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Resume La loi Claeys-Leonetti du 2 fevrier 2016 a apporte des modifications au dispositif des directives anticipees introduit initialement en France en 2005 pour ameliorer la prise en charge des personnes en fin de vie. Pourtant, pres de 15 ans apres sa mise en œuvre, il s’avere que la population s’est peu saisie de ce dispositif, moins de 15 % des Francais de plus de 50 ans ayant redige leurs directives anticipees, malgre des campagnes d’information et des debats publics organises en region de facon plus soutenue depuis quelques annees. L’espace de reflexion ethique de Normandie s’est saisi du sujet des directives anticipees pour reflechir sur les difficultes d’application, les limites et les consequences de ce dispositif sur le territoire normand. Deux groupes de travail ont ete mis en place a Caen et a Rouen, reunissant une soixantaine de personnes a trois reprises au printemps 2019. Les espaces de reflexion ethique regionaux (ERER) ayant pour mission d’etre observatoires dans les territoires afin de nourrir les reflexions au plan national et collectif, ce travail de restitution et de partage d’experiences vise a integrer les remontees du terrain dans le debat national, cette dynamique s’inscrivant dans la perspective d’un debat plus continu et regulier avec les citoyens et les professionnels de terrain.

Drafting a death certificate is an obligation for any physician called upon to note a death. It has a legal and epidemiological impact. The objective of this study is to highlight the obstacles encountered by professionals when this process takes place in a home setting.A study was carried out by means of a questionnaire sent to doctors in the Normandy region.One fifth (20%) of the general practitioners (GPs), 25% of the SAMU practitioners (intervening in mobile emergency throughout the country), 27.3% of SOS doctors (intervening 24 hours a day in the deceased person's home in the absence of a GP) stated that they had at least once refused to establish a death certificate. Only 36.4% of SOS doctors, 62.5% of emergency physicians and 41% of GPs considered the drafting of a death certificate to be one of their mandatory missions. No less than 17% of GPs, 25% of SAMU doctors and 9% of SOS doctors stated that due to lack of time, they were occasionally unable to travel to fill out a death certificate, a factor causing delays that were detrimental, especially for the surviving relatives. We highlighted several other obstacles to the completion of death certificates: the difficulty of completing them accurately without knowledge of the deceased person's history, possible inability of professionals on tight schedules to deal with unforeseen requests and, more rarely, the issues raised by an absence of remuneration.Our study highlights major obstacles in the preparation of death certificates, obstacles that should be taken into consideration insofar as they affect the quality of the data collected, and entail ethical challenges.

Resume Une precedente etude avait montre que les decisions de limitation ou d’arret des traitements (LAT) prises en reanimation n’etaient pas partagees par les services destinataires des enfants survivants. Objectifs de l’etude Mettre a jour les freins a cette prise en compte et les analyser dans une perspective d’amelioration de la continuite des soins. Methode Etude qualitative realisee a partir d’entretiens semi-diriges aupres de medecins seniors exterieurs a la reanimation confrontes au protocole de decisions de LAT. Resultats Neuf medecins ont ete interroges (neuropediatres, neurochirurgiens pediatriques et onco-hematologues pediatres). Le corpus d’entretien representait 80 pages dactylographiees. Trois situations generatrices de tensions ont ete identifiees. La plus frequemment rapportee etait leur intervention a titre d’expert charge d’etablir un pronostic a la demande des reanimateurs. Les 2 autres correspondaient a l’admission de leurs patients en reanimation lorsqu’ils devaient justifier de l’existence d’un projet de soin et a la sortie lorsque le patient survivait apres une decision de LAT. Conclusion La modelisation du raisonnement medical utilisee pour la formalisation des LAT en reanimation est source de tensions quand elle est confrontee aux modelisations des autres specialites. Ces modelisations representent des modes differents d’integration de la part de subjectivite de tout raisonnement medical. La reintegration de cette subjectivite dans la pratique, favoriserait la deliberation autour du malade qui est necessaire a la continuite de sa prise en charge.

Resume Objectifs Il s’agit dans un premier temps d’evaluer la qualite de la mise en place de l’anonymat a la maternite ; dans un second temps, d’apprecier le niveau d’information de l’equipe medicale. Materiel et methode Tout d’abord une etude retrospective de l’integralite des dossiers d’accouchements « sous X », a ete pratiquee de janvier 2000 a decembre 2003 au sein d’une maternite parisienne. Puis, un questionnaire a ete remis aux medecins et sages-femmes du meme etablissement, afin d’etudier leur niveau de connaissance et leur point de vue. Resultat Au total, dans 11 dossiers sur 17, l’anonymat n’est pas absolu et on peut retrouver le nom de la patiente. La tenue des dossiers est dependante de la date de prise de decision d’accoucher sous le secret de son identite : l’anonymat est meilleur s’il est instaure lors de la premiere consultation, et est de moins bonne qualite s’il intervient plus tard. Enfin, les questionnaires soulignent le manque de connaissances des professionnels, et l’insuffisance de procedures claires mises a leur disposition. Conclusion L’etablissement d’une procedure standardisee apparait indispensable et protegerait mieux la volonte de la patiente, conformement a la loi du 4 mars 2002. Ce point est d’autant plus important qu’a terme un enfant devenu majeur peut demander la consultation du dossier pour les parties qui le concernent.

