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The better understanding of the molecular, cellular, and immunological mechanisms of cancer has led to the development of targeted therapies, then immunotherapy, which have changed the approach to cancer treatment. While these treatments differ from chemotherapy in their mechanisms of action, they also allow for increased personalization of cancer care through the development of technologies that target patients more precisely. However, they are associated with several challenges: the management of uncertainty associated with their risk-benefit balance due to the lack of long-term data and sometimes scientific evidence on their effects; the complexity of integrating molecular and immunological data into the therapeutic decision; the challenge of inequalities in access to these treatments often considered revolutionary due to the required molecular characterization and/or inclusion criteria for early-phase trials; and the challenge of their appropriation and adoption by physicians and patients. This narrative review explores each of these challenges in the context of shared decision-making, the promotion of which is a guarantee of quality and safety of care for cancer patients., (Copyright © 2024 Société Française du Cancer. Published by Elsevier Masson SAS. All rights reserved.)

Context: At least 40% of cancers are linked to environmental or behavioral factors, and dietary behavior appears to be a major lever. Epidaure Market is a prevention initiative developed using a method for co-constructing health promotion initiatives and prevention programs that stratifies evidence from the scientific literature and combines it with experiential knowledge (DEVA, TPB, BCT). It promotes a sustainable diet (i.e., healthy, ecological and ethical nutrition) among 5th and 4th grade students during the crucial period of adolescence, when these behaviors are often far from the recommendations., Method: The protocol implemented was carried out in 72 middle school classes in the Montpellier and Dijon academies. The intervention included teaching sessions and a virtual supermarket game, integrated into the school curriculum and delivered by science teachers. Effectiveness is tested in a cluster randomized controlled trial with 3 evaluation times (pre- and post-intervention and 1 follow-up). The study also includes an implementation assessment, with process analysis and implementation elements, as well as a transferability assessment based on key functions (FIC model and Astaire grid)., Expected Outcomes: The study is still underway within the school. The primary expected outcome is a positive influence on the motives underlying food choices to move towards a sustainable diet. Secondary expectations involve changes in variables such as self-efficacy and perceived social norms, as well as an increase in knowledge about healthy eating. We also expect the qualitative approaches to provide information on the deployment process in the new territories., Discussion: The study aims not only to demonstrate the effectiveness of Epidaure Market, but also to identify the optimal conditions for its nationwide implementation in France's middle schools. Ultimately, the initiative aims to help reduce the incidence of cancer by promoting healthier eating habits among teenagers., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Curnier et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: Critical illness is associated with long-term increased mortality and impaired quality of life (QoL). We assessed whether multidisciplinary consultations would improve outcome at 12 months (M12) after intensive care unit (ICU) discharge., Methods: We performed an open, multicenter, parallel-group, randomized clinical trial. Eligible are patients discharged alive from ICU in 11 French hospitals between 2012 and 2018. The intervention group had a multidisciplinary face-to-face consultation involving an intensivist, a psychologist, and a social worker at ICU discharge and then at M3 and M6 (optional). The control group had standard post-ICU follow-up. A consultation was scheduled at M12 for all patients. The QoL was assessed using the EuroQol-5 Dimensions-5 Level (Euro-QoL-5D-5L) which includes five dimensions (mobility, self-care, usual activities, pain, and anxiety/depression), each ranging from 1 to 5 (1: no, 2: slight, 3: moderate, 4: severe, and 5: extreme problems). The primary endpoint was poor clinical outcome defined as death or severe-to-extreme impairment of at least one EuroQoL-5D-5L dimension at M12. The information was collected by a blinded investigator by phone. Secondary outcomes were functional, psychological, and cognitive status at M12 consultation., Results: 540 patients were included (standard, n = 272; multidisciplinary, n = 268). The risk for a poor outcome was significantly greater in the multidisciplinary group than in the standard group [adjusted odds ratio 1.49 (95% confidence interval, (1.04-2.13)]. Seventy-two (13.3%) patients died at M12 (standard, n = 32; multidisciplinary, n = 40). The functional, psychological, and cognitive scores at M12 did not statistically differ between groups., Conclusions: A hospital-based, face-to-face, intensivist-led multidisciplinary consultation at ICU discharge then at 3 and 6 months was associated with poor outcome 1 year after ICU., (© 2024. Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Spouses are often the front-line caregivers for colon cancer patients. Providing this support requires a particular set of coping skills. Our objective was to identify key skills that healthcare and medico-social sector professionals could assess in routine practice that would allow them to propose appropriate support to spouses who are accompanying colon cancer patients in their care pathway., Methods: An online two-round Delphi study was conducted among French colon cancer patients, spouses and professionals. The content of the Delphi study was developed from a previously published qualitative study., Results: In the first round of the study, 63% of the participants were professionals (n = 40), 19% spouses (n = 12) and 17% patients (n = 11). In the second round, they were respectively 55% (n = 22), 22% (n = 9) and 22% (n = 9). Twenty-seven of the 75 proposed skills were consensually identified as key skills. Nine were related to emotional and psychological well-being, six to social relations, four to organisation, five to health and three to domestic domains. The three most consensual skills (≥ 90% agreement) for spouses were (1) helping the tired patient in everyday life, (2) stimulating the patient to prevent him/her from giving up and (3) limiting one's amount of personal time to care for the patient., Conclusion: The study identified the key skills needed by spouses of patients being treated for colon cancer. Better awareness of these skills among professionals would enable them to offer tailored support to help patients and spouses maintain their physical and emotional well-being., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Risk factors and cardiovascular diseases are overrepresented in people with severe and persistent mental disorders. A person diagnosed with schizophrenia or bipolar disorder is two to three times more likely to die of cardiovascular disease than the general population., Purpose of Research: An empowerment program has been co-created to reduce these health inequalities. It is one part of the COPsyCAT project. The people-centered approach has been used. The participation of the patients, caregivers, and health professionals was decisive., Results: Stakeholders redefined the objectives of the program. The aim is to improve quality of life, rather than reducing cardiovascular risk. Existing tools -that have been evaluated for their usability - were selected to allow for self-directed patient orientation, so that the constraints between psychiatry and primary care could be circumvented. The program is based on the pooling of existing resources in a territory. The individual power of action and the organization of healthy offers are thus designed to reinforce each other., Conclusions: This article concretely describes the steps through to which the COPsyCAT empowerment program was designed, in co-construction by the researchers of the study, the users and user associations and healthcare professionals at based on their experiential knowledge. The feasibility of the program and the appropriation of tools in real situations will soon be evaluated. The measure of the program’s effectiveness on cardiovascular risk will come in second time.

Purpose: Survivors after acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19) are at high risk of developing respiratory sequelae and functional impairment. The healthcare crisis caused by the pandemic hit socially disadvantaged populations. We aimed to evaluate the influence of socio-economic status on respiratory sequelae after COVID-19 ARDS., Methods: We carried out a prospective multicenter study in 30 French intensive care units (ICUs), where ARDS survivors were pre-enrolled if they fulfilled the Berlin ARDS criteria. For patients receiving high flow oxygen therapy, a flow ≥ 50 l/min and an FiO 2  ≥ 50% were required for enrollment. Socio-economic deprivation was defined by an EPICES (Evaluation de la Précarité et des Inégalités de santé dans les Centres d'Examens de Santé - Evaluation of Deprivation and Inequalities in Health Examination Centres) score ≥ 30.17 and patients were included if they performed the 6-month evaluation. The primary outcome was respiratory sequelae 6 months after ICU discharge, defined by at least one of the following criteria: forced vital capacity < 80% of theoretical value, diffusing capacity of the lung for carbon monoxide < 80% of theoretical value, oxygen desaturation during a 6-min walk test and fibrotic-like findings on chest computed tomography., Results: Among 401 analyzable patients, 160 (40%) were socio-economically deprived and 241 (60%) non-deprived; 319 (80%) patients had respiratory sequelae 6 months after ICU discharge (81% vs 78%, deprived vs non-deprived, respectively). No significant effect of socio-economic status was identified on lung sequelae (odds ratio (OR), 1.19 [95% confidence interval (CI), 0.72-1.97]), even after adjustment for age, sex, most invasive respiratory support, obesity, most severe P/F ratio (adjusted OR, 1.02 [95% CI 0.57-1.83])., Conclusions: In COVID-19 ARDS survivors, socio-economic status had no significant influence on respiratory sequelae 6 months after ICU discharge., (© 2023. The Author(s).)

