Continuous and Deep Sedation Maintained Until Death in French Nursing Homes

Continuous and Deep Sedation Maintained Until Death in French Nursing Homes | 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 Continuous and Deep Sedation Maintained Until Death in French Nursing Homes Clémence GONON, Clément Guineberteau, Marine Asfar, xavier gocko This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8211204/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 In France, since 2016, a patient (or its relatives) in cases of refractory or unbearable pain, if death is expected within the next few hours or days, may request a continuous and deep sedation until death. A collective decision is mandatory. In 2021, 13.1% of all deaths took place in a nursing home. Objective To determine the rate of deep and continuous sedation until death in nursing homes in two French cities in 2022. Method Quantitative study based on computerized records of deceased patients. Data were extracted from nursing homes patient files. The data extracted included patient demographics and documented use of sedatives medications. Results No continuous and deep sedation until death compliant with the recommendation was found. Sedatives medications were used in the last week of life in 30.6% of cases. The use of sedatives medications was associated with the presence of a coordinating physician and a night nurse. Midazolam recommended by the French National Authority for Health was rarely used. Discussion What are the possible explanations for the absence of continuous and deep sedation meeting the criteria of the law and following the recommendations? It’s possible, but highly unlikely that no patient or family asked for deep and continuous sedation until death. The difficulty of organizing a multidisciplinary decision, the fear of actively hastening death can also be evoked. Conclusion The absence of continuous and deep sedation until death compliant with the recommendation in two Frenches cities could be confirmed in a national longitudinal study. Deep sedation death nursing homes Key summary points Aim To determine the rate of deep and continuous sedation until death in nursing homes in two French cities in 2022. Findings No continuous and deep sedation until death compliant with the recommendation was found. Message Sedatives medications were used in the last week of life in 30.6% of cases outside of recommendations. INTRODUCTION In France establishments for dependent elderly people have been created in 2002 and refers to nursing homes. These homes are intended for people over the age of 60, who require care and assistance on a daily basis. In 2019, there were around 7,400 nursing homes, of which just under half were public establishments, the others being private for-profit establishments or private associations. [ 1 ] In 2021, 13.7% of deaths in France occurred in these nursing homes, a figure that has been rising since the COVID pandemic [ 2 ]. Well-being in nursing homes is an issue highlighted by media scandals. It makes sense to take an interest in death in long-term care. [ 3 ] In France, since 2016, patients and people at the end of life can request a Continuous and Deep Sedation Until Death (CDS). CDS may be considered in cases of refractory or unbearable pain if death is expected within the next few hours or days. [ 4 ] This period varies with the guidelines, e.g. 7 days for the European Association of Palliative Care guidelines. [ 5 ] In other cases, reversible sedation with a depth proportional to the intensity of the symptoms is discussed with the patient. CDS may be implemented for a patient unable to express his or her wishes, if he made the request by drafting advance directives. The CDS decision is a “collegial” one (term defined by the law), involving mandatory the patient, the patient's physician, the care team (nurses, psychologists, etc.) and an external physician with no hierarchical link to the first. The final decision rests with the physician in charge of the patient. [ 4 ] The systematic review by Locatelli (2025) reminds us that CDS can alleviate suffering but raises ethical and communication challenges for both families and healthcare providers. [ 6 ] The French legal framework clearly distinguishes CDS from euthanasia. Most physicians approve the law. However there is a persistent controversy. [ 7 ] In a national study from 2024, the prevalence of sedation was low (2,7%) in palliative care services. The median age of the patients was 70 years and 78.8% had cancers. Almost all sedation events occurred at a hospital (90.4%), mostly in specialized beds (74.4%). Among the 39.1% of patients who were unable to provide consent; only two had written advance directives. A collegial procedure was implemented in 80.4%. [ 8 ] Midazolam recommended for CDS by the French National Authority for Health, and since 2021 available for outpatient care outside the hospital, was widely used (85.9%), [ 4 , 8 ] If in hospitals palliative care is most often provided by specialized palliative care physicians within the Nursing Homes, these services are provided by a general practitioner, sometimes assisted by a palliative care team. [ 4 , 8 ] A Flemish study reported three types of barriers to the shared decision to implement CDS in nursing homes. Personal barriers were linked to the knowledge and skills of caregivers. Relational barriers concerned communication and collaboration both between healthcare professionals and with the family. The third barrier was organizational, such as the absence of a physician in the establishment [ 9 ]. In 2019, in Germany, in a retrospective cohort study in nursing homes, 16% of patients had received a CDS during their last week of life [ 10 ]. To our knowledge, there is no study measuring the use of CDS in nursing homes in France. For the researchers, end-of-life situations with the potential for CDS in Nursing Homes were frequent, and patients and families could ask for it. The researchers' hypotheses based on literature data were that i. the presence of a nurse at night, ii. the presence of a caregiver with university training in palliative care (mainly nurses in France), iii. the intervention of a mobile palliative care unit or home hospitalization, iv. caregivers' meetings with ethical discussions about people at the end of life, v. the days when the physicians were present, vi. patient characteristics, influenced the realization of CDS [ 7 – 10 ]. The aim of this study was to determine the frequency of use of CDS according to the recommendations of the French National Authority for Health in nursing homes in two cities Saint-Etienne and Angers during 2022. METHODS A retrospective, quantitative, multicentre study was carried out on patients who died in nursing homes to determine whether they had received CDS in the seven days prior to death. The data collection grid was based on the article by Schidmann and al. and adapted to the French context [ 10 ]. DATA COLLECTION Saint-Etienne and Angers were chosen because of the researchers' experience in end-of-life issues CGU, MA, XG). All nursing home physicians (general practitioners) in these two cities were contacted and followed up several times by email and telephone between June and November 2023. Nursing homes residents in Saint-Etienne and Angers who died during 2022 were included. Residents who died outside the establishment, in particular in hospital, were excluded. The data were collected by the investigators (CG, CGU) in each town after meetings with the nurse coordinators, managers or coordinating physicians using Excel® spreadsheet. After their agreement, their presence was not required. Data were extracted from patients' computerized medical records. The grid consisted of two parts. The first part analyzed the operation of the nursing homes, looking for the presence of a night nurse, people competent in palliative care and ethical meetings, and the number of days that one of the coordinating physicians was present in the establishment. The second part recorded the following information for each patient: age, gender, medical history, treatments used at the end of life and involvement of a mobile palliative care team. DATA ANALYSIS AND JUDGMENT CRITERIA The primary endpoint was the performance of a CDS according to the recommendations of the French National Authority for Health. Only CDSs meeting the definition: collegiality, and drugs approved by the French National Authority for Health were classified as CDSs. These