducted, and we evaluated the questionnaire's internal consistency using Cronbach's alpha, its stability across various strata, and the correlation between the QUALI-PALLI-FAM (factors, total score, and global satisfaction) and the total score of the FAMCARE (FAMily satisfaction with CARE) questionnaire. Results: This multicentric prospective cross-sectional survey was conducted in seven French hospitals, namely, three palliative care units and four standard medical units with a mobile palliative care team. The questionnaire was completed by 170 relatives of patients (more than 90% of patients had advanced cancer). The final questionnaire included 14 items across three domains: organization of care and availability of caregivers, medical information provision, and confidence and involvement of relatives. Internal consistency was good for all subscales (Cronbach's α = 0.74–0.86). Our questionnaire was stable across various strata: age and gender (patients and relatives), Palliative Performance Scale scores, and care settings. The QUALI-PALLI-FAM total score was correlated with the total FAMCARE score. Conclusion: The QUALI-PALLI-FAM appears to be a valid, reliable, and well-accepted tool to explore relatives' perception of quality of inpatient palliative care and complements the QUALI-PALLI-PAT questionnaire. Further testing is required in various settings and countries.

Resume Objectif En France, nous manquons de donnees objectives sur l’incidence des demandes d’euthanasie en contexte de soins palliatifs. Le but de cette etude est de recueillir, classifier et comptabiliser les expressions du souhait de mourir a partir des dossiers informatises des patients hospitalises en unites de soins palliatifs en 2010–2011. Methode Deux chercheurs ont extrait et analyse les observations des soignants contenant les mots « souhait de mourir », « euthanasie » ou d’autres expressions relatives a la mort. Les observations relatant un souhait de mourir ont ete classees dans l’ordre « demande d’euthanasie », puis « idee suicidaire », puis « autre expression d’un souhait de mourir » (sans demande d’euthanasie ni idee suicidaire). La trajectoire des patients ayant reitere leur demande d’euthanasie a ete analysee qualitativement. Resultats Cent quatre-vingt-quinze des 2157 patients (9 %) ont exprime un souhait de mourir : 61 « demandes d’euthanasie » (3 %), 15 « idees suicidaires » (1 %) et 119 « autres expressions d’un souhait de mourir » (6 %). Ce groupe de 195 patients etait a predominance feminine, avait une mediane de sejour superieure et recevait plus d’anxiolytiques et d’antidepresseurs. Vingt-six patients du groupe « demande d’euthanasie » ont aussi exprime a un autre moment « un autre souhait de mourir » et deux patients, une « idee suicidaire ». Six patients ont reitere leur demande : tous avaient des symptomes insuffisamment controles, ayant des repercussions sur leur etat mental. Conclusion Il existe differentes expressions du souhait de mourir avec une faible incidence des demandes d’euthanasie. Independamment de la variabilite des ces expressions, leur existence meme doit inciter a considerer la dynamique de leur changement, et a renouveler l’attention a la personne, a sa souffrance et a son contexte.

Resume La dyspnee est un symptome frequent dont la prevalence augmente en fin de vie, affectant 40 % des patients en unite de soins palliatifs. Elle est particulierement frequente dans les pathologies tumorales, notamment en cas d’atteinte thoracique primitive ou secondaire. Il existe vraisemblablement des dyspnees exclusivement terminales, independantes de la pathologie sous-jacente, dont les mecanismes physiopathologiques et la prise en charge sont a distinguer des dyspnees plus precoces. La dyspnee est un symptome complexe et multidimensionnel, a l’origine d’une souffrance physique, psychique, sociale et spirituelle que l’on peut nommer « dyspnee totale ». Bien que particulierement invalidant, ce symptome est trop souvent sous-estime par les soignants et reste difficile a soulager, notamment en raison de mecanismes physiopathologiques complexes et intriques. Une evaluation systematique de ce symptome semble necessaire a l’amelioration des pratiques. Quand elle est possible, l’autoevaluation doit etre privilegiee ; neanmoins, la frequence des troubles de la vigilance et de la confusion en fin de vie justifie souvent le recours a l’evaluation par un tiers. L’echelle Respiratory Distress Observation Scale (RDOS) est utile dans ces situations. L’American Thoracic Society insiste sur le caractere multidimensionnel de la dyspnee et recommande son evaluation objective et systematique chez les patients atteints d’insuffisance respiratoire ou cardiaque chronique. La frequence de la dyspnee en fin de vie et son impact en termes de qualite de vie incite a etendre cette recommandation a tout patient en phase terminale de maladie.

