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Objectives Psychological consequences of grief among relatives are insufficiently known. We reported incidence of prolonged grief among relatives of deceased patients with cancer. Methods Prospective cohort study of 611 relatives of 531 patients with cancer hospitalized for more than 72 hours and who died in 26 palliative care units was conducted. The primary outcome was prolonged grief in relatives 6 months after patient death, measured with the Inventory Complicated Grief (ICG > 25, range 0–76, a higher score indicates more severe symptoms) score. Secondary outcomes in relatives 6 months after patient death were anxiety and depression symptoms based on Hospital Anxiety and Depression Scale (HADS) score (range 0 [best]–42 [worst]), higher scores indicate more severe symptoms, minimally important difference 2.5. Post-traumatic stress disorder symptoms were defined by an Impact Event Scale-Revised score >22 (range 0–88, a higher score indicates more severe symptoms). Results Among 611 included relatives, 608 (99.5%) completed the trial. At 6 months, significant ICG scores were reported by 32.7% relatives (199/608, 95% CI, 29.0–36.4). The median (interquartile range ICG score) was 20.0 (11.5–29.0). The incidence of HADS symptoms was 87.5% (95% CI, 84.8–90.2%) at Days 3–5 and 68.7% (95% CI, 65.0–72.4) 6 months after patient’s death, with a median (interquartile range) difference of −4 (–10 to 0) between these 2 time points. Improvement in HADS anxiety and depression scores were reported by 62.5% (362/579) relatives. Significance of results These findings support the importance of screening relatives having risk factors of developing prolonged grief in the palliative unit and 6 months after patient’s death.

Resume Objectif de l’etude La place du domicile dans la fin de vie, est un sujet de societe. Il est pourtant l’objet d’un paradoxe : de nombreuses etudes montrent que les Francais souhaitent mourir au domicile et pourtant la majorite des deces se fait a l’hopital. En France, un des lieux de fin de vie, en milieu hospitalier, est l’unite de soins palliatifs. L’objectif principal de cette etude etait de d’evaluer l’impact de la provenance des patients accueillis en unite de soins palliatifs sur le taux de retour a domicile. L’objectif secondaire etait d’etudier si d’autres facteurs influencaient le retour a domicile des patients apres une hospitalisation en unite de soins palliatifs. Materiel et methodes Nous avons realise une etude retrospective monocentrique, sur les dossiers de patients ayant sejourne du 1er janvier 2019 au 31 decembre 2019 dans une unite de soins palliatifs parisienne. Les donnees recueillies etaient les modalites d’entrees et de sorties des patients, la presence d’un entourage et le suivi prealable a l’hospitalisation par l’equipe de soins palliatifs. Resultats Trente-neuf pour cent des patients etaient hospitalises directement de leur domicile dans l’unite de soins palliatifs. Les patients provenant du domicile rentraient plus au domicile, 32,5 % d’entre eux contre 7,6 % de ceux hospitalises a partir d’un autre service hospitalier. Le pourcentage de deces etait superieur pour les patients transferes d’un autre service (77,4 %) compare a ceux venant du domicile (67,5 %). Discussion Les patients hospitalises en unite de soins palliatifs directement du domicile passent plus de temps en fin de vie au domicile, d’autant plus s’ils sont suivis par l’equipe de soins palliatifs.

Resume Introduction Certains patients atteints de cancer presentent des difficultes sociales (presentes avant la maladie, ou y faisant suite). Cela entraine des difficultes dans le parcours de soins des patients, notamment par rapport au maintien a domicile. Nous avons cherche a determiner, par une etude prospective observationnelle, le nombre de patients estimant ne pas pouvoir rentrer a domicile pour des raisons sociales, les raisons de ces difficultes, et evaluer leurs besoins. Materiel et methodes Pendant 4 mois, nous avons interroges les patients en situation palliative precoce dans 2 services hospitaliers de l’Est parisien sur leur maintien a domicile et leur situation sociale, avec evaluation d’une possible precarite par le score EPICES. Nous avons interroge leur medecin et les soignants les prenant en charge, concernant la situation des patients et leurs besoins en termes d’aide et de soins. Resultats Sur les 235 patients interroges, 13 % (soit 30/235) estime avoir des difficultes sociales pour rester a domicile (raison de logement, financiere, et d’aide). 70 % d’entre eux (soit 21/235) ont effectivement ete reperes par le medecin. Par ailleurs, celui-ci repere 18 % des patients comme ayant des difficultes a rester au domicile. Ces patients necessitent de l’aide pour les gestes du quotidien et pour certains soins. 54 % des patients interroges sont precaires d’apres le score EPICES. Seulement 25 % des patients ont rencontre au moins une fois un travailleur social, et 28 % des patients precaires. Conclusion Le nombre de patients ne pouvant rester a domicile est consequent et constitue donc un vrai probleme. La reflexion autour d’une structure particuliere pouvant les accueillir doit etre reflechi. Par ailleurs, le nombre de patients precaires est important. Pourtant peu de patient ont rencontres un travailleur social. L’accompagnement social des patients atteints de cancer est un sujet primordial qui doit etre mieux pense.

