Regards de médecins sur les directives anticipées en oncologie vingt ans après la loi Leonetti : constats et perspectives

Evaluation of surgical oncology fellowship websites: Are we showing what applicants need to see?

Widespread Misinterpretation of Advance Directives and Portable Orders for Life-Sustaining Treatments Threatens Patient Safety and Causes Undertreatment and Overtreatment.

Dr. Raphael Pollock Elected President of the Society of Surgical Oncology

Nicholas Petrelli, M.D., Elected SSO President;William Cance, M.D., Becomes President-electNicholas J. Petrelli, M.D., Newark, DE, was installed as 2007-08 President of the Society of Surgical Oncology (SSO) at its annual business meeting in Washington, D.C. He succeeds Raphael E. Pollock, MD, PhD, Houston, TX.Others elected to serve on the SSO Executive Council are: William G. Cance, MD, Gainesville, FL, President-elect; Fabrizio Michelassi, MD, New York, NY, Vice President; Monica Morrow, MD, Philadelphia, PA, Secretary; Kenneth K. Tanabe, MD, Boston, MA, Executive Council Member; Douglas S. Tyler, .D, Durham, NC, Executive Council Member; and Martin J. Heslin, MD, Birmingham, AL, Councillor-at-Large.Dr. Nicholas J. Petrelli: SSO President Dr. Petrelli is Medical Director of the Helen H. Graham Cancer Center, ChristianaCare, Newark, DE, and Professor of Surgery at Thomas Jefferson University, Philadelphia, PA.A former SSO President-elect and Vice President, Dr. Petrelli served two previous three-year terms on the Executive Council. He is former Chair of the Corporate Relations and Continuing Medical Education Committees; served on the Scientific Program, Training Program Directors, and Nominating Committees; spent five years on the James Ewing Foundation Board of Directors, and was Section Editor (Gastrointestinal) for Annals of Surgical Oncology.Dr. Petrelli earned his medical degree at Tulane University Medical School, New Orleans, LA. He completed residency training at St. Mary's Hospital and Medical Center, San Francisco, CA, and a surgical oncology fellowship at Roswell Park Cancer Institute, Buffalo, NY. Dr. Petrelli also completed a Union InternationaleContre le Cancer (International Union Against Cancer, or UICC) Fellowship in Milan, Italy.President-elect: Dr. William CanceDr. Cance is Professor and Chairman, Department of Surgery, and Professor, Department of Biochemistry and Molecular Biology at the University of Florida.Dr. Cance is a past SSO Vice President and Treasurer, and served as a member of the Executive Council from 1999-2002. In addition, he has served as a member - and chair - of both the Scientific Program and Issues & Government Affairs Committees, and on the Editorial Board of Annals of Surgical Oncology.Dr. Cance earned his medical degree from Duke University, Durham, NC, where he also completed a Bachelor's of Science degree in Zoology. He completed residency training at Barnes Hospital, St. Louis, MO, and fellowship training at Memorial Sloan-Kettering Cancer Center, New York, NY.Vice President: Dr. Fabrizio MichelassiDr. Michelassi is the Lewis Atterbury Stimson Professor of Surgery andChairman of the Department of Surgery at Weill Medical College of Cornell University, and Surgeon-in-Chief at the New York Presbyterian Hospital-Weill Cornell Medical Center.An SSO member since 1989, Dr. Michelassi has previously served on the Executive Council as Secretary and Councillor-at-Large. He was chair of the Scientific Program Committee for the 2001 Annual Meeting in Washington, D.C., and has served on several committees, including the Continuing Medical Education, Local Arrangements, and Clinical Affairs Committees.Dr. Michelassi graduated Summa cum Laude from the University of Pisa, School of Medicine, Italy, then completed residencies at the University of Pisa, Department of Surgery, and New York University.Secretary: Dr. Monica MorrowDr. Morrow is the G. Willing Pepper Chair in Cancer Research and theChairperson of the Department of Surgery at Fox Chase Cancer Center. She is also Professor of Surgery, Temple University School of Medicine.She previously served on the Executive Council from 1993 ˆ 1996, and 2003-2006. Dr. Morrow also served on the Issues Committee, and as a member of the Annals of Surgical Oncology Editorial Board. She was Secretary/Treasurer of the James Ewing Foundation, and chaired the SSO Committee on Standards for the Diagnosis and Management of Breast Disease.Dr. Morrow earned her Bachelor's degree Magna cum Laude from Pennsylvania State University, and completed her medical degree at Jefferson Medical College. Upon graduation, she completed her surgical residency at the Medical Center of Vermont, followed by two years of surgical oncology training at Memorial Sloan Kettering Cancer Center.Executive Council Member: Dr. Kenneth TanabeDr. Tanabe is Chief, Division of Surgical Oncology, Massachusetts General Hospital, and Associate Professor of Surgery, Harvard Medical School. He is also Deputy Clinical Director of the MGH Cancer Center.Dr. Tanabe is a member of the Editorial Board of Annals of Surgical Oncology. He has chaired the Constitution & Bylaws Committee, and served on the Program Committee and Fellowship & Research Grant Committee.Dr. Tanabe earned his Bachelor's degree at Stanford University, then completed his medical degree at the University of California, San Diego. He completed residency training at The New York Hospital Cornell Medical Center and Memorial Sloan-Kettering Cancer Center. Dr. Tanabe then completed surgical oncology training at M. D. Anderson Cancer Center, Houston, TX.Executive Council Member: Dr. Douglas TylerDr. Tyler is Professor of Surgery, Chief of the Section of Surgical Oncology, and Vice Chairman (VA Services) of the Department of Surgery at Duke University Medical Center. He is also a member of Duke's Institute of Genomic Sciences and Policy, and the Institution's Comprehensive Cancer Center. In addition, Dr. Tyler is Chief of the Surgical Services at Durham Veterans Affairs Medical Center.Dr. Tyler currently serves on the Issues & Government Affairs Committee and the Editorial Board of Annals of Surgical Oncology. He served a three-year term on the Membership Committee.Dr. Tyler earned his medical degree from Dartmouth College, Hanover, New Hampshire, underwent residency training at Duke University Medical Center, and completed a fellowship in surgical oncology at M. D. Anderson Cancer Center, Houston, TX.Dr. Martin J. Heslin: Councillor-at-LargeDr. Heslin is Professor of Surgery, Department of Surgery, at the University of Alabama School of Medicine in Birmingham. He is also Associate Chief of Staff at the University of Alabama Hospital.An SSO member since 1997, Dr. Heslin serves as the Gastrointestinal Surgery Reviewer for Annals of Surgical Oncology.Dr. Heslin completed a Bachelor's of Science degree in Microbiology at Cornell University, then earned his medical degree from State University of New York Health Science Center at Syracuse, College of Medicine. He completed residency training at New York University Medical Center, and a surgical oncology fellowship at Memorial Sloan-Kettering Cancer Center, New York, NY.The Society of Surgical Oncology was founded in 1940 to broaden the study of cancer. Its more than 2,000 members include physicians from several medical specialties, including colorectal surgery, general surgical oncology, gynecologic oncology, head and neck surgery, medical oncology, neurosurgical oncology, orthopedic oncology, pathology, pediatric surgical oncology, plastic andreconstructive surgery, radiation oncology, thoracic surgical oncology, and urologic oncology.