drugs were midazolam in the first line, and diazepam and clonazepam, chlorpromazine and levomepromazine in the second line. The secondary endpoint was the use of sedation drugs outside the definition of CDS. For the secondary endpoint, all use of the above-mentioned sedatives during the last week of the patient's life was recorded. A univariate analysis was performed to test each of the hypotheses that could vary the CSD rate (e.g. presence of a nurse at night). The analysis was carried out at the end of the data collection with the help of a statistician. Results were expressed as numbers and percentages, mean and standard deviation, or median and interquartile range. Qualitative variables were compared using a Chi2 statistical test; where this was not possible, a Fisher exact test was used. Comparisons of means for quantitative variables were made using a Student's test. The significance level was set at 5%. SAS V9.4 software was used for all tests. ETHICS The ethics committee approved this research as a multicenter study for both Saint-Etienne and Angers under number CE-202378 on June 7, 2023. The caregivers were informed of the purpose of the study by telephone, email and with the information leaflet. Approval for the data collection was then given by the coordinating physicians, health managers and/or directors of the establishments. RESULTS DESCRIPTION OF THE POPULATION Eight of the 23 nursing homes in Saint-Etienne agreed to participate. Within these 8 nursing homes, 186/218 deaths were included; 32 deaths outside the institutions were excluded. In Angers, 8 of the 20 existing establishments agreed to participate. Within these 8 nursing homes, 160/196 deaths were included; 17 deaths outside establishments and 19 deaths (from the same nursing home) were excluded for lack of data. The statistical analysis covered a total of 346 files from 15 different nursing homes in the two cities. The median age was 91, and 71.4% were women. Dementia and behavioral problems were the most frequent medical history (76.6%). Mobile palliative care unit or home hospitalization teams were involved in 7.8% of deaths, with greater use of home hospitalization in Angers. Disparities were identified in terms of the number of days that coordinating physicians were present, from 2 to 5 days in Saint-Etienne, and from 0 to 7 days in Angers (one nursing home without a coordinating physician), with an average of 3.3 days. (Tables 1 and 2 summarize all the characteristics of the patients and nursing homes.) Table 1 Nursing homes patient characteristics Nursing homes structural criteria Total (15 Nursing home) n = 346 Saint-Etienne (8 Nursing home) n = 186 Angers (7 Nursing home) n = 160 Number of establishments with a nurse on the site at night (%) 4 (37.9) 2 (27.4) 2 (50) < 0.0001 Number of establishments with ethics meetings (%) 3 (14.2) 1 (12.4) 2 (16.2) 0.30 Number of establishments with staff trained in palliative care (%) 10 (67.6) 4 (53.2) 6 (84.3) < 0.0001 Average number of days of coordinating doctor presence (standard deviation) 3.3 (2.2) 3.3 (1.1) 3.4 (3) 0.64 Table 2 factors associated with the use of sedation drugs outside the definition of CDS Total n = 346 Saint-Etienne n = 186 Angers n = 160 Sedated Patients n = 106 Non sedated patients n = 240 p Sedated Patients n = 74 Non sedated patients n = 112 p Sedated Patients n = 32 Non sedated patients n = 128 p n (%) n (%) n (%) n (%) n (%) n (%) Sex Male 30 (30.3) 69 (69.7) 0.91 23 (46) 26 (54) 0.31 7 (14.2) 42 (85.8) 0.22 Age at death - years (mean / standard deviation) 88.2 +/- 8.8 90.1 +/- 7.6 0.04 87.7 +/- 8.6 89.5 +/- 7.9 0.15 89.5 +/- 9.2 90.7 +/- 7.4 0.43 Chronic heart failure or other cardiovascular disease* 50 (34.3) 96 (65.7) 0.21 31 (46.2) 36 (53.7) 0.18 19 (24.1) 60 (75.9) 0.21 Chronic kidney disease 18 (29.5) 43 (70.5) 0.85 12 (32.4) 25 (67.6) 0.30 6 (25) 18 (75) 0.58 Dementia or mental behavior disorder 83 (31.3) 182 (68.7) 0.62 62 (40.8) 90 (59.2) 0.55 21 (18.6) 92 (81.4) 0.49 Neurological or neurovascular disease 27 (34.2) 52 (65.8) 0.44 21 (40.4) 31 (59.6) 0.96 6 (22.2) 21 (77.8) 0.75 Cancer 24 (39.3) 37 (60.7) 0.11 19 (45.2) 23 (54.8) 0.44 5 (26.3) 14 (73.7) 0.54 Chronic respiratory disease 7 (22.6) 24 (77.4) 0.30 5 (20.8) 19 (79.2) 0.04 2 (28.6) 5 (71.4) 0.62 Nurse presence at night 51 (38.9) 80 (61.1) 0.01 21 (41.2) 30 (58.8) 0.81 30 (37.5) 50 (62.5) < 0.0001 Person trained in palliative care 69 (29.5) 165 (70.5) 0.50 37 (37.4) 62 (62.6) 0.47 32 (23.7) 103 (76.3) 0.01 Ethical meetings 7 (14.3) 42 (85.7) 0.01 7 (30.4) 16 (69.6) 0.32 0 (0) 26 (100) 0.005 Presence of a physician (mean / standard deviation) 4.3 +/- 1.96 3.07 +/- 2.25 < 0.0001 3.4 +/- 1.1 3.2 +/- 1.1 0.36 6.6 +/- 1.6 2.9 +/- 2.9 < 0.0001 Mobile palliative care unit or a home hospitalization intervention** 12 (44.4) 15 (55.6) 0.11 6 (75) 2 (25) 0.06 6 (31.6) 13 (68.4) 0.22 PRIMARY ENDPOINT No CDS respecting the recommendations of the French National Authority for Health was carried out in any of the nursing homes in Saint-Etienne and Angers. SECONDARY ENDPOINT The use of sedation drugs outside the definition of CDS was identified in 106 files (30.6%), more frequently in Saint-Etienne 74 (39.8%) than in Angers 32 (20%) (p < 0.0001). Use of the first-line drug, midazolam, was found in one nursing homes in Angers and 31 concerned patients. In the other cases, diazepam was prescribed. (Table 3 shows the univariate analysis performed on the secondary endpoint.) Table 3 factors associated with the use of sedation drugs outside the definition of Continuous and deep sedation Total n = 346 Saint-Etienne n = 186 Angers n = 160 Sedated Patients n = 106 Non sedated patients n = 240 p Sedated Patients n = 74 Non sedated patients n = 112 p Sedated Patients n = 32 Non sedated patients n = 128 p n (%) n (%) n (%) n (%) n (%) n (%) Sex Male 30 (30.3) 69 (69.7) 0.91 23 (46) 26 (54) 0.31 7 (14.2) 42 (85.8) 0.22 Age at death - years (mean / standard deviation) 88.2 +/- 8.8 90.1 +/- 7.6 0.04 87.7 +/- 8.6 89.5 +/- 7.9 0.15 89.5 +/- 9.2 90.7 +/- 7.4 0.43 Chronic heart failure or other cardiovascular disease* 50 (34.3) 96 (65.7) 0.21 31 (46.2) 36 (53.7) 0.18 19 (24.1) 60 (75.9) 0.21 Chronic kidney disease 18 (29.5) 43 (70.5) 0.85 12 (32.4) 25 (67.6) 0.30 6 (25) 18 (75) 0.58 Dementia or mental behavior disorder 83 (31.3) 182 (68.7) 0.62 62 (40.8) 90 (59.2) 0.55 21 (18.6) 92 (81.4) 0.49 Neurological or neurovascular disease 27 (34.2) 52 (65.8) 0.44 21 (40.4) 31 (59.6) 0.96 6 (22.2) 21 (77.8) 0.75 Cancer 24 (39.3) 37 (60.7) 0.11 19 (45.2) 23 (54.8) 0.44 5 (26.3) 14 (73.7) 0.54 Chronic respiratory disease 7 (22.6) 24 (77.4) 0.30 5 (20.8) 19 (79.2) 0.04 2 (28.6) 5 (71.4) 0.62 Nurse presence at night 51 (38.9) 80 (61.1) 0.01 21 (41.2) 30 (58.8) 0.81 30 (37.5) 50 (62.5) < 0.0001 Person trained in palliative care 69 (29.5) 165 (70.5) 0.50 37 (37.4) 62 (62.6) 0.47 32 (23.7) 103 (76.3) 0.01 Ethical meetings 7 (14.3) 42 (85.7) 0.01 7 (30.4) 16 (69.6) 0.32 0 (0) 26 (100) 0.005 Presence of a physician (mean / standard deviation) 4.3 +/- 1.96 3.07 +/- 2.25 < 0.0001 3.4 +/- 1.1 3.2 +/- 1.1 0.36 6.6 +/- 1.6 2.9 +/- 2.9 < 0.0001 Mobile palliative care unit or a home hospitalization intervention** 12 (44.4) 15 (55.6) 0.11 6 (75) 2 (25) 0.06 6 (31.6) 13 (68.4) 0.22 Sedated patients outside the definition of CDS were younger than non-sedated patients ( p = 0.04). A statistical association was found between the use of sedation drugs outside the definition of CDS and with the presence of a night nurse, the presence of a physician, and ethical meetings. These statistically significant differences concerning the night nurse and ethical meetings were not found in the Saint-Etienne nursing homes analyzed independently. No association was found between the use of sedatives and medical history, with the exception of respiratory insufficiency in Saint-Etienne, which was associated with lower use. Use of a mobile palliative care team was not significantly associated with the use of sedatives. DISCUSSION NO CDS, BUT FREQUENT USE OF SEDATION DRUGS OUTSIDE THE DEFINITION OF CDS No CDS meeting the French National Authority for Health definition was found in the 15 nursing homes in Saint-Etienne and Angers. No multidisciplinary collegial decision involving the patient and his family was found. The study of residents' files in Saint-Etienne and Angers did not reveal whether sedation was continuous during the last seven days of life. During the last week of life, 31% of patients in the study received sedation drugs outside the definition