L. Deliens

End-of-life decisions in medical practice in Flanders, Belgium: a nationwide survey

BACKGROUNDnOur study is a repeat of the Dutch death-certificate study on end-of-life decisions (ELDs). The main objective was to estimate the frequency of euthanasia (the administration of lethal drugs with the explicit intention of shortening the patients life at the patients explicit request), physician-assisted suicide (PAS), and other ELDs in medical practice in Flanders, Belgium.nnnMETHODSnA 20% random sample of 3999 deaths was selected from all deaths recorded between Jan 1 and April 30, 1998. The physicians who signed the corresponding death certificates received one questionnaire by post per death.nnnFINDINGSnThe physicians response rate was 1355 (52%). 1925 deaths were described. The results were corrected for non-response bias, and extrapolated to estimated annual rates after seasonal adjustment for death causes, and we estimate that 705 (1.3%, 95% CI 1.0-1.6) deaths resulted from euthanasia or PAS. In 1796 (3.2%, 2.7-3.8) cases, lethal drugs were given without the explicit request of the patient. Alleviation of pain and symptoms with opioids in doses with a potential life-shortening effect preceded death in 10,416 (18.5%, 17.3-19.7) cases and non-treatment decisions in 9218 (16.4%, 15.3-17.5) cases, of which 3261 (5.8%, 5.1-6.5) with the explicit intention of ending the patients life.nnnINTERPRETATIONnELDs are prominent in medical practice in Flanders. The frequency of deaths preceded by an ELD is similar to that in the Netherlands, but lower than that in Australia. However, in Flanders the rate of administration of lethal drugs to patients without their explicit request is similar to Australia, and significantly higher than that in the Netherlands.

Attitudes, Sociodemographic Characteristics, and Actual End-of-Life Decisions of Physicians in Flanders, Belgium

Aim. To study the effect of sociodemographic and attitudinal determinants of physicians making end-of-life decisions (ELDs). Methods. The physicians having signed 489 consecutive death certificates in the city of Hasselt (Belgium) were sent an anonymous questionnaire regarding their ELDs and another on their attitudes toward voluntary euthanasia (EUTH) and physician-assisted suicide (PAS).Results.55% response rate. Nontreatment decisions occurred in 16.7% of all death cases; in 16%, there was potentially life-shortening use of drugs to alleviate pain and symptoms; in 4.8% of cases,death was deliberately induced by lethal drugs, including EUTH, PAS, and life termination without explicit request by the patient. In their attitudes toward EUTH and PAS, the 92 responding physicians clustered into 3 groups: positive and rule oriented, positive rule-adverse, and opposed. Cluster groupmembership, commitment to life stance, years of professional experience, and gender were each associated with specific ELD-making patterns.

End-of-life Decisions of Physicians in the City of Hasselt (Flanders, Belgium)

OBJECTIVESnThe objective of this study is to estimate the proportion of different types of end-of-life decisions (ELDs) of physicians in the city of Hasselt (Flanders, Belgium). The question is addressed to what degree these ELD meet legal constraints and the ethical requirements for prudent practice.nnnMETHODOLOGYnAll physicians of the city of Hasselt who signed at least one death certificate in 1996 (N=166) received an anonymous self-administered mail questionnaire per death case (max. 5/doctor).nnnRESULTSnThe response rate was 55% (N=269). In 37.3% of all cases at least one ELD was made (16.5% non-treatment decisions; 16% potential life-shortening by intensifying the treatment of pain and symptoms; 4.8% administration, supply or prescription of lethal drugs). In 59.5% of the cases where an ELD was made that decision was legally questionnable. Patient characteristics were clearly related to the type of ELD. There was no influence of physician characteristics, except for commitment to life-stance. In 71.3% of the cases the ELD was in no way discussed with the patient. 8.1% of the ELD-cases were in response to a direct request from the patient.nnnCONCLUSIONSnThe incidences of ELDs in Hasselt are consistent with earlier findings. The study shows that religious commitment influences the behaviour of physicians at the end of their patients life. The patients and her familys entitlements to participation in the decision making process were rather poorly respected.

