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International audience; ObjectiveTo describe clinical, biological, radiological presentation and W4 status in COVID-19 elderly patients.Patients and methodsAll patients ≥ 70 years with confirmed SARS-CoV-2 infection and hospitalized in the Infectious Diseases department of the Pitié-Salpêtrière hospital, Paris, France, from March 1st to April 15th 2020 were included. The primary outcome was death four weeks after hospital admission. Data on demographics, clinical features, laboratory tests, CT-scan findings, therapeutic management and complications were collected.ResultsAll in all, 100 patients were analyzed, including 49 patients ≥ 80 years. Seventy percent had ≥2 comorbidities. Respiratory features were often severe as 48% needed oxygen support upon admission. Twenty-eight out of 43 patients (65%) with a CT-scan had mild to severe parenchymal impairment, and 38/43 (88%) had bilateral impairment. Thirty-two patients presented respiratory distress requiring oxygen support ≥ 6 liters/minute. Twenty-four deaths occurred, including 21 during hospitalization in our unit, 2 among the 8 patients transferred to ICU, and one at home after discharge from hospital, leading to a global mortality rate of 24% at W4. Age, acute renal failure and respiratory distress were associated with mortality at W4.ConclusionA substantial proportion of elderly COVID-19 patients with several comorbidities and severe clinical features survived, a finding that could provide arguments against transferring the most fragile patients to ICU.

Introduction L’âge et les comorbidites sont les facteurs de risque de deces les plus clairement etablis au cours du COVID-19. L’objectif de notre travail etait de decrire la presentation clinique, biologique et radiologique des patients de plus de 70 ans hospitalises dans un service de maladies infectieuses et tropicales d’un ESR metropolitain pour une infection a Sars-CoV-2, et de determiner le taux de mortalite 4 semaines (S4) apres l’admission dans le service. Materiels et methodes Etude observationnelle monocentrique ayant inclus tous les patients ≥ 70 ans admis dans le service du 01/03 au 15/04/2020, pour un COVID-19 confirmee biologiquement. Critere de jugement principal : statut vital a S4 apres l’admission dans le service. Criteres de jugement secondaires : duree d’hospitalisation, plus haut debit d’oxygene administre, lieux de vie a S4 pour les survivants, facteurs clinicobiologiques associes au deces a S4. Resultats Cent patients furent inclus pour l’analyse, dont 59 % d’hommes, avec un âge median (IQR) de 79 ans (74–85). Cinquante-six pour cent avaient un score de Charlson ≥ 5 et 71 % avaient au moins 2 comorbidites [HTA (56 %), insuffisance cardiaque (31 %), demence (25 %), diabete (24 %) et/ou un cancer actif (21 %)]. Onze patients etaient sous immunosuppresseur et/ou corticoide au long cours. Soixante-dix pour cent etaient admis avant le 7e jour des symptomes, 55 % avaient un score NEWS-2 ≥ 3, et 22 % necessitaient une oxygenotherapie ≥ 3 litres/min a l’admission. Les symptomes les plus frequents etaient fievre (57 %), toux (50 %), dyspnee (36 %) et diarrhee (16 %). Une lymphopenie etait presente dans 80 % de cas et une insuffisance renale aigue a l’admission dans 32 %. Parmi les 41 patients ayant eu un scanner thoracique, 68 % presentaient une atteinte parenchymateuse moderee a severe (≥ 25 %), 57 % une atteinte bilaterale. Une oxygenotherapie ≥ 6 litres/min a ete necessaire pour 32 patients en mediane 8 jours apres le debut des symptomes. Trente-deux pour cent ont recu des antibiotiques, 30 % de l’hydroxychloroquine et 7 % des corticoides. Le taux de mortalite a S4 etait de 24 % (20 % chez les 70–79 ans, 31 % chez les 80–89 ans, 30 % chez les ≥ 90 ans), incluant 19 deces survenus pendant l’hospitalisation. Quarante-quatre pour cent des survivants etaient au domicile a S4 et 21 % en SSR. En analyse multivariee, seules l’insuffisance renale aigue a l’admission (OR : 73,8, IC95 % : 5,7–3721,2, p = 0,006) et une duree d’hospitalisation plus courte (7,1 vs. 11,1 jours, OR : 0,70, IC95 % : 0,47–0,88, p = 0,017) etaient significativement associees au deces. Conclusion Le taux de mortalite lors de l’epidemie de COVID des patients âges de plus de 70 ans est de 19 %. Le deces survenait dans les premiers jours d’hospitalisation temoignant de l’aggravation brutale autour de j7–9. Toutefois certains patients malgre un âge avance et de nombreuses comorbidites ont survecu malgre des besoins en oxygene massifs et sans traitement etiologique efficace.