Since 1991, war crimes in the former Yugoslavia have been the subject of several international medico-legal investigations of mass graves within the framework of inquiries led by the International Criminal Tribunal for the former Yugoslavia (ICTY). Forensic pathologists involved in the ICTY missions could be subjected to ethical tensions due to the difficulties of the missions, the emergent conflicts between forensic scientists of the investigating teams and the original nature of the ICTY proceedings. In order to study the nature of such ethical tensions, we sent a questionnaire to 65 forensic pathologists who have been involved in the ICTY missions. The rate of response was 38%. The majority of forensic pathologists questioned (n=18) did not know how the medico-legal data was exploited by the ICTY. Three of them have been subjected to pressures. Three of them were aware of mass grave sites knowingly not investigated by the ICTY. Fifteen considered that the ICTY respected the elementary rules of the law and four of them questioned the impartiality of the justice led by the ICTY. Two conflicting types of ethics can be drawn from these results: conviction ethics, which are shared by most of the forensic pathologists questioned, and responsibility ethics. In the former, the forensic pathologist completely agrees with the need for an international war crimes tribunal, even if such justice can be challenged regarding the respect of human rights and impartiality. In the latter, he or she needs to conduct him or herself in ways that do not infringe impartiality. As medical deontology duty requires impartiality ethics, discursive ethics are needed to ease ethical tensions and to suggest ethical guidelines. Alternatives to international justice, through a truth and reconciliation commission and by way of humanitarian missions combining victims' identification with forensic investigations for historical purposes, could be considered.

Resume But de l'etude. – Le but de cette etude est de realiser un etat des lieux des modalites d'informations ainsi que de rechercher une variabilite dans l'estimation du risque en chirurgie esthetique, sur deux interventions les plus repandues. Materiel et methode. – Un questionnaire a ete adresse a 100 chirurgiens plasticiens tires au sort sur la liste d'aptitude de l'ordre des medecins. Cette liste est constituee de 50 chirurgiens travaillant dans le secteur public et 50 chirurgiens installes en ville. Un premier questionnaire anonyme general recueille le type d'activite, les annees d'experience, les moyens et les methodes d'informations utilises. Un second questionnaire, en sept items fermes, evalue les elements d'informations necessaires, ainsi que les complications les plus redoutees pour chaque chirurgien, en fonction de son experience et de la nature de son activite concernant les mammoplasties de reduction et les abdominoplasties. Resultats. – Cent questionnaires ont ete envoyes. Cinquante pour cent nous sont parvenus et ont pu etre analyses. Une variabilite significative existe dans l'evaluation du risque de ces deux operations. Une difference existe entre la perception du risque par le chirurgien et l'information qu'il delivre aux patients. En effet, des complications sont mises de cote alors qu'elles sont tres frequentes. Les annees d'experiences du praticien semblent etre le seul facteur significativement discriminatif. Le nombre d'annees d'experience du chirurgien influence de facon significative son interet pour l'information et la facon dont il la dispense. En outre, la nature majoritaire de l'activite (esthetique–reparatrice) influence l'interet pour les procedures d'information. Conclusion. – Il existe au sein de la communaute chirurgicale pratiquant la chirurgie morphologique une enorme variabilite dans les perceptions des benefices et des risques des interventions et donc une variabilite significative dans la facon de donner l'information.

Le patient est devenu un «consommateur de soins» aupres d’un praticien reduit au statut de «prestataire de services» et les rapports traditionnellement bases sur la confiance ont evolue vers la defiance. Dans ce contexte un patient sur six abandonne son orthodontiste en cours de traitement d’orthopedie-dento-faciale. L’objet de notre travail est d’evaluer le comportement ethique de l’orthodontiste lors de ce transfert par une etude retrospective dans deux cabinets d’orthodontie parisiens de 42 dossiers patients, et nous utiliserons comme parametre la qualite de l’echange. Sur les 42 patients qui consultaient le second orthodontiste (de reference), 27 (64 %) avaient un courrier de qualite variable, 21 (50 %) leurs moulages de depart et 30 (70 %) leurs radiographies. Si le patient quittait son clinicien du fait d’un demenagement, le 1er orthodontiste mettait tout en oeuvre pour faciliter son suivi therapeutique, par contre dans le cas d’une mesentente il le sanctionnait en echangeant peu ou pas de donnees avec le confrere. 75 % des cliniciens liberaux contre 50 % de ceux exercant en institution transmettent le dossier patient au confrere. Les dossiers patients en odontologie sont plus ou moins bien tenus, quelques fois egares et seuls 42 % d’entre eux comportent un questionnaire medical. Nous n’avons pour l’instant que peu de recul par rapport a la loi du 4 mars 2002 pour pouvoir noter une modification des comportements des orthodontistes et des patients. L’attitude de l’orthodontiste n’est pas toujours tres ethique vis-a-vis de son patient (sanction) et de son confrere. Nous proposons trois solutions pour faciliter le transfert et le suivi des patients : le carnet de sante bucco-dentaire, une fiche de transfert etablie d’apres les recommandations de l’ANAES* ou encore un dossier medical electronique.

