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Scott MM, Webber C, Clarke AE, Hafid A, Isenberg SR, Jones A, Hsu AT, Conen K, Downar J, Manuel DG, Howard M, Tanuseputro P. Physician home visits to rostered patients during their last year of life: a retrospective cohort study. CMAJ Open 2023; 11:E597-E606. [PMID: 37402554 DOI: 10.9778/cmajo.20220123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Physician home visits are associated with better health outcomes, yet most patients near the end of life never receive such a visit. Our objectives were to describe the receipt of physician home visits during the last year of life after a referral to home care - an indication that the patient can no longer live independently - and to measure associations between patient characteristics and receipt of a home visit. METHODS We conducted a retrospective cohort study using linked population-based health administrative databases housed at ICES. We identified adult (aged ≥ 18 yr) decedents in Ontario who died between Mar. 31, 2013, and Mar. 31, 2018, who were receiving primary care and were referred to publicly funded home care services. We described the provision of physician home visits, office visits and telephone management. We used multinomial logistic regression to calculate the odds of receiving home visits from a rostered primary care physician, controlling for referral during the last year of life, age, sex, income quintile, rurality, recent immigrant status, referral by rostered physician, referral during hospital stay, number of chronic conditions and disease trajectory based on the cause of death. RESULTS Of the 58 753 decedents referred in their last year of life, 3125 (5.3%) received a home visit from their family physician. Patient characteristics associated with higher odds of receiving home visits compared to office-based or telephone-based care were being female (adjusted odds ratio [OR] 1.28, 95% confidence interval [CI] 1.21-1.35), being 85 years of age or older (adjusted OR 2.42, 95% CI 1.80-3.26) and living in a rural area (adjusted OR 1.09, 95% CI 1.00-1.18). Increased odds were associated with home care referrals by the patient's primary care physician (adjusted OR 1.49, 95% CI 1.39-1.58) and referrals occurring during a hospital stay (adjusted OR 1.20, 95% CI 1.13-1.28). INTERPRETATION A small proportion of patients near the end of life received home-based physician care, and patient characteristics did not explain the low visit rates. Future work on system- and provider-level factors may be critical to improve access to home-based end-of-life primary care.
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Affiliation(s)
- Mary M Scott
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont.
| | - Colleen Webber
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - Anna E Clarke
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - Abe Hafid
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - Sarina R Isenberg
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - Aaron Jones
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - Amy T Hsu
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - Katrin Conen
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - James Downar
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - Douglas G Manuel
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - Michelle Howard
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - Peter Tanuseputro
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
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de Graaf E, van der Baan F, Grant MP, Verboeket C, van Klinken M, Jobse A, Ausems M, Leget C, Teunissen S. Hospice Care Access: a national cohort study. BMJ Support Palliat Care 2022:bmjspcare-2022-003579. [PMID: 36307176 DOI: 10.1136/spcare-2022-003579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 10/02/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Hospice care in the Netherlands is provided in three different types of hospice facilities: volunteer-driven hospices (VDH), stand-alone hospices (SAHs) and hospice unit nursing homes (HU). The organisational structures range from care directed by trained volunteers in VDH to care provided by multiprofessional teams in SAH and HU units.This study aims to characterise the patient populations who access Dutch hospices and describe the patient profiles in different hospice types. METHODS A retrospective cohort study using clinical records of adult hospice inpatients in 2017-2018 from a random national sample of hospices. RESULTS In total 803 patients were included from 51 hospices, mean age 76.1 (SD 12.4). 78% of patients had a primary diagnosis of cancer, 3% identified as non-Dutch cultural background and 17% were disorientated on admission. At admission, all patients were perceived to have physical needs. Psychological needs were reported in 37%, 36% and 34%, social needs by 53%, 52% and 62%, and existential needs by 23%, 30% and 18% of patients in VDH, SAH, HU units, respectively. 24%, 29% and 27% of patients from VDHs, SAHs and HUs had care needs in three dimensions, and 4%, 6% and 3% in all four dimensions. CONCLUSIONS People who access Dutch hospices predominantly have cancer, and have a range of physical, psychological, social and existential needs, without substantial differences between hospice types. Patients with non-malignant disease and non-Dutch cultural backgrounds are less likely to access hospice care, and future policy would ideally focus on facilitating their involvement.