ADVANCE DIRECTIVES PROVIDE A LEGAL MEANS FOR PATIENTS to state treatment preferences in advance, should they later become unable to participate in decisions about their care. In 1990, Congress adopted the Patient Self Determination Act, which sought to increase the use of advance directives. However, a 1999 study of members of a health maintenance organization found that only one-third of patients aged 65 years or older reported having filed an advance directive. Although such decisions may later be made by others acting as proxies, their judgments of patients’ treatment preferences may not be accurate. Through communication with their patients about advance directives, physicians can play a key role in making advance directives a more effective part of patient care. In the previously cited study, only 15% of patients reported having been asked about their advance care preferences by a physician or nurse, although patients were 3 times more likely to establish an advance directive if they have been asked about their wishes. Many physicians fail to initiate such discussions because they may worry about spending too much time on them, but in fact such discussions average less than 3 minutes in length. Physicians may also fear that patients are uncomfortable discussing issues surrounding their own mortality. In contrast to this assumption, one study found that 93% of outpatients and 89% of the general public were interested in discussing advance directives, with young and healthy individuals expressing as much interest as older, less healthy people. A retrospective study of decedents in a Midwestern community found that 85% had had advance directives, and suggested that the unusually high rate of use was the result of an extensive educational program on end-of-life planning. This implies that advance directives can be both widely used and effective, provided the resources exist to increase patient awareness. While increasing advance directives is an important goal, a greater challenge lies in modifying them to better reflect patient preferences. Advance directive forms that are standard in US health care facilities ask patients general questions, which may or may not be applicable to a patient’s individual circumstances. In addition, patients often misunderstand their options to refuse or withdraw treatment or to choose palliative care. It is possible that even with an advanced directive in place, patients may not receive the care they would want. Patients must be educated about treatment options in order to make well-informed decisions about their future care. A simple way to accomplish this goal is to focus on the acceptability of potential treatment outcomes to the patient. A recent qualitative study of elderly individuals found they were more concerned with functional outcome than with the medical techniques used to achieve that outcome. One method of assessing the acceptability of treatment is to use scenario-based decision aids describing different treatment options and their potential outcomes. Assessing patients’ understanding and willingness to accept potential treatment outcomes increases the likelihood of informed consent and enhances the utility of advance directives. In some cases, advance care decisions are made by someone other than the patient. The accuracy of proxy judgments can be enhanced when the patient and his or her proxy have discussed advance care issues. This is in accord with research demonstrating that patients consider planning advance care to be a social interaction between loved ones, rather than simply a matter of signing forms. Promoting collaboration between family members and loved ones may minimize the ambiguity often found in advance directives, and may better prepare surrogates to make treatment decisions. Physicians can take an active part in this process by encouraging their patients to discuss advance care issues with their chosen surrogates. Although systemic changes such as computerized reminders can encourage physicians to integrate advanced planning directives in their routine patient care, such discussions will still require meaningful communication with patients. Through such discussions, physicians have the opportunity to play a central role in increasing both the effectiveness and use of advance directives.