Les traitements orthodontiques sont longs et conduisent a une lassitude des patients, les poussant quelques fois a changer de praticien en cours de traitement.Etant donne qu'il n'y a pas de consensus dans les therapeutiques orthodontiques, le but de ce travail est de savoir si le second orthodontiste continue ou change le plan de traitement deja commence par le premier.Il s'agit d'une etude retrospective et anonyme de 1700 dossiers conduite sur treize annees (de 1989 a 2002) dans un centre d'orthodontie de reference parisien.Les patients inclus dans l'etude devaient repondre aux criteres suivants : avoir change de praticien en cours de traitement, etre arrives appareilles au cabinet de reference, y avoir termine le traitement et avoir eu une phase therapeutique de type multibague. Puis, pour chaque patient inclus, une serie de parametres a ete etudiee selon une grille. Seuls 49 patients (âges de 10 a 19 ans) repondant aux criteres d'inclusion ont ete retenus.Le praticien de reference a adapte sa conduite therapeutique, meme contre ses convictions dans 25 % des cas, a change de plan de traitement dans 25 % des cas, et dans 50 % des cas l'a poursuivi. La duree globale du traitement en cas de changement de praticien est augmentee par rapport a une prise en charge unique. Dans plus de 50 % des cas, il n'y a pas eu de communication praticien-patient et entre praticiens.

Resume A l’occasion de la publication au Journal Officiel de la Republique Francaise du decret du 29 decembre 1999 authentifiant les resultats du recensement general de la population, nous avons decide de comparer ces resultats dans notre region a differents aspects de l’accession a l’independance chez une population de fente labiomaxillopalatine unilaterale totale operee dans l’enfance. Tous les patients, operes par l’auteur senior dans l’enfance de fente labiomaxillopalatine unilaterale totale et actuellement âges de 18 a 35 ans, ont ete inclus dans l’etude. Un questionnaire reprenant quelques items du recensement a permis d’etablir des criteres d’independance (vie en couple, histoire scolaire, insertion professionnelle). Le groupe temoin d’adultes de 18 a 35 ans a ete constitue par la methode des echantillons de menages. La difference entre les groupes a ete etablie par le test de Student pour les variables continues et le χ 2 pour les variables categorielles. Quatre-vingt-deux patients ont ete inclus, les resultats montrent une histoire scolaire marquee par un retard significatif dans le groupe de patients, une independance du logement et une vie en couple plus tardives : au total un retard significatif dans l’accession a l’independance.

Resume But. – Le but de cette etude etait d’analyser les suites des patients inclus dans le protocole du ganglion sentinelle dans le melanome cutane malin. Materiel et methode. – Une etude prospective est menee depuis fevrier 2002. Elle inclut actuellement 45 patients. Sont etudies l’âge et le sexe, les delais de prise en charge, la duree d’hospitalisation, la duree totale des soins, la duree d’arret de travail, le taux de morbidite et les differentes complications, la duree des soins en cas de complication. Le poids de la procedure est compare en tous points a la strategie de reference anterieure. Resultats. – Le delai moyen de prise en charge est de 36 jours. La sensibilite de la technique est de 100 % dans les localisations du tronc et des membres, 66 % pour la tete. La duree moyenne d’hospitalisation dans les cas simples etait de trois jours, avec 20 jours de soins a domicile. La duree d’arret de travail dependait de la tolerance a l’interferon. Des complications survenaient dans 25 % des cas, a type de lymphorrhees, d’infections locales, avec une duree moyenne de pansements de 45 jours. Conclusion. – Le ganglion sentinelle est une technique chere, invasive avec un taux eleve de complications. Elle allonge les delais de prise en charge des patients, seul garant de benefices en termes de survie.