Introduction: Non-beneficial stays in the intensive care unit (ICU) may have repercussions for patients and their families, but can also cause suffering among the nursing staff. We aimed explore the perceptions of nursing staff in the ICU about patient stays that are deemed to be "non-beneficial" for the patient, to identify areas amenable to intervention, with a view to improving how the nursing staff perceive the patient pathway before, during and after intensive care., Methods: Multicentre, qualitative study using individual, semi-structured interviews. All qualified nurses and nurses' aides who were full-time employees in the ICU of three participating centres were invited to participate. Interviews were recorded, transcribed and analyzed using textual content analysis., Results: A total of 21 interviews were performed from February 2020 to October 2021, at which point saturation was reached in the data. Average age of participants was 38.5±7.5 years, and they had an average of 10.7±7.4 years of experience working in the ICU. Four major themes emerged from the interviews, namely: (1) the work is oriented towards life-threatening emergencies, technical procedures and burdensome care; (2) a range of specific criteria and circumstances influence the decisions to admit patients to ICU; (3) there are significant organisational, physical and psychological repercussions associated with a non-beneficial stay in the ICU; (4) respondents made some proposals for improvements to the patient care pathway., Conclusion: Nursing staff have a similar perception to physicians regarding admission decisions and non-beneficial ICU stays. The possibility of future ICU admission needs to be anticipated, discussed systematically with patients and integrated into healthcare goals that are consistent with the patient's wishes and preferences, in multi-professional collaboration including nursing and medical staff., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Mathey et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: Conflicts between relatives and physicians may arise when decisions are being made about limiting life-sustaining therapies (LST). The aim of this study was to describe the motives for, and management of team-family conflicts surrounding LST limitation decisions in French adult ICUs., Methods: Between June and October 2021, French ICU physicians were invited to answer a questionnaire. The development of the questionnaire followed a validated methodology with the collaboration of consultants in clinical ethics, a sociologist, a statistician and ICU clinicians., Results: Among 186 physicians contacted, 160 (86%) answered all the questions. Conflicts over LST limitation decisions were mainly related to requests by relatives to continue treatments considered to be unreasonably obstinate by ICU physicians. The absence of advance directives, a lack of communication, a multitude of relatives, and religious or cultural issues were frequently mentioned as factors contributing to conflicts. Iterative interviews with relatives and proposal of psychological support were the most widely used tools in attempting to resolve conflict, while the intervention of a palliative care team, a local ethics resource or the hospital mediator were rarely solicited. In most cases, the decision was suspended at least temporarily. Possible consequences include stress and psychological exhaustion among caregivers. Improving communication and anticipation by knowing the patient's wishes would help avoid these conflicts., Conclusion: Team-family conflicts during LST limitation decisions are mainly related to requests from relatives to continue treatments deemed unreasonable by physicians. Reflection on the role of relatives in the decision-making process seems essential for the future., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Giabicani et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: Women of low socioeconomic status have been described as having suboptimal prenatal care, which in turn has been associated with poor pregnancy outcomes. Many types of conditional cash transfer (CCT) programmes have been developed, including programmes to improve prenatal care or smoking cessation during pregnancy, and their effects demonstrated. However, ethical critiques have included paternalism and lack of informed choice. Our objective was to determine if women and healthcare professionals (HPs) shared these concerns., Design: Prospective qualitative research., Setting: We included economically disadvantaged women, as defined by health insurance data, who participated in the French NAITRE randomised trial assessing a CCT programme during prenatal follow-up to improve pregnancy outcomes. The HP worked in some maternities participating in this trial., Participants: 26 women, 14 who received CCT and 12 who did not, mostly unemployed (20/26), and - 7 HPs., Interventions: We conducted a multicentre cross-sectional qualitative study among women and HPs who participated in the NAITRE Study to assess their views on CCT. The women were interviewed after childbirth., Results: Women did not perceive CCT negatively. They did not mention feeling stigmatised. They described CCT as a significant source of aid for women with limited financial resources. HP described the CCT in less positive terms, for example, expressing concern about discussing cash transfer at their first medical consultation with women. Though they emphasised ethical concerns about the basis of the trial, they recognised the importance of evaluating CCT., Conclusions: In France, a high-income country where prenatal follow-up is free, HPs were concerned that the CCT programme would change their relationship with patients and wondered if it was the best use of funding. However, women who received a cash incentive said they did not feel stigmatised and indicated that these payments helped them prepare for their baby's birth., Trial Registration Number: NCT02402855., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: In a nationwide survey of practices, we sought to define the criteria, circumstances and consequences of non-beneficial admissions to the intensive care unit (ICU), with a view to proposing measures to avoid such situations., Methods: ICU physicians from a French research in ethics network participated in an online survey. The first part recorded age, sex, and years' experience of the participants. In the second part, there were 8 to 12 proposals on each of 4 main domains: (1) What criteria could be used to qualify an ICU stay as non-beneficial? (2) What circumstances result in the admission of a patient whose ICU stay may later be deemed non-beneficial? (3) What are the consequences of a non-beneficial stay in the ICU? (4) What measures could be implemented to avoid admissions that later come to be considered as non-beneficial? Responses were on a 5-point Likert scale ranging from "Strongly disagree" to "Strongly agree"., Results: Among 164 physicians contacted, 154 (94%) responded. The majority cited several criteria used to qualify a stay as non-beneficial. Similarly, >80% cited several possible circumstances that could result in non-beneficial admissions, including lack of knowledge of the case and the patient's history, and failure to anticipate acute deterioration. Possible consequences of non-beneficial stays included stress and anxiety for the patient/family, misunderstandings and conflict. Discussing the utility of possible ICU admission in the framework of the patient's overall healthcare goals was hailed as a means to prevent non-beneficial admissions., Conclusion: The results of this survey suggest that joint discussions should take place during the patient's healthcare trajectory, before the acute need for ICU arises, with a view to limiting or avoiding ICU stays that may later come to be deemed "non-beneficial"., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Quenot et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The management of patients with rare diseases (RD) presents many challenges including diagnosis, coordination of care, and orientation in the health system. For these patients, the general practitioner (GP) is not always the referring physician. The aim of this study was to determine the place of the GP in management of patients with RD. We used a qualitative study by case-study. From March to October 2020, semi-structured interviews were conducted by telephone with the families of adult patients with RD and intellectual disability, and with the health professionals involved in their management. Patients were recruited through RD reference centres, patient associations or GPs. The interviews were transcribed and analysed by two independent investigators. A grounded theory-based analysis was performed. Eight case studies were conducted with 20 participants. Our results highlighted the trajectory of the patients through the development of the career of the primary informal caregiver. The caregivers developed skills required for the management of the care recipient. Within this trajectory, the GP found his place depended on the skills he could provide, their interest in the disease, the skills developed by the caregiver, and the caregiver/care recipient needs. The GP was mostly consulted for routine care and administrative procedures, but when a trusting relationship was established, they also accompanied the patient and their family by providing appropriate medical, social or psychological support. The GP will be all the more a privileged actor in the care process that he will be involved in the coordination of all other actors, professional as non-professionals., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Introduction: We investigated the reflections and perceptions of non-ICU physicians about anticipating the need for ICU admission in case of acute decompensation in patients with chronic disease., Methods: We performed a qualitative multicentre study using semi-structured interviews among non-ICU specialist physicians. The interview guide, developed in advance, focused on 3 questions: (1) What is your perception of ICU care? (2) How do you think advance directives can be integrated into the patient's healthcare goals? and (3) How can the possibility of a need for ICU admission be integrated into the patient's healthcare goals? Interviews were recorded, transcribed and analysed by thematic analysis. Interviews were performed until theoretical saturation was reached., Results: In total, 16 physicians (8 women, 8 men) were interviewed. The main themes related to intensive care being viewed as a distinct specialty, dispensing very technical care, and with major human and ethical challenges, especially regarding end-of-life issues. The participants also mentioned the difficulty in anticipating an acute decompensation, and the choices that might have to be made in such situations. The timing of discussions about potential decompensation of the patient, the medical culture and the presence of advance directives are issues that arise when attempting to anticipate the question of ICU admission in the patient's healthcare goals or wishes., Conclusion: This study describes the perceptions that physicians treating patients with chronic disease have of intensive care, notably that it is a distinct and technical specialty that presents challenging medical and ethical situations. Our study also opens perspectives for actions that could promote a pluridisciplinary approach to anticipating acute decompensation and ICU requirements in patients with chronic disease., Competing Interests: The authors have declared that no competing interests exist.

