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Ferrand E, Jabre P, Vincent-Genod C, Aubry R, Badet M, Badia P, Cariou A, Ellien F, Gounant V, Gil R, Jaber S, Jay S, Paillaud E, Poulain P, Regnier B, Reignier J, Socie G, Tardy B, Lemaire F, Brun-Buisson C, Marty J, . Circumstances of Death in Hospitalized Patients and Nurses' PerceptionsFrench Multicenter Mort-a-l’Hôpital Survey. Arch Intern Med. 2008;168(8):867–875. doi:10.1001/archinte.168.8.867
Copyright 2008 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2008
In developed countries at present, death mostly occurs in hospitals, but the circumstances and factors associated with the quality of organization and care surrounding death are not well described.
We designed a large multicenter cross-sectional study to analyze the setting and clinical course of each patient on the day of death. We included 2750 clinical departments of 294 hospitals. Of these, 1033 departments (37.6%) of 200 hospitals (68.0%) contributed to the Mort-a-l’Hôpital survey. Data were collected prospectively by the bedside nurse of each patient within 10 days of the occurrence of death. Main outcome measures included circumstances of death in hospitalized patients; secondary outcomes, nurses' perceptions of quality of end-of-life care.
Of the 1033 participating departments, 420 recorded no deaths during the study period and 613 declared at least 1 death. In the 3793 patients who died and were included for assessment, only 925 (24.4%) had loved ones present at the time of death; 70.1% had respiratory distress during the period before death; and only 12.0% were in pain. Written protocols for end-of-life care were available in 12.2% of participating departments. Only 35.1% of nurses judged the quality of dying and death acceptable for themselves. Principal factors significantly associated with this perception were availability of a written protocol for end-of-life care, anticipation of death, informing the family, surrogate designation, adequate control of pain, presence of family or friends at the time of death, and staff meeting with the family after the death.
This large prospective study identifies nonoptimal circumstances of death for hospitalized patients and a number of suggestions for improvement. A combination of factors reflected in the nurses' satisfaction may improve the quality of end-of-life care.
For the terminally ill patient, returning home to die has been suggested as a means of ensuring a peaceful and dignified death in the company of loved ones while providing pain control. Nevertheless, most deaths now occur in hospitals on both sides of the Atlantic.1,2
In recent years, a reappraisal of treatment goals and patient rights has driven major changes in the definition of what could be termed “a good death,” which now involves an experience that is as positive as possible for the patient and family. Work conducted in the United States to uphold patients' rights prompted the development of a number of recommendations.3-5 In France, where medical care is often described as paternalistic, recommendations have been developed by learned societies,6,7 prompted in part by heated public debates and widely publicized trials of physicians charged with hastening the deaths of terminally ill patients.8 Legislation passed in 1999 and 2002 now mandates that the rights of dying patients be upheld and that high-quality end-of-life palliative care be provided and futile curative therapies be withdrawn.9-11
Paradoxically, the circumstances surrounding the growing proportion of deaths occurring in hospitals have received little research attention.12 A few studies published during the past few years suggested that recommendations were frequently ignored, staff members were not trained in end-of-life issues, and markers for the quality of dying were not evaluated.12-17 However, most of these studies were conducted before the introduction of new legislation in the relevant countries or focused on treatment limitation decisions in the intensive care units (ICUs).16,18
We conducted a large multicenter cross-sectional study of French hospitals, shortly after the introduction of the new legislation, to investigate the circumstances in which patients died and to evaluate factors associated with nurses' perceptions of the quality of death.
First, we reviewed the literature for factors associated with quality of end-of-life care2,5,6,19-22 and used this information to develop a preliminary questionnaire, after conducting semidirective interviews with a panel of 8 bedside nurses and 4 physicians working in the ICUs and wards of the 900-bed Henri Mondor Hospital near Paris. The questionnaire explored markers for good communication, quality of end-of-life care, traceability, and degree of satisfaction of the physician and nurse with the quality of the death. The questionnaire was then field tested during a 4-week qualitative feasibility study in the surgical ICU. Finally, we conducted a quantitative feasibility assessment among the staff members of 18 clinical departments in the same hospital, during which physicians and bedside nurses were asked to describe the last death that had occurred in the department. Of the 235 deaths described, 54 (3 in each department) were retrospectively evaluated by the study investigators, who interviewed the staff members involved in the patients' care and reviewed the patients' medical records and nurses' logs.
The results of this preliminary phase showed that very few physicians were able to describe the last hours of dying patients; indeed, the nurses reported that physicians were present in 22 cases (9.4%). In addition, there was a substantial amount of missing data for deaths that had occurred more than 10 days before completion of the questionnaire.
The final instrument consisted of the following: (1) a description of the main characteristics of the department and of the dying patient, including subjective assessment of the patient's consciousness by the nurse during the corresponding shift; (2) the reason for admission according to the senior physician, determined at admission; (3) the last hours preceding the patient's death, including information given by the medical staff about a death that was expected for at least 3 days or during the corresponding shift, decisions about life-sustaining treatment before the time of death, information given to the patient and family, changes in clinical course, analgesic use, comfort care, and the presence of loved ones; (4) the information recorded at the time of death, including the level of analgesia and presence of staff, loved ones, or a member of the clergy; and (5) a subjective assessment by the nurses of the quality of the death, in particular in a positive response to the question “Do you feel that these circumstances would be acceptable for yourself?” The questionnaire (translated into English) is available from the authors on request.