The precautionary principle first appeared in France during the health crisis following the contamination of patients with HIV via blood transfusion. This study analyses whether the risk associated with blood transfusion was taken into account early enough considering the context of scientific uncertainty between 1982 and 1985. The aim was to evaluate whether a precautionary principle was applied and whether it was relevant. First, we investigated the context of scientific uncertainty and controversies prevailing between 1982 and 1985. Then we analysed the attitude and decisions of the French authorities in this situation to determine whether a principle of precaution was applied. Finally, we explored the reasons at the origin of the delay in controlling the risk. Despite the scientific uncertainties associated with the potential risk of HIV contamination by transfusion in 1983, we found that a list of recommendations aiming to reduce this risk was published in June of that year. In the prevailing climate of uncertainty, these measures could be seen as precautionary. However, the recommended measures were not widely applied. Cultural, structural and economic factors hindered their implementation. Our analysis provides insight into the use of precautionary principle in the domain of blood transfusion and, more generally, medicine. It also sheds light on the expectations that health professionals should have of this principle. The aim of the precautionary principle is to manage rather than to reduce scientific uncertainty. The principle is not a futile search for zero risk. Rather, it is a principle for action allowing precautionary measures to be taken. However, we show that these measures must appear legitimate to be applied. This legitimacy requires an adapted decision-making process, involving all those concerned in the management of collective risks.

Resume La transfusion sanguine presente des risques principalement virologiques, bacteriens, immunohematologiques et volemiques ; les deux derniers concernent plus particulierement les acteurs de l’etablissement de sante. La maitrise des risques transfusionnels se caracterise par une abondante reglementation. Cet article precise la responsabilite du prescripteur de produits sanguins labiles. Compte tenu de la reglementation qui encadre l’activite, le prescripteur doit connaitre et mettre en œuvre les exigences relatives a sa pratique pour eviter de voir engager sa responsabilite, ou celle de l’etablissement de sante dans lequel il travaille, en cas de dommage occasionne au patient du fait de l’absence de leur respect. L’article a pour objectif d’identifier les principales exigences reglementaires afin de les maitriser malgre un environnement difficile, dans le respect des droits des patients au regard des benefices et des consequences de l’acte transfusionnel. Ces exigences portent notamment sur l’information et le consentement a la transfusion sanguine, la prescription des produits sanguins labiles ainsi que sur l’information et le suivi post-transfusionnel des patients. Pour chacun de ces aspects des elements de preuve du respect des exigences doivent pouvoir etre apportes.

Resume En France, le principe de precaution a fait irruption dans le champ de la sante publique a travers la transfusion sanguine, sans qu’il y ait eu une reflexion prealable quant a sa definition, son objectif, ses modalites d’application et ses consequences. La question de la pertinence de son application reste entiere. Cette etude realisee a partir d’entretiens avec des acteurs de la transfusion sanguine a pour objectif d’etablir les representations qu’ils ont de l’application du principe de precaution dans ce champ particulier et des consequences en termes de gestion des risques et des droits des patients. A partir de ces representations, les elements favorables et defavorables a l’application du principe de precaution sont analyses. A l’issue de l’analyse, il apparait que le principe de precaution releve d’une confusion. Il est plus percu comme une protection pour le decideur que pour le malade, et pousse a l’extreme il pourrait etre prejudiciable a la logique medicale. Cependant, il apparait aussi porteur d’elements qui renouvellent et font evoluer la gestion du risque transfusionnel.

Resume Les textes regissant l’obligation d’information pesant sur le medecin vis-a-vis de son patient semblent a premiere vue ecarter les risques potentiels de leur champ d’application. Cependant, en France, le domaine de la transfusion sanguine vu son extreme sensibilite va se distinguer en etendant cette obligation au risque potentiel de la transmission eventuelle par voie sanguine de l’agent infectieux responsable de la MCJ (maladie de Creutzfeldt-Jakob). D’un point de vue ethique, l’information sur le risque transfusionnel theorique ne releve-t-elle pas d’une approche scientiste ? D’un point de vue formel, le moyen utilise pour effectuer une telle extension (c’est-a-dire une circulaire) est sujet a discussion, etait-il le moyen adequat ? Et enfin, peut-on alors parler d’exception francaise en matiere d’information sur le risque potentiel transfusionnel ? Au vu des textes posterieurs, le principe d’une obligation d’information sur les risques potentiels ne semble pas generalise, ni meme confirme. Peut-on voir en ces textes un retour au « bon sens » ? Et ce, dans la mesure ou il ne faut pas nourrir l’illusion de l’existence d’un risque zero…

Resume Si la loi du 4 mars 2002 contient des avancees importantes pour les droits des patients, elle a egalement le merite de reprendre, en les regroupant, des dispositions deja contenues dans divers textes legislatifs ou reglementaires, et de transposer les devoirs imposes par la deontologie des professionnels de sante, en droits pour les patients. Les informations genetiques ont largement beneficie des apports de cette loi. Realisee dans le cadre d'un partenariat de recherche Franco-quebecois 1 , cette analyse a pour objet de presenter les particularites de la protection des donnees genetiques en France avec quelques comparaisons avec le droit Quebecois. Nous exposons le cadre legal preexistant, et sa modification par la loi du 4 mars.