of CDS. The use of midazolam was limited in this study to a nursing home in Angers (31 patients). National data on the rate of CDS in nursing homes are not available for comparison. The CDS rate in palliative care services was 2,7% in 2024. [ 8 ] It is difficult to compare the 31% sedation rate with international data due to changes in legislation in recent years in different countries. For example, in Flanders in 2007, 9.4% of patients who died in nursing homes had received continuous sedation [ 11 ]. Between 2005 and 2008, a study found that 15% of patients in Flanders, 8% in the Netherlands and 17% in the UK were undergoing continuous deep sedation until death, irrespective of the place of death (hospital, home or other establishments) [ 12 ]. The study of Schildmann et al. seems the most appropriate for comparison: between 2015 and 2017, 28% of sedatives were used at the end of life in German nursing homes, half of which were continuous [ 10 ]. A CDS THAT IS DIFFICULT TO ORGANIZE AND CONTROVERSIAL What are the possible explanations for the absence of CDS meeting the criteria of the law and following the recommendations? It’s possible, but highly unlikely that no patient or family asked for CDS. The difficulty of organizing a multidisciplinary decision, the fear of actively hastening death can be evoked. The feasibility of CDS in EHPAD is questionable. It seems difficult to organize a collegial, multidisciplinary decision with another physician without any hierarchical link. Implementing CDS also requires the presence of staff to monitor its continuity [ 6 , 13 ]. The presence of a night nurse and the presence of a physician were linked to the practice of sedation outside the definition of CDS. At a nursing home in Angers, the physician was present 7 days a week. It was in this nursing home that the use of midazolam was found. At the end of 2019, only 12% of establishments had a nurse on site 24 hours a day. The aim of the 2022 and 2023 Law funding project was to encourage the funding of nurses in order to optimize continuity of care [ 1 ]. This shortage of staff, compounded by the COVID crisis, may contribute to the difficulty of organizing a CDS. The most common barriers to the use of CSD were a lack of communication between patients and caregivers, and a lack of understanding of the objectives of sedation. [ 7 ] It is possible that nursing home caregivers equate CSUD with euthanasia. [ 7 ] The fear of actively hastening death is linked to the regular ethical debates surrounding requests for anticipated death: euthanasia and assisted suicide. These debates address the ethical principles of double effect and intentionality. French law makes a clear distinction between CDS and euthanasia. The ethical argument of intentionality is an intention to relieve, not to kill. CDS does not meet with unanimous approval. Some ethicists believe that consciousness is an objective human good and therefore physicians should not intentionally (and permanently) suppress it. [ 14 ] A statistical association was found between the use of sedation drugs outside the definition of CDS and with the holding ethical meetings in nursing homes. Sedation drugs are also used at the end of life to control symptoms such as agitation and provide comfort. [ 15 ] A multicenter European study analyzed the content of more than a hundred ethical meetings in nursing homes. These ethical meetings provided an opportunity for greater openness and dialogue, and for questions to be asked about the fundamental issues of human life. Participants stressed the importance of a structure, ethics education and support from the administration. The majority had positive feedback on the systematic holding of these meetings. Families rarely took part in these meetings [ 16 ]. STRENGTHS AND LIMITATIONS OF THE STUDY This study was innovative because it looked at the practice of CDS in nursing homes, whereas most studies are usually carried out in hospital. The multi-center investigation made it possible to increase the power of the study and compare practices in two different regions in France. This study investigated both CDS and its official setting, and the use of sedatives outside this setting, which corresponds to the practice observed. The need to have teams (physicians or nurses) available for data collection may have been an obstacle to their participation. Nursing homes with a coordinating doctor who was less present, or those without one, probably responded less, even though the figures found in this study varied from 2 to 5 days in Saint-Etienne, and from 0 to 7 days in Angers. The presence of a coordinating doctor and a nurse at night was linked to the use of sedation. It is difficult to speculate on the impact of including all the nursing homes in Saint-Etienne and Angers. Another limitation may have been the method used to collect patient histories. This was done using computerized records. The lack of International Classification in Primary Care coding limits the accuracy of the results. In the city of Angers, one of the participating establishments was a large facility, accounting for 72 deaths. Their quasi-hospital setting meant that they were able to manage most situations on their own. This nursing home influenced the results regarding the use of midazolam. CONCLUSION The aim of this study was to measure the frequency of use of CDS in nursing homes in Saint-Etienne and Angers in 2022. No CDS, as recommended by the French National Authority for Healthcare, was found. The absence of CDS raises the question of feasibility and the fear of actively hastening death. Declarations Authors have no conflicts to declare No source of financials Clémence Gonon, Clément Guineberteau and Marine Asfar participated in the data collection. Xavier Gocko supervised the methodology and writing of the article and replied to reviewers. The four authors participated in the writing and in the proofreading. Acknowledgments: Pre Béatrice Paviot Trombert for producing the statistics References National Information Portal for Older Adults and Their Loved Ones. 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Palliat Med 35(4):670–682 Takla A, Savulescu J, Wilkinson DJC (2021) A conscious choice: Is it ethical to aim for unconsciousness at the end of life? Bioethics 35(3):284–291 Rijpstra M, Vissers K, Belar A, Van der Elst M, Surges SM, Adile C, Rojí R, Grassi Y, Bronkhorst E, Mercadante S, Radbruch L, Menten J, Centeno C, Kuip E, Hasselaar J (2024) Assessment of the efficacy of palliative sedation in advanced cancer patients by evaluating discomfort levels: a prospective, international, multicenter observational study. BMC Med 22(1):608 Bollig G, Rosland JH, Gjengedal E, Schmidt G, May AT, Heller A (2017) A European multicenter study on systematic ethics work in nursing homes. Scand J Caring Sci 31(3):587–601 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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12:22:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":832625,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8211204/v1/a3941059-bc1d-44f3-bd31-140d22e737e5.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eContinuous and Deep Sedation Maintained Until Death in French Nursing Homes\u003c/p\u003e","fulltext":[{"header":"Key summary points","content":"\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e To determine the rate of deep and continuous sedation until death in nursing homes in two French cities in 2022.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings\u003c/strong\u003e No continuous and deep sedation until death compliant with the recommendation was found.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMessage\u003c/strong\u003e Sedatives medications were used in the last week of life in 30.6% of cases outside of recommendations.\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eIn France establishments for dependent elderly people have been created in 2002 and refers to nursing homes. These homes are intended for people over the age of 60, who require care and assistance on a daily basis. In 2019, there were around 7,400 nursing homes, of which just under half were public establishments, the others being private for-profit establishments or private associations. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] In 2021, 13.7% of deaths in France occurred in these nursing homes, a figure that has been rising since the COVID pandemic [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Well-being in nursing homes is an issue highlighted by media scandals. It makes sense to take an interest in death in long-term care. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eIn France, since 2016, patients and people at the end of life can request a Continuous and Deep Sedation Until Death (CDS). CDS may be considered in cases of refractory or unbearable pain if death is expected within the next few hours or days. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] This period varies with the guidelines, e.g. 7 days for the European Association of Palliative Care guidelines. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] In other cases, reversible sedation with a depth proportional to the intensity of the symptoms is discussed with the patient. CDS may be implemented for a patient unable to express his or her wishes, if he made the request by drafting advance directives. The CDS decision is a \u0026ldquo;collegial\u0026rdquo; one (term defined by the law), involving mandatory the patient, the patient's physician, the care team (nurses, psychologists, etc.) and an external physician with no hierarchical link to the first. The final decision rests with the physician in charge of the patient. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] The systematic review by Locatelli (2025) reminds us that CDS can alleviate suffering but raises ethical and communication challenges for both families and healthcare providers. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] The French legal framework clearly distinguishes CDS from euthanasia. Most physicians approve the law. However there is a persistent controversy. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] In a national study from 2024, the prevalence of sedation was low (2,7%) in palliative care services. The median age of the patients was 70 years and 78.8% had cancers. Almost all sedation events occurred at a hospital (90.4%), mostly in specialized beds (74.4%). Among the 39.1% of patients who were unable to provide consent; only two had written advance directives. A collegial procedure was implemented in 80.4%. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Midazolam recommended for CDS by the French National Authority for Health, and since 2021 available for outpatient care outside the hospital, was widely used (85.9%), [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eIf in hospitals palliative care is most often provided by specialized palliative care physicians within the Nursing Homes, these services are provided by a general practitioner, sometimes assisted by a palliative care team. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] A Flemish study reported three types of barriers to the shared decision to implement CDS in nursing homes. Personal barriers were linked to the knowledge and skills of caregivers. Relational barriers concerned communication and collaboration both between healthcare professionals and with the family. The third barrier was organizational, such as the absence of a physician in the establishment [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In 2019, in Germany, in a retrospective cohort study in nursing homes, 16% of patients had received a CDS during their last week of life [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo our knowledge, there is no study measuring the use of CDS in nursing homes in France. For the researchers, end-of-life situations with the potential for CDS in Nursing Homes were frequent, and patients and families could ask for it. The researchers' hypotheses based on literature data were that i. the presence of a nurse at night, ii. the presence of a caregiver with university training in palliative care (mainly nurses in France), iii. the intervention of a mobile palliative care unit or home hospitalization, iv. caregivers' meetings with ethical discussions about people at the end of life, v. the days when the physicians were present, vi. patient characteristics, influenced the realization of CDS [\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe aim of this study was to determine the frequency of use of CDS according to the recommendations of the French National Authority for Health in nursing homes in two cities Saint-Etienne and Angers during 2022.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eA retrospective, quantitative, multicentre study was carried out on patients who died in nursing homes to determine whether they had received CDS in the seven days prior to death. The data collection grid was based on the article by Schidmann and al. and adapted to the French context [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eDATA COLLECTION\u003c/h2\u003e\u003cp\u003eSaint-Etienne and Angers were chosen because of the researchers' experience in end-of-life issues CGU, MA, XG). All nursing home physicians (general practitioners) in these two cities were contacted and followed up several times by email and telephone between June and November 2023.\u003c/p\u003e\u003cp\u003eNursing homes residents in Saint-Etienne and Angers who died during 2022 were included. Residents who died outside the establishment, in particular in hospital, were excluded.\u003c/p\u003e\u003cp\u003eThe data were collected by the investigators (CG, CGU) in each town after meetings with the nurse coordinators, managers or coordinating physicians using Excel\u0026reg; spreadsheet. After their agreement, their presence was not required. Data were extracted from patients' computerized medical records.\u003c/p\u003e\u003cp\u003eThe grid consisted of two parts. The first part analyzed the operation of the nursing homes, looking for the presence of a night nurse, people competent in palliative care and ethical meetings, and the number of days that one of the coordinating physicians was present in the establishment. The second part recorded the following information for each patient: age, gender, medical history, treatments used at the end of life and involvement of a mobile palliative care team.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eDATA ANALYSIS AND JUDGMENT CRITERIA\u003c/h3\u003e\n\u003cp\u003eThe primary endpoint was the performance of a CDS according to the recommendations of the French National Authority for Health. Only CDSs meeting the definition: collegiality, and drugs approved by the French National Authority for Health were classified as CDSs. These drugs were midazolam in the first line, and diazepam and clonazepam, chlorpromazine and levomepromazine in the second line. The secondary endpoint was the use of sedation drugs outside the definition of CDS. For the secondary endpoint, all use of the above-mentioned sedatives during the last week of the patient's life was recorded.\u003c/p\u003e\u003cp\u003eA univariate analysis was performed to test each of the hypotheses that could vary the CSD rate (e.g. presence of a nurse at night).\u003c/p\u003e\u003cp\u003eThe analysis was carried out at the end of the data collection with the help of a statistician. Results were expressed as numbers and percentages, mean and standard deviation, or median and interquartile range.\u003c/p\u003e\u003cp\u003eQualitative variables were compared using a Chi2 statistical test; where this was not possible, a Fisher exact test was used. Comparisons of means for quantitative variables were made using a Student's test. The significance level was set at 5%. SAS V9.4 software was used for all tests.\u003c/p\u003e\n\u003ch3\u003eETHICS\u003c/h3\u003e\n\u003cp\u003eThe ethics committee approved this research as a multicenter study for both Saint-Etienne and Angers under number CE-202378 on June 7, 2023. The caregivers were informed of the purpose of the study by telephone, email and with the information leaflet. Approval for the data collection was then given by the coordinating physicians, health managers and/or directors of the establishments.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eDESCRIPTION OF THE POPULATION\u003c/h2\u003e\u003cp\u003eEight of the 23 nursing homes in Saint-Etienne agreed to participate. Within these 8 nursing homes, 186/218 deaths were included; 32 deaths outside the institutions were excluded. In Angers, 8 of the 20 existing establishments agreed to participate. Within these 8 nursing homes, 160/196 deaths were included; 17 deaths outside establishments and 19 deaths (from the same nursing home) were excluded for lack of data. The statistical analysis covered a total of 346 files from 15 different nursing homes in the two cities.