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Affiliation(s)
- Everlien de Graaf
- Center of Expertise in Palliative Care, Department of General Practice, Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Frederieke van der Baan
- Center of Expertise in Palliative Care, Department of General Practice, Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Matthew Paul Grant
- Center of Expertise in Palliative Care, Department of General Practice, Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Cathelijne Verboeket
- Center of Expertise in Palliative Care, Department of General Practice, Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Merel van Klinken
- Center of Expertise in Palliative Care, Department of General Practice, Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Adri Jobse
- Center of Expertise in Palliative Care, Department of General Practice, Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Marieke Ausems
- Dutch College of General Practitioners, Utrecht, The Netherlands
| | - Carlo Leget
- University of Humanistic Studies, Utrecht, The Netherlands
| | - Saskia Teunissen
- Center of Expertise in Palliative Care, Department of General Practice, Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
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Ding J, Johnson CE, Auret K, Ritson D, Masarei C, Chua D, Licqurish S, Mitchell G, Cook A. Comparison of end-of-life care for people living in home settings versus residential aged care facilities: A nationwide study among Australian general practitioners. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:91-101. [PMID: 33825245 DOI: 10.1111/hsc.13375] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 10/30/2020] [Accepted: 02/23/2021] [Indexed: 06/12/2023]
Abstract
We have little knowledge of differences in end-of-life care between home settings and residential aged care facilities (RACFs) where people spend most of their last year of life. This study aimed to compare end-of-life care between home settings and RACFs from the perspective of Australian general practitioners (GPs). A descriptive study was conducted with 62 GPs from Western Australia, Queensland and Victoria. Participants were asked to provide reports on end-of-life care of decedents in their practice using a validated clinic-based data collection process developed by our team between September 2018 and August 2019. Of the 213 reported expected deaths, 66.2% mainly lived at home in the last year of life. People living at home were more likely to die at a younger age (median 77 vs. 88, p < 0.001), to be male (51.1% vs. 33.3%, p = 0.01) and to die of cancer (53.9% vs. 4.2%, p < 0.001) compared to those in RACFs. There were no significant differences between the two patient groups for seven out of the eight assessed symptoms, except nausea. GPs' perceived roles in caring for patients and levels of their involvement in provision of common palliative care services were comparable between the two groups. The usual accommodation setting was most frequently considered the preferred place of death in both groups. However, more home residents ended up dying in hospital compared to RACF residents. There were significantly higher frequencies of end-of-life discussions (ORs ranged 5.46-9.82 for all topic comparisons) with GPs associated with people living at home versus RACFs. One opportunity for improved care is through promoting greater involvement of GPs in end-of-life discussions with RACF residents and staff. In general, more Australians could potentially remain at home until death if provided with greater access to essential specialist palliative care services and supportive services in home settings.