Case management is a new professional field in France. It is addressed to elderly persons living in community whose situation is regarded as particularly complex. Case managers have to assess needs and coordinate necessary services. One common criteria of complexity is refusal of care. The objective of this study is to compare the words of users with those of case managers about refusal of care, in order to understand its meaning, professionals' attitudes and ethical challenges.Two researchers have cooperated on this qualitative research: the first one, anthropologist, interviewed 19 individuals, and 11 of their caregivers. The second one, geriatrician and researcher in medical ethics, lead four focus groups gathering a total of 18 case managers.Refusal of care often is the result of the will of preserving one's identity, compromised by illness. Individuals seek control on their life. Facing this behaviour, case managers try to secure the individual, by establishing a personal relationship that respects their choices, even if care has to be delayed. Refusal of care may sometimes disclose a desire to vanish, in front of which professionals meet their own limits.To recognise an elderly person that refuses care as a unique individual who can make choices secure his identity, and allow him to change.

Based on international and national recommendations, organized breast cancer screening in France raises questions of medical ethics built around the key concepts of individual autonomy and public health policy. Because of the evolving knowledge, professionals and institutions involved in the program must review the ethical values associated with this medical practice.The ethical aspects of organized breast cancer screening were studied. In response to newly acquired knowledge highlighted by a review of texts governing this practice in France, proposals for changes resulting from reflections of a working group coordinated by the National Cancer Institute are presented.Ethical issues raised by screening must find expression in the general principles of the program's organization: acceptability of screening, efficiency, adverse effects, equity of access, free care…, but also at different stages of the procedure: information delivery, first and second invitations, refusal of further diagnostic investigation…A better match between breast cancer screening and recently developed knowledge requires optimal information delivery to women targeted by the program as well as a stronger role for the referring healthcare professional.

La cryopreservation des embryons humains a permis de traiter de nombreuses formes de sterilite mais pose des problemes ethiques considerables, non encore tous regles par les legislations. En particulier, qu'adviendra-t-il en cas de demande de prolongation de la garde par des couples au-dela de cinq ans ? Quelles seront les modalites de la conservation des embryons au-dela de cette limite ? Quels seront les liens entre la garde des embryons et l'interdiction de la recherche ? Les pratiques effectives et leurs analyses sur le terrain s'averent sur tous ces points fondamentales au regard de l'approche reglementaire qui n'aura de valeur que si elles s'accompagnent d'une evaluation rigoureuse.

To review outcomes following reductions in trichorionic triplet pregnancies at our institution.Retrospective analysis of the outcome of trichorionic triamniotic triplets reduced to singletons (group I, n = 44) or twins (group II, n = 136) at 10 and 12 weeks of gestation.Reduction to one or two was based on parent's preference, hence unrelated to any specific obstetrical or maternal issue. Early fetal loss rate (e.g.24 weeks) was 9.1% in group I versus 5.1% in group II (p = 0.83). In group I, the take-home baby rate was 86.4% versus 91.9% in group II (p = 0.8). In group I, 17.5% of the women gave birth between 33 and 36(+6) weeks of gestation versus 40.6% in group II (p = 0.026). Delivery beyond 37 weeks was 72.5% in group I and 46.9% in group II (p = 0.01). Intrauterine growth restriction rate was 27.0% in group I versus 45.0% in group II (p = 0.049).Reduction to one rather than two fetuses led to significantly higher term delivery rate without significant differences in fetal loss rate or take-home baby rate.

To describe the condition of the decision-making of admission and non-admission in intensive care unit.Non-interventional observational cohort.Retrospective analysis of declarative terms of decision-making of patients admitted or denied in a surgical intensive care unit. The decision-making in the two admitted or not admitted troops was compared.That it is during a non-admission (149 decisions) or of an admission (149 decisions), the decision-making process was not very different. The instruction of the files was regarded as collegial in nearly 80% of the cases by the intensivist in load. The dialogue precedent the decision utilized generally several speakers but who could be residents. The participation of the patient and/or his close relations, as that of the ancillary medical personnel was rare. No person of confidence or anticipated directive was quoted. More than 50% of the decisions were taken within a time lower than 30 minutes. The decisions of non-admission were considered to be more difficult than the decisions of admission. Traceability was not automatically given.Thus, this study shows that in its current form the intensivists of the service estimate that in the majority of the cases the instruction of the files was collegial. However, the conditions of seniorisation of the decision, the collection of opinion of the patient and/or his close relations and the traceability are tracks of improvement to be implemented in certain circumstances of admission or non-admission.