\u003c/p\u003e\u003cp\u003eThe median age was 91, and 71.4% were women. Dementia and behavioral problems were the most frequent medical history (76.6%).\u003c/p\u003e\u003cp\u003eMobile palliative care unit or home hospitalization teams were involved in 7.8% of deaths, with greater use of home hospitalization in Angers.\u003c/p\u003e\u003cp\u003eDisparities were identified in terms of the number of days that coordinating physicians were present, from 2 to 5 days in Saint-Etienne, and from 0 to 7 days in Angers (one nursing home without a coordinating physician), with an average of 3.3 days.\u003c/p\u003e\u003cp\u003e(Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarize all the characteristics of the patients and nursing homes.)\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\u003eNursing homes patient characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" 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=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNursing homes structural criteria\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003cp\u003e(15 Nursing home)\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;346\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSaint-Etienne\u003c/p\u003e\u003cp\u003e(8 Nursing home)\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;186\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAngers\u003c/p\u003e\u003cp\u003e(7 Nursing home)\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;160\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of establishments with a nurse on the site at night (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4 (37.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2 (27.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.0001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of establishments with ethics meetings (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3 (14.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (12.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (16.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of establishments with staff trained in palliative care (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10 (67.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4 (53.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (84.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.0001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAverage number of days of coordinating doctor presence (standard deviation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.3 (2.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.3 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.4 (3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.64\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\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\u003efactors associated with the use of sedation drugs outside the definition of CDS\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"10\"\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=\"char\" char=\".\" 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\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eTotal n\u0026thinsp;=\u0026thinsp;346\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eSaint-Etienne n\u0026thinsp;=\u0026thinsp;186\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003eAngers n\u0026thinsp;=\u0026thinsp;160\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSedated Patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;106\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eNon sedated patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;240\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eSedated Patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003eNon sedated patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003eSedated Patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003eNon sedated patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex Male\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30 (30.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69 (69.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23 (46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e26 (54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e7 (14.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e42 (85.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge at death - years (mean / standard deviation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e88.2 +/- 8.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e90.1 +/- 7.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e87.7 +/- 8.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e89.5 +/- 7.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e89.5 +/- 9.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e90.7 +/- 7.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.43\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic heart failure or other cardiovascular disease*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 (34.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e96 (65.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e31 (46.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e36 (53.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e19 (24.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e60 (75.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic kidney disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (29.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43 (70.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12 (32.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e25 (67.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6 (25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e18 (75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.58\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDementia or mental behavior disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e83 (31.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e182 (68.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62 (40.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e90 (59.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e21 (18.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e92 (81.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.49\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeurological or neurovascular disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27 (34.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52 (65.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21 (40.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e31 (59.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6 (22.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e21 (77.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (39.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37 (60.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19 (45.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e23 (54.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e5 (26.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e14 (73.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.54\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic respiratory disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (22.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (77.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5 (20.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e19 (79.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2 (28.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e5 (71.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNurse presence at night\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51 (38.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e80 (61.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21 (41.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e30 (58.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e30 (37.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e50 (62.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.0001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerson trained in palliative care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e69 (29.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e165 (70.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37 (37.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e62 (62.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e32 (23.