To assess preferences among individuals aged ≥80 years for a future hypothetical critical illness requiring life-sustaining treatments. Observational cohort study of consecutive community-dwelling elderly individuals previously hospitalised in medical or surgical wards and of volunteers residing in nursing homes or assisted-living facilities. The participants were interviewed at their place of residence after viewing films of scenarios involving the use of non-invasive mechanical ventilation (NIV), invasive mechanical ventilation (IMV), and renal replacement therapy after a period of invasive mechanical ventilation (RRT after IMV). Demographic, clinical, and quality-of-life data were collected. Participants chose among four responses regarding life-sustaining treatments: consent, refusal, no opinion, and letting the physicians decide. The sample size was 115 and the response rate 87 %. Mean participant age was 84.8 ± 3.5 years, 68 % were female, and 81 % and 71 % were independent for instrumental activities and activities of daily living, respectively. Refusal rates among the elderly were 27 % for NIV, 43 % for IMV, and 63 % for RRT (after IMV). Demographic characteristics associated with refusal were married status for NIV [relative risk (RR), 2.9; 95 % confidence interval (95 %CI), 1.5–5.8; p = 0.002] and female gender for IMV (RR, 2.4; 95 %CI, 1.2–4.5; p = 0.01) and RRT (after IMV) (RR, 2.7; 95 %CI, 1.4–5.2; p = 0.004). Quality of life was associated with choices regarding all three life-sustaining treatments. Independent elderly individuals were rather reluctant to accept life-sustaining treatments, especially IMV and RRT (after IMV). Their quality of life was among the determinants of their choices.

Los cuidados paliativos constituyen un conjunto de cuidados activos basados en una gestion multidisciplinaria y multiprofesional en la que el control del paciente es global, fisico y psiquico, en su marco sociofamiliar y espiritual. El enfoque comunitario de estos pacientes ha dejado paso a una gestion institucional destinada a garantizar la calidad en su asistencia. La legislacion francesa organiza los cuidados paliativos dentro de sus estructuras y garantiza los derechos de los pacientes.

El «tratamiento» de un paciente que recibe cuidados paliativos incluye una valoracion rigurosa, en el marco mas general del proceso paliativo. Esta valoracion, mediante la clinica y pruebas complementarias, permite realizar un estudio de las necesidades del enfermo y proponer medidas adaptadas que se relacionan principalmente con los sintomas incapacitantes que siente o expresa el paciente, teniendo siempre en cuenta sus deseos y la fase evolutiva de la enfermedad. La expresion «cuidados paliativos» pone de manifiesto el hecho de que se integran en un marco terapeutico, por lo tanto multiprofesional y multidisciplinario, al que se asocia la participacion de voluntarios. Se relacionan con el paciente que padece una enfermedad grave y evolutiva, en un marco biopsicosocioespiritual, es decir, una persona enferma que vive en un entorno social y familiar, con sus creencias filosoficas o religiosas y su psique. Los cuidados paliativos se organizan y se institucionalizan progresivamente, siendo regulados por decretos y leyes. Este articulo tratara principalmente de terapeutica. Huelga decir que cualquier indicacion o abstencion de tratamiento depende del estado del paciente, de sus deseos y de las informaciones aportadas por su entorno.

La «gestione» di un paziente che beneficia di cure palliative integra una valutazione rigorosa, nel quadro piu globale dell’iter palliativo. Questa valutazione, clinica e di laboratorio, permette un bilancio delle esigenze della persona malata e la proposta di misure appropriate. Queste riguardano in particolare i sintomi invalidanti avvertiti o espressi dal paziente, tenendo sempre conto dei suoi desideri e della fase evolutiva della malattia. L’espressione «cure palliative» pone in primo piano il fatto che esse si integrano in un quadro di cure, pertanto multiprofessionale e multidisciplinare, al quale si associa la partecipazione di volontari. Esse riguardano il paziente che soffre di una malattia grave ed evolutiva, in un approccio bio-psico-socio-spirituale, vale a dire di una persona, malata, che vive in un ambiente sociale e familiare, con le sue credenze filosofiche o religiose e la sua psiche. Le cure palliative si organizzano e si istituzionalizzano progressivamente e sono disciplinate in Francia da differenti leggi e decreti. Questo capitolo trattera essenzialmente la terapia. Va da se che tutte le indicazioni al trattamento o le astensioni da esso sono poste secondo lo stato del paziente, i suoi desideri e le informazioni raccolte presso le persone vicine.

