Karin Faisst

End-of-life decision-making in six European countries: descriptive study

BACKGROUND Empirical data about end-of-life decision-making practices are scarce. We aimed to investigate frequency and characteristics of end-of-life decision-making practices in six European countries: Belgium, Denmark, Italy, the Netherlands, Sweden, and Switzerland. METHODS In all participating countries, deaths reported to death registries were stratified for cause (apart from in Switzerland), and samples were drawn from every stratum. Reporting doctors received a mailed questionnaire about the medical decision-making that had preceded the death of the patient. The data-collection procedure precluded identification of any of the doctors or patients. All deaths arose between June, 2001, and February, 2002. We weighted data to correct for stratification and to make results representative for all deaths: results were presented as weighted percentages. FINDINGS The questionnaire response rate was 75% for the Netherlands, 67% for Switzerland, 62% for Denmark, 61% for Sweden, 59% for Belgium, and 44% for Italy. Total number of deaths studied was 20480. Death happened suddenly and unexpectedly in about a third of cases in all countries. The proportion of deaths that were preceded by any end-of-life decision ranged between 23% (Italy) and 51% (Switzerland). Administration of drugs with the explicit intention of hastening death varied between countries: about 1% or less in Denmark, Italy, Sweden, and Switzerland, 1.82% in Belgium, and 3.40% in the Netherlands. Large variations were recorded in the extent to which decisions were discussed with patients, relatives, and other caregivers. INTERPRETATION Medical end-of-life decisions frequently precede dying in all participating countries. Patients and relatives are generally involved in decision-making in countries in which the frequency of making these decisions is high.

Influence of physicians’ life stances on attitudes to end-of-life decisions and actual end-of-life decision-making in six countries

Aim: To examine how physicians’ life stances affect their attitudes to end-of-life decisions and their actual end-of-life decision-making. Methods: Practising physicians from various specialties involved in the care of dying patients in Belgium, Denmark, The Netherlands, Sweden, Switzerland and Australia received structured questionnaires on end-of-life care, which included questions about their life stance. Response rates ranged from 53% in Australia to 68% in Denmark. General attitudes, intended behaviour with respect to two hypothetical patients, and actual behaviour were compared between all large life-stance groups in each country. Results: Only small differences in life stance were found in all countries in general attitudes and intended and actual behaviour with regard to various end-of-life decisions. However, with regard to the administration of drugs explicitly intended to hasten the patient’s death (PAD), physicians with specific religious affiliations had significantly less accepting attitudes, and less willingness to perform it, than non-religious physicians. They had also actually performed PAD less often. However, in most countries, both Catholics (up to 15.7% in The Netherlands) and Protestants (up to 20.4% in The Netherlands) reported ever having made such a decision. Discussion: The results suggest that religious teachings influence to some extent end-of-life decision-making, but are certainly not blankly accepted by physicians, especially when dealing with real patients and circumstances. Physicians seem to embrace religious belief in a non-imperative way, allowing adaptation to particular situations.

Der Sterbeort: „Wo sterben die Menschen heute in der Schweiz?“

ZusammenfassungHintergrundAmtliche Informationen zum Sterbeort werden seit 1987 im Bundesamt für Statistik (BfS) nicht mehr erhoben. Somit können aus dieser Quelle für die Schweiz keine Aussagen über die Entwicklung des Sterbeortes gemacht werden.MethodenMittels eines Fragebogens wurden Ärztinnen und Ärzte aus der Deutsch-Schweiz, welche zwischen dem 1. Juni und dem 30. Oktober 2001 ein Todesfallformular unterzeichneten, zum konkreten Todesfall schriftlich befragt. Die Häufigkeitsverteilungen zum Sterbeort (zu Hause, im Spital, Alters-, Pflege- und Krankenheim, anderer Ort) werden mit den amtlichen Daten zum Sterbeort für die Jahre 1969 bis 1986 verglichen. Anhand logistischer Regressionen werden die Einflussgrößen für die Sterbeorte identifiziert.ErgebnisseDer Tod ereignete sich im Jahre 2001 in der Deutsch-Schweiz am häufigsten im Spital (37,2% der Todesfälle). Am zweit häufigsten fand der Tod im Alters-, Kranken- oder Pflegeheim statt (33,5%) und an dritter Stelle stand das Sterben zu Hause (22,7%). Determinanten für den Sterbeort waren die Todesursache, das Geschlecht, der Zivilstand und teilweise die Religion. Während sich zwischen 1969 und 1986 eine Entwicklung zum institutionellen Sterben abzeichnete, verlagerte sich zwischen 1986 und 2001 das Sterben innerhalb der Institutionen von den Spitälern weg in die Alters- und Pflegeheime.SchlussfolgerungDie Bedeutung der Alters- und Pflegeheime als Sterbeort dürfte in Zukunft noch stärker wachsen, da in der kommenden Zeit der Anteil von alten Menschen ansteigen wird. Um Personen zu ermöglichen, die Pflege- und Betreuungsaufgaben von Angehörigen zu Hause erfüllen zu können, müssten die ambulanten Hilfsdienste erhöht werden und Anreize geschaffen und Unterstützungen geboten werden.SummaryBackgroundOfficial information on the place of death has not been collected by the Swiss Federal Office of Statistics since 1987. Thus, no statements can be made for the developments in Switzerland.MethodsPhysicians from the German speaking part of Switzerland who had filled in a death certificate between June 1 and October 30, 2001 were sent a questionnaire about circumstances of the specific death case. The frequencies of the place of death (at home, in hospital, in home for elderly, in nursing home, other place) were compared with the official data of the years 1969 until 1986. Using logistic regressions predictors for the place of death were estimated.ResultsIn 2001 in the German speaking part of Switzerland death occurred most frequently in hospital (37.2% of all death cases) followed by a home for elderly (33.5%) and dying at home (22.7%). Relevant predictors for the place of death were cause of death, sex, marital status and partly religion. Whereas between 1969 and 1986 a development towards dying in institutions was found, between 1986 and 2001 the place of death shifted within the institutions from hospitals to homes for elderly.ConclusionThe relevance of the home for elderly as the place of death will further grow in the future. To allow people to fulfill the tasks of caring for their relatives at home the ambulant emergency services will have to be augmented and relatives have to be motivated and supported.