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e103 (76.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEthical meetings\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (14.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (85.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 (30.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e16 (69.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e26 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePresence of a physician\u003c/p\u003e\u003cp\u003e(mean / standard deviation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.3 +/- 1.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.07 +/- 2.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.0001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.4 +/- 1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3.2 +/- 1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6.6 +/- 1.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e2.9 +/- 2.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.0001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMobile palliative care unit or a home hospitalization intervention**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (44.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (55.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6 (75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2 (25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6 (31.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e13 (68.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003ePRIMARY ENDPOINT\u003c/h2\u003e\u003cp\u003eNo CDS respecting the recommendations of the French National Authority for Health was carried out in any of the nursing homes in Saint-Etienne and Angers.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSECONDARY ENDPOINT\u003c/h3\u003e\n\u003cp\u003eThe use of sedation drugs outside the definition of CDS was identified in 106 files (30.6%), more frequently in Saint-Etienne 74 (39.8%) than in Angers 32 (20%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Use of the first-line drug, midazolam, was found in one nursing homes in Angers and 31 concerned patients. In the other cases, diazepam was prescribed. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the univariate analysis performed on the secondary endpoint.)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003efactors associated with the use of sedation drugs outside the definition of Continuous and deep sedation\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"10\"\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=\"char\" char=\".\" 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\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eTotal n\u0026thinsp;=\u0026thinsp;346\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eSaint-Etienne n\u0026thinsp;=\u0026thinsp;186\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003eAngers n\u0026thinsp;=\u0026thinsp;160\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSedated Patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;106\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eNon sedated patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;240\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eSedated Patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003eNon sedated patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003eSedated Patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003eNon sedated patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex Male\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30 (30.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69 (69.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23 (46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e26 (54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e7 (14.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e42 (85.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge at death - years (mean / standard deviation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e88.2 +/- 8.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e90.1 +/- 7.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e87.7 +/- 8.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e89.5 +/- 7.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e89.5 +/- 9.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e90.7 +/- 7.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.43\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic heart failure or other cardiovascular disease*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 (34.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e96 (65.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e31 (46.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e36 (53.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e19 (24.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e60 (75.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic kidney disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (29.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43 (70.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12 (32.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e25 (67.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6 (25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e18 (75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.58\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDementia or mental behavior disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e83 (31.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e182 (68.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62 (40.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e90 (59.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e21 (18.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e92 (81.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.49\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeurological or neurovascular disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27 (34.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52 (65.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21 (40.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e31 (59.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6 (22.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e21 (77.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (39.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37 (60.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19 (45.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e23 (54.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e5 (26.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e14 (73.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.54\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic respiratory disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (22.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (77.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5 (20.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e19 (79.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2 (28.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e5 (71.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNurse presence at night\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51 (38.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e80 (61.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21 (41.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e30 (58.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e30 (37.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e50 (62.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.0001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerson trained in palliative care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e69 (29.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e165 (70.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37 (37.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e62 (62.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e32 (23.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e103 (76.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEthical meetings\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (14.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (85.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 (30.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e16 (69.