The purpose of this study was to analyze modalities of the transition from pediatric to adult epilepsy care and patients' acquisition of autonomy.This study was conducted using semidirected interviews composed of three major parts: the patient's criteria of transition toward adult healthcare (factors taken into account, anticipation, the patient's opinion, etc.), conditions (teamwork with the neurologists, transmission of the medical record, continuity of health care, etc.), and the role played by social workers and psychologists. We interviewed 10 doctors belonging to six major Parisian hospital units involved in the monitoring of children and adolescents with epilepsy and working in Pediatric Neurology Departments of the Île-de-France region.For most of the doctors, reaching 18 years of age was the major argument taken into account to consider transition to adult care. According to the doctors interviewed, parents are generally worried when their child has to find another doctor (7/10). According to eight out of 10 doctors, the neurologist is selected to take over. The doctors recognize the importance of psychologists and social workers even if they are not always included. The process by which the patient gains autonomy depends a great deal on the role played by the pediatricians and parents, although some parents are very protective. This behavior weakens the patient's capacity for autonomy and it varies according to the degree of his or her physical and/or neurological disabilities. Furthermore, developing autonomy requires interdisciplinary work that is not yet fully in place.The lack of structures well-adapted to the uniqueness of each patient and the lack of coordination between the various institutions do not favor the acquisition of autonomy. A network that could efficiently respond to the needs of epileptic patients as well as medical care tailored to adolescents would be the answer to this dilemma.

The fact that some children may survive despite a limitation of treatment decision (LTD) made in the pediatric intensive care unit (PICU) is a recent concern. A previous study pointed out that the teams in charge of children after the PICU stay did not take previous PICU LTDs into account.To identify the problems different units experience in cooperating with the PICU team, in order to increase the continuity of care for these children.Qualitative single-center study, using semi-structured interviews with physicians in charge of children who were discharged from the PICU even though a LTD was made.Nine pediatric subspecialists (hemato-oncologists, neurologists, and neurosurgeons) were interviewed, producing a corpus of approximately 80 pages of typed text. Three conflictual situations were identified by these physicians. The most frequently reported situation was being asked by the PICU team to give expert advice on a patient's prognosis, before a LTD was made. The 2 others had to defend a true care plan for children who were transferred to the PICU and designing a new care plan for children who were discharged from the PICU after a LTD was made.The medical reasoning model that is used for LTDs in the PICU generates conflictual situations when compared to the models that are used in other specialties. These models represent various expressions of subjectivity, as in any medical decision. Acknowledging this fact could facilitate its integration into clinical practice and should improve authentic debates that are necessary to ensure continuity of care for these children.

International audience; Following a report by the Health Ministry recommending a greater implication of general practitioners (GP) in the diagnosis and care of mistreated older people, we wanted to evaluate what was actually their role in this matter. A study was made of files of mistreated older persons referred to the social services in a Parisian suburb. For each file, we noted who raised the first suspicions of mistreatment, who diagnosed it, what happened next, and what precisely the GP's role was. Out of 600 files, we found 12 cases, concerning 14 persons (two couples). Although all the patients had health problems requiring frequent consultations with their GP, none of these situations were diagnosed by the GP. In all cases, the GP played only a secondary role, if at all. The following points are discussed: The link between family problems and history cannot be ignored in the follow up of such situations. The GP's role is discussed regarding clinical knowledge of mistreatment and the legal rules they have to deal with. Our results bring to light how the balance between the person's autonomy and the necessary direct action is especially delicate in this field.

THE NOTION OF A PERSON OF TRUST: Introduced by the law dated March 4th 2002, the person of trust is there to accompany the patient in all his/her measures of care; this person is also conceived as an helper in medical decisions or when the patient participates in biomedical research protocols. DESIGNATION MODALITIES: Any adult, unprotected patient can designate a person of trust, whose intervention is not only limited to hospitalisation (the nursing staff are obliged to propose such a person), but can also intervene during care at home or at the doctor's. The designation is made in writing and can be revoked at any time. The person of trust can be a relative, a friend or even the treating physician. A SPECIFIC ROLE: The person of trust can be of help in medical measures in routine medicine when the patients needs to be accompanied, and in the case of diagnosis or serious prognosis, and when the patient is incapable of expressing him/herself.

Blood transfusion presents mainly virological, bacteriological, immunohaematological and volemic risks; with the latter two particularly concerning health establishment employees. This article tackles the physician's responsibility in blood transfusion. Taking into account the regulations that surround the activity, prescribing physicians must know and put into action the relative requirements in their practises in order to avoid taking on its responsibility, or that of the health establishment in which they work, as any lack of respect for the rules and regulations could result in being held liable for any side affects suffered by the patient. The article has the objective of identifying the main regulation requirements in order to control them despite a difficult environment, from the point of view of patients' rights regarding the benefits and the consequences of transfusion. These requirements focus mainly on information and patient consent, the prescription of blood products as well post transfusion information and the follow-up care. Proof of respect for these rule requirements must be available for each of these aspects.

The concept of risk cannot be limited to simply knowing the probability of occurrence and the seriousness of the damages caused. It's a matter of social construction and numerous elements contribute towards its perception and acceptability. These elements have been studied for 20 years or so. Some of these elements influence risk perception such as awfulness, unfamiliarity, the number of people exposed to it, other elements influence its acceptance such as individual perceptions, social factors, ethics and equity. Their knowledge allows a better understanding of the evolution of perception and of the risk acceptability in general and transfusion risk in particular.