Given the results of the preliminary study, the bedside nurse was considered the most knowledgeable staff member regarding patient treatment and the wishes of the patient and family at the time of death. Nurses were thus asked to complete the questionnaire for the next death occurring within a 2-month period. A single death was expected to be recorded by a given nurse within each department. Data on the setting and clinical course for each patient on the day of death were collected prospectively, and the questionnaire was to be completed and sent back within 10 days of the death. Deaths described more than 10 days after they occurred were excluded from data analysis.
Among the 1000 public hospitals in France, we selected only those that had an ICU. In January 2004, an invitation to participate in the study was sent to the heads and senior head nurses of all clinical departments of the 294 French public hospitals (85 teaching hospitals and 209 general hospitals). Reminders for a reply were sent 2 and 4 weeks after the first invitation.
The centers agreeing to participate were sent the questionnaire to collect the main characteristics of the department, including their annual number of admissions and deaths, number of nurses, ratio of nurses to patients, and usual practice for treatment of dying patients.
The institutional review board of Henri Mondor Hospital approved the study. The questionnaire contained no information that identified the patient or the nurse. Informed consent was waived for this anonymous observational questionnaire survey.
Data are reported as means (1 SD) or medians (25th-75th percentile range) for continuous variables and as percentages for qualitative variables. Univariate associations were evaluated using the Wilcoxon signed rank test for quantitative data and the χ2 test for qualitative data or the Fisher exact test for groups with low frequencies. All statistical tests were 2-tailed, and P < .05 was considered significant. The odds ratios and respective 95% confidence intervals were estimated separately for each variable using unconditional logistic regression models. A logistic regression was performed. The dependent variable was perception of the death as acceptable to the nurses according to self-report. Variables yielding P < .10 in the univariate analysis were considered for multivariate analysis and examined in multiple 2 × 2 analyses to assess first-order interactions and confounding by fitting multiplicative models. A backward step-by-step procedure was used to enter the variables thus selected into a logistic regression model. Goodness of fit of the model was assessed using the Hosmer-Lemeshow test. Statistical tests were performed using SAS statistical software (version 9.1.3; SAS Institute Inc, Cary, North Carolina).
The 2750 clinical departments within the 294 hospitals selected for participation were contacted directly. Of these 2750, 1517 (55.2%) initially agreed to participate; 1033 (37.6%) completed the survey, and 484 (31.9%) were secondarily excluded because of missing information on the preliminary questionnaire (n = 234), lack of availability of the corresponding nurse to record the circumstances of the last death (n = 57), or inability to complete the survey because of organizational constraints (n = 193).
Of the 1033 participating clinical departments, 420 recorded no death during the study period and 613 declared at least 1 death. These 613 departments were located in 200 hospitals (68.0% of the initial 294) distributed throughout France (92.0% of 100 French districts); 189 (30.8%) were housed in teaching hospitals and 424 (69.2%) in general public hospitals. A local palliative care structure was available in 123 hospitals (61.5%).
Data were recorded on 3793 deaths, with a range of 5 to 20 per department. Approximately two-thirds of deaths (2513 [66.3%]) occurred in the wards, including medical wards (1694 [44.7%]), surgical wards (407 [10.7%]), geriatric wards (375 [9.9%]), and palliative care wards (35 [0.9%]) (data were missing for 2 deaths that occurred in the wards). The remaining deaths occurred in emergency departments (228 [6.0%]) or in ICUs (1052 [27.7%]). Specific written protocols for end-of-life decision making and care were available in only 75 departments (12.2%), but 991 of the deaths analyzed (26.1%) occurred in these departments.
The ratio of male to female responding nurses was 0.13, and their mean age was 35 (9) years. The mean number of patients in the charge of each respondent was 4 (2) in the ICUs, 6 (3) in emergency departments, and 9 (2) in the wards. Approximately two-fifths of the nurses (n = 1452 [38.3%]) had received 1 or more training sessions on end-of-life issues.
The male to female ratio of the 3793 dying patients was 1.28 and their mean age was 68 (18) years. End of life was the main reason for admission for 882 patients (23.3%), and a malignant neoplasm was the most common chronic disease recorded (Table 1). Only 645 patients (17.0%) were institutionalized before hospital admission. Almost one-half of the patients (1881 [50.0%]) had been identified as terminally ill for at least 3 days before death (Table 2), and 1822 (48.0%) had not-to-be-resuscitated (NTBR) orders; of these, most (1722 patients [45.4%]) also had decisions to withhold or withdraw other treatments, which were recorded in their medical record in 759 cases (44.1%). Almost one-third of patients (1128 [29.7%]) were conscious; only 249 (6.6%) had expressed their wishes about no life-prolonging treatment and 544 (14.3%) had designated a surrogate decision maker, including 351 patients (18.7%) in whom death was expected for at least 3 days (Table 2).
The staff members had met with at least 1 family member of the dying patient in most cases (3721 [98.1%]), and the family had been informed in the preceding hours that death was imminent (2613 [68.9%]). The nurse expected the patient to die during the corresponding shift in 2809 cases (74.1%).
Slightly more than half of the patients (2032 [53.6%]) died during the day, between 7 AM and 7 PM. A family member or relative was present at the time of the death in only 925 of all cases (24.4%), and in 809 (43.0%) when death was expected for at least 3 days (Table 2 and Table 3). In 612 cases (16.1%), no one was in the room (Table 3). The bedside nurse was actually in the room at the time of death in 1678 cases (44.2%), but rarely was a physician present (770 cases [20.3%]) (Table 3). One or more members of the health care team met with the family after the death in 2798 cases (73.8%); in half of all deaths (1903 [50.2%]), these meetings were conducted by the nurse alone.