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e26 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePresence of a physician\u003c/p\u003e\u003cp\u003e(mean / standard deviation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.3 +/- 1.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.07 +/- 2.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.0001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.4 +/- 1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3.2 +/- 1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6.6 +/- 1.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e2.9 +/- 2.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.0001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMobile palliative care unit or a home hospitalization intervention**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (44.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (55.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6 (75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2 (25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6 (31.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e13 (68.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSedated patients outside the definition of CDS were younger than non-sedated patients (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.04). A statistical association was found between the use of sedation drugs outside the definition of CDS and with the presence of a night nurse, the presence of a physician, and ethical meetings. These statistically significant differences concerning the night nurse and ethical meetings were not found in the Saint-Etienne nursing homes analyzed independently.\u003c/p\u003e\u003cp\u003eNo association was found between the use of sedatives and medical history, with the exception of respiratory insufficiency in Saint-Etienne, which was associated with lower use.\u003c/p\u003e\u003cp\u003eUse of a mobile palliative care team was not significantly associated with the use of sedatives.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eNO CDS, BUT FREQUENT USE OF SEDATION DRUGS OUTSIDE THE DEFINITION OF CDS\u003c/h2\u003e\u003cp\u003eNo CDS meeting the French National Authority for Health definition was found in the 15 nursing homes in Saint-Etienne and Angers. No multidisciplinary collegial decision involving the patient and his family was found. The study of residents' files in Saint-Etienne and Angers did not reveal whether sedation was continuous during the last seven days of life.\u003c/p\u003e\u003cp\u003eDuring the last week of life, 31% of patients in the study received sedation drugs outside the definition of CDS. The use of midazolam was limited in this study to a nursing home in Angers (31 patients).\u003c/p\u003e\u003cp\u003eNational data on the rate of CDS in nursing homes are not available for comparison. The CDS rate in palliative care services was 2,7% in 2024. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] It is difficult to compare the 31% sedation rate with international data due to changes in legislation in recent years in different countries. For example, in Flanders in 2007, 9.4% of patients who died in nursing homes had received continuous sedation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Between 2005 and 2008, a study found that 15% of patients in Flanders, 8% in the Netherlands and 17% in the UK were undergoing continuous deep sedation until death, irrespective of the place of death (hospital, home or other establishments) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The study of Schildmann et al. seems the most appropriate for comparison: between 2015 and 2017, 28% of sedatives were used at the end of life in German nursing homes, half of which were continuous [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eA CDS THAT IS DIFFICULT TO ORGANIZE AND CONTROVERSIAL\u003c/h2\u003e\u003cp\u003eWhat are the possible explanations for the absence of CDS meeting the criteria of the law and following the recommendations? It\u0026rsquo;s possible, but highly unlikely that no patient or family asked for CDS. The difficulty of organizing a multidisciplinary decision, the fear of actively hastening death can be evoked.\u003c/p\u003e\u003cp\u003eThe feasibility of CDS in EHPAD is questionable. It seems difficult to organize a collegial, multidisciplinary decision with another physician without any hierarchical link. Implementing CDS also requires the presence of staff to monitor its continuity [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The presence of a night nurse and the presence of a physician were linked to the practice of sedation outside the definition of CDS. At a nursing home in Angers, the physician was present 7 days a week. It was in this nursing home that the use of midazolam was found. At the end of 2019, only 12% of establishments had a nurse on site 24 hours a day. The aim of the 2022 and 2023 Law funding project was to encourage the funding of nurses in order to optimize continuity of care [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This shortage of staff, compounded by the COVID crisis, may contribute to the difficulty of organizing a CDS.\u003c/p\u003e\u003cp\u003eThe most common barriers to the use of CSD were a lack of communication between patients and caregivers, and a lack of understanding of the objectives of sedation. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] It is possible that nursing home caregivers equate CSUD with euthanasia. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] The fear of actively hastening death is linked to the regular ethical debates surrounding requests for anticipated death: euthanasia and assisted suicide. These debates address the ethical principles of double effect and intentionality. French law makes a clear distinction between CDS and euthanasia. The ethical argument of intentionality is an intention to relieve, not to kill. CDS does not meet with unanimous approval. Some ethicists believe that consciousness is an objective human good and therefore physicians should not intentionally (and permanently) suppress it. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] A statistical association was found between the use of sedation drugs outside the definition of CDS and with the holding ethical meetings in nursing homes. Sedation drugs are also used at the end of life to control symptoms such as agitation and provide comfort. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] A multicenter European study analyzed the content of more than a hundred ethical meetings in nursing homes. These ethical meetings provided an opportunity for greater openness and dialogue, and for questions to be asked about the fundamental issues of human life. Participants stressed the importance of a structure, ethics education and support from the administration. The majority had positive feedback on the systematic holding of these meetings. Families rarely took part in these meetings [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eSTRENGTHS AND LIMITATIONS OF THE STUDY\u003c/h2\u003e\u003cp\u003eThis study was innovative because it looked at the practice of CDS in nursing homes, whereas most studies are usually carried out in hospital. The multi-center investigation made it possible to increase the power of the study and compare practices in two different regions in France.\u003c/p\u003e\u003cp\u003eThis study investigated both CDS and its official setting, and the use of sedatives outside this setting, which corresponds to the practice observed.\u003c/p\u003e\u003cp\u003eThe need to have teams (physicians or nurses) available for data collection may have been an obstacle to their participation. Nursing homes with a coordinating doctor who was less present, or those without one, probably responded less, even though the figures found in this study varied from 2 to 5 days in Saint-Etienne, and from 0 to 7 days in Angers. The presence of a coordinating doctor and a nurse at night was linked to the use of sedation. It is difficult to speculate on the impact of including all the nursing homes in Saint-Etienne and Angers.\u003c/p\u003e\u003cp\u003eAnother limitation may have been the method used to collect patient histories. This was done using computerized records. The lack of International Classification in Primary Care coding limits the accuracy of the results.\u003c/p\u003e\u003cp\u003eIn the city of Angers, one of the participating establishments was a large facility, accounting for 72 deaths. Their quasi-hospital setting meant that they were able to manage most situations on their own. This nursing home influenced the results regarding the use of midazolam.