The problems lead by the binding law of advance directives, in the main population

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After exclusion of duplicates, these exclusion criteria were applied on abstracts:
– No availability of the abstracts (I), writing format: scientific (IMRAD), legal or humanities; Articles not in a peer-reviewed journal were systematically excluded.
– Not about the Advance Directives (II), as the main subject of the article, articles about psychiatric advance directives or euthanasia were excluded.
– Not about Community (III), for example, references referring specifically to a part of the population such as dialysis patients or hospitalized were excluded, in order to collect opinions concerning the population as a whole.
– Not about ethic (IV), because ethics is at a main topic of this research.
This phase was carried out in a double-blind manner by a second investigator. After comparing the selection, in case of disagreement on a reference, it was selected.

Eligibility criteria:

The full-articles related to abstracts were found using the Brest Library University Access on the internet and by asking the Brest Library University for international import if not found on the internet. The full-articles were submitted at eligibility process using the following inclusion’s criteria:
– About the binding nature of the law (I), in order to be in accordance with the Claeys-Leonetti french law, which changed the relationship with the ADs.
– About the Advance directives (II), what is the main topic.
– About the general population (III), the case reports were not included, as the articles about hospitalized, institutionalized or sick patients; in order to reflect the population as a whole, without the influence of the state of health.
– Available language (IV), languages used were French and English so that the articles would be fully understood by the investigators.
– Accessibility of the article (V), in order to have a proper thematic analysis.
– Adapted format of the article (VI), the books, chapters, comments or editorials were not included. The majority of the articles found were not in IMRAD format.
Two blinded investigators at the screening step performed the eligibility process.
Disagreements were resolved by consensus or by consulting with external researchers.


In order to be exhaustive, a snowballing was applied to bibliography of full-articles included using the same PRISMA statement and exclusion/inclusion criteria respective at each respective step. The new full-articles included were added to those already included for narrative analysis.

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Thematic analysis:

The following step was performed according quality criteria of the qualitative research.(11,12) Excerpts from text related to the research question were extracted from the included articles, then grouped and discussed. These text extracts have been transcribed and conceptualized to give open codes. Open codes have been grouped into stable fundamental concepts: axial codes. The next phase was hermeneutics: that is a stable and consistent interpretation and explanation of the texts. It was thematic hermeneutics because it went through the prism of the research question. To do this, the axial codes have been grouped into different conceptual fields: selective codes (or sub-themes), themselves grouped into focus codes (or themes). In order to give more coherence to the research work of the Brest group, the thematic analysis has been harmonized with that of a thesis of the same group published earlier, of Dr Zambonino(1). The subject of this thesis was the search for factors that hindered the achievement of AD for the community since the Claeys-Leonetti law, a systematic review of gray literature. To view the coding and compare their data, the coders used an Excel spreadsheet. The hermeneutical themes extracted allowed a targeted analysis of the themes and sub-themes. To understand this hermeneutics quickly, intuitively and globally, a heuristic diagram was then produced, in order to understand the interaction between the themes.

Table of contents :

I – Introduction:
II – Method:
A. Protocol:
B. Screening:
C. Eligibility criteria:
D. Snowballing:
E. Thematic analysis:
III – Results:
A. Study selection:
1. Exclusion phase
2. Eligibility phase
3. Snowballing
B. Study characteristics
C. Thematic analysis
IV – Discussion:
A. The problems lead by the binding law of advance directives, in the main population
1. Individual Sphere
2. Entourage
3. Caring Sphere
4. Society
5. The Court
6. Principles of bioethics
7. Elaboration of the document
8. Temporality
9. Communication
10. Interpretation
B. Implications for practice
C. Strengths and limitations
D. Conclusion
V – Funding :
VI – List of abbreviations:
VII – Bibliography
VIII – Appendix
A.Annexe 1 : Table of the extraction of raw datas and their coding
B.Annexe 2 : Serment d’Hippocra


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