title: [Refusal of care faced by case manager from elderly persons in complex situation: cross perspectives].
abstract: OBJECTIVE
  Case management is a new professional field in France. It is addressed to elderly persons living in community whose situation is regarded as particularly complex. Case managers have to assess needs and coordinate necessary services. One common criteria of complexity is refusal of care. The objective of this study is to compare the words of users with those of case managers about refusal of care, in order to understand its meaning, professionals' attitudes and ethical challenges.
  
  
  METHODS
  Two researchers have cooperated on this qualitative research: the first one, anthropologist, interviewed 19 individuals, and 11 of their caregivers. The second one, geriatrician and researcher in medical ethics, lead four focus groups gathering a total of 18 case managers.
  
  
  RESULTS
  Refusal of care often is the result of the will of preserving one's identity, compromised by illness. Individuals seek control on their life. Facing this behaviour, case managers try to secure the individual, by establishing a personal relationship that respects their choices, even if care has to be delayed. Refusal of care may sometimes disclose a desire to vanish, in front of which professionals meet their own limits.
  
  
  CONCLUSIONS
  To recognise an elderly person that refuses care as a unique individual who can make choices secure his identity, and allow him to change.
authors.affiliation: German center for neurodegenerative diseases (DZNE), Bonner Talweg, 57, 53113 Bonn, Allemagne. Electronic address: aline.corvol@dzne.de.
authors.forename: A
authors.initials: A
authors.lastname: Corvol
authors.affiliation: Inserm U 710 « Démographie et santé », 34000 Montpellier, France.
authors.forename: F
authors.initials: F
authors.lastname: Balard
authors.affiliation: Unité de médecine sociale, hôpital Corentin-Celton/HEGP, AP-HP, 75015 Paris, France; Éthique médicale et médecine légale, université Paris-Descartes, 75006 Paris, France.
authors.forename: G
authors.initials: G
authors.lastname: Moutel
authors.affiliation: Service de gériatrie, CHU de Rennes/université Rennes-1, 35000 Rennes, France.
authors.forename: D
authors.initials: D
authors.lastname: Somme
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D001293:Attitude to Death; D001294:Attitude to Health; D002961:Civil Rights; D006301:Health Services Needs and Demand / Q000458:organization & administration*; D006699:Home Care Services / Q000458:organization & administration*; D006801:Humans; D026684:Personal Autonomy; D010817:Physician-Patient Relations; D016312:Treatment Refusal / Q000523:psychology / Q000706:statistics & numerical data; D035862:Vulnerable Populations
keywords: Anthropologie; Anthropology; Case management; Elderly; Ethics; Gestion de cas; Qualitative study; Refus de soins; Refusal of care; Sujet âgé; Éthique; Étude qualitative