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.

Early palliative care is now recommended in international guidelines. A meta-analyze combining seven randomized studies has been published in 2007. It confirms that early palliative care improves patient's quality of life and reduces symptom burden. There is also a trend for the reduction of depressive disorder and the increase of overall survival. Other studies show that early palliative care improves quality of life of patient's relatives and reduces end of life care aggressiveness. Most of the time, early palliative care is introduced as soon as the diagnosis of advanced cancer is made, and the precise referral criteria need to be addressed. Other studies have assessed the palliative care consultation; patient-centered care, focusing on symptom management, filling information and education needs about illness and prognosis, helping psychologic adaptation and coping.

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.

Context Advance care planning is essential to enable informed medical decisions to be made and to reduce aggressiveness in end-of-life (EOL) care. Objectives This study aimed to explore whether a question prompt list (QPL) adapted to French language and culture could promote discussions, particularly on prognosis and EOL issues, among advanced cancer patients attending outpatient palliative care (PC) consultations. Methods In this multicenter randomized study, patients assigned to the intervention arm received a QPL to help them prepare for the next consultation one month later. The main inclusion criteria were advanced cancer patients referred to the PC team with an estimated life expectancy of less than one year. The primary endpoint was the number of questions raised, globally and by topic. The secondary objectives were the impact of the QPL on psychological symptoms, quality of life, satisfaction with care, and coping styles at two months. Results Patients (n = 71) in the QPL arm asked more questions (mean 21.8 vs. 18.2, P = 0.03) than patients in the control arm (n = 71), particularly on PC (5.6 vs. 3.7, P = 0.012) and EOL issues (2.2 vs. 1, P = 0.018) but not on prognosis (4.3 vs. 3.6, not specified). At two months, there was no change in anxiety, depression, or quality of life in either arm; patient satisfaction with doctors' technical skills was scored higher (P = 0.024), and avoidance coping responses were less frequent (self-distraction, P = 0.015; behavioral disengagement, P = 0.025) in the QPL arm. Conclusion Questions on PC and EOL issues in outpatient PC consultations were more frequent, and patient satisfaction was better when a QPL was made available before the consultation.

Early palliative care is now recommended in international guidelines. A meta-analyze combining seven randomized studies has been published in 2007. It confirms that early palliative care improves patient's quality of life and reduces symptom burden. There is also a trend for the reduction of depressive disorder and the increase of overall survival. Other studies show that early palliative care improves quality of life of patient's relatives and reduces end of life care aggressiveness. Most of the time, early palliative care is introduced as soon as the diagnosis of advanced cancer is made, and the precise referral criteria need to be addressed. Other studies have assessed the palliative care consultation; patient-centered care, focusing on symptom management, filling information and education needs about illness and prognosis, helping psychologic adaptation and coping.

This overview reports published data about the interaction between physical activity and sport during and after cancer on one hand and improvement in psychological parameters, survival and biological mechanisms underlying this effect on the other hand. Practising physical activity and sport during cancer modifies parameters assessing fatigue and quality of life and reduces symptoms of depression. An association also exists between the practise of physical activity and sport and overall and cancer-specific survivals, especially after breast cancer, colon cancer and prostate cancer. These benefits seem to be mediated by a modification of circulating levels of estrogens, insulin, IGF-1 and by a decrease in insulin-resistance, by alterations in the secretion of adipokines, and by a reduction in chronic inflammation through decreased levels of cytokines. There exist some obstacles to the practise of physical activity. These obstacles are mainly related to a fear of pain induced by physical activity and to overweight. These programmes of physical activity and sport cannot be offered to all patients since there are several contra-indications, with some being present since the initial visit and others appearing during cancer management either due to disease progression or related to iatrogenic effects. Whereas benefits from physical activity and sport among cancer patients seem obvious, there are still several pending clinical and biological issues.