More than two-thirds of the patients (n = 2659 [70.1%]) were described as having respiratory distress, but only 455 (12.0%) were considered in pain and the opioid dosage was increased for 336 patients (8.9%) within a few hours before death. Overall, 1676 of all patients (44.2%) received opioid analgesics as comfort treatment at the moment of death, including 1092 (58.1%) of those in whom death was expected for at least 3 days (Table 2).
A palliative care consultation was considered for 638 patients (16.8%). It was actually provided to 460 patients (12.1%) (442 [17.6%,] 15 [1.4%], and 3 [1.3%] patients dying in wards, ICUs, and emergency wards, respectively), including 381 patients (20.3%) of those in whom death was anticipated for at least 3 days (Table 2).
Life-sustaining treatment was provided to 1214 patients (32.0%), including in 814 of deaths occurring in ICUs (77.4%), 48 of those in emergency departments (21.1%), and 352 of those in wards patients (14.0%). At the time of death, resuscitation was attempted in 542 patients (14.3%), 98 (18.1%) of whom had NTBR or treatment-limitation orders.
The quality of the death was judged acceptable by nurses in 1560 deaths (41.1%), and in 1332 (35.1%), the nurses believed that it would be perceived as such by themselves or their own relatives. Variables significantly associated with the perception by the nurses of an acceptable death were the availability of a written protocol for end-of-life care in the department, a higher ratio of nurses to patients, anticipation of death by the nurse, designation by the patient of a surrogate decision maker, an NTBR order or treatment-limitation decision recorded in the patient's medical record, adequate control of pain before death, information from the family that death was imminent, the presence of family or friends at the time of death, and a staff meeting with the family after the death (Table 4 and Table 5).
Among the most subjective reasons why nurses judged the quality of the patient's death as poor in 2233 cases were the physical deterioration (267 cases [12.0%]), major moral suffering (167 [7.5%]), loneliness at the time of death (121 [5.4%]), major inappropriate care despite an expectation of death (109 [4.9%]), and major physical suffering (98 [4.4%]).
We conducted, to our knowledge, the largest study of the organizational features of end-of-life care and circumstances surrounding death among hospitalized patients in more than 600 hospital departments throughout France. Our results show the common absence of loved ones at the patient's bedside, several markers of an insufficient palliative care approach at the time of death, and a high level of dissatisfaction among nurses. The findings were only marginally better when death had been anticipated.
The major finding of our study is the frequent failure to adopt a palliative care approach at the time of death, despite anticipation of death in 74.1% of patients and admission of approximately one-fourth (23.3%) for end-of-life care. First, only one-fourth of the patients (24.4%) had loved ones present at the time of death, and one-fifth were left alone. Studies in ICUs have shown that the presence of relatives at the time of death is associated with the perception of a higher quality of end-of-life care.18,23 Second, although 70.1% of patients showed symptoms of respiratory distress,4,17,24 only 44.2% received opiate analgesics during the last few hours of life and only 12.1% had a palliative care consultation. Although the patients in our study were younger, more self-sufficient, and less likely to have cancer compared with those in earlier studies,1,17 pain management in dying patients also varies widely with physician-related factors, such as experience and individual characteristics.25,26 The blurred boundaries between advanced disease and end-of-life care, notably when the patient is not diagnosed as having a terminal illness, may generate reluctance among staff members to make the transition from curative to palliative care.27 In addition, staff members may fail to fully appreciate the overall course of the patient and adapt the level of care or to consider the patient's and the family's views.27 In our study, 18.1% of patients underwent invasive resuscitation with NTBR or treatment limitation orders. This could be explained by the insufficient spread of a culture for shared decisions and of insufficient communication about palliative care, suggesting a need for improved training of nursing staff in end-of-life care issues and of physicians on palliative care.28 Changes in legislation and good clinical practices in this field receive minimal attention in the medical school curriculum in France.
That only 35.1% of nurses were satisfied with the quality of death of their patients is another important finding in our study. As confirmed in our study, nurses are at the hub of end-of-life care because they are in a unique position to interact with the patient, the family, and the physicians.29,30 Failure to involve the nurse at all steps of the patients' treatment is often associated with nurse dissatisfaction.15,18,31 Other factors may include a high ratio of patients to nurses. Our data, which reflect usual practice in French hospitals, raise concern that dissatisfaction with end-of-life care may generate frustration, feelings of guilt, and lack of a sense of achievement among staff.15 Factors associated by nurses with the perception of adequate end-of-life care in our multivariate analysis were attention to end-of-life issues manifesting as regular staff meetings and the availability of written protocols for end-of-life care, recorded in only 12.2% of the departments in our study. Written procedures that are accepted by all staff members decrease the risk that individual opinions may influence difficult decisions and improve the quality of patient care at the end of life.32 The implementation of such procedures has been shown to detect a higher rate of treatment refusal by patients24,33,34 and to improve the acceptance and traceability of decisions.33
Our study has a number of limitations. First, the 22.3% response rate from clinical departments suggests a potential selection bias. Conceivably, nurses who participated were more likely to be dissatisfied. Nevertheless, our study is the largest survey in this field that includes a representative sample of French hospitals. Second, although all questionnaires were completed within 10 days of the death, the ratings are difficult to interpret, most notably those on the competence of the patient or the method used to designate the surrogate. Third, to keep the questionnaire reasonably short, we did not obtain qualitative data on items such as communication with the patient. Fourth, we did not explore the perceptions of physicians and relatives, which would have been a useful complement to the analysis of the nurses' perceptions. Although a “good death” certainly varies according to the individual patient's needs and is difficult to define in operational terms, staff and relatives' satisfaction are accepted surrogate markers to assess its quality.24,31,35,36 Several recent studies have shown that attention to families' needs has a positive effect on their satisfaction.37-39 However, because of the frequent absence of relatives and physicians at the patient's bedside, we selected to study only the nurses' perceptions to assess the routine quality of organization and care provided to dying patients. Finally, our data represent clusters of patients within departments, but we did not account for this clustering in our analysis. The possible discrepancy resulting from this analysis must be small given that there is an important number of departments and small clusters of patients per department.