We distributed 282 questionnaires to doctors to ascertain their opinions on obtaining the advance directives regarding the end-of-life treatment of patients at the terminal stage. We received 136 (48%) responses. A total of 62% of the respondents stated a desire for patients to indicate their advance directives "if at all possible". Only 36% stated that the need for advance directives "depended on the circumstances". A total of 80% of doctors aged under 40 wished patients to provide advanced directives "if at all possible", while 59% of doctors over 61 wanted advanced directives "depending on the circumstances" (p=0.008). A large number of doctors stated a desire for patients to indicate their preference in writing, particularly directives regarding the "use of a ventilator to prolong life" (76%) or the "use of artificial nourishment through a gastric fistula etc. as part of a proactive approach to sustaining life" (67%). Regarding the optimal timing of this declaration, 59% chose "at the first diagnosis of a terminal illness", and 47% chose "at the diagnosis of a chronic illness", regardless of whether it could become terminal. Of those respondents under 40, 32% believed that doctors should strictly follow the patients' advance directives, while only 11% of doctors over 61 years old believed the same. There was a statistically significant relationship between aging and dealing with advance directives of patients in the terminal stages of illness (p=0.002). These results suggest that doctors under 40 years of age should focus on how to correctly interpret the wishes of the patients expressed in the directives, while doctors over 61 should concentrate on the importance of the clinical application of advance directives, and how to balance the need to make qualified medical decisions on treatment in compliance with the wishes of end-stage terminal patients.