Background: Intensive care unit (ICU) staff have faced unprecedented levels of stress, in the context of profound upheaval of their working environment due to the COVID-19 pandemic. We explored the perceptions of frontline ICU staff about the first wave of the COVID-19 pandemic, and how this experience impacted their personal and professional lives., Methods: In a qualitative study as part of the PsyCOVID-ICU project, we conducted semi-structured interviews with a random sample of nurses and nurses' aides from 5 centres participating in the main PsyCOVID study. Interviews were recorded and fully transcribed, and analysed by thematic analysis., Results: A total of 18 interviews were performed from 13 August to 6 October 2020; 13 were nurses, and 5 were nurses' aides. Thematic analysis revealed three major themes, namely: (1) Managing the home life; (2) Conditions in the workplace; and (3) the meaning of their profession., Conclusion: In this qualitative study investigating the experiences and perceptions of healthcare workers caring for critically ill patients during the first COVID-19 wave in France, the participants reported that the crisis had profound repercussions on both their personal and professional lives. The main factors affecting the participants were a fear of contamination, and the re-organisation of working conditions, against a background of a media "infodemic"., Competing Interests: The authors have declared that no competing interests exist.

Background: In France, there are two main types of psychosocial educational therapies for people with mental disorders: (1) therapeutic patient education (TPE) or "training", and (2) psychoeducation. Both types of educational therapy aim to improve disease morbidity, treatment compliance and patient quality of life, but they have very different modes of application. The aim of this study was to interview mental health professionals in order to explore and identify the determinants (barriers and enablers) underlying their acceptance of therapeutic patient education (TPE) in order to facilitate the implementation of these programmes among people with severe mental illness such as schizophrenia. Methods: In this multicentre cross-sectional study, we opted for a qualitative approach based on individual semi-structured interviews with 21 mental health professionals trained in TPE, regardless of whether they had practiced it before or not. In accordance with the "Jardé" law (Decree no 2016-1537 dated 16 November 2016 published on 17 November 2016 in the Official Journal of the French Republic). No regulatory approval was required for this study. Results: The major themes that emerged from the analysis were grouped into the following conceptual framework: (1) mental health professionals (MHPs) highlight important organizational and institutional challenges that they feel are beyond their scope; (2) MHPs mention in parallel their own perceptions and representations of TPE in the context of mental health care; and (3) MHPs' representations could hide a lack of knowledge or awareness that would prevent them from appropriating TPE programmes. For each major theme, the sub-themes identified are presented. Conclusions: Although TPE is of interest in the process of patient empowerment, we found that caregivers were reluctant to appropriate this approach to care. Efforts must be made in the initial and ongoing training of MHPs to move from a paternalistic model to a patient partnership model, which is made possible by TPE. These efforts must also be firmly supported by health care facilities, and proactive governance is required for the successful implementation of TPE.

French authorities created mental health support services to accompany HCWs during the pandemic. We aimed to obtain feedback from staff providing these mental health support services within French hospitals to identify positive and negative features and avenues for improvement. A mixed-methods study was performed between 1 April and 30 June 2020. We contacted 77 centres to identify those providing mental health support services. We developed a questionnaire containing questions about the staff providing the service (quantitative part), with open questions to enable feedback from service providers (qualitative part). Of the 77 centres, 36 had mental health support services; 77.8% were created specifically for the epidemic. Services were staffed principally by psychologists, mainly used a telephone platform, and had a median opening time of 8 h/day. Thirty-seven professionals provided feedback, most aged 35-49 years. For 86.5%, it was their first time providing such support. Median self-reported comfort level was 8 (interquartiles 3-10), and 95% would do it again. Respondents reported (i) difficulties with work organisation, clinical situations, and lack of recognition and (ii) a desire for training. This study suggests that mental health support needs to be adapted to the needs of HCWs, both in terms of the content of the service and the timing of delivery.

Background: We investigated the criteria that hospitalized patients in intensive care units (ICUs) deem important when designating relatives who are best qualified to interact with the caregiving staff., Methods: We conducted an exploratory, observational, prospective, multicenter study between March 1, 2018, and October 31, 2018, within two ICUs. A 12-item questionnaire was distributed to patients in the ICUs by the investigating physicians. Patients were considered eligible if they had a good understanding of the French language and if they had not officially designated surrogates before ICU admission., Results: Seventy-one patients whose average age was 63.9± 17.3 years, of whom 21 (29.5%) were females, completed the questionnaire. The average Charlson comorbidity score was 2.5 ± 2.4, and the average Simplified Acute Physiology Score (SAPS II) was 39.8 ± 16.5. The main etiology was respiratory infection (40.8%), followed by sepsis (23.9%). The most important criteria identified by patients when selecting reference persons were a good knowledge of the patient's wishes and values, an emotional attachment to the patient, and being a family member., Conclusion: Our findings reveal that ICU patients considered the following criteria to be critical when designating reference persons: knowledge of their wishes and the existence of emotional and family attachments., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s).)

People with severe mental illness (PSMI) have a shorter life expectancy and are more likely to have cardiovascular disease than the general population. Patients, carers, psychiatric professionals and primary care providers can all play a role in increasing PSMI physical health. The present qualitative exploratory study aimed to explore the views of these four populations as part of the multi-phase COPsyCAT project, whose objective is to build and test a cardiovascular risk prevention programme for PSMI. Overall, 107 people participated in the study's 16 focus groups, which were transcribed and analysed in a thematic analysis. With a view to building the health promotion programme, major themes identified in the corpus were translated into a list of needs as follows: communication, information, training and support. Results show that it is essential to improve communication between all the different stakeholders in mental health. The greatest challenge facing this programme will be to adapt it to the needs and expectations of PSMI while facilitating work between the various mental health stakeholders. Simple and inexpensive actions could be taken to improve the cardiovascular health of PSMI and will be experimented with during the programme's feasibility study which will start in September 2022.