In conclusion, despite the availability of national legislation and recent guidelines for end-of-life care,7,11 our study identifies a number of barriers to high-quality end-of-life care and provides a number of suggestions for improvement. Improved training of health care workers and greater recognition of the importance of end-of-life care in hospitals constitute potential avenues for improvement. Our results suggest that a combination of factors reflected in nurses' satisfaction can define quality in end-of-life care, including the presence of loved ones, designation by the patient of a surrogate decision maker, and written procedures.2,18 Our results also suggest a need for concerted and pragmatic efforts, including the widespread implementation of qualitative assessment of end-of-life procedures, following the example set in other fields of medicine.35,36,40 An important potential benefit would be to reduce the burden imposed on the patients, their families, and the staff associated with inappropriate therapies.15,31,41 In the long term, these efforts are expected to fully integrate palliative care into the spectrum of medical school curricula and into care delivered in hospitals, and also to improve quality of care through widely shared approaches.29,42,43
Ferrand, PhD, Department of Anesthesiology and Intensive Care, Henri Mondor
Hospital, Assistance Publique–Hôpitaux de Paris, Paris 12
University, 94010 Créteil CEDEX, France
Accepted for Publication: October 29, 2007.
Author Contributions: Dr Ferrand had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Ferrand, P. Jabre, Vincent-Genod, Lemaire, and Marty. Acquisition of data: Ferrand, P. Jabre, Vincent-Genod, Aubry, Badet, Badia, Cariou, Ellien, Gounant, Gil, S. Jaber, Jay, Paillaud, Poulain, Regnier, Reignier, Socie, and Tardy. Analysis and interpretation of data: Ferrand, P. Jabre, Lemaire, and Brun-Buisson. Drafting of the manuscript: Ferrand, P. Jabre, and Lemaire. Critical revision of the manuscript for important intellectual content: Ferrand, P. Jabre, Vincent-Genod, Aubry, Badet, Badia, Cariou, Ellien, Gounant, Gil, S. Jaber, Jay, Paillaud, Poulain, Regnier, Reignier, Socie, Tardy, Lemaire, Brun-Buisson, and Marty. Statistical analysis: P. Jabre. Obtained funding: Ferrand. Administrative, technical, and material support: Ferrand, Vincent-Genod, Aubry, Badet, Badia, Ellien, Gounant, Gil, S. Jaber, Jay, Paillaud, Poulain, Regnier, Reignier, Socie, and Tardy. Study supervision: Cariou, Lemaire, and Marty.
Financial Disclosure: None reported.
Funding/Support: This study was supported by grant PHRC AOM 01 074 from the French Ministry of Health, Direction de la Recherche Clinique.
Additional Contributions: A. Wolfe, MD, provided helpful advice and thoughtful reading of this manuscript. Sébastien Boyer (Sigillat Institute) assisted in analysis of the data. We thank all of the nurses whose dedicated efforts ensured the high quality of the data.
Marie Dupont, RN, Michel Kfoury, MD, Centre Hospitalier, Abbeville; Pierre Jarry, MD, Centre Hospitalier, Aix-en-Provenc; Marie Engelhorn, RN, Bénédicte Laroche, RN, Centre Hospitalier, Albertville; Bruno Bayol, RN, Françoise Bompart, RN, Centre Hospitalier, Albi; Gisèle Blanc, RN, Centre Hospitalier, Ales; Marc Bulcourt, RN, Hervé Dupont, MD, Annie Levasseur, RN, Anne Theron, RN, Patrick Thiery, RN, Centre Hopitalier Universitaire (CHU), Amiens; Sylvie Alleman, RN, Jeanne Chalopin, RN, Catherine Coster, RN, Françoise Foin, RN, Monique Fouchier, RN, Catherine Hily, RN, Laurence Laignel, RN, Valérie Plessis, RN, CHU, Angers; Isabelle Bartoletti, RN, Pascale Deletraz, RN, Laurence Lenoir, RN, Murielle Rendu, RN, Catherine Salaun, RN, Centre Hospitalier, Annecy; Lynda Taib Merbai, RN, Centre Hospitalier, Arpajon; Sylvie Bertrand-Pellicer, RN, Centre Hospitalier, Aubagne; Jeanne Bertrand-Pellicier, RN, Monique