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Affiliation(s)
- Jinfeng Ding
- Xiangya School of Nursing, Central South University, Changsha, China
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - Claire E Johnson
- Palliative Care Outcomes Collaboration, University of Wollongong, Wollongong, NSW, Australia
- School of Nursing and Midwifery, Monash University, Melbourne, VIC, Australia
- Supportive and Palliative Care, Eastern Health, Melbourne, VIC, Australia
| | - Kirsten Auret
- Rural Clinical School of Western Australia, The University of Western Australia, Albany, WA, Australia
| | - Dianne Ritson
- The Val Lishman Health Foundation, Bunbury, WA, Australia
| | | | - David Chua
- Primary Care Clinical Unit, The University of Queensland, Brisbane, QLD, Australia
| | - Sharon Licqurish
- School of Nursing and Midwifery, Monash University, Melbourne, VIC, Australia
| | - Geoffrey Mitchell
- Primary Care Clinical Unit, The University of Queensland, Brisbane, QLD, Australia
| | - Angus Cook
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
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Honinx E, Piers RD, Onwuteaka-Philipsen BD, Payne S, Szczerbińska K, Gambassi G, Kylänen M, Deliens L, Van den Block L, Smets T. Hospitalisation in the last month of life and in-hospital death of nursing home residents: a cross-sectional analysis of six European countries. BMJ Open 2021; 11:e047086. [PMID: 34385245 PMCID: PMC8362714 DOI: 10.1136/bmjopen-2020-047086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To examine the rate and characteristics of hospitalisation in the last month of life and place of death among nursing home residents and to identify related care processes, facility factors and residents' characteristics. SETTING A cross-sectional study (2015) of deceased residents in 322 nursing homes in six European countries. PARTICIPANTS The nursing home manager (N=1634), physician (N=1132) and primary nurse (N=1384) completed questionnaires. OUTCOME MEASURES Hospitalisation and place of death were analysed using generalised linear and logistic mixed models. Multivariate analyses were conducted to determine associated factors. RESULTS Twelve to 26% of residents were hospitalised in the last month of life, up to 19% died in-hospital (p<0.001). Belgian residents were more likely to be hospitalised than those in Italy, the Netherlands and Poland. For those dying in-hospital, the main reason for admission was acute change in health status. Residents with a better functional status were more likely to be hospitalised or to die in-hospital. The likelihood of hospitalisation and in-hospital death increased if no conversation on preferred care with a relative was held. Not having an advance directive regarding hospitalisations increased the likelihood of hospitalisation. CONCLUSIONS Although participating countries vary in hospitalisation and in-hospital death rates, between 12% (Italy) and 26% (Belgium) of nursing home residents were hospitalised in the last month of life. Close monitoring of acute changes in health status and adequate equipment seem critical to avoiding unnecessary hospitalisations. Strategies to increase discussion of preferences need to be developed. Our findings can be used by policy-makers at governmental and nursing home level.
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Affiliation(s)
- Elisabeth Honinx
- Huisartsgeneeskunde, Vrije Universiteit Brussel, Jette, Brussels, Belgium
| | - Ruth D Piers
- Geriatrics, University Hospital Ghent, Gent, Oost-Vlaanderen, Belgium
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health/EMGO Institute for Health and Care Research/Expertise Center for Palliative Care, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Sheila Payne
- Institute for Health Research, Lancaster University Faculty of Health and Medicine, Lancaster, Lancashire, UK
| | - Katarzyna Szczerbińska
- Sociology of Medicine, Jagiellonian University Medical College Faculty of Medicine, Krakow, Poland
| | - Giovanni Gambassi
- Internal Medicine, Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia, Roma, Lazio, Italy
| | - Marika Kylänen
- Department of Health, National Institute for Health and Welfare, Helsinki, Uusimaa, Finland
| | - L Deliens
- Chronic Care, Universiteit Gent Faculteit Geneeskunde en Gezondheidswetenschappen, Gent, Belgium
| | - Lieve Van den Block
- Huisartsgeneeskunde, Vrije Universiteit Brussel Faculteit Geneeskunde en Farmacie, Brussel, Belgium
| | - Tinne Smets
- Huisartsgeneeskunde, Vrije Universiteit Brussel Faculteit Geneeskunde en Farmacie, Brussel, Belgium