Background: Critically ill patients are at risk of developing a postintensive care syndrome (PICS), which is characterized by physical, psychological, and cognitive impairments and which dramatically impacts the patient's quality of life (QoL). No intervention has been shown to improve QoL. We hypothesized that a medical, psychological, and social follow-up would improve QoL by mitigating the PICS., Objective: This multicenter, randomized controlled trial (SUIVI-REA) aims to compare a multidisciplinary follow-up with a standard postintensive care unit (ICU) follow-up., Methods: Patients were randomized to the control or intervention arm. In the intervention arm, multidisciplinary follow-up involved medical, psychological, and social evaluation at ICU discharge and at 3, 6, and 12 months thereafter. In the placebo group, patients were seen only at 12 months by the multidisciplinary team. Baseline characteristics at ICU discharge were collected for all patients. The primary outcome was QoL at 1 year, assessed using the Euro Quality of Life-5 dimensions (EQ5D). Secondary outcomes were mortality, cognitive, psychological, and functional status; social and professional reintegration; and the rate of rehospitalization and outpatient consultations at 1 year., Results: The study was funded by the Ministry of Health in June 2010. It was approved by the Ethics Committee on July 8, 2011. The first and last patient were randomized on December 20, 2012, and September 1, 2017, respectively. A total of 546 patients were enrolled across 11 ICUs. At present, data management is ongoing, and all parties involved in the trial remain blinded., Conclusions: The SUVI-REA multicenter randomized controlled trial aims to assess whether a post-ICU multidisciplinary follow-up improves QoL at 1 year., Trial Registration: Clinicaltrials.gov NCT01796509; https://clinicaltrials.gov/ct2/show/NCT01796509., International Registered Report Identifier (irrid): DERR1-10.2196/30496., (©Diane Friedman, Lamiae Grimaldi, Alain Cariou, Philippe Aegerter, Stéphane Gaudry, Abdel Ben Salah, Haikel Oueslati, Bruno Megarbane, Nicolas Meunier-Beillard, Jean-Pierre Quenot, Carole Schwebel, Laurent Jacob, Ségloène Robin Lagandré, Pierre Kalfon, Romain Sonneville, Shidasp Siami, Aurelien Mazeraud, Tarek Sharshar. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 09.05.2022.)

Introduction: Prognosis of patients with COVID-19 depends on the severity of the pulmonary affection. The most severe cases may progress to acute respiratory distress syndrome (ARDS), which is associated with a risk of long-term repercussions on respiratory function and neuromuscular outcomes. The functional repercussions of severe forms of COVID-19 may have a major impact on quality of life, and impair the ability to return to work or exercise. Social inequalities in healthcare may influence prognosis, with socially vulnerable individuals more likely to develop severe forms of disease. We describe here the protocol for a prospective, multicentre study that aims to investigate the influence of social vulnerability on functional recovery in patients who were hospitalised in intensive care for ARDS caused by COVID-19. This study will also include an embedded qualitative study that aims to describe facilitators and barriers to compliance with rehabilitation, describe patients' health practices and identify social representations of health, disease and care., Methods and Analysis: The "Functional Recovery From Acute Respiratory Distress Syndrome (ARDS) Due to COVID-19: Influence of Socio-Economic Status" (RECOVIDS) study is a mixed-methods, observational, multicentre cohort study performed during the routine follow-up of post-intensive care unit (ICU) functional recovery after ARDS. All patients admitted to a participating ICU for PCR-proven SARS-CoV-2 infection and who underwent chest CT scan at the initial phase AND who received respiratory support (mechanical or not) or high-flow nasal oxygen, AND had ARDS diagnosed by the Berlin criteria will be eligible. The primary outcome is the presence of lung sequelae at 6 months after ICU discharge, defined either by alterations on pulmonary function tests, oxygen desaturation during a standardised 6 min walk test or fibrosis-like pulmonary findings on chest CT. Patients will be considered to be socially disadvantaged if they have an "Evaluation de la Précarité et des Inégalités de santé dans les Centres d'Examen de Santé" (EPICES) score ≥30.17 at inclusion., Ethics and Dissemination: The study protocol and the informed consent form were approved by an independent ethics committee (Comité de Protection des Personnes Sud Méditerranée II) on 10 July 2020 (2020-A02014-35). All patients will provide informed consent before participation. Findings will be published in peer-reviewed journals and presented at national and international congresses., Trial Registration Number: NCT04556513., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Like other countries, France has invested in a national medical genomics program. Among the four pilot research studies, the DEFIDIAG project focuses on the use of whole genome sequencing (WGS) for patients with intellectual disability (ID), a neurodevelopmental condition affecting 1-3% of the general population but due to a plethora of genes. However, the access to genomic analyses has many potential individual and societal issues in addition to the technical challenges. In order to help decision-makers optimally introduce genomic testing in France, there is a need to identify the socio-economic obstacles and leverages associated with the implementation of WGS. Methods and Analysis: This humanities and social sciences analysis is part of the DEFIDIAG study. The main goal of DEFIDIAG is to compare the percentage of causal genetic diagnoses obtained by trio WGS (including the patient and both parents) (WGS T ) to the percentage obtained using the minimal reference strategy currently used in France (Fragile-X testing, chromosomal microarray analysis, and gene panel strategy including 44 ID genes) for patients with ID having their first clinical genetics consultation. Additionally, four complementary studies will be conducted. First, a cost-effectiveness analysis will be undertaken in a subsample of 196 patients consulting for the first time for a genetic evaluation; in a blinded fashion, WGS T and solo (index case, only) genomic analysis (WGS S ) will be compared to the reference strategy. In addition, quantitative studies will be conducted: the first will estimate the cost of the diagnostic odyssey that could potentially be avoidable with first-line WGS T in all patients previously investigated in the DEFIDIAG study; the second will estimate changes in follow-up of the patients in the year after the return of the WGS T analysis compared to the period before inclusion. Finally, through semi-directive interviews, we will explore the expectations of 60 parents regarding genomic analyses. Discussion: Humanities and social sciences studies can be used to demonstrate the efficiency of WGS and assess the value that families associate with sequencing. These studies are thus expected to clarify trade-offs and to help optimize the implementation of genomic sequencing in France. Ethics Statement: The protocol was approved by the Ethics Committee Sud Méditerranée I (June 2019)-identification number: 2018-A00680-55 and the French data privacy commission (CNIL, authorization 919361). Clinical Trial Registration : (ClinicalTrials.gov), identifier (NCT04154891)., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Lejeune, Robert-Viard, Meunier-Beillard, Borel, Gourvès, Staraci, Soilly, Guillemin, Seror, Achit, Bouctot, Asensio, Briffaut, Delmas, Bruel, Benoit, Simon, Gerard, Hadj Abdallah, Lyonnet, Faivre, Thauvin-Robinet, Odent, Heron, Sanlaville, Frebourg, Muller, Duffourd, Boland, Deleuze, Espérou, Binquet and Dollfus.)