Feraud, RN, Hôpital Raymond Garcin, Aubagne; Martine Blin, RN, Sylvie Champeau, MD, Nadine Coroier, RN, Daniel Royer, MD, Centre Hospitalier, Auxerre; Yolande Brajon, RN, Michel Courant, MD, Centre Hospitalier, Avignon; France Royer, RN, Centre Hospitalier, Bar-le-Duc; Sophie Rousset, RN, Centre Hospitalier, Bayeux; Danny Bertrand, RN, Marc Duteil, MD, Catherine Poinin-Aubaye, RN, Marie Senecal, RN, Centre Hospitalier, Beaumont-sur-Oise; Catherine Barreillon, RN, Isabelle Boyaux, RN, Anne Collin, RN, Valérie Parthiot, RN, Centre Hospitalier, Beaune; Noëlle Vidal, RN, Centre Hospitalier, Beauvais; Régine Antoine, RN, Georges Beck, RN, Françoise Bouverot, RN, Sylvaine Sabas, RN, Centre Hospitalier, Belfort; Jean Becker Schneider, MD, Annie Gloriod, RN, Francis Lemaire, MD, Hôpital Jean Minjoz, Besançon; Françoise Riffard, RN, Hôpital Saint-Jacques, Besançon; Dominique Bus, RN, Odile Daviaud Fortain, RN, Sylvie Dubois, RN, Marie Guevellou, RN, Centre Hospitalier, Béziers; Anne Baudin, RN, Martine Chaillou, RN, Chantal Chereau, RN, Françoise Metaireau, RN, Centre Hospitalier, Blois; Françoise Judith, RN, Karen Lessieur, RN, Myriam Moureaud, RN, Jeanne Mignot, RN, Alice Perrin, RN, Huguette Vassalo, RN, Hôpital Avicenne, Bobigny; Jean Luc Le Corre, RN, CHU, Bordeaux; Sylvie Gaillard, RN, Marie Josée Orsini, RN, Centre Hospitalier, Briançon; Marie-France Bonnet, RN, Francis Dollard, MD, Catherine Maurice, RN, Marie Paderi, RN, Centre Hospitalier, Briey; Brigitte Elouard, RN, Institut de Cancérologie et d’Hématologie, Hôpital Morvan, Brest; Jean Cledes, MD, Marc Legall, MD, Hôpital de la Cavale Blanche, Brest; France Akkari, RN, Sylvie Vaultier, RN, Centre Hospitalier, Brignoles; Georgette Eymard, RN, Brigitte Lafaquiere, RN, Jeanne Sauviat, RN, Centre Hospitalier, Brive; Jeanne Bretonnet, RN, Béatrice Faure, RN, Catherine Halley, RN, CHU, Caen; Régine Jallet, RN, Centre Hospitalier, Cahors; Michèle Cornu, RN, Centre Hospitalier, Calais; Chantal Chandelier, RN, Centre Hospitalier, Cannes; Ghislaine Guillon, RN, Marie-Hélène Le Bilhan, RN, Sophie Pellen, RN, Centre Hospitalier, Carhaix-Plouger; Jean-Pierre Gandon, MD, Centre Hospitalier, Castres; Anne Marie Recordon, RN, Centre Hospitalier, Chalon; Pierre Bondil, MD, Véronique Guegan, RN, Centre Hospitalier, Chambéry; Régine Ferry, MD, Hôpital Manchester, Charleville-Mézières; Jérôme Buton, RN, Catherine Darde, RN, Christine Grabot, RN, Paul Sandrine, RN, Virginie Trouillet, RN, Centre Hospitalier, Chartres; Aline Mongereau, RN, Centre Hospitalier, Châteauroux; Serge Rineau, RN, Henri Sechet, RN, Centre Hospitalier, Cholet; François Mustier, RN, Nicole Peyraud, RN, Florence Policard, RN, Catherine Saint Leger, RN, Hôpital Gabriel Montpied, Clermont-Ferrand; Isabelle Panchevre, RN, Paul Richter, RN, Jean-Philippe Roddier, MD, Hôpital Hotel-Dieu, Clermont-Ferrand; Roland Lopitaux, MD, Hôpital Nord, Clermont-Ferrand; Chantal Bicocchi, RN, Françoise Heintz, RN, Jeanne Legrand, RN, Marie Soulie, RN, Christine Taillandier, RN, Marie Tapia, RN, Hôpital Beaujon, Clichy; Sophie Arnoux, RN, Marc Brun, MD, Françoise Hug, RN, Michèle Kowolik, RN, Aline Maranzana, RN, Marie Schelcher, RN, Michel Schoenenberger, MD, Hôpitaux Civils, Colmar; Véronique Camalet, RN, Chantal Grondin, RN, Anne-Marie Lable, RN, Sophie Lenfant, RN, Catherine Liebert, RN, Hôpital Louis Mourier, Colombes; Ghislaine Benhamou-Jantelet, RN, Christine Saliou, RN, Hôpital Henri Mondor, Créteil; Louis Alessandrin, MD, Michel Carpentier, RN, Martine Dourte, RN, Marie Dugrand, RN, Audrey Durruty, RN, Elodie Labarthe, RN, Françoise Sanguingt, RN, Pierre Senjean, MD, Centre Hospitalier, Dax; René Coatmeur, MD, Marie Guillaume, RN, Claude Sautereau, RN, Complexe du Bocage, CHU, Dijon; Gabrielle Jacquemin, RN, Hôpital général, CHU, Dijon; Emmanuel Sciluna, MD, Centre Hospitalier, Dinan; Martine