Creating an appropriate model of advance care planning for women with breast cancer, Delphi method

Creating an appropriate model of advance care planning for women with breast cancer, Delphi method | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Creating an appropriate model of advance care planning for women with breast cancer, Delphi method Yaritza Caineiro, Axelle Martinet, Clara Blanchard, Julia Mauhourat, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1843342/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Breast cancer, the most common cancer in women, affects young women. Advance directives allow the expression of one's wishes concerning end of life wishes but they are poorly drafted. General practitioners report, in fact, real difficulties in talking about the end of life. Purpose This study aims to propose a model of advance directives that facilitates the exchange between the doctor and a breast cancer patient. Methods It is the result of a consensus of experts, obtained by the Delphi method. Twenty-one experts were included. A Delphi survey consisting of three rounds. The panel of experts were caregivers in contact with breast cancer patients, a Doctor of Sociology, deputy director of the National Center for Palliative Care and End of Life, as well as a former patient in remission from cancer. breast, association president. This new innovative model obtained takes into account in a more intimate way the moral values, the wishes of care and their environment. Results The first round lasted three weeks. Of the 29 questions posed to the experts, 20 were deemed relevant by over 70% of the experts. The second round lasted four weeks. Nine reworded questions were addressed to the experts. Eight of them were validated. The last question was validated in the third round. All experts responded to all three rounds. Conclusion The model created is a tool to create a more efficient dialogue between the physician and the patient. It is intended to be a faithful testimony of the patients’ wishes. advance directive breast cancer end of life experts' consensus Figures Figure 1 Figure 2 Introduction Deaths due neoplasms are expanding threats to global health. At the same time, there were large increases in years of life lost from neoplasms ( 1 ). Breast cancer, the first female cancer, had 58500 new cases in 2016 and affected young women as the average age at diagnosis was 63 years. 20% of breast cancer diagnosis concerned women under the age of 50. ( 2 ) Vincent Lambert's highly publicized story shows the importance of writing advance directives (AD) and designating a trusted person as healthcare proxy ( 3 ). The Claeys-Leonetti Law of 2 February 2016 introduces the AD, making it possible to spell out the wishes of the person regarding his end of life, the conditions of pursuing, limiting, stopping or refusing of care treatments. Any adult can write his AD. They can be revised and revoked at any time, and are enforceable against the doctor’s recommendations ( 4 ). In February 2021, the “« Brulé, Ville et Associé » (BVA) opinion , an expert group on behavior in Human Sciences and Data Sciences, studied the opinion of French people over 50 on the end of life. The survey highlights the low rate of writing ADs: only 18% of the participants over 65 have written them; 52% of the study group was unaware of their existence ( 5 , 6 ). Other studies have shown the difficulty it is for caregivers to talk about a serious illness or death with their patients ( 7 , 8 ). Doctors spoke of a real fear of causing anxiety in patients by talking to them about AD and difficulties in finding the right time for discussion ( 9 , 10 ). Finally, most general practitioners say they have little training in palliative care communication ( 11 ). Based on these findings, we asked ourselves whether it was possible to create an AD model that was appropriate for all adults with breast cancer, regardless of the stage of the disease. Method We carried out a Delphi consensus method, summarized in Figure 1. (12, 13) Preparation of the questionnaire The introductory step was to search for existing AD s in France, Belgium, Switzerland, Luxembourg, Spain, Germany, USA, England, Australia to develop a first version of an AD model. This initial model consisted of questions subdivided into three themes: moral values of the subject, wishes on medical treatments, wishes on supportive care (paramedical care, care environment and accompaniment). Selection of experts We asked the following experts: caregivers involved in the care of breast cancer patients, a sociologist and a patient association president. Each expert had to provide his or her consent in writing. Distribution of the questionnaire The Sphinxdeclic © software allowed the realization of the Delphi rounds. The experts accessed each round by computer. For each question, experts rated its relevance from 1 (not at all relevant) to 10 (quite relevant). They could propose a redrafting or a commentary. Analysis of responses For each question, the position of the group and the degree of convergence were assessed. The position of the group was given by the median score: irrelevant question (median ≤ 3), equivocal (4 ≤ median ≤ 6) relevant question (median ≥ 7). The opinion of the group was consensual if at least 70% of the experts gave a score ≥ 7 (question validated) or a score ≤ 3 (question removed). Validated and eliminated questions were not submitted again in the next rounds. Questions with a median score between 4 and 6, or with a low degree of convergence (less than 70%) were reformulated and submitted again in the next round. The algorithm for analyzing the experts' answers is schematized in Figure 2. Each round was subjected to the same analysis until the final AD model was validated. Results Twenty-one experts were included. Table 1 describes their characteristics. Table 1 Characteristics of selected experts Profession Discipline and type of exercise Gender Age Particular role or distinction 1 Nurse Hospital, Oncology Department and Palliative Care Unit (PSU) F 45 2 Doctor General Practitioner, Head of Mobile Palliative Care Unit (UMSP) M 54 3 Doctor Oncologist, formerly hospital F 49 Departmental Council of the Order of Physicians 17 4 Sociologist Doctor of Sociology F 50 Deputy Director of the National Center for Palliative