Purpose: We investigated experiences of families who provide consent for research on behalf of a loved-one hospitalized in intensive care (ICU)., Methods: Multicentre, qualitative, descriptive study using semi-directive interviews in 3 ICUs. Eligible relatives were aged >18 years, and had provided informed consent for a clinical trial on behalf of a patient hospitalized in ICU. Interviews were conducted from 06/2018 to 06/2019 by a qualified sociologist, recorded and transcribed., Results: Fifteen relatives were interviewed; average age 50.3 ± 15 years. All emphasized their interest in clinical research, seeing it as a duty. Involving their loved-one in research allowed them to find meaning in the events. Participants underlined that trust in caregivers and communication are determinant. The strict regulation of research was perceived as a guarantee of safety. Participants felt they lacked the intellectual capacity and knowledge to question explanations. The greatest fear was not that they might incur a risk for the patient, but rather, that they might deprive the patient of a chance at a cure., Conclusion: Acceptance of research opportunities by relatives on behalf of decisionally-incapacitated patients is underpinned by trust in the physicians and the legislative framework. Communication and the quality of information provided by the caregivers are key., Competing Interests: Declaration of Competing Interest No author has any competing interest to declare., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: During the COVID pandemic, many hospitals had to mobilize reinforcement healthcare workers, especially in intensive care (ICUs). We investigated the perceptions and experiences of reinforcement workers deployed to ICUs, and the impact of deployment on their personal and professional lives., Methods: For this qualitative study, a random sample of 30 reinforcement workers was drawn from 4 centres participating in the larger PsyCOVID-ICU study. Individual semi-structured interviews were held, recorded, transcribed and analyzed by thematic analysis., Results: Thirty interviews were performed from April to May 2021 (22 nurses, 2 anesthesiology nurses, 6 nurses' aides). Average age was 36.8±9.5 years; 7 participants had no ICU experience. Four major themes emerged, namely: (1) Difficulties with integration, especially for those with no ICU experience; (2) lack of training; (3) difficulties with management, notably a feeling of insufficient communication; (4) Mental distress relating to the unusual work and fear of contaminating their entourage., Conclusion: Healthcare workers deployed as reinforcements to ICUs at the height of the pandemic had a unique experience of the crisis, and identified important gaps in organisation and preparation. They also suffered from a marked lack of training, given the stakes in the management of critically ill patients in the ICU., Competing Interests: The authors declare that no competing interests exist.

Background: Intensive care units (ICU) are among the healthcare services most affected by the COVID-19 crisis. Stressors related to insecurity, unpredictability, patient death and family distress are significant, and put healthcare workers (HCWs) at high risk of post-traumatic stress disorder (PTSD). The aims of this study were to measure the prevalence of post-traumatic stress disorder in HCWs and to identify risk factors and protective factors during the epidemic in France., Methods: During the first peak of the epidemic (from 22 April to 13 May 2020), we assessed sources of stress (PS-ICU scale), mental health (GHQ-12) and coping strategies (Brief-COPE). Three months later (03 June to 6 July 2020), PTSD was assessed using the IES-R scale, with additional questions about sources of support. Data were collected using self-report questionnaires administered online., Results: Among 2153 professionals who participated in the study, 20.6% suffered from potential PTSD, mostly intrusion symptoms. Risk factors for the development of PTSD were having experienced additional difficult events during the crisis, having a high level of psychological distress, a high level of perceived stress related to the workload and human resources issues, the emotional burden related to the patient and family, and stressors specific to COVID-19 during the first peak of the crisis. The use of positive thinking coping strategies decreased the relationship between perceived stress and the presence of PTSD, while social support seeking strategies increased the relationship. Finally, the HCWs preferred to use support from colleagues, relatives and/or a psychologist, and very few used the telephone hotlines., Conclusion: The epidemic has had a strong traumatic impact on intensive care HCWs. Given the risk of PTSD, we need to consider implementing easily-accessible support services that focus on positive thinking coping strategies, during and after the crisis., Competing Interests: Binquet C. reports grant from the PHRC-N, during the conduct of the study. No other author has any conflict of interest to declare., (© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Introduction: This qualitative study based on focus group study aims to identify experiences, expectations, and representations of people with long-term mental illness and their caregivers regarding cardiovascular disease and its risk factors. The aim of this work is to build a cardiovascular risk reduction program for people affected by long-term mental illness., Results: Four major themes were identified in the corpus: (1) knowledge concerning physical health, (2) barriers to the implementation of better practices, (3) levers towards a healthier life and (4) expectations and needs for a better lifestyle., Conclusions: This work has provided us with concrete elements for the creation of a cardiovascular risk reduction program for people living with long-term mental illness. The challenges of this program will be to adapt to the needs and expectations of people living with long-term mental illness while facilitating the role of caregivers.

Introduction: Cardiovascular diseases represent one of the major causes of mortality in France and are the main cause of excess mortality in people suffering from long-term mental disorders (LTMD), apart from causes related to suicide., Aim of the Study: The aim of this article is to identify, from the point of view of primary care and psychiatric professionals, psychiatric users&#8217; expectations and needs in order to help them improve their medical and paramedical management of cardiovascular risk (CVR)., Method: This is a prospective, multi-centered qualitative study carried out in two phases: An exploratory phase, with individual interviews at the beginning of the study to enable the creation of ad hoc collective interview grids, followed by a proper qualitative study, which is in line with medical anthropology and the sociology of health systems., Results: The 30 psychiatric professionals interviewed agreed on the need for better coordination with out-of-hospital care providers. Even if openness is advocated, there is a reminder of the specificities of psychiatry and the importance of taking these specificities into account in general. The 26 primary care professionals show a desire to learn more about psychiatric disorders, pathologies, and treatments in order to facilitate the management of these patients with specific needs., Conclusion: The cross-referencing of these results will allow to propose an appropriate intervention in order to induce convincing effects on the reduction of the CVR in people suffering from LTMD.

Background: We investigated the impact of the COVID-19 crisis on mental health of professionals working in the intensive care unit (ICU) according to the intensity of the epidemic in France., Methods: This cross-sectional survey was conducted in 77 French hospitals from April 22 to May 13 2020. All ICU frontline healthcare workers were eligible. The primary endpoint was the mental health, assessed using the 12-item General Health Questionnaire. Sources of stress during the crisis were assessed using the Perceived Stressors in Intensive Care Units (PS-ICU) scale. Epidemic intensity was defined as high or low for each region based on publicly available data from Santé Publique France. Effects were assessed using linear mixed models, moderation and mediation analyses., Results: In total, 2643 health professionals participated; 64.36% in high-intensity zones. Professionals in areas with greater epidemic intensity were at higher risk of mental health issues (p < 0.001), and higher levels of overall perceived stress (p < 0.001), compared to low-intensity zones. Factors associated with higher overall perceived stress were female sex (B = 0.13; 95% confidence interval [CI] = 0.08-0.17), having a relative at risk of COVID-19 (B = 0.14; 95%-CI = 0.09-0.18) and working in high-intensity zones (B = 0.11; 95%-CI = 0.02-0.20). Perceived stress mediated the impact of the crisis context on mental health (B = 0.23, 95%-CI = 0.05, 0.41) and the impact of stress on mental health was moderated by positive thinking, b = - 0.32, 95% CI = - 0.54, - 0.11., Conclusion: COVID-19 negatively impacted the mental health of ICU professionals. Professionals working in zones where the epidemic was of high intensity were significantly more affected, with higher levels of perceived stress. This study is supported by a grant from the French Ministry of Health (PHRC-COVID 2020).

With next generation sequencing, physicians are faced with more complex and uncertain data, particularly incidental findings (IF). Guidelines for the return of IF have been published by learned societies. However, little is known about how patients are affected by these results in a context of oncogenetic testing. Over 4 years, 2500 patients with an indication for genetic testing underwent a gene cancer panel. If an IF was detected, patients were contacted by a physician/genetic counsellor and invited to take part in a semi-structured interview to assess their understanding of the result, the change in medical care, the psychological impact, and the transmission of results to the family. Fourteen patients (0.56%) were delivered an IF in a cancer predisposition gene (RAD51C, PMS2, SDHC, RET, BRCA2, CHEK2, CDKN2A, CDH1, SUFU). Two patients did not collect the results and another two died before the return of results. Within the 10 patients recontacted, most of them reported surprise at the delivery of IF, but not anxiety. The majority felt they had chosen to obtain the result and enough information to understand it. They all initiated the recommended follow-up and did not regret the procedure. Information regarding the IF was transmitted to their offspring but siblings or second-degree relatives were not consistently informed. No major adverse psychological events were found in our experience. IF will be inherent to the development of sequencing, even for restricted gene panels, so it is important to increase our knowledge on the impact of such results in different contexts., (Published by Elsevier Masson SAS.)