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Primary care service use by end-of-life cancer patients: a nationwide population-based cohort study in the United Kingdom. BMC FAMILY PRACTICE 2020; 21:76. [PMID: 32349696 PMCID: PMC7191808 DOI: 10.1186/s12875-020-01127-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 03/11/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND End of life (EoL) care becomes more complex and increasingly takes place in the community, but there is little data on the use of general practice (GP) services to guide care improvement. This study aims to determine the trends and factors associated with GP consultation, prescribing and referral to other care services amongst cancer patients in the last year of life. METHODS A retrospective cohort study of cancer patients who died in 2000-2014, based on routinely collected primary care data (the Clinical Practice Research DataLink, CPRD) covering a representative sample of the population in the United Kingdom. Outcome variables were number of GP consultations (primary), number of prescriptions and referral to other care services (yes vs no) in the last year of life. Explanatory variables included socio-demographics, clinical characteristics and the status of palliative care needs recognised or not. The association between outcome and explanatory variables were evaluated using multiple-adjusted risk ratio (aRR). RESULTS Of 68,523 terminal cancer patients, 70% were aged 70+, 75% had comorbidities and 45.5% had palliative care needs recognised. In the last year of life, a typical cancer patient had 43 GP consultations (Standard deviation (SD): 31.7; total = 3,031,734), 71.5 prescriptions (SD: 68.0; total = 5,074,178), and 21(SD: 13.0) different drugs; 58.0% of patients had at least one referral covering all main clinical specialities. More comorbid conditions, prostate cancer and having palliative care needs recognised were associated with more primary care consultations, more prescriptions and a higher chance of referral (aRRs 1.07-2.03). Increasing age was related to fewer consultations (aRRs 0.77-0.96), less prescriptions (aRR 1.09-1.44), and a higher chance of referral (aRRs 1.08-1.16) but less likely to have palliative care needs recognised (aRRs 0.53-0.89). CONCLUSIONS GPs are very involved in end of life care of cancer patients, most of whom having complex care needs, i.e. older age, comorbidity and polypharmacy. This highlights the importance of enhancing primary palliative care skills among GPs and the imperative of greater integration of primary care with other healthcare professionals including oncologists, palliative care specialists, geriatricians and pharmacists. Research into the potential of deprescribing is warranted. Older patients have poorer access to both primary care and palliative care need to be addressed in future practices.
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Buiting HM, Bolt EE. Patients with incurable cancer as a separate group of survivors in the primary care setting. Cancer 2019; 125:4541. [DOI: 10.1002/cncr.32473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | - Eva E. Bolt
- Department of Social Medicine Center for Palliative Care Amsterdam UMC, Location VUMC Amsterdam The Netherlands
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Dierickx S, Onwuteaka-Philipsen B, Penders Y, Cohen J, van der Heide A, Puhan MA, Ziegler S, Bosshard G, Deliens L, Chambaere K. Commonalities and differences in legal euthanasia and physician-assisted suicide in three countries: a population-level comparison. Int J Public Health 2019; 65:65-73. [DOI: 10.1007/s00038-019-01281-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/12/2019] [Accepted: 06/28/2019] [Indexed: 01/22/2023] Open
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Mühlensiepen F, Thoma S, Marschke J, Heinze M, Harms D, Neugebauer EAM, von Peter S. ["If they were to stop coming, I'd panic" : Palliative care networks from the perspectives of patients and informal care givers]. Schmerz 2019; 33:320-328. [PMID: 31267168 DOI: 10.1007/s00482-019-0384-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study examines the perspectives of patients and family caregivers on outpatient palliative care networks. It contrasts primary palliative care (AAPV) and specialized outpatient care (SAPV) services, particularly in regard to pain management. METHODS The study is based on 27 semi-structured, problem-focussed interviews with 21 patients and 19 informal caregivers. Recruitment was based on purposive sampling in two regions of Brandenburg, Germany. The data were analysed using qualitative content analysis. RESULTS In AAPV, the general practitioner (GP) is both the central point of contact as well as the coordinator of the care network. In SAPV, the GP plays a less important role. This can lead to conflicts between GPs and health care professionals of the palliative care team. Compared to AAPV, palliative care teams are attributed greater intervention capacities in acute situations as well as expertise in pain therapy. Thus, the option of parenteral administration of opioids is considered a benefit of specialized care. The use of nursing services varies considerably depending on the individual care network-in some cases care is completely taken over by relatives. Relatives are the closest to the patient within the care network and perform key tasks. CONCLUSION The personal and professional composition of networks of outpatient palliative care varies individually according to care situation and form. Care networks of AAPV and SAPV differ with regard to the accessibility of health care professionals and pain therapy. Home-based palliative care is often made possible by informal care givers in the first place.