and End-of-Life Care 5 Pensioner F 68 Former patient, President of a patient association 6 Doctor Gynecologist, Head of Pole in Gynecology-Obstetrics M 60 7 Doctor General practitioner, Hospital, oncology department M 30 8 Nurse Hospital, USP M 50–55 9 Doctor Emergency Physician, Continuing Care Unit M 52 Author of articles for the Société de Réanimation de Langue Française 10 Psychologist Hospital, Department of General Oncology and Oncohematology F 24 11 Psychologist Hospital, USP and Mobile Palliative Care Team (PMSC) F 37 12 Nurse Hospital, USP and PMSC F 56 University Diploma "Pain" 13 Nurse Hospital, Home Hospitalization Service (HAD) F 38 Executive quality department of the HAD service 14 Retired physician Generalist, hospital in Geriatrics and USP M 63 15 Doctor Generalist, Head of USP M 62 16 Doctor Gynecologist, Department of Gynecology Obstetrics and Senology M 45 17 Psychologist Hospital, HAD department F 29 18 Doctor Generalist, Head of Department and Coordinator of the Haute Autorité de Santé (HAD) F 38 19 Doctor Generalist, liberal M 64 Associate Professor of General Medicine, University Internship Master 20 Doctor Generalist, hospital in USP F 53 21 Doctor Generalist, liberal F 60 Associate Professor of General Medicine, University Internship Master Round Analysis The first round lasted three weeks. Of the 29 questions asked to the experts, 20 were deemed relevant by more than 70% of the experts. The remaining 9 questions were reformulated and reviewed in the second round. For the second round, the experts were allowed not to answer a question if they felt that it was not part of their area of expertise. The second round lasted four weeks. Eight out of nine questions were validated by consensus. The last question was submitted to the group for a third and final round that lasted a month. This last question was validated in the third round. Table 2 Results of the three rounds. Delphi Round Results Duration N First round 3 weeks Number of questions submitted 29 Questions validated by consensus 20 Unvalidated questions 9 Number of participating experts 21 Number of experts lost to sight 0 Second round 4 weeks Number of questions submitted 9 Questions validated by consensus 8 Unvalidated questions 1 Number of participating experts 21 Number of experts lost to sight 0 Third round 4 weeks Number of questions submitted 1 Questions validated by consensus 1 Unvalidated questions 0 Number of participating experts 21 Number of experts lost to sight 0 TOTAL: Final Document Number of questions validated 29 Experts who responded in full 21 Discussion Consensus was reached in three Delphi rounds thanks to the evaluation of the 21 experts. The multidisciplinary nature of the experts made it possible to confront very different points of view based on solid field experience. The involvement of the experts, all of whom participated in the entire study, should be pointed out. Approaching the subject of the end of life, of death, is not easy. ( 14 ) In the article A physician's guide to talking about end-of-life care ( 15 ), Richard B Balaban describes a way of approaching end-of-life issues. It proposes to initiate discussions leading the patient to a general reflection on the end of life, and then to specify the wishes through continuation of care oriented questions. It is in this spirit that our DA form was designed. It addresses both moral values, wishes regarding medical care and support wishes. Easy at first, it begins with more light questions, allowing an exchange between the doctor and his patient on what brings him comfort before tackling the more difficult questions, such as respiratory assistance, resuscitation or the treatment of pain and anxiety. Three objectives emerge from this DA model: 1 - Get the patient to reflect on what matters to her, and what she is willing to accept or not to stay alive. 2 - Open an exchange between the doctor and his patient on her wishes and care projects. ( 16 ) 3 - Guide caregivers when the patient no longer has the ability to communicate, allowing him to adapt her environment, to bring her comfort and offer personalized support. The “ Société de Réanimation de Langue Française ” offers an AD form which elaborates in detail the sequels a patient can tolerate or not. Our AD model provides few examples of care-related sequels. We insisted on what the patient likes, her values, what brings her comfort. These questions, less focused on technique, put the patient back at the center of care, as a whole, reminding us that she is not just a body to be cared for but a person with a history, beliefs and wishes regarding her end of life. In a Chinese study, five factors for an end of life in good conditions are formulated by patients with metastatic breast cancer: managing physical symptoms, avoiding unnecessary prolongation of life, preserving dignity, alleviating the burden on the family and deepening ties with loved ones ( 17 ). Our AD informs caregivers on what the patient wants for her medical care, what matters to her, and relieves loved ones of decisions that may be too difficult to take. ADs assume continuity in the patient's wishes and perceptions of life, but a person can change their mind ( 18 ). In the USA, patients are offered to review their AD when one of the 5Ds occurs: change of decade, Death of a loved one, Divorce, Diagnosis of a serious illness, significant Decline in body functions ( 20 ). In Canada, the Advance Care Planning (ACP) incorporates the psychosocial dimension as it does medical considerations and offers to update the patient’s expectations at each new stage of care, as in Switzerland ( 20 ). Decreased self-esteem, adaptation of the couple to the stress of cancer, difficulties at work, feelings of loneliness and misunderstanding are recurring issues. To meet the patient’s expectations, the role of the general practitioner goes beyond assessing the tolerance to treatments, yet, in the Lloyd-Williams’ study, less than a third of general practitioners felt that they had received an adequate training on pain and symptom management and less than 10% thought that their competency of psychological support was enough ( 21 , 22 ). However, the quality of communication could be greatly improved if training programs for general practitioners were developed ( 23 ). A list of competent professionals