Organisation des soins palliatifs en Belgique - KCE

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120 Palliative Care KCE reports 115 9.3.5.1 Expectations from the treatment plan Physicians and nurses paid more attention to patients’ comfort (71.9% and 73.5%, respectively) than to life prolongation (26.1% and 24.9%, respectively). Nevertheless, physicians and nurses didn’t know the wishes of the patients or families in 28.5% of cases (see next table). Table 26: Expectations from the treatment plan Patients Families Physicians Nurses N (%) N (%) N (%) N (%) To prolong life 81 (32.5%) 70 (28.1%) 65 (26.1%) 62 (24.9%) To improve comfort 66 (26.5%) 105 (42.2%) 179 (71.9%) 183 (73.5%) No specific wishes 31 (12.5%) 5 (2.0%) 1 (0.4%) 1 (0.4%) No information available 21 (8.5%) 44 (17.7%) 4 (1.6%) 3 (1.2%) Not able to speak or absent 50 (20.0%) 25 (10.0%) - - Total 249 249 249 249 The most important patients’ expectations from the current treatment was a life prolongation (81/249, 32.5%) and secondly a comfort’s improvement (66/249, 26.5%). Among the families, the expectations about comfort were more frequent (105/249, 42.2%) (table above). When the patients expected a life prolongation, the families expressed the same expectations in 60.5% of cases (49/81), the physicians (nurses) in 51.9% (50.6%) of cases (42/81, 41/81). Conversely when the physicians considered only a symptomatic treatment, the families agreed in 57.5% of cases (103/179) and the patients in 35.2% of cases (63/179). When analysing the physician’s point of view, the proportions of life prolongation expectations were similar for patients suffering from cancer (32/128. 25.0%) and for patients suffering from other pathologies (33/121, 27.3%). Among non cancer patients, these proportions varied with the pathologies. The lowest one was recorded in case of dementia (1/32, 3.1%). Higher frequencies were recorded in case of heart failure (5/16, 31.3%), stroke (6/17, 35.3%), respiratory failure (6/16, 37.5%) and hepatic failure (8/13, 61.5%). The proportion of life prolongation’s expectations decreased with patients’ age: from 38.1% for 55-64 years old patients to 19.2% for patients older than 85 years. The contrary was observed in case of comfort improvement’s expectations: 62.5% for 55-64 years old patients to 80.7% for patients older than 85 years. The proportion of life prolongation’s expectations increased with patients’ prognosis: 6.3% for a prognosis equal or lower than 3 months (5/79), 22.5% for a prognosis of 4-6 months (9/40), 33.3% for a prognosis of 7-12 months (19/57) and 41.8% for a prognosis of at least 1 year (28/67). The frequency of life prolongation’s expectations was the lowest in the geriatric beds (11/77, 14.3%), intermediate in acute beds (43/149, 28.9%) and the highest in the special treatment beds (11/23, 47.8%). From the physician’s point of view, the proportion of life prolongation’s expectations little changed between day 1 (26.1%) and day 14 (42) (28.9%). Nevertheless, this slight increase partly resulted from shifts in the treatment’s expectations. Indeed 27.7% (18/65) of patients treated with a life prolongation’s intention at day 1 were shifted at day 14 (42) to a treatment aiming to control symptoms. Contrarily, at day 14 (42) the treatment’s objective became a life prolongation for 12.8% of patients (23/179) treated at day 1 to control the symptoms. The first shift, life’s prolongation to symptom’s control, was higher among nurses (25/62, 40.3%). 9.3.5.2 Therapeutic strategies The type of treatment was generally clearly expressed and well defined by the caregivers (see next table). For a large proportion of patients, they excluded a cardiac resuscitation (177/249, 71.1%) and a transfer to intensive care unit (155/249, 62.2%) (next table).
KCE Reports 115 Palliative Care 121 When an admission in intensive care unit was considered (81/249, 32.6%), the main objective was to prolong life (41/81, 50.6%) and the second was to improve the symptoms (20/81, 24.7%). Other motivations were mentioned for 2 patients (2/81, 2.5%) (table 28). Antibiotics were considered planned or ongoing for 90.0% of patients (224/249), transfusion for 78.3% of patients (195/249), a specific treatment of the pathology (like chemotherapy or radiotherapy for cancer patients) for 57.0% of patients (142/249) and parenteral or enteral infusions for 49.8% of patients (124/249) (table 27). Specific treatment of the pathology, antibiotics and transfusion were given in order to control symptoms respectively in 56.3%, 66.5% and 73.8%. The objectives of treatment like parenteral or enteral infusion were almost equally distributed among life’s prolongation and symptom’s control (table 28). Table 27: Therapeutic strategies at day 1 Excluded Considered/planned Ongoing Not defined N (%) N (%) N (%) N (%) Cardiac resuscitation 177 (71.1%) 64 (25.7%) - 8 (3.2%) Admission in intensive care unit 155 (62.2%) 81 (32.6%) - 13 (5.2%) Specific treatment of the pathology 94 (37.7%) 24 (10.9%) 118 (47.4%) 13 (5.2%) Parenteral and/or enteral infusion 110 (44.2%) 82 (32.9%) 42 (16.9%) 15 (6.0%) Antibiotics 20 (8.0%) 157 (63.1%) 67 (26.9%) 5 (2.0%) Transfusion 43 (17.3%) 178 (71.5%) 17 (6.8%) 11 (4.4%) Table 28: Treatment’s objectives at day 1 To prolong life N (%) Only to control symptoms N (%) Only as psychologica l support N (%) Other objective N (%) Not précised N (%) Admission in intensive care unit 41 (50.6%) 20 (24.7%) - 2 (2.5%) 18 (22.2%) 81 Specific treatment of the pathology 52 (36.6%) 80 (56.3%) 3 (2.1%) 6 (4.2%) 1 (0.7%) 142 Parenteral and/or enteral infusion 59 (47.6%) 56 (45.2%) 4 (3.2%) 4 (3.2%) 1 (0.8%) 124 Antibiotics 72 (32.1%) 149 (66.5%) 1 (0.4%) 2 (0.9%) 0 (0.0%) 224 Transfusion 49 (25.3%) 144 (73.8%) 1 (0.5%) - 1 (0.5%) 195 At day 14 (42), the number of patients for whom a treatment was excluded increased whatever the treatment analysed (next table). This frequency was the highest for the specific treatment of the pathology and for admission in intensive care unit. For few patients, the treatment was excluded at day 1 and was considered, planned or ongoing at day 14 (42) (see table 30). Table 29: Therapeutic stategies at day 14 or 42 Excluded Considered/planned Ongoing Not defined N (%) N (%) N (%) N (%) Cardiac resuscitation 191 (76.7%) 51 (20.5%) - 7 (2.8%) Admission in intensive care unit 183 (73.5%) 54 (21.7%) 2 (0.8%) 10 (4.0%) Parenteral and/or enteral infusion 118 (47.4%) 77 (30.9%) 42 (16.9%) 12 (4.8%) Specific treatment of the pathology 126 (50.6%) 14 (5.6%) 103 (41.4%) 6 (2.4%) Antibiotics 40 (16.1%) 158 (63.4%) 46 (18.5%) 5 (2.0%) Transfusion 58 (23.3%) 162 (65.1%) 12 (4.8%) 17 (6.8%) Total
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