Purpose: Deciding not to re-admit a patient to the intensive care unit (ICU) poses an ethical dilemma for ICU physicians. We aimed to describe and understand the attitudes and perceptions of ICU physicians regarding non-readmission of patients to the ICU., Materials and Methods: Multicenter, qualitative study using semi-directed interviews between January and May 2019. All medical staff working full-time in the ICU of five participating centres (two academic and three general, non-academic hospitals) were invited to participate. Participants were asked to describe how they experienced non-readmission decisions in the ICU, and to expand on the manner in which the decision was made, but also on the traceability and timing of the decision. Interviews were recorded, transcribed and analyzed using textual content analysis., Results: In total, 22 physicians participated. Interviews lasted on average 26±7 minutes. There were 14 men and 8 women, average age was 35±9 years, and average length of ICU experience was 7±5 years. The majority of respondents said that they regretted that the question of non-readmission was not addressed before the initial ICU admission. They acknowledged that the ICU stay did lead to more thorough contemplation of the overall goals of care. Multidisciplinary team meetings could help to anticipate the question of readmission within the patient's care pathway. Participants reported that there is a culture of collegial decision-making in the ICU, although the involvement of patients, families and other healthcare professionals in this process is not systematic. The timing and traceability of non-readmission decisions are heterogeneous., Conclusions: Non-readmission decisions are a major issue that raises ethical questions surrounding the fact that there is no discussion of the patient's goals of care in advance. Better anticipation, and better communication with the patients, families and other healthcare providers are suggested as areas that could be targeted for improvement., Competing Interests: The authors declare that they have no competing interests.

Purpose: We investigated the criteria that patients' relatives deem important for choosing, among themselves, the person best qualified to interact with the caregiving staff., Methods: Exploratory, observational, prospective, multicentre study between 1st March and 31st October 2018 in 2 intensive care units (ICUs). A 12-item questionnaire was completed anonymously by family members of patients hospitalized in the ICU 3 and 5 days after the patient's admission. Relatives were eligible if they understood French and if no surrogate had been appointed by the patient prior to ICU admission. More than one relative per patient could participate., Results: In total, 87 relatives of 73 patients completed the questionnaire, average age of relatives was 58 ± 15 years, 46% were the spouse, 30% were children/grandchildren. Items classed as being the most important attributes for a reference person were: good knowledge of the patient's wishes and values; an emotional attachment to the patient; being a family member; and having an adequate understanding of the clinical status and clinical history., Conclusion: This study identifies the attributes considered by relatives to be most important for designating, among themselves, a reference person for a patient hospitalized in the ICU., Competing Interests: Declaration of Competing Interest No author has any conflict of interest to declare., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The influence of socioeconomic status on patient outcomes is unclear. We assessed the impact of socioeconomic deprivation on severity of illness at intensive care unit (ICU) admission, and on the risk of death at 3 months after ICU admission., Methods: The IVOIRE study was a prospective, observational, multicentre cohort study in the ICU of 8 participating hospitals in France, including patients aged ≥ 18 years admitted to the ICU and receiving at least one life support therapy for organ failure. The primary outcomes were severity at admission (assessed by SAPSII score), and mortality at 3 months. Socioeconomic data were obtained from interviews with patients or family. Deprivation was assessed using the EPICES score., Results: Among 1294 patents included between 2013 and 2016, 629 (48.6%) were classed as deprived and differed significantly from non-deprived subjects in terms of sociodemographic characteristics and pre-existing conditions. The mean SAPS II score at admission was 50.1 ± 19.4 in deprived patients and 52.3 ± 17.3 in non-deprived patients, with no significant difference by multivariable analysis (β = - 1.85 [95% CI - 3.86; + 0.16, p = 0.072]). The proportion of death was 31.1% at 3 months, without significant differences between deprived and non-deprived patients, even after adjustment for confounders., Conclusions: Deprivation is frequent in patients admitted to the ICU and is not associated with disease severity at admission, or with mortality at 3 months between deprived and non-deprived patients. Trial registration The IVOIRE cohort is registered with ClinicalTrials.gov under the identifier NCT01907581, registration date 17/7/2013.

Background: Clinical research is an essential step in the successful translation of knowledge from basic research into concrete clinical applications, yet many people are reluctant to provide consent when actually approached to actively participate in clinical trials., Aims: We investigated the factors that influence older patient's (≥ 65 years) decisions to accept or refuse to participate in a prospective randomized clinical trial in secondary prevention after acute coronary syndrome., Methods: Qualitative approach based on individual semi-structured interviews with patients who were approached for consent to participate in a currently ongoing clinical trial was adopted. Patients were interviewed after the consent process (8 accepted; 8 refused the trial). Interviews were analysed using grounded theory methodology., Results: Sixteen patients aged ≥ 65 years participated. The main concept to emerge from these interviews is that the actual trial itself does not appear to be the primary determinant in the decision to participate in clinical research. Rather, patients' decisions to participate (or not) in clinical research appear to be primarily determined by their capacity to deal with the current health event that has disrupted their life, and by their available mental and physical resources., Discussion and Conclusion: Older patients display varying levels of engagement in their own health, ranging from low engagement with high trust in the medical profession, to high engagement mirrored by distrust of the medical profession. Structural conditions, such as personal benefit from trial participation, or logistic barriers to participation, seem to affect both accepters and refusers in the same manner.

Background: Persons with a diagnosis of severe mental illness have a life expectancy that is 20 years lower than the general population, and they are disproportionately affected by cardiovascular disorders. Improving the management of cardiovascular risk is one of the main challenges for the public health system. In the care pathway of persons with a diagnosis of severe mental illness, a better understanding of limiting and facilitating factors is required. The objective was to include persons with a diagnosis of severe mental illness, carers, and primary and mental health professionals in the creation and evaluation (feasibility) of a health promotion program designed to improve cardiovascular risk management through empowerment., Methods: This study combines a mixed methodology with qualitative and quantitative components. A multicenter prospective qualitative study was conducted in seven mental health units in France and was coordinated by a steering committee composed of persons with a diagnosis of severe mental illness, carers, and primary and mental health professionals., Results: This health promotion program must enable persons with a diagnosis of severe mental illness to assert their right to self-determination and to exercise greater control over their lives, beyond their diagnosis and care. Following a preliminary feasibility study, the effectiveness of this new tool will be evaluated using a randomized controlled trial in a second study., Conclusions: The findings can be used by health organizations as a starting point for developing new and improved services for persons with a diagnosis of severe mental illness. Trial registration Clinical Trials Gov NCT03689296. Date registered September 28, 2018., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2019.)

Purpose: We sought to describe the characteristics that lead physicians to perceive a stay in the intensive care unit (ICU) as being non-beneficial for the patient., Materials and Methods: In the first step, we used a multidisciplinary focus group to define the characteristics that lead physicians to consider a stay in the ICU as non-beneficial for the patient. In the second step, we assessed the proportion of admissions that would be perceived by the ICU physicians as non-beneficial for the patient according to our focus group's definition, in a large population of ICU admissions in 4 French ICUs over a period of 4 months., Results: Among 1075 patients admitted to participating ICUs during the study period, 155 stays were considered non-beneficial for the patient, yielding a frequency of 14.4% [95% confidence interval (CI) 8.9, 19.9]. Average age of these patients was 72 ±12.8 years. Mortality was 43.2% in-ICU [95%CI 35.4, 51.0], 55% [95%CI 47.2, 62.8] in-hospital. The criteria retained by the focus group to define a non-beneficial ICU stay were: patient refusal of ICU care (23.2% [95%CI 16.5, 29.8]), and referring physician's desire not to have the patient admitted (11.6% [95%CI 6.6, 16.6]). The characteristics that led physicians to perceive the stay as non-beneficial were: patient's age (36.8% [95%CI 29.2, 44.4]), unlikelihood of recovering autonomy (61.9% [95%CI 54.3, 69.6]), prior poor quality of life (60% [95%CI 52.3, 67.7]), terminal status of chronic disease (56.1% [95%CI 48.3, 63.9]), and all therapeutic options have been exhausted (35.5% [95%CI 27.9, 43.0]). Factors that explained admission to the ICU of patients whose stay was subsequently judged to be non-beneficial included: lack of knowledge of patient's wishes (52% [95%CI 44.1, 59.9]); decisional incapacity (sedation) (69.7% [95%CI 62.5, 76.9]); inability to contact family (34% [95%CI 26.5, 41.5]); pressure to admit (from family or other physicians) (50.3% [95%CI 42.4, 58.2])., Conclusions: Non-beneficial ICU stays are frequent. ICU admissions need to be anticipated, so that patients who would yield greater benefit from other care pathways can be correctly oriented in a timely manner., Competing Interests: The authors have declared that no competing interests exist.