to whom to refer patients: social workers, psychologists, sexologists, socio-beauticians, physiotherapists trained in sports rehabilitation, could also improve the overall care of cancer patients ( 24 ). Conclusion Our advance directives model is the result of a consensus of 26 experts involved in the field. It enables a dialogue between the physician and a patient and provides a reflection on what matters, the moral values and wishes of patients for their lives and their care. It facilitates the dialogue, improves our knowledge of breast cancer patients, and allows advanced planning of a therapeutic project centered on the patient. ADs remain adaptable as the patient’s wishes and disease progress. They are complementary to a good network of contacts and appropriate training for general practitioners. Abbreviations AD Advance directives BVA “Brulé, Ville et Associé” HAD Haute Autorité de Santé Declarations All cited authors have seen and approved the final version of the manuscript. The authors have no relevant financial or non-financial interests to disclose. The authors did not receive support from any organization for the submitted work. Ethics approval : 'Not applicable' Consent to participate : Each expert had to provide his or her consent in writing. Consent for publication : 'Not applicable' Conflict of interest : The authors declare no competing interests. Contribution: AM, BF contributed to the conception and design of the work and the analysis and interpretation of the data for the work. YC AM BF participated in writing the work and critically reviewing it; YC, AM, CB, MB, JM, BF approved the final version for publication and agreed to be responsible for all aspects of the work. Acknowledgments: There were no payments to participants. We thank all participants : Laurent Montaz (Poitiers, France), Cédric Nadeau (Poitiers), Imane saleh Jawiche (Poitiers), Ceveau Nicolas(Poitiers), Thierry Valette (La Rochelle, France), Valérie.Victor Chapelet (Neuville-de-Poitou, France), Anne Bernard( La Rochelle, France), Virginie.Verliac (Saintes, France), Julien Beguec (La Rochelle, France), Dominique Cambon (Saintes, France), Denis Del Nista (Rochefort, France), Marcel Venault (Confolens and Ruffec, France), Magali Audis (Poitiers, France), Mme Jougon (Poitiers, France), Mr Clément (Poitiers, France), Mme Henoux (Poitiers, France), Gaëlle Puaud (Poitiers, France), Anne-Charlotte Foubert (Poitiers, France), Marie Denis (Poitiers, France), Sandrine Bretonnière (Paris, France), Annie Brousse (Paris, France) References GBD 2017 Causes of Death Collaborators. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017 [published correction appears in Lancet. 2019 Jun 22;393(10190):e44] [published correction appears in Lancet. 2018 Nov 17;392(10160):2170]. Lancet . 2018;392(10159):1736–1788. Defossez G, Le Guyader-Peyrou S, Uhry Z, Grosclaude P, Colonna M, Dantony E, et al. National estimates of cancer incidence and mortality in metropolitan France between 1990 and 2018 . Saint-Maurice (Fra): Santé publique France; 2019. p. 372. Merot, N., Pourchet, S. (2014). Affaire Vincent Lambert: l’émergence des droits des proches. Médecine Palliative: Soins de Support-Accompagnement-Éthique , [The Vincent Lambert case: the emergence of the rights of relatives. Palliative Medicine: Supportive Care-Accompaniment-Ethics] 13 (1), 39–43. Le Dorze M, Kandelman S, Veber B; SFAR's Ethics Committee. End-of-life care in the French ICU: Impact of Claeys-Leonetti law on decision to withhold or withdraw life-supportive therapy. Anaesth Crit Care Pain Med. 2019 Dec;38(6):569–570. doi: 10.1016/j.accpm.2019.10.013 . Bravo G, Dubois MF, Wagneur B. Assessing the effectiveness of interventions to promote advance directives among older adults: a systematic review and multi-level analysis. Soc Sci Med. 2008 Oct;67(7):1122–32. doi: 10.1016/j.socscimed.2008.06.006 . Epub 2008 Jul 20. Fagerlin A, Schneider CE. Enough. The failure of the living will. Hastings Cent Rep. 2004 Mar-Apr;34(2):30–42. Hirsch G. Illness progression, advance directives, support person: how and when to communicate with the patient?. Rev Prat. 2017 Dec;67(10):1134–1138. Yoo SH, Choi W, Kim Y, Kim MS, Park HY, Keam B, Heo DS. Difficulties Doctors Experience during Life-Sustaining Treatment Discussion after Enactment of the Life-Sustaining Treatment Decisions Act: A Cross-Sectional Study. Cancer Res Treat. 2021 Apr;53(2):584–592. doi: 10.4143/crt.2020.735 . Vinant P, Rousseau I, Huillard O, Goldwasser F, Guillard MY, Colombet I. Respect des volontés en fin de vie: étude de faisabilité d'une information sur la personne de confiance et les directives anticipées [Respecting patient's end of life wishes: feasibility study of an information on surrogate and advance directives]. Bull Cancer. 2015 Mar;102(3):234 – 44. French. doi: 10.1016/j.bulcan.2015.01.009 . De Vleminck A, Houttekier D, Pardon K, Deschepper R, Van Audenhove C, Vander Stichele R, Deliens L. Barriers and facilitators for general practitioners to engage in advance care planning: a systematic review. Scand J Prim Health Care. 2013 Dec;31(4):215–26. Slort W, Blankenstein AH, Wanrooij BS, van der Horst HE, Deliens L. The ACA training programme to improve communication between general practitioners and their palliative care patients: development and applicability. BMC Palliat Care. 2012 Jun 27;11:9. McPherson S, Reese C, Wendler MC. Methodology Update: Delphi Studies. Nurs Res. 2018 Sep/Oct;67(5):404–410. Barrett D, Heale R. What are Delphi studies? Evid Based Nurs. 2020 Jul;23(3):68–69. Bacqué MF, Mertz J, Parler améliore la vie subjective des mourants: revue de la littérature , [Talking improves the subjective life of the dying: a review of the literature] Médecine Palliative 2021, ISSN 1636–6522 Balaban RB. A physician's guide to talking about end-of-life care. J Gen Intern Med. 2000 Mar;15(3):195–200. Grossman CH, Brooker J, Michael N, Kissane D. Death anxiety interventions in patients with advanced cancer: A systematic review. Palliat Med. 2018 Jan;32(1):172–184. doi: 10.1177/0269216317722123 . Matsuoka J, Kunitomi T, Nishizaki M, Iwamoto T, Katayama H. Advance care planning in metastatic breast cancer. Chin Clin Oncol. 