Bricourt, RN, Brigitte Perez, RN, Centre Hospitalier, Dole; Jean De Lamartiere, MD, Centre Hospitalier, Doullens; Serge Dubouis, MD, Catherine Ledant, RN, Centre Hospitalier de la Dracenie, Draguignan; Marie Pascale Bourdon, RN, Dorothée Chambrin, RN, Christophe Cocheteux, MD, Pascale Deronne, RN, Sylvie Vaillant, RN, Virginie Willems, RN, Centre Hospitalier, Dunkerque; Edwige Guistel, RN, Centre Hospitalier Auban-Moet, Epernay; Nathalie Morel, RN, Centre Hospitalier, Epinal; Pierre Coathalem, RN, Centre Hospitalier, Eaubonne; Carole Pelissier, RN, Robert Verdier, MD, Centre Hospitalier Eure-Seine, Evreux; Christiane Garcia, RN, Centre Hospitalier du Val d’Ariège, Foix; Sylvie Bordeau, RN, Danielle Chabrand, RN, Christiane Kieffer, RN, Valérie Wiegelt, RN, Centre Hospitalier, Gap; Jean Bernard, MD, Jocelyne Noel, RN, Hôpital Raymond Poincaré, Garches; Marie Thérèse Garnier, RN, Centre Hospitalier, Gonesse; Béatrice Maurand, RN, Bruno Steffann, MD, Centre Hospitalier, Gray; Laurence Colombat, RN, Anne Engelstein, RN, Ghislaine Masson, RN, Jean Reyt, MD, CHU, Grenoble; Eric Roy, MD, Centre Hospitalier, Guéret; Samia Malek, RN, Centre Hospitalier, Lagny; Isabelle Couasnon, RN, Chantal Letailleur, RN, Centre Hospitalier, L’Aigle; Sylvie Labrouche, RN, Pierre Plagnol, MD, Centre Hospitalier, Langon; Françoise Dume, RN, Laurence Dupont, RN, Christian Liez, MD, Centre Hospitalier, Laon; Martine Barreteau, RN, Paul Baudouin, RN, Christian Brechet, RN, Chantal Coic, RN, Natacha Maquigneau, RN, Florence Rabahand, RN, Jean-Marc Villeneuve, RN, Centre Hospitalier Départemental, La Roche-sur-Yon; Alain Goichon, MD, Centre Hospitalier, La Teste de Buch; Michelle Belaud, RN, Lydia Costec, RN, Centre Hospitalier, Laval; Francis Gabez, MD, Magali Philibert, RN, Centre Hospitalier, Le Creusot; Marie Biressi, RN, Christine Branchard, RN, Marc Doyen, RN, Françoise Escure, RN, Catherine Vincent, RN, Hôpital Bicêtre, Le Kremlin-Bicêtre; Jocelyne Descours, RN, Francis Lussiez, RN, Centre Hospitalier, Lens; Pierre Ceccaldi, MD, Catherine Macaud, RN, Centre Hospitalier, Libourne; Maryline Bourgoin, RN, Clinique Marc Linquette, Lille; Catherine Bachy, RN, Hôpital Albert Calmette, Lille; Christiane De Conninck, RN, Christine Morel, RN, Marc Pezim, RN, Hôpital Claude Hurriez, Lille; Catherine Grayeau, RN, Hôpital Les Bateliers, Lille; Odile Caron, RN, Yvan Roos, RN, Dominique Thely, RN, Centre Hospitalier, Limeil-Brevannes; Christelle Durand, RN, Emilie Durand, RN, Nathalie Houdard, RN, Françoise Marneix, RN, Françoise Marot, RN, CHU, Limoges; Bernadette Holland, RN, Nathalie Saint Wril, RN, Hôpital Roger Salengro, Lille; Marie Josée D’Anjou, RN, Evelyne Michel, RN, Centre Hospitalier, Lisieux; Marion Chipaux, RN, Catherine Guedon, RN, France Lucas, RN, Centre Hospitalier, Longjumeau; Sylvie Ostermann, RN, Centre Hospitalier, Lons-le-Saunier; Catherine Begnic, RN, Centre Hospitalier de Bretagne Sud, Lorient; Martine Abadie, RN, Sylvie Boutelier, RN, Françoise Girard, RN, Renée Lamarque, RN, Martine Macias, RN, Jean-Pierre Mansaut, RN, Louis Perez, MD, Sylvie Pernin, RN, Eric Stoltz, MA, Centre Hospitalier, Lourdes; Pierre Welfringer, MD, Patricia Zanon, RN, Centre Hospitalier, Luneville; Patrick Lepers, MD, Hôpital De Brousse, Lyon; Marie Cilia, RN, Catherine Fournier, RN, Martine Saillant, RN, Hôpital de la Croix-Rousse, Lyon; Jeanne Urbain, RN, Hôpital Hotel-Dieu, Lyon; Pierre Cartalat, MD, Marie Frene, RN, Hôpital Neuro-Chirurgical Pierre Wertheimer, Lyon; Isabelle Medalin, RN, Hôpital Cardio-Vasculaire, Lyon; Pascal Bosq, MD, Centre Hospitalier, Manosque; Anne Dobbeistein, RN, Véronique Jacque, RN, Centre Hospitalier, Mantes-la-Jolie; Jeanne Costa, RN, Isabelle Garcin, RN, Jean Pellet, MD, Catherine Tetard, RN, Hôpital Sainte-Marguerite, Marseille; Nathalie Berteau, Hôpital Nord, Marseille; Anne Deneubourg, RN, Philippe