A prospective phase II multicenter study was performed in two steps in paclitaxel-treated ovarian cancer patients in France. A French version of the four-item Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity (FACT/GOG-Ntx) questionnaire was validated. This was then used to evaluate neurotoxicity in relation to erythropoietin treatment. Patients received standard second-line paclitaxel-based chemotherapy and erythropoietin for anemia. Neurotoxicity and hemoglobin levels were evaluated every cycle with the FACT/GOG-Ntx and NCI-CTCAE. The translated questionnaire was tested in 20 patients to confirm the translation accuracy. The final questionnaire was validated in 98 patients with internal consistency (Cronbach’s coefficient) and item correlation (Pearson’s r coefficient) tests. Neurotoxicity severity was analyzed according to erythropoietin intake (first three cycles versus no or late intake) and correlated with anemia. Patients received a median of six paclitaxel cycles (range 1–9). Neurotoxicity was validated in 484 questionnaires. Internal consistency was excellent with Cronbach’s coefficients of ≥0.89 at inclusion, after 3 cycles and at study end. Inter-question correlation was high with Pearson’s coefficients of 0.65–0.85. FACT/GOG-Ntx and NCI-CTCAE severity scoring was similar. Globally, the incidence of severe neurotoxicity (FACT/GOG-Ntx and NCI-CTCAE) was found significantly higher in patients with severe anemia. Of 98 evaluable patients, 31 received erythropoietin during the first three cycles. Mean hemoglobin level was significantly lower in this group from baseline to cycle 4; however, these anemic patients with early EPO intake did not develop an increase rate of severe neurotoxicity. The French FACT/GOG-Ntx questionnaire is a reliable and valid tool for assessing chemotherapy-induced neuropathy. This study raises the possibility that erythropoietin might play a neuroprotective role when administered with paclitaxel.

Objective: We assessed whether breast cancer survivors' (BCSs) supportive care needs, posttraumatic growth (positive psychological changes) and satisfaction with doctors' interpersonal skills could be related to physical activity (PA). Methods: A total of 426 BCSs were approached during the last week of treatment. Eight months later, 278 (65%) provided information on their PA levels. Ordinal logistic multiple regressions were performed. Results: PA levels included no PA (n = 68), some PA (n = 83), high PA levels more than twice or more than 2 h per week (n = 127). The multivariate model significantly explained 13% of PA variance (p = 0.001). An increase in posttraumatic growth total scores (proportional OR = 1.310; p < 0.05) and a decrease in physical and daily living supportive care needs subscale scores (proportional OR = 0.980; p < 0.001) and in satisfaction with doctors' interpersonal skill scores (proportional OR = 0.898; p < 0.05) were significantly associated with an increase in the likelihood of performing higher levels of PA. A lower educational level was associated with a decrease in the likelihood of performing PA. Conclusion: The prevalence of PA in BCSs should be improved. Positive psychological changes after a breast cancer experience might contribute to performing PA. Encouraging PA needs to be accompanied by the alleviation of physical symptoms.

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.

Objective: To provide a qualitative description of a clinical pilot experiment in a French cancer center, conducted by a nurse after the treatment decision consultation attended by new cancer patients during the initial phase of the care process. Methods: The Psychological Distress Thermometer (PDS) and a problem checklist were administered to 255 patients before nurse consultation, helping her to manage the clinical interview, explore patient's distress and supportive care needs, and finally refer the patients in need to the required Supportive Care units. Results: Patients were primarily referred to the social service unit (35% patients), followed by the physiotherapy unit (23.9%) and the psycho-oncology unit (19.6% of patients). In cases of significant distress (43% patients with PDS>3), the percentage of patients referred to the psychosocial units increased (44% referred to the Social Unit, 35% to the Psycho-Oncology Unit). However, the main interest of our screening procedure resides in its qualitative and didactic dimension, based on clinical training and cooperation with healthcare professionals during the process of investigating patients' distress and their supportive care needs. Difficulties and limitations are also described. Conclusions: This first clinical experiment conducted among dedicated nurses involved in a Therapeutic Decision Consultation in a French cancer center has provided evidence in support of the idea that non-specialist professionals are able to identify patients' distress and their Supportive Care needs (particularly in the psychosocial field) provided that they have received appropriate training. Copyright © 2011 John Wiley & Sons, Ltd.

