Background: Polypharmacy and the use of potentially inappropriate medications are frequent safety issues among nursing home (NH) residents. Deprescribing can significantly reduce the number of drugs used, medication costs, and mortality. This qualitative study sought to understand and compare the perceptions and practices of nurses, pharmacists, and physicians regarding deprescribing in Swiss NHs, referring to an implementation approach on three levels of action: the individual, the institution, and the healthcare system. Methods: Two focus groups were held with 21 participants: one focus group with 11 pharmacists, another with 10 nurses and six semi-structured interviews with physicians were conducted and focused on their individual experience and practices. They were audiotaped and fully transcribed, and a content analysis was performed using to MAXQDA (Ver 12) software. Results: (1) At an individual level, physicians were concerned by consequences of deprescribing in terms of safety. Nurses were closest to residents and stressed the importance of finding the right time, creating a bond of trust before deprescribing and considering the purpose of the stay in the NH. Pharmacists relied on structured guides for deprescribing, which led their reflection and practice. All professionals saw the complexity of the clinical situations, as well as residents’ and relatives’ fears of interruption of care. (2) At an institutional level, the professionals stressed the lack of time to discuss patients’ health and treatment, while pre-existing interprofessional collaboration, specifically, quality circles, seemed useful tools to create common knowledge. In order to reduce prescriptions, better coordination between physicians, nurses, pharmacists and specialists seemed crucial. (3) At the health system level, funding still needs to be provided to consolidate the process, go beyond organisational constraints and ensure deprescribing serves the patient’s wellbeing above all. Conclusions: At the individual level of implementation, the different healthcare professionals expressed specific concerns about deprescribing, depending on their defined role in NHs. Their perspective about the different levers to promote deprescribing at institutional and healthcare system levels converge towards interprofessional collaboration supported by the healthcare system. Specific funding and incentives are therefore needed to support a sustainable interprofessional team.

In Switzerland, where assisted suicide but not euthanasia is permitted, the authors sought to understand how physicians integrate palliative sedation in their practice and how they reflect on existential suffering and death hastening. They interviewed 31 physicians from different care settings. Five major attitudes emerged. Among specialized palliative care physicians, convinced, cautious and doubtful attitudes were evident. Within unspecialized settings, palliative sedation was more likely to be considered as death hastening: clinicians either avoid it with an inexperienced attitude or practice it with an ambiguous attitude, raising the issue of unskilled and abusive uses of sedatives at the end of life.

Objective: Previous literature has suggested that laws and regulations may impact the use of palliative sedation. Our present study compares the attitudes of French-speaking physicians practicing in the Quebec and Swiss environments, where different laws are in place regarding physician-assisted suicide.Method: Data were drawn from two prior studies, one by Blondeau and colleagues and another by Beauverd and coworkers, employing the same two-by-two experimental design with length of prognosis and type of suffering as independent variables. Both the effect of these variables and the effect of their interaction on Swiss and Quebec physicians' attitudes toward sedation were compared. The written comments of respondents were submitted to a qualitative content analysis and summarized in a comparative perspective.Results: The analysis of variance showed that only the type of suffering had an effect on physicians' attitudes toward sedation. The results of the Wilcoxon test indicated that the attitudes of physicians from Quebec and Switzerland tended to be different for two vignettes: long-term prognosis with existential suffering (p= 0.0577) and short-term prognosis with physical suffering (p= 0.0914). In both cases, the Swiss physicians were less prone to palliative sedation.Significance of results: The attitudes of physicians from Quebec and Switzerland toward palliative sedation, particularly regarding prognosis and type of suffering, seem similar. However, the results suggest that physicians from Quebec could be slightly more open to palliative sedation, even though most were not in favor of this practice as an answer to end-of-life existential suffering.