Stephane, MD, Chantal Tisserand, RN, Martine Vermeersch, RN, Centre Hospitalier, Maubeuge; Christine Geslin, RN, Centre Hospitalier, Mayenne; Florence Dupre, RN, Françoise Lemaire, RN, Hépato-Centre Hospitalier, Meaux; Véronique Da Silva, RN, Centre Hospitalier, Millau; Anne Berthier, RN, Bruno Thomas, RN, Centre Hospitalier, Montaigu; Pierre Gendre, MD, Centre Hospitalier, Montauban; Patricia Bourquin, RN, Chantal Houze, RN, Marie Houze, RN, Nathalie Morel, RN, Andrée Rodier, RN, Marc Dufour, MD, Centre Hospitalier, Montbéliard; Jean Grand, MD, Centre Hospitalier, Montbrison; Brigitte Neuville, RN, Marie Tarriottes, RN, Centre Hospitalier, Montelimar; Martine Gregy, RN, Martine Hasley, RN, Centre Hospitalier, Montereau; Françoise Lutgen, RN, Centre Hospitalier, Montfermeil; Francis Chausset, MD, Centre Hospitalier, Montluçon; Pascale Baillet, RN, Said Mokhtari, MD, Hôpital Simone Weil, Montmorency; Thierry Gressier, RN, Clinique Antonin Balmes, Montpellier; Jeanne Rouby, RN, Hôpital Guy de Chauliac, Montpellier; Nicole Lezin, RN, Hôpital Lapeyronnie, Montpellier; Josiane Geminard, RN, Hôpital Saint-Eloi, Montpellier; Anne-Marie Derrien, RN, Martine Gireault, RN, Marie Maillet-Vioud, MD, Brigitte Mel, RN, Françoise Quemener, RN, Christine Troadec, RN, Centre Hospitalier, Morlaix; Catherine Bruder, RN, Béatrice Nass, RN, Viviane Pflugfelder, RN, Centre Hospitalier, Mulhouse; Noelle Dawint, RN, Charles Fauvel, MD, Jeanne Laumesfeld, RN, Pierre Taillandier, MD, Hôpital Central, Nancy; Régis Caillaud, MD, Renaud Clement, MD, Philippe Leconte, MD, Anne Mallet, RN, Hôpital Hotel-Dieu, Nantes; Catherine Demier, RN, Fabienne Meinier, RN, Centre Hospitalier, Nevers; Francis Borelci, RN, Jean Bourgeon, MD, Pierre Caroli-Bosc, MD, Valérie Castera, RN, Emmanuel Herrout, RN, Régine Ladame-Hoff, RN, Véronique Mondain, MD, Catherine Raffermi, RN, Marie-Pierre Vigue, RN, Hélène Virello, RN, Hôpital Archet, Nice; Elisabeth Patatut, RN, CHU, Nîmes; Marc Bertet, MD, Jeanne Cauderlier, RN, Sophie Desmarais, RN, Sylvie Quatrehomme, RN, Huguette Skarniak, RN, Centre Hospitalier régional, Orléans; Sylvie Dachicourt, RN, Christelle Desclaux, RN, Dominique Larroux, RN, Catherine Prat, RN, Centre Hospitalier, Orthez; Marie Goncalves, RN, Centre Hospitalier, Paimpol; Nathalie Corbel, RN, Catherine Saltel, RN, Hôpital Ambroise Paré, Paris; Sabine Belorgey, RN, Nelly Derennes, RN, Jeanne Kohler, RN, Gérard Partouche, RN, Marie Roussel, RN, Catherine Veron, RN, Hôpital Bichat, Paris; Gabriel Abitbol, MD, Hôpital Broca, Paris; Martine Jean, RN, François Leconte, RN, Marie-Josée Nadaud, RN, Jean Yves Picart-Jacq, RN, Joëlle Pion Graff, RN, Anne Tissier, RN, Michèle Vezirian, RN, Hôpital Cochin, Paris; Annick Bosc, RN, Sylvie Thibaud, MD, Hôpital des Diaconesses, Paris; Marie Vezzoci, RN, Hôpital Fernand-Vidal, Paris; Paris; Françoise Bruguiere-Fontenille, RN, Dominique Denis, RN, Fred Sopta, RN, Eliane Thieffry, RN, Catherine Vinot, RN, Hôpital George Pompidou, Paris; Alice Brebant, RN, Stéphanie Sanchez, RN, Hôpital Hôtel-Dieu, Paris; Betty Bendahan, RN, Françoise Chardayre, RN, Maryse Charlot, RN, Mylène De Bernardy, RN, Gisèle Hoarau, RN, Nicole Masseau, RN, Michèle Mione, RN, Hôpital la Pitié Salpêtrière, Paris; Catherine Batllo, RN, Evelyne Bourlier, RN, Solange Herpin, RN, Françoise Pezzetti, RN, Noelle Thomas, RN, Nathalie Vignaud, RN, Hôpital Lariboisière, Paris; Brigitte Maga, RN, Hôpital Rossini-Chardon Lagache, Paris; Muriel Duverger, RN, Martine Grador, RN, Michelle Marie, RN, Hôpital Saint-Antoine, Paris; Sophie Diard, RN, Michèle Jaubert, RN, Jean Taboulet, MD, Marie Vincent, RN, Hôpital Saint-Louis, Paris; Jeanne Costa, MD, Sylvie Dupuy, RN, Marie Leconte, RN, Hôpital Tenon, Paris; Dominique Marteil, MD, Centre Hospitalier, Parthenay; Catherine Clavio, RN, Nadège Lambion, MA, Centre Hospitalier, Pau; Franck Geneau, MD, Centre