The medical information becomes integrated into a communications strategy, the generally admitted model of which is centered on the patient; that is in the listening of these concerns and these values. The medical quality information is facilitated by the preliminary collection of the symptoms and the needs of the patients thanks to the questionnaires of quality of life, if they are used during the consultation to direct the discussion. Satisfactory medical information includes a discussion about the questions of the patients in terms of outcomes. Patient's individual factors can influence the need of medical information, as the age and the pathology. Patient's needs can also vary with time and according to the phase of the disease. Cultural factors are essential, in particular as regards the information about prognosis. Tools to help giving the medical information are now validated as the audio cassettes or video. Those tools can take the shape of a prompt list to help patients to ask questions. The majority preference of style of participation in the medical and therapeutic decisions and is the collaborative mode. Physician's attitude is determinant to leave the patients who wish it to have an active role, what allows them a very beneficial feeling psychologically of control over the disease. Decision-making helps are successfully sometimes elaborated to support the participation of the patients. In palliative phase, the need of medical information about prognosis associated with preservation of hope is not still understood by physicians who oscillate between saying the all or none. Honest information at the right time is the majority wish of the patients, although certain patients adopt clearly a strategy of avoidance. The medical communication requires a specific training on this subject. Talking time must be opened to the doctors to approach the relational problems which they meet. The clinical research has to continue to understand better the interactions in doctors/patients communication.

The objective of this study was to assess the prevalence and associated factors of sexual activity, sexual problems or sexual satisfaction in French early-stage breast cancer survivors (BCS).Eight hundred and fifty eligible, post-treatment (6 months-5 years) female patients, aged 18-70 years, randomly selected from a consultation list, were invited to fill in questionnaires exploring quality of life (EORTC QLQ-C30 and QLQ-BR23), body image scale, and sexuality (Sexual Activity Questionnaire-SAQ; Relationship and Sexuality Scale; French Sexual Behaviour Survey-CSF).Fifty-three percent of BCS agreed to participate. Participating women (n=378) were younger, more often premenopausal at diagnosis and with a more recent diagnosis than non-respondents. The prevalence of sexual problems was significantly higher in BCS compared with adjusted data from a French female representative sample (p0.0001). In logistic regression, no sexual activity (R(2) =0.37) or sexual dissatisfaction (R(2) =0.28) were associated with the feeling of emotional separation in the couple or of partner's fear of sexual intercourse, lower emotional functioning, poorer body image, or co-morbidities. In sexually active women (71% of respondents), lower frequency of sexual activity (R(2) =0.26), lower sexual pleasure (R(2) =0.22), or higher sexual discomfort (R(2) =0.22) were associated with the feeling of emotional separation in the couple or of partner's fear of sexual intercourse, lower emotional functioning, age (50 years), nausea, or insomnia (all Hosmer-Lemeshow tests: p=NS).Psychological factors including the perception of the couple relationship appeared prominent in BCS women's experience of sexual problems.

This pilot study was designed to evaluate the impact of management by the Interdisciplinary Supportive Care Department for Cancer Patients (Département Interdisciplinaire de Soins de Support pour le Patient en Oncologie-DISSPO) at the Institut Curie in Paris, France on patient quality of life and satisfaction with care.Patients hospitalised for cancer treatment and referred to DISSPO during their hospitalisation were invited to complete the European Organization for Research and Treatment of Cancer core quality of life (EORTC QLQ-C30) and patient satisfaction (EORTC IN-PATSAT32) questionnaires during the week following their initial management by DISSPO (T0) and 2 months later (T1). These patients were compared with control patients matched for age, gender, ward and period of hospitalisation in terms of quality of life and satisfaction with care.One hundred fourteen (77%) DISSPO patients at T0 and 72 (48%) patients at T1 and 102 (89%) control patients at T0 and 66 (57%) at T1 returned their completed questionnaires. Baseline characteristics of DISSPO patients and control patients were significantly different in terms of duration of the current hospitalisation, interval between the date of diagnosis of the cancer and inclusion in the study (both longer for DISSPO patients) and Karnofsky performance status (lower for DISSPO patients). For the 43 pairs of patients who completed the questionnaires at the two time points, significant independent positive effects of management by DISSPO and age (less than or equal to 60 years) were demonstrated for patient satisfaction in relation to the availability of the nursing and paramedical team. In particular, patients over the age of 60 not managed by DISSPO presented a significant reduction of patient satisfaction scores over the 2 months compared to age-matched patients managed by DISSPO.Management of cancer patients by an interdisciplinary supportive care department appears to have a positive impact on patient satisfaction in relation to availability of the nursing and paramedical team. These results need to be confirmed in a larger study.

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.