Physician Visits and Recognition of Residents' Terminal Phase in Long-Term Care Facilities: Findings From the PACE Cross-Sectional Study in 6 EU Countries

OBJECTIVESnTo describe the relation between physician visits and physicians recognition of a residents terminal phase in long-term care facilities (LTCFs) in Belgium, England, Finland, Italy, the Netherlands, and Poland.nnnDESIGNnIn each country, a cross-sectional study was conducted across representative samples of LTCFs. Participating LTCFs reported all deaths of residents in the previous 3xa0months, and structured questionnaires were sent to several proxy respondents including the treating physician.nnnSETTING AND PARTICIPANTSn1094 residents in 239 LTCFs, about whom 505 physicians returned the questionnaire.nnnMEASURESnNumber of physician visits, the residents main treatment goal, whether physicians recognized the residents terminal phase and expected the residents death, and resident and physician characteristics.nnnRESULTSnThe number of physician visits to residents varied widely between countries, ranging from a median of 15 visits in the last 3xa0months of life in Poland to 5 in England, and from 4 visits in the last week of life in the Netherlands to 1 in England. Among all countries, physicians from Poland and Italy were least inclined to recognize that the resident was in the terminal phase (63.0% in Poland compared to 80.3% in the Netherlands), and residents in these countries had palliation as main treatment goal the least (31.8% in Italy compared to 92.6% in the Netherlands). Overall however, there were positive associations between the number of physician visits and the recognition of the residents terminal phase and between the number of physician visits and the resident having palliation as main treatment goal in the last week of life.nnnCONCLUSIONS AND IMPLICATIONSnThis study suggests that LTCFs should be encouraged to work collaboratively with physicians to involve them as much as possible in caring for their residents. Joint working will facilitate the recognition of a residents terminal phase and the timely provision of palliative care.

Trends between 2009 and 2014 in advance care planning for older people in Belgium and the Netherlands.

BackgroundnnAdvance care planning (ACP) is of particular importance for older people and those at risk of cognitive decline at the end of life. While ACP has gained attention from practice and policy-makers over the past decades, there are no studies evaluating trends in physician’s awareness of patient preferences.nnMethodsnnRetrospective survey regarding deceased patients among a cohort of representative nationwide GP sentinel networks in 2009, 2010, 2013 and 2014 in Belgium and the Netherlands. Patients who died non-suddenly aged 65 years or older were included in the study. GPs were asked about patient preferences for a medical treatment at the end of life; whether or not a proxy decision maker was known; and whether or not this proxy decision maker was consulted if a situation arose where this was necessary.nnResultsnnGPs were aware of a preference for a medical treatment at the end of life increased in Belgium (n = 2785) for 27% of decedents in 2009 to 40% in 2014 and in the Netherlands (n = 1083) from 53% to 66%. Awareness of a preference for a proxy decision maker increased in Belgium from 29% in 2009 to 43% in 2014 and in the Netherlands from 30% to 57%, with the preference being recorded in writing in a fifth to a third of cases in both countries (borderline significant decrease in the Netherlands from 28% to 25%, p = 0.05). These trends were significant in all studied patient groups. In the majority of cases where the situation arose, proxy decision makers were consulted at the end of life in both countries (71%-96%), though Dutch GPs more often indicated that no such situation arose (61%).nnConclusionsnnGPs were much more frequently aware of their patients’ preferences in 2014 than in 2009 in both countries, which suggests that increased attention to ACP is bringing rapid changennKey messages: nn•Between 2009 and 2014, physician’s knowledge of patients preferences regarding care at the end of life increased significantly in both Belgium and the Netherlandsnnn•Rapid improvement in advance care planning is possible, with some indicators doubling in only 6 years

Implementatie van niet-reanimeerbeleid op afdelingen acute geriatrie van Vlaamse ziekenhuizen in 2002 nog niet voltooid

Do-Not-Resuscitate Policy on Acute Geriatric Wards in Flanders, Belgium. This study describes the historical development and status of a do-not-resuscitate (DNR) policy on acute geriatric wards in Flanders, Belgium. In 2002 (the year Belgium voted a law on euthanasia), a structured mail questionnaire was sent to all head geriatricians of acute geriatric wards in Flanders (N=94). Respondents were asked about the existence, development, and implementation of the DNR policy (guidelines and order forms).The response was 76.6%. Development of DNR policy began in 1985, with a step-up in 1997 and 2001. In 2002, a DNR policy was available in 86.1% of geriatric wards, predominantly with institutional DNR guidelines and individual, patient-specific DNR order forms. The policy was initiated and developed predominantly from an institutional perspective by the hospital. The forms were not standardized and generally lacked room to document patient involvement in the decision making process.Implementation of institutional DNR guidelines and individual DNR order forms on geriatric wards in Flanders lagged behind that of other countries and was still incomplete in 2002. DNR policies varied in content and scope and were predominantly an expression of institutional defensive attitudes rather than a tool to promote patient involvement in DNR and other end-of-life decisions.Tijdschr Gerontol Geriatr 2007; 38: 246-254SamenvattingDeze studie beschrijft de beschikbaarheid en historische ontwikkeling van niet-reanimeer (NR) beleid op afdelingen voor acute geriatrie in ziekenhuizen in Vlaanderen. Via een gestructureerde postenquête, verstuurd naar alle diensthoofden geriatrie in Vlaanderen in 2002 (N=94), werd de aanwezigheid, ontwikkeling en implementatie van NR-beleid (richtlijnen en codebladen) op de afdeling voor geriatrie bevraagd. Het responspercentage bedroeg 76,6%. De ontwikkeling van NR-beleid startte in 1985, en nam sterk toe in de jaren 1997 en 2001. In 2002 was op 86,1% van de afdelingen een NR-beleid aanwezig, meestal in de vorm van zowel institutionele richtlijnen als patiënt-specifieke codebladen. Het initiatief tot en de ontwikkeling van het NR-beleid kwam vooral tot stand vanuit het ziekenhuis. De formulieren waren niet gestandardiseerd en er was zelden plaats om de mate van betrokkenheid van de patiënt in het besluitvormingsproces te noteren. In vergelijking met andere landen kwam in Vlaanderen de ontwikkeling van NR-richtlijnen en -codebladen op ziekenhuisafdelingen voor acute geriatrie laat op gang. Het was nog steeds onvolledig in 2002. De documenten verschilden sterk qua inhoud en doel en waren eerder de uitdrukking van een defensieve houding van de instelling dan een instrument om de betrokkenheid van patiënten in beslissingen rond het levenseinde aan te moedigen.