Resume Objectif Selon une etude francaise, les demandes d’euthanasie en unites de soins palliatifs sont peu frequentes et instables. Comprendre la genese d’une demande d’euthanasie et son devenir demande de considerer la dynamique relationnelle entre patient, proches et soignants via une etude prospective multicentrique. L’objectif de la presente etude pilote est de verifier sa faisabilite et d’apprehender le rapport subjectif des soignants a la demande d’euthanasie. Methode Durant 4 mois, des entretiens semi-directifs ont ete menes avec tous les soignants d’unites de soins palliatifs de la maison medicale Jeanne-Garnier a qui une demande d’euthanasie a ete adressee, a j0 et j7, et avec les patients lorsque cela etait possible. Ces entretiens ont ete enregistres, retranscrits et leur analyse qualitative thematique realisee a l’aide du logiciel STONE. Resultats Les soignants ont rapporte neuf demandes d’euthanasie et quatre patients ont pu etre interviewes. L’analyse des entretiens des soignants indique que quatre des neuf situations signalees correspondent reellement a une demande d’euthanasie : des expressions du desir de mourir sont entendues comme des demandes d’euthanasie, en particulier par les medecins. Meme si unanimement les soignants affirment ne pas etre affectes par ces demandes, celles-ci sont vecues dans l’impuissance, comme des effractions, des remises en cause de leurs competences et des capacites de l’institution, habituellement idealisees. Conclusion Pour les soignants d’unites de soins palliatifs, accepter d’entendre ces demandes d’euthanasie est difficile et destabilisant. L’importance de l’interpretation des souhaits de mourir comme des demandes d’euthanasie est a souligner. Le contexte de fragilite des patients est un facteur limitant la realisation d’une etude prospective de l’impact de la dynamique relationnelle sur la demande d’euthanasie.

Alors que certaines pratiques cliniques, au regard de l'evolution des legislations relatives a la fin de vie, sont ou seront confrontees a "une demande de mort" de la part du patient, le concept de transgression apparait central, tant dans sa nommination que sa prise en compte au coeur de l'action clinique et son evaluation, afin de qualifier les enjeux ethiques d'une possible reponse.

Background Despite recent advances in palliative medicine, sedating a terminally ill patient is regarded as an indispensable treatment to manage unbearable suffering. With the prospect of widespread use of palliative sedation, the feelings and representations of health care providers and staff (carers) regarding sedation must be carefully explored if we are to gain a better understanding of its impact and potential pitfalls. The objective of the study was to provide a comprehensive description of the opinions of carers about the use of sedation practices in palliative care units (PCU), which have become a focus of public attention following changes in legislation. Methods Data were collected using a qualitative study involving multi-professional focus groups with health care providers and staff as well as personal narratives written by physicians and paramedical staff. A total of 35 medical and paramedical providers volunteered to participate in focus group discussions in three Palliative Care Units in two French hospitals and to write personal narratives. Results Health care provider and staff opinions had to do with their professional stance and competencies when using midazolam and practicing sedation in palliative care. They expressed uncertainty regarding three aspects of the comprehensive care: biomedical rigour of diagnosis and therapeutics, quality of the patient/provider relationship and care to be provided. Focusing on the sedative effect of midazolam and continuous sedation until death, the interviewed health care providers examined the basics of their professional competency as well as the key role played by the health care team in terms of providing support and minimizing workplace suffering. Nurses were subject to the greatest misgivings about their work when they were called upon to sedate patients. Conclusions The uncertainty experienced by the carers with regard to the medical, psychosocial and ethical justification for sedation is a source of psychological burden and moral distress, and it has proved to be a major source of suffering in the workplace. Lastly, the study shows the uncertainty can have the positive effect of prompting the care team to devise ways to deal with it.