2018 Jun;7(3):33. Messinger-Rapport BJ, Baum EE, Smith ML. Advance care planning: Beyond the living will. Cleve Clin J Med. 2009 May;76(5):276–85. Myers J, Cosby R, Gzik D, Harle I, Harrold D, Incardona N, Walton T. Provider Tools for Advance Care Planning and Goals of Care Discussions: A Systematic Review. Am J Hosp Palliat Care. 2018 Aug;35(8):1123–1132. doi: 10.1177/1049909118760303 . Vayne-Bossert P, Vailloud C, Ducloux D, Matis C, Déramé L. Planification du projet thérapeutique et directives anticipées dans la prise en soins palliative [Advance directives and advance care planning]. Rev Med Suisse. 2017 Feb 1;13(548):310–314. French. Lloyd-Williams M, Lloyd-Williams F. Palliative care teaching and today's general practitioners–is it adequate? Eur J Cancer Care (Engl). 1996 Dec;5(4):242–5. Boudy CA, Bouchez T, Caprini D, Pourrat I, Munck S, Barbaroux A. Home-based palliative care management: what are the useful resources for general practitioners? a qualitative study among GPs in France. BMC Fam Pract. 2020 Oct 31;21(1):222. Slort W, Blankenstein AH, Deliens L, van der Horst HE. Facilitators and barriers for GP-patient communication in palliative care: a qualitative study among GPs, patients, and end-of-life consultants. Br J Gen Pract. 2011 Apr;61(585):167–72. Mitchell GK. How well do general practitioners deliver palliative care? A systematic review. Palliat Med. 2002 Nov;16(6):457–64. Cowppli-Bony A, Colonna M, Ligier K, Jooste V, Defossez G, Monnereau A; le Réseau Francim; Réseau des registres de cancer Francim. Épidémiologie descriptive des cancers en France métropolitaine: incidence, survie et prévalence [Descriptive epidemiology of cancer in metropolitan France: Incidence, survival and prevalence]. Bull Cancer. 2019 Jul-Aug;106(7–8):617–634. French. doi: 10.1016/j.bulcan.2018.11.016 . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1843342","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":128440525,"identity":"580462cf-1cd8-4d7b-8900-6572bd4a5f9c","order_by":0,"name":"Yaritza Caineiro","email":"","orcid":"","institution":"University of Poitiers","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yaritza","middleName":"","lastName":"Caineiro","suffix":""},{"id":128440526,"identity":"fd83d98f-2539-4d36-8800-49e33ffea0b8","order_by":1,"name":"Axelle Martinet","email":"","orcid":"","institution":"University of 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threats to global health. At the same time, there were large increases in years of life lost from neoplasms (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Breast cancer, the first female cancer, had 58500 new cases in 2016 and affected young women as the average age at diagnosis was 63 years. 20% of breast cancer diagnosis concerned women under the age of 50. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eVincent Lambert's highly publicized story shows the importance of writing advance directives (AD) and designating a trusted person as healthcare proxy (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The Claeys-Leonetti Law of 2 February 2016 introduces the AD, making it possible to spell out the wishes of the person regarding his end of life, the conditions of pursuing, limiting, stopping or refusing of care treatments. Any adult can write his AD. They can be revised and revoked at any time, and are enforceable against the doctor\u0026rsquo;s recommendations (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn February 2021, the \u003cem\u003e\u0026ldquo;\u0026laquo; Brul\u0026eacute;, Ville et Associ\u0026eacute; \u0026raquo; (BVA) opinion\u003c/em\u003e, an expert group on behavior in Human Sciences and Data Sciences, studied the opinion of French people over 50 on the end of life. The survey highlights the low rate of writing ADs: only 18% of the participants over 65 have written them; 52% of the study group was unaware of their existence (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Other studies have shown the difficulty it is for caregivers to talk about a serious illness or death with their patients (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Doctors spoke of a real fear of causing anxiety in patients by talking to them about AD and difficulties in finding the right time for discussion (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Finally, most general practitioners say they have little training in palliative care communication (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBased on these findings, we asked ourselves whether it was possible to create an AD model that was appropriate for all adults with breast cancer, regardless of the stage of the disease.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eWe carried out a Delphi consensus method, summarized in Figure 1. (12, 13)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreparation of the questionnaire\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe introductory step was to search for existing AD s in France, Belgium, Switzerland, Luxembourg, Spain, Germany, USA, England, Australia to develop a first version of an AD model. This initial model consisted of questions subdivided into three themes: moral values of the subject, wishes on medical treatments, wishes on supportive care (paramedical care, care environment and accompaniment).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelection of experts\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe asked the following experts: caregivers involved in the care of breast cancer patients, a sociologist and a patient association president. Each expert had to provide his or her consent in writing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDistribution of the questionnaire\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Sphinxdeclic\u003csup\u003e\u0026copy;\u003c/sup\u003e software allowed the realization of the Delphi rounds. The experts accessed each round by computer. For each question, experts rated its relevance from 1 (not at all relevant) to 10 (quite relevant). They could propose a redrafting or a commentary.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis of responses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor each question, the position of the group and the degree of convergence were assessed. The position of the group was given by the median score: irrelevant question (median \u0026le; 3), equivocal (4 \u0026le; median \u0026le; 6) relevant question (median \u0026ge; 7). The opinion of the group was consensual if at least 70% of the experts gave a score \u0026ge; 7 (question validated) or a score \u0026le; 3 (question removed). Validated and eliminated questions were not submitted again in the next rounds. Questions with a median score between 4 and 6, or with a low degree of convergence (less than 70%) were reformulated and submitted again in the next round.