Swiss consensus guidelines for hysterectomy

Objective: The quality of the indication for hysterectomy is widely discussed at present. In early 1996, the committee for quality assurance of the Swiss Society of Gynecology and Obstetrics decided to set up nationally accepted guidelines for the indication of hysterectomy. Methods: A modified Delphi approach was used. In a first step, general guidelines and actions prior to hysterectomy were defined. An expert panel of 17 Swiss gynecologists rated 74 frequent indications, twice for appropriateness (more benefits than risks for the patient), once for necessity (n=34; procedure has to be offered or discussed with the patient), and outlined suggestions to be performed prior to hysterectomy. Results: In a home rating round before the first panel met, there was an agreement rate of 48%. In 45% we observed neither agreement nor disagreement; in 7% we found disagreement. After the panel discussion 89% of experts agreed, 11% were indeterminate, and there was no disagreement. The necessity ratings showed agreement in 68% while 32% were indeterminate. The average median rating on a 1–9 point scale (1=extremely inappropriate, 9=extremely appropriate or necessary) was 5.4 over all single indications for appropriateness and 7.8 in single indications for necessity. After a second panel for consensus all panelists agreed on both appropriateness and necessity. Conclusion: The results of the appropriateness and necessity consensus presented in this paper reflect the findings of a 17 member Swiss panel. This joint effort by a medical society may be a step towards the direction of a peer controlled healthcare system.

HEALTH TECHNOLOGY ASSESSMENT OF THREE SCREENING METHODS IN SWITZERLAND

OBJECTIVE To describe the level of health technology assessments for three screening methods in Switzerland. METHODS Analysis of documents and expert opinions on mammography screening, ultrasound examinations during normal pregnancy, and screening for prostate-specific antigen (PSA) with a focus on services provided, recommendations, formal regulations, national papers, projects, and formal assessments. RESULTS Preventive services are explicitly recommended by the Swiss federal law on health insurance. Two routine ultrasound examinations during normal pregnancy as well as PSA analysis for men over 40 years of age on medical indication are covered by basic health insurance. Mammography screening every 2 years has been covered since 1997 for women over 50 years. A systematic screening program for mammography exists in the western part of Switzerland, and a nationwide program is planned. However, a national program may not come into being until a quality assurance program for evaluation is established, and a nationwide fee for reimbursement-to include all costs of such a program-is accepted by providers and insurers. CONCLUSION According to the Swiss health insurance law, the effectiveness of mammography screening and ultrasound examinations during normal pregnancy have to be proven. Systematic evaluation of these screening methods is in preparation. PSA is not part of current evaluation. It can be concluded that health technology assessment in Switzerland is now required by law for several medical services. However, limited financial and personnel resources as well as the lack of disease registers may hamper progress in the near future.

The Check Bus Project and its Effectiveness on Health Promotion at Work

The Check Bus Project and its Effectiveness on Health Promotion at Work: Julian Schilling, et al. Institute of Social and Preventive Medicine, University of Zurich, Switzerland— Employees of two large companies in Switzerland took part in a nationwide health information and promotion campaign at work, which included various physical examinations. A total of 5,849 consecutive participants were sent a questionnaire to determine whether changes had been made in their lifestyles and if they had benefited from participation; 2,361 (40.4%) responded. The campaign was rated highly at 8.3 on a scale from 1 to 10. Respondents reported benefiting most from the personal examination results, in particular the measurement of bone density, examination of the carotid arteries and discussions with the staff. Of the respondents, 921 stated they changed their lifestyle in the area of physical activity (64.4%) and nutrition (63.6%). Multiple logistic regression analysis showed the variables predictive of responding were age, hierarchy, diet and smoking. Health promotion at work and the choice of offered examinations may influence the effects of health care promotion at the workplace and the readiness of participants to improve their attitudes to health. Health promotion at work is highly regarded by employees who pay more attention to diet, smoke less and in particular those over 50 yr of age. High‐tech equipment in a mobile unit may attract employers and employees may profit most from the individual examination results; 39% of the respondents stated they changed their lifestyle as a consequence of the Check Bus campaign.

EUROPEAN JOINT ASSESSMENTS AND COORDINATION OF FINDINGS AND RESOURCES

The aim of Working Group 3 has been to identify possible joint assessments and to coordinate findings and existing resources within the community to support joint assessments. Healthcare decision makers throughout Europe face similar uncertainties about health care and are in need of reliable information. Closer collaboration and coordination between scientific information and healthcare decision making is imperative. International joint assessments relating to health technology offer one approach since they promote synergy, avoid duplication of effort, and are the most efficient way to produce the rigorous and comprehensive information needed. However, the success of joint assessments depends on several factors that need to be explored to improve the effectiveness and impact of future joint assessment projects.