Purpose: Family caregivers play an important role in caring for patients with advanced cancer. To become competent, individuals must draw on and mobilise an adequate combination of resources. Our goal was to identify the skills developed by caregivers of patients with advanced cancer and the associated resources mobilised. We chose to do it with partners of patients with colon cancer., Methods: The study used a cross-sectional qualitative design based on 20 individual interviews and a focus group. Partners were recruited from patients treated in three hospitals of France. Semi-structured interviews were conducted until data saturation was achieved. Each interview was transcribed verbatim, and thematic analyses were performed to extract significant themes and subthemes., Results: Results from the individual and focus group interviews showed that the skills implemented by the partners (in domains of social relationships and health, domestic, organisational, emotional and well-being dimensions) were singular constructs, dependant on if resources (personal, external and schemes) may have been missing and insufficient. In addition, partners may have had these resources but not mobilised them., Conclusion: The identification of the skills and associated resources could allow healthcare professionals better identifying and understanding of the difficulties met by partners in taking care of patients. This could enable them to offer appropriate support to help the caregivers in their accompaniment.

Purpose: We investigated, using a multicentre survey of practices in France, the practices of ICU physicians concerning the decision not to readmit to the ICU, in light of current legislation., Materials and Methods: Multicentre survey of practices among French ICU physicians via electronic questionnaire in January 2016. Questions related to respondents' practices regarding re-admission of patients to the ICU and how these decisions were made. Criteria were evaluated by the health care professionals as regards importance for non-readmission., Results: In total, 167 physicians agreed to participate, of whom 165 (99%) actually returned a completed questionnaire from 58 ICUs. Forty-five percent were aged <35 years, 74% were full-time physicians. The findings show that decisions for non-readmission are taken at the end of the patient's stay (87%), using a collegial decision-making procedure (89% of cases); 93% reported that this decision was noted in the patient's medical file. While 73% indicated that the family/relatives were informed of non-readmission decisions, only 29% reported informing the patient, and 91% considered that non-readmission decisions are an integral part of the French legislative framework., Conclusion: This study shows that decisions not to re-admit a patient to the ICU need to be formally materialized, and anticipated by involving the patient and family in the discussions, as well as the other healthcare providers that usually care for the patient. The optimal time to undertake these conversations is likely best decided on a case-by-case basis according to each patient's individual characteristics., Competing Interests: The authors have declared that no competing interests exist.

Background: Professional societies call for integration of end-of-life discussions early in the trajectory of heart failure, yet it remains unclear where current practices stand in relation to these recommendations. We sought to describe the perceptions and attitudes of caregivers in cardiology regarding end-of-life situations., Methods: We performed a qualitative study using semi-directive interviews in the cardiology department of a university teaching hospital in France. Physicians, nurses and nurses' aides working full-time in the department at the time of the study were eligible. Participants were asked to describe how they experienced end-of-life situations. Interviews were recorded, transcribed and coded using thematic analysis to identify major and secondary themes., Results: All physicians (N = 16)(average age 43.5 ± 13 years), 16 nurses (average age 38.5 ± 7.6 years) and 5 nurses' aides (average age 49 ± 7.8 years) participated. Interviews were held between 30 March and 17 July 2017. The main themes to emerge from the physicians' discourse were the concept of cardiology being a very active discipline, and a very curative frame of mind was prevalent. Communication (with paramedical staff, patients and families) was deemed to be important. Advance directives were thought to be rare, and not especially useful. Nurses also reported communication as a major issue, but their form of communication is bounded by several factors (physicians' prior discourse, legislation). They commonly engage in reconciling: between the approach (curative or palliative) and the reality of the treatment prescribed; performing curative interventions in patients they deem to be dying cases causes them distress. The emergency context prevents nurses from taking the time necessary to engage in end-of-life discussions. They engage in comfort-giving behaviors to maximize patient comfort., Conclusion: Current perceptions and practices vis-à-vis end-of-life situations in our department are individual, heterogeneous and not yet aligned with recommendations of professional societies.

Background: Our objective was to assess, through a qualitative, exploratory study, the thought processes of patients regarding the formulation of advance directives (AD) after a stay in the ICU., Methods: The study was conducted from May to July 2016 using telephone interviews performed by four senior ICU physicians. Inclusion criteria were: patients discharged from ICU to home>3 months earlier. Semi-directive interviews with patients focused on 5 main points surrounding AD., Results: In total, among 159 eligible patients, data from 94 (59%) were available for analysis. Among all those interviewed, 83.5% had never heard of "advance directives". Only 2% had executed AD before ICU admission, and 7% expressed a desire to prepare AD further to their ICU stay. Among the barriers to preparation of AD, lack of information was the main reason cited for not executing AD. Patients noted the following in their AD: withdrawal of life-support in case of vegetative/minimally conscious state or when there is no longer any hope, in case of uncontrollable pain, and if impossible to wean from mechanical ventilation., Conclusion: The ideal time to engage patients in these discussions is most likely well before an acute health event occurs, although this warrants further investigation both before and after ICU admissions., (Copyright © 2017 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

A large proportion of patients admitted to the intensive care unit (ICU) are unable to express themselves, often due to acute illness, shock or trauma, and this precludes any communication and/or consent for care that might reflect their wishes and opinions. In such cases, the only solution for the ICU physician is to include the patient's family in the healthcare decisions. This can represent a significant burden on the family, on top of the psychological distress of the ICU environment and hospitalisation of their relatives, and many family members may suffer from anxiety, depression or symptoms of post-traumatic stress disorder (PTSD) during or after the hospitalisation and/or death of a loved one in the ICU. Good communication remains the cornerstone of family satisfaction in the ICU. Information imparted to the patient and/or family should cover diagnosis, prognosis and treatment. Information should be given orally, in person, using accessible language. Several other measures that can lessen the burden on the families of patients in the ICU and help to reduce anxiety and stress are also detailed in this review. Overall, family-centred care in the ICU requires a systematic communication strategy within the healthcare team, combined with an environment that is as amenable as possible to the family's presence and involvement, in order to maximize family satisfaction with ICU care, and ensure that the patient's values and preferences are respected., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