Hospitalier, Peronne; Pierre Koninck, MD, Christian Negre, MD, Centre Hospitalier, Perpignan; Dominique Conbarnous, RN, Centre Hospitalier Lyon Sud, Pierre-Bénite; Bernard Pocquet, MD, Centre Hospitalier, Pithiviers; Béatrice Le Mercier, RN, Centre Hospitalier, Ploermel; Henry Carpin, RN, Jean-Pierre Do, MD, Jeanne Moustache, RN, CHU de Guadeloupe, Pointe-à-Pitre; Marc Baudry, MD, Nicole Bernardet, RN, Marie-Line Debarre, RN, Odile Feston, RN, Nathalie Lassagne-Bertrand, RN, Emmanuelle Luneau, RN, Corinne Milon, RN, Pascale Paitre, RN, Isabelle Troubat, RN, Hôpital de La Milétrie, Poitiers; Françoise Archambault, RN, Marie Puente, RN, Centre Hospitalier Intercommunal, Poissy; Audrey Vedis, RN, Centre Hospitalier, Poissy; Daniel Monnier, MD, Centre Hospitalier, Pont L’Abbé; Virginie Perrin, RN, Centre Hospitalier, Pontarlier; Luc Dubost, MD, Catherine Guilleux, RN, Centre Hospitalier René Dubos, Pontoise; Madeleine Gouriten, RN, Centre Hospitalier, Quimper; Martine Alain, RN, Jean Paul Rohn, MD, Centre Hospitalier, Quimperlé; Chantal Legrand, RN, Centre Hospitalier, Rang du Fliers; Isabelle Kazes, RN, Hôpital Maison Blanche, Reims; Marianne Dufour, RN, Hôpital Robert Debré, Reims; Patricia Morin, RN, Marie-Pierre Nouvion, RN, Hôpital Sébastopol, Reims; Brigitte Letissier, RN, résidence des Capucins, Reims; Marie-Noëlle Gillet, RN, Centre Hospitalier, Remiremont; Pierre Grosbois, MD, Béatrice Loisel, RN, CHU, Rennes; Pierre Husson, MD, Centre Hospitalier, Rethel; Loic Vallaeus, MD, Centre Hospitalier, Rochefort; Christine Marteel, RN, Savary Maryse, RN, Centre Hospitalier, Roubaix; Catherine Beaufils, RN, Laurence Duclos, RN, Marie Le Brun Woinet, RN, Jean Rale, MD, Nadine Toupin, RN, Hôpital Charles Nicolle, Rouen; Rachel Bejot, RN, Centre Hospitalier, Saint-Dié; Danielle Brun, RN, Monique Pichon-Galland, RN, Jean Stierlam, MD, CHU, Saint-Etienne; Martine Alcaraz, RN, Laurent Vives, MD, Centre Hospitalier, Saint Gaudens; Monique Palak, RN, Centre Hospitalier Mémorial France-Etats-Unis, Saint Lô; François Vieau, RN, Centre Hospitalier, Saint Malo; Anne Clavier, RN, Centre Hospitalier, Saint Nazaire; Béatrice Morin, RN, Centre Hospitalier, Saint-Omer; Béatrice Boussouak, RN, Centre Hospitalier, salon de Provence; Pascale Chevet, RN, Centre Hospitalier, Saumur; Isabelle Moser, RN, Centre Hospitalier, Saverne; Elisabeth Mugnier, RN, Sylvie Renaudin, RN, Anne Rossignol, RN, Centre Hospitalier, Sens; Jean Chan, MD, Centre Hospitalier, Sisteron; Claire Cayla, RN, Chantal Ferry, RN, Ghislaine Houde, RN, Sophie Mulpas, RN, Centre Hospitalier, Soissons; Philippe Loirat, MD, Marie Françoise Vidal, RN, Hôpital Foch, Suresnes; Jean Decamps, MD, Centre Hospitalier, Tarbes; Annie Morgante, RN, Hôpital de la Grave, Toulouse; Roselyne Forner, RN, Hôpital Larrey, Toulouse; Marc Delory, RN, Thérèse Forget, RN, Catherine Palanque, RN, Hôpital Purpan, Toulouse; Fouad Atallah, RN, Béatrice Guillaume, RN, Marie Plaza, RN, Hôpital Rangueil, Toulouse; Yves Boileau, MD, Isabelle Bouffart, RN, Marc Lanson, MD, Annick Meunier, RN, Muriel Pourrain, RN, Marie Serna, RN, CHU, Tours; Marc Simon, MD, Centre Hospitalier, Troyes; Valérie Godin, RN, Françoise Rudant, RN, Centre Hospitalier, Valenciennes; Marie Lafrogne, RN, Isabelle Raclot, RN, Emmanuelle Roy, RN, Marilyne Vantini, RN, Hôpital de Brabois, Vandoeuvre-Les-Nancy; Magali Cobillon, RN, Béatrice Gierens, RN, Centre Hospitalier Bretagne Atlantique, Vannes; Maité Bitsindou, RN, Centre Hospitalier, Vendôme; Anne Marie Roche, RN, Centre Hospitalier, Vierzon; Jocelyne Gourdet, RN, Didier Peillon, MD, Centre Hospitalier, Villefranche sur Saône; Catherine Dubouch, RN, Elisabeth Lecaudey, RN, Monique Prades, RN, Institut Gustave Roussy, Villejuif; Marie Christine Boblioue, RN, Anne Halbin, RN, Centre Hospitalier, Vitry le François; Catherine Izylowski, RN, Centre Hospitalier, Voiron.