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Affiliation(s)
- Felix Mühlensiepen
- KV Consult- und Managementgesellschaft mbH, Pappelallee 5, 14469, Potsdam, Deutschland. .,Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Deutschland. .,Universität Witten-Herdecke, Witten, Deutschland.
| | - Samuel Thoma
- Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Deutschland.,Hochschulklinik Psychiatrie und Psychotherapie, Immanuel Klinik Rüdersdorf, Rüdersdorf, Deutschland
| | - Judith Marschke
- Kassenärztliche Vereinigung Brandenburg, Potsdam, Deutschland
| | - Martin Heinze
- Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Deutschland.,Hochschulklinik Psychiatrie und Psychotherapie, Immanuel Klinik Rüdersdorf, Rüdersdorf, Deutschland
| | - Dirk Harms
- Palliative Care Team Harms GmbH, Brandenburg an der Havel, Deutschland
| | - Edmund A M Neugebauer
- Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Deutschland.,Universität Witten-Herdecke, Witten, Deutschland
| | - Sebastian von Peter
- Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Deutschland.,Hochschulklinik Psychiatrie und Psychotherapie, Immanuel Klinik Rüdersdorf, Rüdersdorf, Deutschland
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Koper I, Pasman HRW, Onwuteaka-Philipsen BD. Experiences of Dutch general practitioners and district nurses with involving care services and facilities in palliative care: a mixed methods study. BMC Health Serv Res 2018; 18:841. [PMID: 30409204 PMCID: PMC6225713 DOI: 10.1186/s12913-018-3644-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 10/23/2018] [Indexed: 01/18/2023] Open
Abstract
Background Generals practitioners (GPs) and district nurses (DNs) play a leading role in providing palliative care at home. Many services and facilities are available to support them in providing this complex care. This study aimed to examine the extent to which GPs and DNs involve these services, what their experiences are, and how involvement of these services and facilities can be improved. Methods Sequential mixed methods consisting of an online questionnaire with structured and open questions completed by 108 GPs and 258 DNs, followed by three homogenous online focus groups with 8 GPs and 19 DNs, analyzed through open coding. Results Most GPs reported that they sometimes or often involved palliative home care teams (99%), hospices (94%), and palliative care consultation services (93%). Most DNs reported sometimes or often involving volunteers (90%), hospices (88%), and spiritual caregivers (80%). The least involved services and facilities were psychologists and psychiatrists (51% and 50%) and social welfare (44% and 57%). Main reason for not involving services and facilities was ‘not needing’ them. If they had used them, most GPs and DNs (68–93%) reported solely positive experiences. Hardly anyone (0–3%) reported solely negative experiences with any of the services and the facilities. GPs and DNs suggested improvements in three areas: (1) establishment of local centers giving information on available services and facilities, (2) presentation of services and facilities in local multidisciplinary meetings, and (3) support organizations to proactively offer their facilities and services. Conclusion Psychological, social, and spiritual services are involved less often, suggesting that the classic care model, which focuses strongly on somatic issues, is still well entrenched. More familiarity with services that can provide additional care in these areas, regarding their availability and their added value, could improve the quality of life for patients and relatives at the end of life.
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Affiliation(s)
- Ian Koper
- Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, NL-1081, BT, Amsterdam, The Netherlands.
| | - H Roeline W Pasman
- Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, NL-1081, BT, Amsterdam, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, NL-1081, BT, Amsterdam, The Netherlands
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Ding J, Johnson CE, Cook A. How We Should Assess the Delivery of End-Of-Life Care in General Practice? A Systematic Review. J Palliat Med 2018; 21:1790-1805. [PMID: 30129811 DOI: 10.1089/jpm.2018.0194] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The majority of end-of-life (EOL) care occurs in general practice. However, we still have little knowledge about how this care is delivered or how it can be assessed and supported. AIM (i) To review the existing evaluation tools used for assessment of the delivery of EOL care from the perspective of general practice; (ii) To describe how EOL care is provided in general practice; (iii) To identify major areas of concern in providing EOL care in this context. DESIGN A systematic review. DATA SOURCES Systematic searches of major electronic databases (Medline, EMBASE, PsycINFO, and CINAHL) from inception to 2017 were used to identify evaluation tools focusing on organizational structures/systems and process of end-of-life care from a general practice perspective. RESULTS A total of 43 studies representing nine evaluation tools were included. A relatively restricted focus and lack of validation were common limitations. Key general practitioner (GP) activities assessed by the evaluation tools were summarized and the main issues in current GP EOL care practice were identified. CONCLUSIONS The review of evaluation tools revealed that GPs are highly involved in management of patients at the EOL, but there are a range of issues relating to the delivery of care. An EOL care registration system integrated with electronic health records could provide an optimal approach to address the concerns about recall bias and time demands in retrospective analyses. Such a system should ideally capture the core GP activities and any major issues in care provision on a case-by-case basis.