Attitudes, beliefs and knowledge concerning antibiotic use and self-medication

PURPOSEnAlthough the relevance of cultural factors for antibiotic use has been recognized, few studies exist in Europe. We compared public attitudes, beliefs and knowledge concerning antibiotic use and self-medication between 11 European countries.nnnMETHODSnIn total, 1101 respondents were interviewed on their attitudes towards appropriateness of self-medication with antibiotics and situational use of antibiotics, beliefs about antibiotics for minor ailments, knowledge about the effectiveness of antibiotics on viruses and bacteria and awareness about antibiotic resistance. To deal with the possible confounding effect of both use of self-medication and education we performed stratified analyses, i.e. separate analyses for users and non-users of self-medication, and for respondents with high and low education. The differences between countries were considered relevant when regression coefficients were significant in all stratum-specific analyses.nnnRESULTSnRespondents from the UK, Malta, Italy, Czech Republic, Croatia, Israel and Lithuania had significantly less appropriate attitudes, beliefs or knowledge for at least one of the dimensions compared with Swedish respondents. The Dutch, Austrian and Belgian respondents did not differ from Swedish for any dimension.nnnCONCLUSIONSnThe most pronounced differences were for awareness about resistance, followed by attitudes towards situational use of antibiotics. Awareness about antibiotic resistance was the lowest in countries with higher prevalence of resistance.

De ontwikkeling van een Belgische zorgleidraad voor huisartsen over beslissingen aan het levenseinde

SamenvattingDeschepper R, Michiels E, Vander Stichele R, Bernheim JL, De Keyser E, Van Der Kelen G, Mortier F, Deliens L. De ontwikkeling van een Belgische zorgleidraad voor huisartsen over beslissingen aan het levenseinde. Huisarts Wet 2006;49(8):404-10.Inleiding In dit onderzoek beschrijven we hoe we een zorgleidraad hebben ontwikkeld voor huisartsen over communicatie met terminaal zieke patiënten die thuis willen sterven.Methoden Driefaseproces. Ontwerpfase: we hebben bevindingen uit de literatuur gestructureerd en gewogen door middel van een focusgroep met huisartsen (n=8). Verdiepingsfase: we verzamelden kwalitatieve data over het patiënten- en zorgverlenersperspectief door middel van een focusgroep van naasten (n=7), diepte-interviews met terminaal zieken (n=17) en een kwaliteitskring van zorgverleners (n=11). Toetsingsfase: we beoordeelden de aanvaardbaarheid van het voorontwerp in bipolaire focusgroepen (huisartsen-verpleegkundigen (n=12) en huisartsen-specialisten (n=9)) en commentaar per e-mail door experts (n=41).Resultaten Zorgverleners en patiënten gaven aan dat ze grote behoefte hebben aan een begrijpelijke zorgleidraad over communicatie aan het levenseinde. Ze kenden de grootste prioriteit toe aan vier thema’s: de waarheidsmededeling, exploratie van wensen rond het levenseinde, omgaan met enerzijds disproportionele behandelingen en anderzijds met euthanasieverzoeken. Andere thema’s die naar voor kwamen, waren: continuïteit van zorg door de huisarts, voeding en vocht in de stervensfase en de technische aspecten van euthanasie.Beschouwing Het bleek haalbaar om een zorgleidraad te ontwikkelen voor huisartsen op basis van de drie hoekstenen van evidence-based medicine: literatuuronderzoek, patiëntenvisies en ervaring van deskundigen. Ondanks verschillen tussen België en Nederland is deze zorgleidraad ook relevant voor Nederlandse huisartsen.