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe algorithm for analyzing the experts\u0026apos; answers is schematized in Figure 2.\u003c/p\u003e\n\u003cp\u003eEach round was subjected to the same analysis until the final AD model was validated.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTwenty-one experts were included. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e describes their characteristics.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of selected experts\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiscipline and type of exercise\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eParticular role or distinction\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHospital, Oncology Department and Palliative Care Unit (PSU)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneral Practitioner, Head of Mobile Palliative Care Unit (UMSP)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOncologist, formerly hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDepartmental Council of the Order of Physicians 17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSociologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDoctor of Sociology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDeputy Director of the National Center for Palliative and End-of-Life Care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePensioner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFormer patient, President of a patient association\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGynecologist, Head of Pole in Gynecology-Obstetrics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneral practitioner, Hospital, oncology department\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHospital, USP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50\u0026ndash;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmergency Physician, Continuing Care Unit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAuthor of articles for the Soci\u0026eacute;t\u0026eacute; de R\u0026eacute;animation de Langue Fran\u0026ccedil;aise\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePsychologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHospital, Department of General Oncology and Oncohematology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePsychologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHospital, USP and Mobile Palliative Care Team (PMSC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHospital, USP and PMSC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUniversity Diploma \"Pain\"\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHospital, Home Hospitalization Service (HAD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eExecutive quality department of the HAD service\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetired physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneralist, hospital in Geriatrics and USP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneralist, Head of USP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGynecologist, Department of Gynecology Obstetrics and Senology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePsychologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHospital, HAD department\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneralist, Head of Department and Coordinator of the \u003cem\u003eHaute Autorit\u0026eacute; de Sant\u0026eacute;\u003c/em\u003e (HAD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneralist, liberal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAssociate Professor of General Medicine, University Internship Master\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneralist, hospital in USP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneralist, liberal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAssociate Professor of General Medicine, University Internship Master\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003c/br\u003e \u003ch2\u003eRound Analysis\u003c/h2\u003e\n\u003cp\u003eThe first round lasted three weeks. Of the 29 questions asked to the experts, 20 were deemed relevant by more than 70% of the experts. The remaining 9 questions were reformulated and reviewed in the second round. For the second round, the experts were allowed not to answer a question if they felt that it was not part of their area of expertise. The second round lasted four weeks. Eight out of nine questions were validated by consensus. The last question was submitted to the group for a third and final round that lasted a month. This last question was validated in the third round.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of the three rounds.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelphi Round Results\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDuration\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst round\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of questions submitted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestions validated by consensus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnvalidated questions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of participating experts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of experts lost to sight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecond round\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of questions submitted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestions validated by consensus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnvalidated questions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of participating experts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of experts lost to sight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThird round\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of questions submitted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestions validated by consensus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnvalidated questions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of participating experts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of experts lost to sight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTOTAL: Final Document\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of questions validated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperts who responded in full\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eConsensus was reached in three Delphi rounds thanks to the evaluation of the 21 experts. The multidisciplinary nature of the experts made it possible to confront very different points of view based on solid field experience. The involvement of the experts, all of whom participated in the entire study, should be pointed out.