The aim of this study was to analyze outcome in patients enrolled in sentinel node biopsy procedure in early-staged cutaneous melanoma.Therefore a prospective study was conducted enrolling patients presenting with early-staged cutaneous melanoma. Our study focused on age and sex, duration from diagnosis to treatment, duration of hospitalization, dressing care and work inability in current follows. Duration from scintigraphy to surgery was analyzed and compared to sensibility of the procedure. What is more we observed rate and kind of complications and economical consequences, increasing duration of dressing care and work inability. The authors aimed at evaluating costs of SLN procedure including hospitalization, lymphoscintigraphy, general anaesthesia, costs of dressings, inability and overcosts of complications.Forty-five patients were enrolled in our study (sex-ratio 1/2) mean aged 60 years old. Duration from diagnosis to treatment was mean 36 days. Sensibility of the procedure was excellent in trunk and limbs cases, lower in head and neck. In current cases patients were mean hospitalized three days, underwent 20 days of dressings and work inability depended on further interferon treatment. Complications occurred in 25% as seroma or local infections requiring antibiotherapy. Duration to healing was then 45 days increasing inability. Global costs of SLN procedure were significantly higher than previous wait and watch policy.SLN biopsy is an expensive and invasive procedure with a high rate of complications. It defers melanoma treatment, only way to gain survival.

The precautionary principle first appeared in France during the health crisis following the contamination of patients with HIV via blood transfusion. This study analyses whether the risk associated with blood transfusion was taken into account early enough considering the context of scientific uncertainty between 1982 and 1985. The aim was to evaluate whether a precautionary principle was applied and whether it was relevant. First, we investigated the context of scientific uncertainty and controversies prevailing between 1982 and 1985. Then we analysed the attitude and decisions of the French authorities in this situation to determine whether a principle of precaution was applied. Finally, we explored the reasons at the origin of the delay in controlling the risk. Despite the scientific uncertainties associated with the potential risk of HIV contamination by transfusion in 1983, we found that a list of recommendations aiming to reduce this risk was published in June of that year. In the prevailing climate of uncertainty, these measures could be seen as precautionary. However, the recommended measures were not widely applied. Cultural, structural and economic factors hindered their implementation. Our analysis provides insight into the use of precautionary principle in the domain of blood transfusion and, more generally, medicine. It also sheds light on the expectations that health professionals should have of this principle. The aim of the precautionary principle is to manage rather than to reduce scientific uncertainty. The principle is not a futile search for zero risk. Rather, it is a principle for action allowing precautionary measures to be taken. However, we show that these measures must appear legitimate to be applied. This legitimacy requires an adapted decision-making process, involving all those concerned in the management of collective risks.

The aim of this study was to establish the status of the means of information and to search for the variability in risk estimation.A questionnaire has been mailed to a hundred plastic surgeons randomly sorted among the habilitation list to be returned in an anonymous enclosed envelope. This random sample comprised 50 liberal practioners and 50 plastic surgeons working at hospital. The first part of this questionnaire dealed with basic data such as the type of activity (reconstructive or aesthetic), years of experience and means of information. The second part dealed in seven items with the most important preoperative information to be given to the patient and the most feared complications according to each surgeon before a reduction mammaplasty and abdominoplasty.A total of 50 (50%) of the 100 questionnaires were returned. Years of experience influenced significantly the importance given to information and the way of transmitting it. Important variability existed between the surgeons' answers. Moreover, current complications were in many cases never mentioned. Risk estimation depended on the experience of the surgeon and the information procedures were influenced by the surgeon's type of activity.Important variability in risk estimation exists among the plastic surgeons leading to an important variability in the kind and way of delivering information.

France has a population of about 60 million peoples and each ten years data about the standard of living are collected by the central bureau of statistics, we considered the collection of data on 5000 households in 1999 in our geographical area would afford a unique opportunity to compare the equivalent status of French adults with repaired cleft of the lip and palate (CLP). Aspects of social adjustment were investigated in a sample of 82 French adults 18-35 years old with repaired complete unilateral cleft of the lip and palate (CLP). All subjects received a standardized regimen of care from the Burgundy cleft palate team of Dijon. The investigation, based on response to a questionnaire, partly replicated a national survey of social and economic life in the population (Standard of living survey Burgundy, INSEE France 1999), so that adults with complete clefts could be compared with a large control sample of the same age. The control group was constituted by subjects between 18 and 35 years in the standard of living survey Burgundy 1999, INSEE France, they were taken from a regional probability sample of households. This report covers education, employment, and marriage. The significant difference between groups was assessed by: Student's t-test or analysis of variance for continuous variables and chi2 test for categorical variables. The results demonstrated that there are significant differences in educational attainment and employment between adults with cleft of the lip and palate and other people. Fewer with cleft of the lip and palate marry, and when they marry they do so later in life, scholarship history showed significant delay in the cleft of the lip and palate group, independence regarding housing was lower in the cleft of the lip and palate group. If cleft of the lip and palate adults functioned within normal limits with regard to employment. However, levels of income were substantively lower than control groups. It would appear that cleft subjects experience some limitation in their ability to secure vocational and economic rewards from society. As a conclusion we can say regarding our results that the cleft of the lip and palate group, even with the smallest degree of malformation (unilateral without associated malformation), showed a significant delay in the independence process.