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Affiliation(s)
- Jinfeng Ding
- 1 School of Population and Global Health, University of Western Australia , Perth, Western Australia, Australia
| | - Claire E Johnson
- 2 Cancer and Palliative Care Research and Evaluation Unit (CaPCREU), Medical School, University of Western Australia , Perth, Western Australia, Australia
- 3 School of Nursing and Midwifery, Monash University , Melbourne, Victoria, Australia
| | - Angus Cook
- 1 School of Population and Global Health, University of Western Australia , Perth, Western Australia, Australia
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11
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Johnson CE, McVey P, Rhee JJO, Senior H, Monterosso L, Williams B, Fallon-Ferguson J, Grant M, Nwachukwu H, Aubin M, Yates P, Mitchell G. General practice palliative care: patient and carer expectations, advance care plans and place of death-a systematic review. BMJ Support Palliat Care 2018:bmjspcare-2018-001549. [PMID: 30045939 DOI: 10.1136/bmjspcare-2018-001549] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/20/2018] [Accepted: 07/04/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND With an increasing ageing population in most countries, the role of general practitioners (GPs) and general practice nurses (GPNs) in providing optimal end of life (EoL) care is increasingly important. OBJECTIVE To explore: (1) patient and carer expectations of the role of GPs and GPNs at EoL; (2) GPs' and GPNs' contribution to advance care planning (ACP) and (3) if primary care involvement allows people to die in the place of preference. METHOD Systematic literature review. DATA SOURCES Papers from 2000 to 2017 were sought from Medline, Psychinfo, Embase, Joanna Briggs Institute and Cochrane databases. RESULTS From 6209 journal articles, 51 papers were relevant. Patients and carers expect their GPs to be competent in all aspects of palliative care. They valued easy access to their GP, a multidisciplinary approach to care and well-coordinated and informed care. They also wanted their care team to communicate openly, honestly and empathically, particularly as the patient deteriorated. ACP and the involvement of GPs were important factors which contributed to patients being cared for and dying in their preferred place. There was no reference to GPNs in any paper identified. CONCLUSIONS Patients and carers prefer a holistic approach to care. This review shows that GPs have an important role in ACP and that their involvement facilitates dying in the place of preference. Proactive identification of people approaching EoL is likely to improve all aspects of care, including planning and communicating about EoL. More work outlining the role of GPNs in end of life care is required.