Background: The quality of palliative care is the foremost preoccupation of clinicians, decision-makers, and managers as well as patients and families. Major input from healthcare professionals is required to develop indicators for the quality of palliative care, but the involvement of patients and families is also recognized as essential, even though this is rarely achieved in practice. Aim: The objectives of this study were to identify (1) convergences and divergences in the points of view of different stakeholders (patients, families, healthcare professionals) relative to key elements of the quality of palliative care and (2) avenues for refining existing indicators of quality of palliative care. Design: Cross-sectional qualitative study. Setting/participants: There were six settings: two hospital-based palliative care units, one hospice, and three other medical units where a mobile palliative care team intervene. Semi-structured interviews were conducted among 61 patients, families, healthcare professionals, and managers. Results: Four major dimensions of quality of care are deemed critical by patients, their families, and professionals: comprehensive support for the patients themselves, clinical management, involvement of families, and care for the imminently dying person and death. Differences exist between various stakeholders regarding perceptions of some dimensions of quality of care. Avenues for improving current quality of care indicators are identified. Conclusion: Our study results can be used to refine or develop quality indicators that truly mirror the points of view of patients and their families and of healthcare professionals.

Resume Cet article presente des recommandations de bonnes pratiques etablies par un groupe de travail pluridisciplinaire concernant l'indication et l'utilisation des differents moyens therapeutiques visant a lever l'occlusion ou en soulager les symptomes chez les patients presentant une occlusion intestinale sur carcinose peritoneale a un stade avance. Ces recommandations ont ete etablies a partir de revues de la litterature et d'accord d'experts. La strategie proposee passe par une evaluation radioclinique avec l'importance de la TDM abdominale qui permettra, associee a l'analyse de criteres pronostiques, de discuter de la place d'une chirurgie ou de la pose de stent qui sont le plus souvent non realisables. Ceci amene a preciser la place et les modalites d'utilisation des differents traitements medicamenteux symptomatiques : corticoides, anti-emetiques, antalgiques et antisecretoires (anti-cholinergiques, analogues de la somatostatine, inhibiteurs de la pompe a protons). La sonde nasogastrique n'est plus systematique et a discuter au cas par cas. Des recentes etudes confirment l'interet des analogues de la somatostatine sur les symptomes lies a l'occlusion, principalement les nausees, les vomissements et la douleur. Toutefois, l'absence d'AMM et leur cout eleve restent un obstacle pour les utiliser en premiere intention. En l'absence d'efficacite de ces traitements sur les symptomes de l'occlusion, la gastrostomie de decharge doit etre discutee rapidement. La rehydratation sera quasi systematique. La place de l'alimentation parenterale devra etre questionnee au regard de certains criteres pronostiques identifies. L'objectif de ces recommandations est bien d'etablir une strategie limitee dans le temps, faisant appel a des equipes pluridisciplinaires, avec pour objectif le confort optimal des patients.

Resume Le fentanyl est un analgesique opioide de synthese, lipophile, de courte duree d’action. Dans la douleur du cancer, il est couramment prescrit par voie transdermique pour traiter la douleur de fond. La forme injectable etait jusqu’a present reservee a l’anesthesie mais elle est desormais autorisee par voie intraveineuse ou sous-cutanee pour la prise en charge de douleurs refractaires en cas d’echec ou d’intolerance a la morphine et a l’oxycodone. Des nouvelles formes galeniques transmuqueuses, buccales ou nasales ont fait preuve de leur efficacite dans la prise en charge des acces douloureux paroxystiques (ADP) ; la periode de titration est souvent delicate car la dose requise pour un soulagement suffisant ne peut pas s’extrapoler a partir de la dose de fond. Cet article passe en revue les aspects pharmacocinetiques, pharmacodynamiques et l’efficacite clinique des ces differents modes d’administration.

This multicenter study was intended to validate the French version of the M. D. Anderson Symptom Inventory (MDASI-Fr) in French cancer patients (n=162) with solid tumors or hematological malignancies. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) was used as a part of the validation. Factor analysis showed three underlying constructs for symptom items: general symptoms (pain, fatigue, disturbed sleep, shortness of breath, drowsiness, dry mouth, and numbness or tingling items); emotional and cognitive components (distress, sadness, and remembering items); and a gastrointestinal component (nausea, vomiting, and lack of appetite items), with Cronbach's alphas of 0.79, 0.73, and 0.71, respectively. Convergent validity was established by comparing MDASI-Fr items with the EORTC QLQ-C30 scale and the Brief Pain Inventory (BPI). Overall, the 19-item MDASI-Fr score correlated well with the QLQ-C30 global health status, and the pain item of the MDASI-Fr was highly correlated with the short form of the BPI. The most prevalent symptoms were fatigue, distress, dry mouth, and pain. Twenty-five percent of patients reported moderate or severe pain (numeric rating scale >4 on 0–10 severity ratings). Physician ratings of global change on a second visit were significantly associated with changes in patient ratings on the MDASI-Fr, supporting the sensitivity of the measure. Symptoms interfered most with work and general activity. The MDASI-Fr is a valid and reliable tool for measuring symptom severity and interference in French cancer patients.