\u003c/p\u003e \u003cp\u003eApproaching the subject of the end of life, of death, is not easy. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) In the article A physician's guide to talking about end-of-life care (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), Richard B Balaban describes a way of approaching end-of-life issues. It proposes to initiate discussions leading the patient to a general reflection on the end of life, and then to specify the wishes through continuation of care oriented questions. It is in this spirit that our DA form was designed. It addresses both moral values, wishes regarding medical care and support wishes. Easy at first, it begins with more light questions, allowing an exchange between the doctor and his patient on what brings him comfort before tackling the more difficult questions, such as respiratory assistance, resuscitation or the treatment of pain and anxiety.\u003c/p\u003e \u003cp\u003eThree objectives emerge from this DA model:\u003c/p\u003e \u003cp\u003e1 - Get the patient to reflect on what matters to her, and what she is willing to accept or not to stay alive.\u003c/p\u003e \u003cp\u003e2 - Open an exchange between the doctor and his patient on her wishes and care projects. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e3 - Guide caregivers when the patient no longer has the ability to communicate, allowing him to adapt her environment, to bring her comfort and offer personalized support.\u003c/p\u003e \u003cp\u003eThe \u0026ldquo;\u003cem\u003eSoci\u0026eacute;t\u0026eacute; de R\u0026eacute;animation de Langue Fran\u0026ccedil;aise\u003c/em\u003e\u0026rdquo; offers an AD form which elaborates in detail the sequels a patient can tolerate or not. Our AD model provides few examples of care-related sequels. We insisted on what the patient likes, her values, what brings her comfort. These questions, less focused on technique, put the patient back at the center of care, as a whole, reminding us that she is not just a body to be cared for but a person with a history, beliefs and wishes regarding her end of life.\u003c/p\u003e \u003cp\u003eIn a Chinese study, five factors for an end of life in good conditions are formulated by patients with metastatic breast cancer: managing physical symptoms, avoiding unnecessary prolongation of life, preserving dignity, alleviating the burden on the family and deepening ties with loved ones (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Our AD informs caregivers on what the patient wants for her medical care, what matters to her, and relieves loved ones of decisions that may be too difficult to take.\u003c/p\u003e \u003cp\u003eADs assume continuity in the patient's wishes and perceptions of life, but a person can change their mind (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In the USA, patients are offered to review their AD when one of the 5Ds occurs: change of decade, Death of a loved one, Divorce, Diagnosis of a serious illness, significant Decline in body functions (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In Canada, the Advance Care Planning (ACP) incorporates the psychosocial dimension as it does medical considerations and offers to update the patient\u0026rsquo;s expectations at each new stage of care, as in Switzerland (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDecreased self-esteem, adaptation of the couple to the stress of cancer, difficulties at work, feelings of loneliness and misunderstanding are recurring issues. To meet the patient\u0026rsquo;s expectations, the role of the general practitioner goes beyond assessing the tolerance to treatments, yet, in the Lloyd-Williams\u0026rsquo; study, less than a third of general practitioners felt that they had received an adequate training on pain and symptom management and less than 10% thought that their competency of psychological support was enough (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). However, the quality of communication could be greatly improved if training programs for general practitioners were developed (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA list of competent professionals to whom to refer patients: social workers, psychologists, sexologists, socio-beauticians, physiotherapists trained in sports rehabilitation, could also improve the overall care of cancer patients (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur advance directives model is the result of a consensus of 26 experts involved in the field. It enables a dialogue between the physician and a patient and provides a reflection on what matters, the moral values and wishes of patients for their lives and their care. It facilitates the dialogue, improves our knowledge of breast cancer patients, and allows advanced planning of a therapeutic project centered on the patient. ADs remain adaptable as the patient\u0026rsquo;s wishes and disease progress. They are complementary to a good network of contacts and appropriate training for general practitioners.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdvance directives\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Brul\u0026eacute;, Ville et Associ\u0026eacute;\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHAD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eHaute Autorit\u0026eacute; de Sant\u0026eacute;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eAll cited authors have seen and approved the final version of the manuscript. The authors have no relevant financial or non-financial interests to disclose. The authors did not receive support from any organization for the submitted work.