\u003c/p\u003e\u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe aim of this study was to measure the frequency of use of CDS in nursing homes in Saint-Etienne and Angers in 2022. No CDS, as recommended by the French National Authority for Healthcare, was found. The absence of CDS raises the question of feasibility and the fear of actively hastening death.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAuthors have no conflicts to declare\u003c/p\u003e\n\u003cp\u003eNo source of financials\u003c/p\u003e\n\u003cp\u003eCl\u0026eacute;mence Gonon, Cl\u0026eacute;ment Guineberteau and Marine Asfar participated in the data collection. Xavier Gocko supervised the methodology and writing of the article and replied to reviewers. The four authors participated in the writing and in the proofreading.\u003c/p\u003e\n\u003cp\u003eAcknowledgments: Pre B\u0026eacute;atrice Paviot Trombert for producing the statistics\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNational Information Portal for Older Adults and Their Loved Ones. Everything You Need to Know About Nursing Homes (2020) Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.pour-les-personnes-agees.gouv.fr/annuaires-et-services/facile-a-lire-et-a-comprendre/tout-savoir-sur-les-ehpad\u003c/span\u003e\u003cspan address=\"https://www.pour-les-personnes-agees.gouv.fr/annuaires-et-services/facile-a-lire-et-a-comprendre/tout-savoir-sur-les-ehpad\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNational Institute of Statistics and Economic Studies. Deaths in 2021 \u0026ndash; Long Series Graph (2021) Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.insee.fr/fr/statistiques/tableau-figure1\u003c/span\u003e\u003cspan address=\"https://www.insee.fr/fr/statistiques/tableau-figure1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFruchart M, Verdier L, Beuscart JB, Lamer A (2023) Publication Dynamics on Social Media During the Orpea Nursing Homes Scandal: A Twitter Analysis. Stud Health Technol Inf 302:502\u0026ndash;503\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFrench Health Authority How do you implement deep and continuous sedation maintained until death? 2020. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.has-sante.fr/upload/docs/application/pdf/2018-03/app_164_guide_pds_sedation_web.pdf\u003c/span\u003e\u003cspan address=\"https://www.has-sante.fr/upload/docs/application/pdf/2018-03/app_164_guide_pds_sedation_web.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCherny NI, Radbruch L, Board of the European Association for Palliative Care (2009) European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 23(7):581\u0026ndash;593\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLocatelli M, Fasse L, Lacombe C, Flahault C Deep Continuous Sedation Until Death and Experience of Relatives and Healthcare Providers: A Systematic Review. J Pain Symptom Manage 2025:S0885-3924(25)00046\u0026thinsp;\u0026ndash;\u0026thinsp;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBretonniere S, Fournier V (2021) Continuous Deep Sedation Until Death: First National Survey in France after the 2016 Law Promulgating It. J Pain Symptom Manage 62(4):e13\u0026ndash;e19\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFrasca M, Jonveaux T, Lhuaire Q, Bidegain-Sabas A, Chanteclair A, Francis-Oliviero F, Burucoa B (2024) Sedation practices in palliative care services across France: a nationwide point-prevalence analysis. BMJ Support Palliat Care 13(e3):e1326\u0026ndash;e1334\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRobijn L, Deliens L, Rietjens J, Pype P, Chambaere K (2020) Barriers in the Decision Making About and Performance of Continuous Sedation Until Death in Nursing Homes. Gerontologist 60(5):916\u0026ndash;925\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchildmann E, Bolzani A, Meesters S, Gr\u0026uuml;ne B, Marheineke A, Remi C, Bausewein C (2022) Sedatives and sedation at the end of life: a nursing home retrospective cohort study. BMJ Support Palliat Care 12(e6):e744\u0026ndash;747\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChambaere K, Bilsen J, Cohen J, Rietjens JA, Onwuteaka-Philipsen BD, Mortier F, Deliens L (2010) Continuous deep sedation until death in Belgium: a nationwide survey. Arch Intern Med 170(5):490\u0026ndash;493\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAnquinet L, Rietjens JA, Seale C, Seymour J, Deliens L, van der Heide A (2012) The practice of continuous deep sedation until death in Flanders (Belgium), the Netherlands, and the UK: a comparative study. J Pain Symptom Manage 44(1):33\u0026ndash;43\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRobijn L, Deliens L, Scherrens AL, Pauwels N, Pype P, Rietjens J, Chambaere K (2021) A systematic review of quality improvement initiatives for continuous sedation until death. Palliat Med 35(4):670\u0026ndash;682\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTakla A, Savulescu J, Wilkinson DJC (2021) A conscious choice: Is it ethical to aim for unconsciousness at the end of life? Bioethics 35(3):284\u0026ndash;291\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRijpstra M, Vissers K, Belar A, Van der Elst M, Surges SM, Adile C, Roj\u0026iacute; R, Grassi Y, Bronkhorst E, Mercadante S, Radbruch L, Menten J, Centeno C, Kuip E, Hasselaar J (2024) Assessment of the efficacy of palliative sedation in advanced cancer patients by evaluating discomfort levels: a prospective, international, multicenter observational study. BMC Med 22(1):608\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBollig G, Rosland JH, Gjengedal E, Schmidt G, May AT, Heller A (2017) A European multicenter study on systematic ethics work in nursing homes. Scand J Caring Sci 31(3):587\u0026ndash;601\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":true,"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":"Deep sedation, death, nursing homes","lastPublishedDoi":"10.21203/rs.3.rs-8211204/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8211204/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e In France, since 2016, a patient (or its relatives) in cases of refractory or unbearable pain, if death is expected within the next few hours or days, may request a continuous and deep sedation until death. A collective decision is mandatory. In 2021, 13.1% of all deaths took place in a nursing home. Objective To determine the rate of deep and continuous sedation until death in nursing homes in two French cities in 2022.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e Quantitative study based on computerized records of deceased patients. Data were extracted from nursing homes patient files. The data extracted included patient demographics and documented use of sedatives medications.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e No continuous and deep sedation until death compliant with the recommendation was found. Sedatives medications were used in the last week of life in 30.6% of cases. The use of sedatives medications was associated with the presence of a coordinating physician and a night nurse. Midazolam recommended by the French National Authority for Health was rarely used.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e What are the possible explanations for the absence of continuous and deep sedation meeting the criteria of the law and following the recommendations? It’s possible, but highly unlikely that no patient or family asked for deep and continuous sedation until death. The difficulty of organizing a multidisciplinary decision, the fear of actively hastening death can also be evoked. Conclusion The absence of continuous and deep sedation until death compliant with the recommendation in two Frenches cities could be confirmed in a national longitudinal study.\u003c/p\u003e","manuscriptTitle":"Continuous and Deep Sedation Maintained Until Death in French Nursing Homes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 12:53:51","doi":"10.21203/rs.3.rs-8211204/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":"cf063098-3bd1-4a97-be3b-8a5a320d0ac3","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T14:28:01+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-08 12:53:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8211204","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8211204","identity":"rs-8211204","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}