Resume Les unites de soins palliatifs (USP) sont tres attachees a preserver au mieux la vigilance et les fonctions cognitives des patients qui leur sont adresses. Une enquete a ete realisee sur les 59 patients presents un jour donne a la maison medicale Jeanne-Garnier (USP). Elle a evalue la vigilance des patients (score de Rudkin) et leurs performances cognitives (test elementaire de concentration, orientation et memoire [Telecom]) et questionne les medecins sur l’intentionnalite des medicaments utilises. Des correlations ont ete recherchees entre ces donnees, la duree de sejour et la survie. Resultats Les patients sont majoritairement eveilles (score de Rudkin : 1,9 ± 1,3) mais 73 % des patients presentent une alteration des fonctions cognitives (test Telecom : 19 ± 10). Une atteinte cerebrale (39 % des patients) altere nettement les performances cognitives sans repercussion sur la vigilance. Les doses administrees de morphine ou de benzodiazepines n’ont pas de correlation avec les scores de vigilance ou des fonctions cognitives. De meme, la duree de vie n’est pas liee a la consommation de ces medicaments. Dans notre hopital, le recours a une sedation n’est pas frequent : aucune sedation selon la definition de la SFAP n’est instauree ce jour-la. Notre enquete met egalement en evidence des disparites interservices et un defaut dans l’information du patient a propos des effets indesirables des medicaments utilises. Elle a aussi permis que les equipes se familiarisent avec des outils simples et utilisent un meme langage pour evaluer la vigilance et depister precocement une confusion trop souvent sous-estimee.

Comme l’ecrivent les auteurs, « les professionnels de soins palliatifs se sont mobilises pour clarifier les concepts, mieux preciser leurs pratiques sedatives, les expliquer, creer et diffuser des outils expliquant les bonnes pratiques a tous les professionnels de sante, bien au-dela des acteurs de soins palliatifs. » L’article de Frederic Guirimand et Marion Broucke repond a cet objectif, en ne fuyant pas l’abord des questions delicates que souleve la sedation profonde.

This article reports on the clinical practice guidelines developed by a multidisciplinary group working on the indications and uses of the various available treatment options for relieving intestinal obstruction or its symptoms in patients with peritoneal carcinomatosis. These guidelines are based on a literature review and expert opinion. The recommended strategy involves a clinical and radiological evaluation, of which CT of the abdomen is a crucial component. The results, together with an analysis of the prognostic criteria, are used to determine whether surgery or stenting is the best option. In most patients, however, neither option is feasible, and the main emphasis, therefore, is on the role and administration of various symptomatic medications such as glucocorticoids, antiemetic agents, analgesics, and antisecretory agents (anticholinergic drugs, somatostatin analogues, and proton-pump inhibitors). Nasogastric tube feeding is no longer used routinely and should instead be discussed on a case-by-case basis. Recent studies have confirmed the efficacy of somatostatin analogues in relieving obstruction-related symptoms such as nausea, vomiting, and pain. However, the absence of a marketing license and the high cost of these drugs limit their use as the first-line treatment, except in highly selected patients (early recurrence). When these medications fail to alleviate the symptoms of obstruction, venting gastrostomy should be considered promptly. Rehydration is needed for virtually every patient. Parenteral nutrition and pain management should be adjusted according to the patient needs and guidelines.