\u003c/p\u003e\n\u003cp\u003eEthics approval : \u0026apos;Not applicable\u0026apos; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent to participate :\u0026nbsp;Each expert had to provide his or her consent in writing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u0026nbsp;: \u0026apos;Not applicable\u0026apos;\u003c/p\u003e\n\u003cp\u003eConflict of interest : The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContribution:\u003c/strong\u003e AM, BF contributed to the conception and design of the work and the analysis and interpretation of the data for the work. YC AM BF participated in writing the work and critically reviewing it; YC, AM, CB, MB, JM, BF approved the final version for publication and agreed to be responsible for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere were no payments to participants. We thank all participants : Laurent Montaz (Poitiers, France), C\u0026eacute;dric Nadeau (Poitiers), Imane saleh Jawiche (Poitiers), Ceveau Nicolas(Poitiers), Thierry Valette (La Rochelle, France), Val\u0026eacute;rie.Victor Chapelet (Neuville-de-Poitou, France), Anne Bernard( La Rochelle, France), Virginie.Verliac (Saintes, France), Julien Beguec (La Rochelle, France), Dominique Cambon (Saintes, France), Denis Del Nista (Rochefort, France), Marcel Venault (Confolens and Ruffec, France), Magali Audis (Poitiers, France), Mme Jougon (Poitiers, France), Mr Cl\u0026eacute;ment \u0026nbsp;(Poitiers, France), Mme Henoux (Poitiers, France), Ga\u0026euml;lle Puaud (Poitiers, France), Anne-Charlotte Foubert (Poitiers, France), Marie Denis (Poitiers, France), Sandrine Bretonni\u0026egrave;re (Paris, France), Annie Brousse (Paris, France)\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGBD 2017 Causes of Death Collaborators. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980\u0026ndash;2017: a systematic analysis for the Global Burden of Disease Study 2017 [published correction appears in Lancet. 2019 Jun 22;393(10190):e44] [published correction appears in Lancet. 2018 Nov 17;392(10160):2170]. \u003cem\u003eLancet\u003c/em\u003e. 2018;392(10159):1736\u0026ndash;1788.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDefossez G, Le Guyader-Peyrou S, Uhry Z, Grosclaude P, Colonna M, Dantony E, et al. \u003cem\u003eNational estimates of cancer incidence and mortality in metropolitan France between 1990 and 2018\u003c/em\u003e. Saint-Maurice (Fra): Sant\u0026eacute; publique France; 2019. p.\u0026nbsp;372.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMerot, N., Pourchet, S. (2014). Affaire Vincent Lambert: l\u0026rsquo;\u0026eacute;mergence des droits des proches. \u003cem\u003eM\u0026eacute;decine Palliative: Soins de Support-Accompagnement-\u0026Eacute;thique\u003c/em\u003e, [The Vincent Lambert case: the emergence of the rights of relatives. Palliative Medicine: Supportive Care-Accompaniment-Ethics] \u003cem\u003e13\u003c/em\u003e(1), 39\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLe Dorze M, Kandelman S, Veber B; SFAR's Ethics Committee. End-of-life care in the French ICU: Impact of Claeys-Leonetti law on decision to withhold or withdraw life-supportive therapy. Anaesth Crit Care Pain Med. 2019 Dec;38(6):569\u0026ndash;570. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.accpm.2019.10.013\u003c/span\u003e\u003cspan address=\"10.1016/j.accpm.2019.10.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBravo G, Dubois MF, Wagneur B. Assessing the effectiveness of interventions to promote advance directives among older adults: a systematic review and multi-level analysis. Soc Sci Med. 2008 Oct;67(7):1122\u0026ndash;32. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.socscimed.2008.06.006\u003c/span\u003e\u003cspan address=\"10.1016/j.socscimed.2008.06.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2008 Jul 20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFagerlin A, Schneider CE. Enough. The failure of the living will. Hastings Cent Rep. 2004 Mar-Apr;34(2):30\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHirsch G. Illness progression, advance directives, support person: how and when to communicate with the patient?. Rev Prat. 2017 Dec;67(10):1134\u0026ndash;1138.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoo SH, Choi W, Kim Y, Kim MS, Park HY, Keam B, Heo DS. Difficulties Doctors Experience during Life-Sustaining Treatment Discussion after Enactment of the Life-Sustaining Treatment Decisions Act: A Cross-Sectional Study. Cancer Res Treat. 2021 Apr;53(2):584\u0026ndash;592. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4143/crt.2020.735\u003c/span\u003e\u003cspan address=\"10.4143/crt.2020.735\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVinant P, Rousseau I, Huillard O, Goldwasser F, Guillard MY, Colombet I. \u003cem\u003eRespect des volont\u0026eacute;s en fin de vie: \u0026eacute;tude de faisabilit\u0026eacute; d'une information sur la personne de confiance et les directives anticip\u0026eacute;es\u003c/em\u003e [Respecting patient's end of life wishes: feasibility study of an information on surrogate and advance directives]. Bull Cancer. 2015 Mar;102(3):234 \u0026ndash; 44. French. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.bulcan.2015.01.009\u003c/span\u003e\u003cspan address=\"10.1016/j.bulcan.2015.01.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Vleminck A, Houttekier D, Pardon K, Deschepper R, Van Audenhove C, Vander Stichele R, Deliens L. Barriers and facilitators for general practitioners to engage in advance care planning: a systematic review. Scand J Prim Health Care. 2013 Dec;31(4):215\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSlort W, Blankenstein AH, Wanrooij BS, van der Horst HE, Deliens L. The ACA training programme to improve communication between general practitioners and their palliative care patients: development and applicability. BMC Palliat Care. 2012 Jun 27;11:9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcPherson S, Reese C, Wendler MC. Methodology Update: Delphi Studies. Nurs Res. 2018 Sep/Oct;67(5):404\u0026ndash;410.