Objective: Palliative sedation is a last resort medical act aimed at relieving intolerable suffering induced by intractable symptoms in patients at the end-of-life. This act is generally accepted as being medically indicated under certain circumstances. A controversy remains in the literature as to its ethical validity. There is a certain vagueness in the literature regarding the legitimacy of palliative sedation in cases of non-physical refractory symptoms, especially “existential suffering.” This pilot study aims to measure the influence of two independent variables (short/long prognosis and physical/existential suffering) on the physicians' attitudes toward palliative sedation (dependent variable).Methods: We used a 2 × 2 experimental design as described by Blondeau et al. Four clinical vignettes were developed (vignette 1: short prognosis/existential suffering; vignette 2: long prognosis/existential suffering; vignette 3: short prognosis/physical suffering; vignette 4: long prognosis/physical suffering). Each vignette presented a terminally ill patient with a summary description of his physical and psychological condition, medication, and family situation. The respondents' attitude towards sedation was assessed with a six-point Likert scale. A total of 240 vignettes were sent to selected Swiss physicians.Results: 74 vignettes were completed (36%). The means scores for attitudes were 2.62 ± 2.06 (v1), 1.88 ± 1.54 (v2), 4.54 ± 1.67 (v3), and 4.75 ± 1.71 (v4). General linear model analyses indicated that only the type of suffering had a significant impact on the attitude towards sedation (F = 33.92, df = 1, p = 0.000).Significance of the results: The French Swiss physicians' attitude toward palliative sedation is more favorable in case of physical suffering than in existential suffering. These results are in line with those found in the study of Blondeau et al. with Canadian physicians and will be discussed in light of the arguments given by physicians to explain their decisions.

Résumé Sur la base de données ethnographiques rendant compte d’échanges quotidiens entre une équipe mobile de soins palliatifs et différents services de « première ligne » d’un hôpital, cet article considère les relations d’intermédicalité entre ces cultures médicales divergentes. Dans un premier temps, les obstacles qui émergent lors de tentatives d’intégration du nouveau modèle proposé par les soins palliatifs seront discutés. En effet, celui-ci introduit une conception nouvelle de la trajectoire de la maladie incurable traduisant des valeurs fondamentales telles que prendre du temps et s’adapter aux besoins du patient tout en soulageant efficacement les symptômes liés à l’incurabilité et à la fin de vie. Les données recueillies dans cette enquête montrent que, tout en se confrontant à l’ordre hospitalier, les soins palliatifs participent dans une certaine mesure au renouvellement de pratiques institutionnelles. Dans un deuxième temps, ces confrontations et transformations seront lues à la lumière d’enjeux de pouvoir sous-jacents influençant le processus de reconnaissance des soins palliatifs dans le champ médical. En tant que nouvelle spécialité « à contre-courant », une forte adaptation est requise laissant poindre le risque d’assimilation de l’équipe mobile à l’institution hospitalière.

A new subfield of oncology has emerged in the last twenty years to raise awareness and address the specific needs of elderly cancer patients, a population that was long neglected in oncology. We sought to understand the individual experiences, as well as moral and social implications of considering elderly cancer patients as "treatable". Following an anthropological critical interpretative approach focusing on practical and symbolic effects of chemotherapy in a rapidly evolving medical field, we conducted 20 semi-structured interviews and observations of medicine storage places at home among elderly cancer patients aged 70 and over in a clearly incurable situation receiving palliative chemotherapy. We used photographs representing paths as triggers in interviews, and compared the patients' views with those of 12 health professionals in oncology during a brief open-ended interview. Elderly cancer patients consider themselves to be survivors and fighters. Their long trajectory is a result of their successful struggle and tolerance of the treatments allowing them to carry on. They continually observe their physical ability and test their resistance, they resist complaining and are grateful to have cancer at a late stage of life. By highlighting their active life rather than the treatment inconveniences, they show they are "young elderly" persons, capable of keeping active physically. They are treated precisely because they demonstrated that they had the physical and moral capacity to take the hit of the chemotherapy to their bodies and had the will to fight. The development of oncogeriatrics has enabled the treatment of the fittest cancer patients over 70, but the ethical debate to treat some elderly patients and not others, and decisions of therapeutic abstention facing frail elderly cancer patients remains an issue rarely discussed. This aspect should not be eluded by the important progress achieved in medicine facing cancer.