Studies in healthy volunteers suggested that the classical counterirritation phenomenon (i.e. pain inhibits pain effect) might depend on diffuse noxious inhibitory controls (DNIC), which modulate the spinal transmission of nociceptive signals. In the present study, we sought to determine whether similar mechanisms were at play in patients with different subtypes of neuropathic pain. Ten patients presenting with a traumatic peripheral nerve injury associated with dynamic mechano-allodynia (i.e. pain triggered by brushing) or static mechano-allodynia (i.e. pain triggered by light pressure stimuli) were included in this study. To investigate counterirritation mechanisms in these patients, we analysed the RIII nociceptive flexion reflex and concomitant painful sensation elicited by electrical stimulation of the sural nerve. We compared the effects of heterotopic 'clinical' conditioning stimuli (i.e. pain evoked by brushing or pressure within the allodynic area located in the upper limb or chest) to those of experimental heterotopic noxious stimuli (HNCS) consisting of a cold pressor test or tourniquet test applied to the normal upper limb. Static mechano-allodynia induced inhibitions of both the RIII reflex and the concomitant painful sensation. These effects were similar to those induced by HNCS and were probably due to an increased activation of DNIC. In contrast, in patients with dynamic allodynia, brushing within the allodynic area reduced the pain sensation at the foot, but did not inhibit the electrophysiological responses, suggesting that in this case the counterirritation effect may take place at the supraspinal level. Thus, the mechanisms of counterirritation are not univocal, but depend on the pathophysiological mechanisms of clinical pain.

Despite the recent discovery of the potential mechanisms underlying the analgesic effects of cannabis, few clinical studies have so far assessed its analgesic effects, notably in the treatment of chronic non-malignant pain. All the studies used administration of cannabis alone. The aim of this open, pilot, study was to assess the efficacy and side effect profile of oral dronabinol (tetrahydrocannabinol - THC) in the treatment of refractory neuropathic pain.Seven patients (3 women/4 men), aged 60 +/- 14 years, suffering from chronic refractory neuropathic pain, received oral THC titrated to the maximum dose of 25 mg/day (mean dose: 15 +/- 6 mg), during an average of 55,4 days (range: 13-128). Various components of pain (continuous, paroxysmal and brush-induced allodynia) were assessed using VAS scores. Health-related Quality of Life (HRQL) was evaluated using the Brief Pain Inventory, and the Hospital Anxiety and Depression scale was used to measure depression and anxiety.THC did not induce significant effect on the various pain, HRQL and anxiety and depression scores. Numerous side effects (notably sedation and asthenia) were observed in 5 patients out of 7, requiring premature discontinuation of the drug in 3 patients.The present study did not reveal any significant efficacy of THC in a small cohort of patients with chronic refractory neuropathic pain, but underlined the unfavorable side effect profile of the drug. These results may partly relate to the fact that oral dronabinol exhibits a poor therapeutic ratio (efficacy at the price of side effects). The development of new and better tolerated cannabinoids is warranted.

Background In the current public debate in France about end-of-life and legalization of euthanasia, palliative care is considered as a suitable answer or an alternative or even a supplement to euthanasia. The debate is based on opinion surveys, partly because there is a lack of objective data about the incidence of euthanasia requests (ER) in palliative care settings. The aim of this study was to collect, classify and quantify the expressions of wishes to die (WD), based on computerized files for patients admitted to an 81-bed palliative care hospital (PCH) in Paris during 2010–2011. Methods Two researchers analyzed the carers’ notes extracted on the basis of containing the words “wish to die”, “euthanasia” or any expressions relating to death. Notes related to WD and the corresponding patients were then classified in the order: ER, suicidal thought (ST) and other wish to die (OWD). Repeated ER were qualitatively analyzed according to a grid. Results We found that 195 of the 2157 patients (9%) expressed a WD: 61 (3%) expressed an ER; 15 (1%) described ST and 119 (6%) expressed an OWD without requiring acting. The WD group was predominantly female, stayed longer in the hospital (median 24 vs. 13 days), and consumed more anxiolytics and antidepressants. None of age, disease or marital status was associated with ER. More women and widows expressed an OWD. Twenty-six ER patients also expressed an OWD and two a ST. Six patients repeated their ER: all had poorly controlled symptoms with repercussions for their mental state. Conclusion Our data show the existence of various expressions of WD with a low incidence of ER in a French PCH. The observation of WD including ER is suggestive of good communication between the patients and the care teams. Independent of the changeability of expressions of WD, their very existence should lead to a consideration of the dynamic changes in these WD, and to care staff paying additional attention to the individual, their suffering and the context.