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarrett D, Heale R. What are Delphi studies? Evid Based Nurs. 2020 Jul;23(3):68\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBacqu\u0026eacute; MF, Mertz J, \u003cem\u003eParler am\u0026eacute;liore la vie subjective des mourants: revue de la litt\u0026eacute;rature\u003c/em\u003e, [Talking improves the subjective life of the dying: a review of the literature] M\u0026eacute;decine Palliative 2021, ISSN 1636\u0026ndash;6522\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalaban RB. A physician's guide to talking about end-of-life care. J Gen Intern Med. 2000 Mar;15(3):195\u0026ndash;200.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrossman CH, Brooker J, Michael N, Kissane D. Death anxiety interventions in patients with advanced cancer: A systematic review. Palliat Med. 2018 Jan;32(1):172\u0026ndash;184. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0269216317722123\u003c/span\u003e\u003cspan address=\"10.1177/0269216317722123\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatsuoka J, Kunitomi T, Nishizaki M, Iwamoto T, Katayama H. Advance care planning in metastatic breast cancer. Chin Clin Oncol. 2018 Jun;7(3):33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMessinger-Rapport BJ, Baum EE, Smith ML. Advance care planning: Beyond the living will. Cleve Clin J Med. 2009 May;76(5):276\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMyers J, Cosby R, Gzik D, Harle I, Harrold D, Incardona N, Walton T. Provider Tools for Advance Care Planning and Goals of Care Discussions: A Systematic Review. Am J Hosp Palliat Care. 2018 Aug;35(8):1123\u0026ndash;1132. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1049909118760303\u003c/span\u003e\u003cspan address=\"10.1177/1049909118760303\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVayne-Bossert P, Vailloud C, Ducloux D, Matis C, D\u0026eacute;ram\u0026eacute; L. \u003cem\u003ePlanification du projet th\u0026eacute;rapeutique et directives anticip\u0026eacute;es dans la prise en soins palliative\u003c/em\u003e [Advance directives and advance care planning]. Rev Med Suisse. 2017 Feb 1;13(548):310\u0026ndash;314. French.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLloyd-Williams M, Lloyd-Williams F. Palliative care teaching and today's general practitioners\u0026ndash;is it adequate? Eur J Cancer Care (Engl). 1996 Dec;5(4):242\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoudy CA, Bouchez T, Caprini D, Pourrat I, Munck S, Barbaroux A. Home-based palliative care management: what are the useful resources for general practitioners? a qualitative study among GPs in France. BMC Fam Pract. 2020 Oct 31;21(1):222.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSlort W, Blankenstein AH, Deliens L, van der Horst HE. Facilitators and barriers for GP-patient communication in palliative care: a qualitative study among GPs, patients, and end-of-life consultants. Br J Gen Pract. 2011 Apr;61(585):167\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMitchell GK. How well do general practitioners deliver palliative care? A systematic review. Palliat Med. 2002 Nov;16(6):457\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCowppli-Bony A, Colonna M, Ligier K, Jooste V, Defossez G, Monnereau A; \u003cem\u003ele R\u0026eacute;seau Francim; R\u0026eacute;seau des registres de cancer Francim. \u0026Eacute;pid\u0026eacute;miologie descriptive des cancers en France m\u0026eacute;tropolitaine: incidence, survie et pr\u0026eacute;valence\u003c/em\u003e [Descriptive epidemiology of cancer in metropolitan France: Incidence, survival and prevalence]. Bull Cancer. 2019 Jul-Aug;106(7\u0026ndash;8):617\u0026ndash;634. French. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.bulcan.2018.11.016\u003c/span\u003e\u003cspan address=\"10.1016/j.bulcan.2018.11.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"advance directive, breast cancer, end of life, experts' consensus","lastPublishedDoi":"10.21203/rs.3.rs-1843342/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1843342/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eBreast cancer, the most common cancer in women, affects young women. Advance directives allow the expression of one's wishes concerning end of life wishes but they are poorly drafted. General practitioners report, in fact, real difficulties in talking about the end of life.\u003c/p\u003e\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThis study aims to propose a model of advance directives that facilitates the exchange between the doctor and a breast cancer patient.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIt is the result of a consensus of experts, obtained by the Delphi method. Twenty-one experts were included. A Delphi survey consisting of three rounds. The panel of experts were caregivers in contact with breast cancer patients, a Doctor of Sociology, deputy director of the National Center for Palliative Care and End of Life, as well as a former patient in remission from cancer. breast, association president. This new innovative model obtained takes into account in a more intimate way the moral values, the wishes of care and their environment.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe first round lasted three weeks. Of the 29 questions posed to the experts, 20 were deemed relevant by over 70% of the experts. The second round lasted four weeks. Nine reworded questions were addressed to the experts. Eight of them were validated. The last question was validated in the third round. All experts responded to all three rounds.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe model created is a tool to create a more efficient dialogue between the physician and the patient. It is intended to be a faithful testimony of the patients\u0026rsquo; wishes.\u003c/p\u003e","manuscriptTitle":"Creating an appropriate model of advance care planning for women with breast cancer, Delphi method","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-08-17 14:32:24","doi":"10.21203/rs.3.rs-1843342/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"69b89ee9-cbf2-4b37-bf5d-b24d87491b93","owner":[],"postedDate":"August 17th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-12-11T13:59:22+00:00","versionOfRecord":[],"versionCreatedAt":"2022-08-17 14:32:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1843342","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1843342","identity":"rs-1843342","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}