Part 2: Ethical Aspects of CPR and ECC

German Legislation has defined the legal significance of advance directives (AD). Nevertheless, many precast ADs are of limited help in clinical decision making. Empirical results are rare and controversial. The SUPPORT study showed that precast ADs had a tendency to being ignored. Value-based AD proved to be of help in the interpretation of patients' wills by physicians. We therefore investigated whether a value-based AD that can be individualized with the help of a check-box-system is a valid instrument of communicating the patient's preferences. This is the first validation of an AD. In our study we evaluated the acceptance and practicability of an AD. Questionnaires and the AD itself were handed out to patients, relatives, and members of the nursing and medical staff. All were asked to fill out the AD, mark all unclear passages, make amendments to the AD if wanted and finally were asked to answer a questionnaire regarding the AD. The level of significance was defined at 5%, meaning that every "unwanted" answer exceeding 5% or passages with more than 5% of the total remarks were analyzed and it was checked whether changes to the AD should be made. The return rate was 64.8% (201 of 310). The results were highly positive for the items "understandable" (81,6%), "clarifying" (65,7%), "helpful" (76,1%), and "sensible" (75,1%). 70% of patients and relatives stated that they were able to express personal wishes and values with this AD, as well as a majority of the medical staff (44% vs. 30%). The discrepancy between the groups was significant (ChiSq=13.11, p<.001). All paragraphs of the check-box-system were validated as understandable and clear in intention. Major concerns were the inability of expressing own wishes and values (by 16,4% of all participants) and the fear of later alterations (15,4%). According to the findings and the evaluations the AD was modified. The value-based AD which is routinely used in a university hospital and which can be individualized by a check-box-system was broadly accepted by the test subjects and showed highly positive results with respect to the analyzed items. Only minor changes were derived from our study to hopefully raise its acceptance even more. The discrepancy between patients, relatives and the medical staff concerning the possibility to express one's wishes and values was surprising and in contradiction to former findings. However, our study cannot answer whether the higher level of distrust among medical staff can be explained by negative professional experiences. The investigated AD with a check box system seems to be an adequate instrument to communicate patient's wishes and directives.

Pregnancy Clauses

Introduction: Advance directives are often promoted as a way to ensure that patient wishes are followed; however, the impact of advance directives on actual care is controversial, and little is known about the impact on in-hospital stroke treatment. We explored the association between pre-stroke advance directives and transition to comfort measures only (CMO) during stroke hospitalization among patients with surrogate-decision makers. Methods: Ischemic stroke and intracerebral hemorrhage (ICH) stroke cases from the Brain Attack Surveillance in Corpus Christi (BASIC) project and their surrogate decision makers from the Outcomes Among Surrogate Decision Makers in Stroke (OASIS) were enrolled. Patient records were abstracted for time to CMO. Surrogates were asked about patient pre-stroke advance directives (advance directive, living will, or durable power of attorney for health care). Cox-proportional-hazards models assessed the relationship between advance directives and time to CMO (censored at death, discharge, or 30 days). Based on the available sample size, adjustment factors were pre-specified and included age, NIHSS, and stroke type. Results: 144 stroke patients were included (ischemic 76%; ICH 24%; age ≥75 45%; female 52%; Mexican American (MA) 59%, NIHSS mean (SD) 13(11)). 22% of cases transitioned to CMO during the hospitalization (median time to CMO 3 days); 39% of patients had an advance directive. Younger individuals, MAs and men were less likely to have advance directives. After adjusting for stroke type, age, and NIHSS, advance directives were not associated with time to CMO (Table). Conclusions: Fewer than half of stroke patients had advance directives; however, the presence of advance directives did not appear to impact in-hospital transitions to CMO, suggesting limited utility of advance directives. Further study in larger samples is needed to determine the best way to ensure patient wishes are followed after stroke.