International audience; BACKGROUND: In France, when a new medical technology is to be applied experimentally to human beings, it must adhere to the principles stipulated by the Huriet-Serusclat law on biomedical research. This law requires that the validation of a protocol applicable to human beings, with its corollary protection and information dimensions, is first submitted to a research committee, known as a Consultative Committee Protecting Persons in Biomedical Research (CCPPRB). We aimed to survey the competence of these committees in biotechnology, and whether or not intracytoplasmic sperm injection (ICSI) had been considered by the committees as being an innovative treatment. METHODS: We presented each of France's 48 CCPPRBs with a questionnaire to assess the choices and criteria for making decisions that arose at the time ICSI was implemented in the different centres in each region. FINDINGS: 36 committees took part. We found that ICSI had been largely introduced in settings outside the scope of the CCPPRBs and of the framework fixed by the law on biomedical research. Only three centres for medically assisted reproduction had submitted applications to a CCPPRB, although ICSI has been implemented in over 20 centres. 21 (58%) committees were of the opinion that the implementation of ICSI could have come under their supervision. 24 (67%) committees believed that, independently of their own involvement, evaluation procedures for ICSI should have been specified before centres decided to introduce it. INTERPRETATION: We observed important differences in the way CCPPRBs handled ICSI as being within or outside the medical research field. The status of the research committees is legally and identically defined. However, committees did not agree on the definition of the limits of their action, and, therefore, their handling of the same issue differed. An inquiry is needed to define how, now that ICSI is done in many centres, it should adhere to principles of evaluation and safety already in existence for other medical technologies.

Between 1978 and 1990, 68 patients, operated on for secondary hyperparathyroidism (HPT), received a forearm intramuscular free autologous parathyroid graft (37 women and 31 men--mean age: 43 +/- 16 years). The transplantation (Wells technique) was performed in the same time as the total parathyroidectomy and the remaining parathyroid material after surgical resection was cryopreserved. The results were evaluated in term of clinical and/or radiological and/or biological response respectively 3 or 5.5 years later, depending of the realisation of a renal transplantation (n = 27) or not. Four patients were lost to follow-up and 4 died post-operatively, including a wrong diagnosis (60 patients evaluated). Mortality rate was 12% (5 cases out of 7 related to chronic renal insufficiency). In 3 patients (5%) the transplanted gland had to be removed because of recurrent HPT (1 graft hyperplasia; 2 wrong diagnosis: 1 cervical gland left over and 1 aluminium intoxication). Second cervicotomy was performed in 3 cases (5%) for remaining cervical parathyroid gland (2 cases) and false-positive Tallium-Technetium scan (1 case). Overall results were good or very good in 51 cases (85%). A review of the literature indicate that subtotal parathyroidectomy in not superior to the Wells technique and the latter remain the landmark technique in the authors' hands in order to treat secondary HPT.

The authors report 4 valvular replacements under cardiopulmonary bypass in chronic hemodialysis-dependent patients. The peri-operative management was the same in every case. The recent improvements of intensive care medicine amend this protocol. Considering the analysis of data from the literature and the results of our 4 valvular replacements these operations and coronary artery-bypass graft, can be scheduled with an acceptable risk in these patients. Because of the hemodynamic improvement secondary to the cardiac operation, which allows a better tolerance of hemodialysis, this surgery must not be delayed.

Results in a series of 24 total parathyroidectomies with immediate reimplantation in patients with chronic renal insufficiency are described, and the advantages of this method discussed. This technique avoids the complications of sub-total parathyroidectomy, and the very rare failures can be easily treated by local excision if it is velated to recurrence of hyperparathyroidism, or by further reimplantations in cases of hypoparathyroidism. Grafts are possible during a second stage, after several months of freezing, but a limit of 9 months should be suspected. This method is proposed as a routine measure in all cases of parathyroid hyperplasia.

80 pages; L'INCa publie un rapport sur les aspects éthiques relatifs au dépistage du cancer du sein. Issu des travaux du Groupe de Réflexion sur l'Ethique du Dépistage (GRED), ce rapport vise à nourrir la réflexion collective sur le dépistage organisé du cancer du sein en France, en apportant notamment des propositions d'évolution. Dans le cadre de ce travail, la réflexion éthique aborde les aspects pratiques du programme de dépistage organisé du cancer du sein tels que les modalités d'inclusion, d'information et de consentement, mais également des questions plus globales autour de la liberté individuelle en regard des devoirs collectifs et d'une organisation optimisée du système de santé. Les questions de l'information et du consentement ont été au centre des discussions du groupe, dans un contexte de débats sur la balance bénéfices/risques du dépistage du cancer du sein.