[Ethical stakes in palliative care in radiation oncology]

In 2021, the Ethics Commission of the SFRO has chosen the issue of the practice of palliative care in radiotherapy oncology. Radiation oncology plays a central role in the care of patients with cancer in palliative phase. But behind the broad name of palliative radiotherapy, we actually find a large variety of situations involving diverse ethical issues. Radiation oncologists have the delicate task to take into account multiple factors throughout a complex decision-making process. While the question of the therapeutic indication and the technical choice allowing it to be implemented remains central, reflection cannot be limited to these decision-making and technical aspects alone. It is also a question of being able to create the conditions for a singularity focused care and to build an authentic care relationship, beyond technicity. It is through this daily ethical work, in close collaboration with patients, and under essential conditions of multidisciplinarity and multiprofessionalism, that our fundamental role as caregiver can be deployed.

[Intellectual disability and cancer in children: An analysis of the decision-making process]

AIM

The aim was to describe and to analyze the ethics of decision-making in situations involving children with intellectual disability and cancer, from the referent-doctor's point-of-view, in pediatric oncology units in France.

METHODS

Pediatricians working in pediatric oncology units were interviewed through an online questionnaire and a semi-directive interview was systematically proposed. We analyzed the ethical issues that arose during the process of decision-making and we made suggestions in order to address them.

RESULTS

Sixteen doctors reported twenty-one clinical cases. Of these cases, one third of the children had a change in their oncologic treatment, with a risk of pejorative outcome on the prognosis. Despite the fact that ethical issues appeared in 80 % of the cases, there were few consultations with ethical committees. Decision-making process showed no difference compared to children without intellectual disability, thus raising ethical issues in the medical team. Our study showed discrepancy between frequently reported ethical issues, high consensus rate regarding treatment decision and lack of consultation with ethical committees.

DISCUSSION

We propose three steps to guide the decision-making process in situations involving children with intellectual disability and cancer: 1/deeper understanding of the child through reinforced interactions with their caregivers, 2/better cross-boundary discussions, to improve the effectiveness of the multidisciplinary staff, and 3/more systematic ethical committees consultation.

Triage practices in stroke units: Physicians' perceptions and ethical issues

OBJECTIVE

We aimed to explore acute stroke admission decisions and to discuss ethical issues in triage practices in stroke units (SUs) in France.

METHODS

In this study, 337 questionnaires were sent to physicians involved in acute admission to SUs in Île-de-France (neurologists and physicians from emergency medical services). The questionnaires comprised questions about physicians' perceptions of the reasonable allocation of SU beds and admission criteria for patients in SU in clinical vignettes illustrating complex situations.

RESULTS

In total, 162 questionnaires were fully completed. There were some discrepancies in perceptions and reporting practices between emergency physicians and neurologists concerning patient admission criteria. Triage choices were more frequently declared by emergency physicians than by neurologists and were related to the difficulty of obtaining a positive response for the admission of certain complex patients (particularly those with comorbidities).

CONCLUSIONS

Despite recommendations stating that all patients with stroke should be admitted to SUs, this study has shown that triage practices exist in stroke admission decisions. The triage depends on the role and perceptions of each physician in acute stroke management. These decisions suggest reflections on the applicability of distributive justice theories and on ethical issues in triage practices in medicine.

[Overmedicalization: When too much medicine harms]

Overmedicalization refers to non-validated medical practices, with no clear benefits, potentially harmful and therefore unnecessarily costly. Awareness is growing with respect to this serious public health problem. Permanent expansion of diagnostic or therapeutic interventions, disease mongering, inadequate management of diagnostic uncertainty, conflict of interest or lack of commitment by physicians and patients in shared decision making. Overmedicalization is made possible by a lack of training of health professionals and users on medical decision process. Only a multidisciplinary research program, involving medical and non-medical worlds, will allow the implementation of corrective actions.

[Did the recommendation of the French public health council modify the antipapillomavirus vaccines' prescription level?]

BACKGROUND

In France, two vaccines are approved for prevention of papillomavirus infection: Cervarix(®) and Gardasil(®). The 17th of December 2010 the French High Committee of Public Hearth changed its recommendation about Cervarix(®) and decided that no scientific element justified a preference using Gardasil(®). This notification was published the 25th of January 2011. Our study aimed to determine whether this decision changed medical prescriptions.

METHODS

An ecological study was performed with reimbursement data for the two vaccines. We performed a Chi(2) test for qualitative variables and Student's t test for quantitative variables.

RESULTS

A significant difference was observed between the prescription of Cervarix(®) before and after the 25th January 2011. The difference favored increased prescription, compared to Gardasil(®) (P ≤ 0.05).

CONCLUSION

This variation can be explained by the impact of recommendations for medical decisions. The strong involvement of pharmaceutical firms in medical education may explain why prescribers reacted so rapidly after the publication of the new recommendations.

[Medical decision in a very elderly patient: a case report of application of the Leonetti law in emergency medicine]

Advanced care decision in emergency medicine is difficult for the elderly. How to be fair, avoiding an unreasonable obstinacy? Based on the case of very old person, we show how an optimal management can be decided in accordance with the spirit of the law.