When, if ever, should a patient's advance directive not be followed? Since it is widely accepted that a competent patient's treatment choice must be respected, and an advance directive can reasonably be understood as the treatment choice of a patient while still competent, some believe that informed, voluntary advance directives should always be followed. However, there are several reasons for special doubts about whether an advance directive accurately reflects what the patient would have wanted. Uncertainty as to how closely an advance directive reflects what a patient actually would want may arise from any of several sources. Advance directives typically require individuals to predict what they would want well in advance of the use of the directive in treatment decisionmaking, and so treatment choices in advance directives often inevitably are less well informed than competent patients' contemporaneous choices. For example, new, highly beneficial treatment may have been developed of which the patient was unaware; or if the directive is very old there may be evidence that the patient's wishes about treatment have changed. Also, advance directives must often be formulated without knowing what it will be like to experience the radically different conditions in which later treatment choices must be made. Further, advance directives are often formulated in somewhat vague or general terms, which inevitably leaves significant discretion in applying them to later treatment choices and, in turn, uncertainty about whether they have been correctly interpreted. Moreover, when competent patients make choices that appear to be seriously in conflict with their well-being or settled preferences and values, these choices will typically be questioned, explored, and even opposed by their physicians, family members, and others who care for them to insure that the patients fully understand the nature and implications of their choices, and that the choices are what they want. Directives executed by no longer competent patients obviously cannot be similarly clarified. Finally, advance directives are often framed with implicit assumptions about the conditions in which the directive will be applied. For example, an advance directive declining CPR may be intended by the patient to apply to circumstances where her overall condition has so deteriorated that she is virtually certain not to survive the attempt. The patient may not have meant her directive to apply, however, should a cardiac arrest be caused by a medical procedure or in reaction to a drug, and in circumstances where CPR is highly likely to succeed and to leave the patient unimpaired. In the second kind of case in which an advance directive might be trumped, what the individual executing the directive really wanted need not be in doubt. Instead, the issue is the moral authority of that individual's advance directive to determine the patient's treatment. That authority can be called into question when the directive appears to be seriously in conflict with important interests of the present patient or the patient has suffered such profound cognitive changes-for example, being now in a persistent vegetative state or severely demented-that there are doubts whether personal identity is maintained between the person who executed the advance directive and the present patient. The strongest cases of this sort for trumping advance directives will be when both these conditions obtain, with directives requesting either the forgoing of treatment or maximally aggressive treatment. …

Are Advance Directives Becoming an Endangered Species?

Ramifications of Diminished Capacity

What Part of ‘Do Not’ Don't We Understand?

Introduction: United States law requires hospitals to document advanced directives for patients on admission with no provision for assessment of their understanding. Aim: We sought to assess patients' knowledge gaps regarding end-of-life care, including do-not-resuscitate and do-not-intubate orders, physician orders for life-sustaining treatment, outcomes after cardiopulmonary resuscitation, and preferences regarding end-of-life care Methods: This is a cross-sectional survey-based study of adult patients aged 55 and older who were being admitted to a large community hospital from the emergency department (ED). Patients were not excluded based on acuity or reason for admission. The survey questioned patients regarding age, primary care provider status, ED visits and hospitalization within the prior year, prior discussions with family, primary care, or inpatient care physicians regarding advanced medical directives, prior completion of advanced medical directives paperwork, knowledge of outcomes after cardiac arrest, and general attitudes regarding priorities related to a “good death”. Results: Although 98% of patients had primary care physicians, only one-fourth recalled discussing advanced directives with their doctors. About half of patients had discussed their wishes with their families, and 52% had signed advanced directive paperwork. Patients overestimated survival after cardiac arrest. The most common elements reported by patients as being important to a “good death” were the absence of pain (26%), the presence of family (24%), and death at home (16%). Conclusion: Patients have clear ideas for what makes a good death but have inadequate knowledge regarding resuscitative outcomes and do not make use of advanced directives. Physicians miss opportunities to educate patients and assist with these difficult decisions. Closing the gap between providers' understanding of patients' desires, and patients' understanding of end-of-life care is an opportunity for improvement. The following core competencies are addressed in this article: Patient care and procedural skills and Systems-based practice.