Objective:To improve the palliative care and more effectively meet the needs of young patients and their families at the end of life, the authors investigated the place of death of adolescents and young adults treated in their institution and identified some of the factors influencing the choice of place of death.Methods:The parents and/or partners of adolescents and young adults (15 to 25 years old) who died at Institut Curie (cancer center) between 2000 and 2003 were contacted. Twenty-one families agreed to participate in the interview between October 2005 and April 2006. Analysis of the interviews comprised a descriptive part and a thematic part.Results:Nineteen out of 21 (90%) families declared that they did not really choose their child's place of death due to lack of time. However, all families said that they preferred the hospital. No family attended a bereavement group after their child's death and only 3 families (14%) consulted a mental health care professional. Thematic analysis showed that representations and beliefs concerning life and death at least partly determined the family's capacity to discuss the place of death with their child.Significance of results:Although progress has been made over recent years in France, there is still considerable room for improvement of palliative care to more effectively meet the needs of young patients and their families at the end of life.

In this article we highlight the main points of the development of bioethics and ethics committees in France. We argue that the French cultural context of medicine and its current political transformations favor new models of hospital ethics committee and we provide an example of such a model developed at Paris's Institut Curie, the oldest French cancer treatment and research centre.

Lorsqu’un patient atteint d’une maladie chronique incurable arrive a la phase ultime de sa vie, les soignants et ses proches se sentent souvent tres demunis devant l’impossibilite qu’ils ont de trouver une solution pour guerir le patient — ou au minimum pour ameliorer sa survie. Leurs priorites se recentrent alors le plus souvent sur deux objectifs: i) permettre au patient d’acceder a un confort maximal avec des traitements symptomatiques adaptes; ii) exaucer les souhaits du malade lorsqu’ils sont realistes. Selon une etude realisee en France en 2003, 57 % des personnes interrogees sur leur lieu de deces souhaite repondent a domicile (Beuzart, 2003). Cette enquete faite en population generale (pour des personnes a priori en bonne sante) est corroboree par les resultats retrouves aupres de patients suivis dans le cadre d’un reseau de soins palliatifs parisien (Ensemble) ou 60 % des patients expriment le souhait de deceder a domicile (21 % en hospitalisation et 19 % n’abordent pas le sujet) (Mauviel, 2005). Les recherches faites a l’etranger montrent des resultats relativement similaires: en Grande-Bretagne, jusqu’a 58 % des patients en phase terminale souhaitent deceder a domicile (Seale, 1994). Actuellement, seuls 26 % des Francais decedent a domicile et rarement dans le contexte d’une maladie chronique (Insee, 2000). Dans cet article, nous allons donc etudier successivement les facteurs qui peuvent participer au choix du lieu de fin de vie pour un patient cancereux dans le contexte francais actuel puis les facteurs pronostiques qui permettent a un patient ayant eu la possibilite de choisir le domicile de rester chez lui jusqu’a son deces.

The concept of continuous and global care is acknowledged today by all as inherent to modern medicine. A working group gathered to propose models for the coordination of supportive care for all severe illnesses in the various private and public health care centres. The supportive care are defined as: "all care and supports necessary for ill people, at the same time as specific treatments, along all severe illnesses". This definition is inspired by that of "supportive care" given in 1990 by the MASCC (Multinational Association for Supportive Care in Cancer): "The total medical, nursing and psychosocial help which the patients need besides the specific treatment". It integrates as much the field of cure with possible after-effects as that of palliative care, the definition of which is clarified (initial and terminal palliative phases). Such a coordination is justified by the pluridisciplinarity and hyperspecialisation of the professionals, by a poor communication between the teams, by the administrative difficulties encountered by the teams participating in the supportive care. The working group insists on the fact that the supportive care is not a new speciality. He proposes the creation of units. departments or pole of responsibility of supportive care with a "basic coordination" involving the activities of chronic pain, palliative care, psycho-oncology, and social care. This coordination can be extended, according to the "history" and missions of health care centres. Service done with the implementation of a "unique counter" for the patients and the teams is an important point. The structure has to comply with the terms and conditions of contract (Consultation, Unit or Centre of chronic pain, structures of palliative care, of psycho-oncology, of nutrition, of social care). A common technical organization is one of the interests. The structure has to set up strong links with the private practitioners, the networks, the home medical care (HAD) and the nurses services at home (SSIAD), when they exist, to guarantee the continuity of the supportive care under all its aspects and in order to take into account the preferences of the patients. According to Hospital 2007 propositions, the extended, flexible and general purpose Group of Sanitary Cooperation (GCS) meets the necessities inherent to the structures of supportive care within the territories of health because it can be established between one or several health care centres and the private health professionals, thus favouring the cooperation between public and private health care centres. PSPH and general medicine.

Ni comite d’experts, ni structure de formation, le Projet ethique de l’Institut Curie ouvre une nouvelle voie a la demarche ethique en soutenant la reflexion des professionnels dans leurs prises de decision.