The decision to limit or withdraw life-support treatment is an integral part of the job of a physician working in the intensive care unit, and of the approach to care. However, this decision is influenced by a number of factors. It is widely accepted that a medical decision that will ultimate lead to end-of-life in the intensive care unit (ICU) must be shared between all those involved in the care process, and should give precedence to the patient's wishes (either directly expressed by the patient or in written form, such as advance directives), and taking into account the opinion of the patient's family, including the surrogate if the patient is no longer capable of expressing themselves. A number of questions still remain unanswered regarding how decisions to limit or withdraw treatment are taken in daily practice, especially when this decision can be anticipated. We discuss here the collegial procedure for decision-making, in particular in the context of recent French legislation on end-of-life issues. We describe how collegial decision-making procedures should be carried out, and what points are covered in shared discussions regarding decisions to limit or withdraw life-sustaining therapies., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: The use of novel sepsis biomarkers has increased in recent years. However, their prognostic value with respect to illness severity has not been explored. In this work, we examined the ability of mid-regional proadrenomedullin (MR-proADM) in predicting mortality in sepsis patients with different degrees of organ failure, compared to that of procalcitonin, C-reactive protein and lactate., Methods: This was a two-centre prospective observational cohort, enrolling severe sepsis or septic shock patients admitted to the ICU. Plasma biomarkers were measured during the first 12 h of admission. The association between biomarkers and 28-day mortality was assessed by Cox regression analysis and Kaplan-Meier curves. Patients were divided into three groups as evaluated by the Sequential Organ Failure Assessment (SOFA) score. The accuracy of the biomarkers for mortality was determined by area under the receiver operating characteristic curve (AUROC) analysis., Results: A total of 326 patients with severe sepsis (21.7%) or septic shock (79.3%) were enrolled with a 28-day mortality rate of 31.0%. Only MR-proADM and lactate were associated with mortality in the multivariate analysis: hazard ratio 8.5 versus 3.4 (p < 0.001). MR-proADM showed the best AUROC for mortality prediction at 28 days in the analysis over the entire cohort (AUROC [95% CI] 0.79 [0.74-0.84]) (p < 0.001). When patients were stratified by the degree of organ failure, MR-proADM was the only biomarker to predict mortality in all severity groups (SOFA ≤ 6, SOFA = 7-12, and SOFA ≥ 13), AUROC [95% CI] of 0.75 [0.61-0.88], 0.74 [0.66-0.83] and 0.73 [0.59-0.86], respectively (p < 0.05). All patients with MR-proADM concentrations ≤0.88 nmol/L survived up to 28 days. In patients with SOFA ≤ 6, the addition of MR-proADM to the SOFA score increased the ability of SOFA to identify non-survivors, AUROC [95% CI] 0.70 [0.58-0.82] and 0.77 [0.66-0.88], respectively (p < 0.05 for both)., Conclusions: The performance of prognostic biomarkers in sepsis is highly influenced by disease severity. MR-proADM accuracy to predict mortality is not affected by the degree of organ failure. Thus, it is a good candidate in the early identification of sepsis patients with moderate disease severity but at risk of mortality.

A major goal of intensive care units (ICUs) is to offer optimal management, but for many patients admitted to the ICU, they are unlikely to yield any lasting benefit. In this context, the ICU physician remains a key intermediary, particularly when a decision regarding possible limitation or withdrawal of life-sustaining therapy becomes necessary. The possibility of admission to the ICU, and the type of care the patient would like to receive there, should be integrated into the healthcare project in agreement with the patient, regardless of the stage of disease that the patient suffers from. These dispositions should be recorded in the patient's file, and should respect the progressive nature of both the disease itself, and the discussions necessary in such complex situations. The ICU physician can serve as a valuable consultant for the treating physician, in particular to guide patient choices when formalizing their healthcare preferences in the form of advance care planning (ACP) or advance directives (AD). Ideally, the best time to address this issue is before the patient's clinical situation deteriorates towards an acute emergency, and providing complete and transparent information to inform the patient's choices., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Scientific and technological progress, as well as increased patient autonomy have profoundly changed the world of healthcare, giving rise to new situations that are increasingly complex and uncertain. Quantitative paradigms, of which the main bastion is evidence-based medicine (EBM), are beginning to reach their limits in daily routine practice of medicine, and new approaches are emerging that can provide novel heuristic perspectives. Qualitative research approaches can be useful for apprehending new areas of knowledge that are fundamental to recent and future developments in intensive care., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Two essential components of the profession of a medical doctor are the constant review of the patient's therapeutic project, and collaboration between healthcare professionals. The profession of intensive care unit (ICU) physician goes further in terms of responsibility, vis-à-vis the intensive treatments dispensed to the patients, and the physician's responsibilities towards the patient's family and the caregiving team, also bearing in mind that ICU care is costly in terms of human and financial resources. In this review, we address the profession of ICU physician from the perspective of the ethical questions that arise constantly, focusing on the timeframe of the reflection process. Firstly, admission to the ICU must be anticipated. The concept of advance care planning is a suitable tool for this, and in case of non-admission to the ICU, does not by any means constitute an abandonment of the patient, because palliative care can also be anticipated, with a view to avoiding suffering for the patient and their family. Next, during an ICU stay, while the technical aspects undoubtedly characterise the ICU best at the start of the patient's stay, the process of reflection rapidly becomes preponderant, and involves the analysis of often complex situations with a view to defining the level of therapeutic engagement and optimizing the care dispensed to the patient. Last, a further ethical issue concerns the decision to re-admit (or not) a patient to the ICU. This decision can be made, for example, in the framework of a systematic, formalised, structured, multidisciplinary meeting at the end of an ICU stay, using a similar procedure to that implemented for decisions relating to withholding or withdrawal of life-sustaining therapies. The profession of ICU physician is not simply a question of prolonging or sustaining life, but is also fraught with ethical questions about how best to employ their competences. In this regard, it is essential to foster interdisciplinary collaboration, and emphasise the need for ICU physicians to be involved in the development of therapeutic projects, particularly when the disease in question is likely to be complicated by acute situations that may require admission of the patient to the ICU., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Improvements in living conditions and increasing life expectancy have combined to result in ever older patients being admitted to hospital. In parallel, the increasing incidence of cancer, along with the improved efficacy of anti-cancer therapies has led to greater needs for intensive care among cancer patients. The objectives underpinning the management of cancer patients in the intensive care unit (ICU) are to achieve a return to a clinical status that would allow the patient to be either, transferred back to the original unit, or discharged from the hospital with an acceptable quality of life, and where warranted, pursuit of cancer therapy. The relevance of ICU admission should be assessed systematically for patients with active cancer. The decision needs to be made taking into account the expected benefit for the patient, the life-support therapies that are possible with discussion about a care project, and also considering the future quality of life and the short and long-term prognosis. Anticipating the question of potential ICU admission should help protect the patient against both inappropriate refusal of intensive care, and inappropriate admission to the ICU that might only lead to unreasonable therapeutic obstinacy. The intensive care physician has a major role to play in helping the cancer patient to develop an appropriate and flexible healthcare project. Anticipating the question of ICU admission in advance, as well as a close alliance between the oncologist and the intensive care physician are the two keys to the success of a healthcare project focused on the patient., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

In the context of healthcare delivery, the vulnerabilities of patients in the intensive care unit (ICU) are intricately linked with those experienced on a daily basis by caregivers in the ICU in a symbiotic relation, whereby patients who are suffering can in turn engender suffering in the caregivers. In the same way, caregivers who are suffering themselves may be a source of suffering for their patients. The vulnerabilities of both patients and caregivers in the ICU are simultaneously constituted through a process that is influenced on the one hand by the healthcare objectives of the ICU, and on the other hand, by the conformity of the patients who are managed in that ICU. The specific challenges of management in high-technology units such as an ICU may have consequences on the practices and work conditions of healthcare professionals. Constructing the patient, collectively redefining the patient's identity, and ascribing the patient to a specific healthcare trajectory enables professionals to circumscribe, contain and fight against the spectrum of extreme vulnerabilities of their patients. Imposing this normative framework is the sole means of guiding these professionals through their daily practices. In spite of this, situations of suffering remain a constitutive feature of the caregiving relation in the ICU., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.