The issue of intensive and palliative care in patients with chronic disease frequently arises. This review aims to describe the prognostic factors of chronic respiratory diseases in stable and in acute situations in order to improve the management of these complex situations. The various laws on patients' rights provide a legal framework and define the concept of unreasonable obstinacy. For patients with chronic obstructive pulmonary disease, the most robust decision factors are good knowledge of the respiratory disease, the comorbidities, the history of previous exacerbations and patient preferences. In the case of idiopathic pulmonary fibrosis, it is necessary to know if there is a prospect of transplantation and to assess the reversibility of the respiratory distress. In the case of amyotrophic lateral sclerosis, treatment decisions depend on the presence of advance directives about the use of intubation and tracheostomy. For lung cancer patients, general condition, cancer history and the tumor treatment plan are important factors. A multidisciplinary discussion that takes into account the patient's medical history, wishes and the current state of knowledge permits the taking of a coherent decision.

The modified French version of the Appropriateness Evaluation Protocol (AEPf) has been validated. Inappropriate days according to simple medical and technical criteria are identified with this tool. The aim of this study is to highlight the interest of investigating the reasons for inappropriate days and to assess the inter-observers reliability of the questionnaire developed for this purpose.This questionnaire collects on one hand the needs of patients - distinguishing health care and accommodation needs - and on the other hand the reasons for inappropriate hospital days. The data were collected from January to September 1998 in nine voluntary medical and surgical departments. For each day of study randomly selected, each inappropriate hospital day according to AEPf has been included. Data were collected by two health professionals (a nurse and a physician), using a concurrent design.The reliability of the over-ride option of the appropriateness assessment of the 345 hospital days was good (overall Kappa coefficient: 0.66; 95% CI: 0.55-0.78). The comparison of the two expert judgments on health care needs fulfilled during the hospital day was acceptable; the Kappa coefficient was 0.62 (95% CI: 0.52-0.72). The reliability of expert assessment on patient accommodation needs (home, housing facilities or hospital) was good (Kappa coefficient: 0.67; 95% CI: 0.60-0.75). When hospital was not the accommodation the most adapted for patient, the reliability of the reasons for inappropriate days was high (Kappa coefficient: 0.75; 95% CI: 0.61-0.80). Kappa coefficients were different between hospitals, indicating a center effect.This instrument has been found to be reliable and should be used in complement of the first part of the AEPf which assess the prevalence of inappropriate days. It might help to detect dysfunctions within or outside the hospital and thus be used for evaluation or planning of health care.

e20649 Background: In order to optimize supportive care for cancer patients, we proposed them to fill a short questionnaire evaluating their potential complaints and we evaluated the concordance of their answers with the perception of their referent physician. Methods: Patients seen in consultation in an oncology unit were proposed to answer anonymously to 7 questions designed to identify potential social, psychological, nutritional problems or uncontrolled pain. Their physician answered to a similar questionnaire. Physicians were blinded to patients’ answers. Results: 155 patients accepted to complete the questionnaire. Median age was 60 yrs [21–85], 45% of patients were in metastatic setting. 70% of patients reported at least one problem, especially in the field of potential social problems (35%) or sleep disorders (25%). Concordance between patients and physicians was high for psychological support need (81%) or nutritional problems (87%) but was lower for social problems (62%) or uncontrolled pain (69%). Physicians tended to underestimate patients’ problems and missed social issues for 30% of patients or sleep disorders for 18% of patients. On the contrary and surprisingly, physicians overestimate patients’ complaints about uncontrolled pain (underestimation in 9% of cases but overestimation in 20% of cases for the item). Conclusions: Discordance between physicians and patients’ perception of supportive care needs emphasizes the importance of extending the use of screening tolls in daily practice. No significant financial relationships to disclose.