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Affiliation(s)
- Claire E Johnson
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
- School of Nursing & Midwifery, Monash University, Melbourne, Victoria, Australia
- Eastern Health, Melbourne, Victoria, Australia
| | - Peta McVey
- Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
| | - Joel Jin-On Rhee
- General Practice Academic Unit, School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Hugh Senior
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- College of Health, Massey University, Auckland, New Zealand
| | - Leanne Monterosso
- School of Nursing & Midwifery, Notre Dame University, Fremantle, Western Australia, Australia
- Centre for Nursing and Midwifery Research, St John of God Murdoch Hospital, Murdoch, Western Australia, Australia
- School of Nursing & Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Briony Williams
- School of General Practice and Rural Medicine, University of Western Australia, Perth, Western Australia, Australia
- Primary Care Collaborative Cancer Clinical Trials Group, University of Melbourne, Melbourne, Victoria, Australia
| | - Julia Fallon-Ferguson
- School of General Practice and Rural Medicine, University of Western Australia, Perth, Western Australia, Australia
- Primary Care Collaborative Cancer Clinical Trials Group, University of Melbourne, Melbourne, Victoria, Australia
| | - Matthew Grant
- Victoria Comprehensive Cancer Centre Palliative Care Research Group, University of Melbourne, Melbourne, Victoria, Australia
| | - Harriet Nwachukwu
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Michèle Aubin
- Département de médecine familiale et de médecined\'urgence, Universite Laval, Faculte de medecine, Québec City, Canada
| | - Patsy Yates
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Geoffrey Mitchell
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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12
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Heins M, Hofstede J, Rijken M, Korevaar J, Donker G, Francke A. Palliative care for patients with cancer: do patients receive the care they consider important? A survey study. BMC Palliat Care 2018; 17:61. [PMID: 29665807 PMCID: PMC5905150 DOI: 10.1186/s12904-018-0315-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 04/03/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In many countries, GPs and home care nurses are involved in care for patients with advanced cancer. Given the varied and complex needs of these patients, providing satisfactory care is a major challenge for them. We therefore aimed to study which aspects of care patients, GPs and home care nurses consider important and whether patients receive these aspects. METHODS Seventy-two Dutch patients with advanced cancer, 87 GPs and 26 home care nurses rated the importance of support when experiencing symptoms, respect for patients' autonomy and information provision. Patients also rated whether they received these aspects. Questionnaires were based on the CQ index palliative care. RESULTS Almost all patients rated information provision and respect for their autonomy as important. The majority also rated support when suffering from specific symptoms as important, especially support when in pain. In general, patients received the care they considered important. However, 49% of those who considered it important to receive support when suffering from fatigue and 23% of those who wanted to receive information on the expected course of their illness did not receive this or only did so sometimes. CONCLUSION For most patients with advanced cancer, the palliative care that they receive matches what they consider important. Support for patients experiencing fatigue may need more attention. When symptoms are difficult to control, GPs and nurses may still provide emotional support and practical advice. Furthermore, we recommend that GPs discuss patients' need for information about the expected course of their illness.
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Affiliation(s)
- Marianne Heins
- Netherlands Institute for Health Services Research (NIVEL), P.O Box 1568, 3500 BN, Utrecht, The Netherlands.
| | - Jolien Hofstede
- Netherlands Institute for Health Services Research (NIVEL), P.O Box 1568, 3500 BN, Utrecht, The Netherlands
| | - Mieke Rijken
- Netherlands Institute for Health Services Research (NIVEL), P.O Box 1568, 3500 BN, Utrecht, The Netherlands
| | - Joke Korevaar
- Netherlands Institute for Health Services Research (NIVEL), P.O Box 1568, 3500 BN, Utrecht, The Netherlands
| | - Gé Donker
- Netherlands Institute for Health Services Research (NIVEL), P.O Box 1568, 3500 BN, Utrecht, The Netherlands
| | - Anneke Francke
- Netherlands Institute for Health Services Research (NIVEL), P.O Box 1568, 3500 BN, Utrecht, The Netherlands.,Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, the Netherlands.,Expertise center palliative care, VU University Medical Center, Amsterdam, the Netherlands
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13
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Casotto V, Rolfini M, Ferroni E, Savioli V, Gennaro N, Avossa F, Cancian M, Figoli F, Mantoan D, Brambilla A, Ghiotto MC, Fedeli U, Saugo M. End-of-Life Place of Care, Health Care Settings, and Health Care Transitions Among Cancer Patients: Impact of an Integrated Cancer Palliative Care Plan. J Pain Symptom Manage 2017; 54:167-175. [PMID: 28479411 DOI: 10.1016/j.jpainsymman.2017.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 03/15/2017] [Accepted: 04/05/2017] [Indexed: 10/19/2022]
Abstract
CONTEXT Frequent end-of-life health care setting transitions can lead to an increased risk of fragmented care and exposure to unnecessary treatments. OBJECTIVES We assessed the relationship between the presence and the intensity of an Integrated Cancer Palliative Care (ICPC) plan and the occurrence of multiple transitions during the last month of life. METHODS Decedents of cancer aged 18-85 years residents in two regions of Italy were investigated accessing their integrated administrative data (death certificates, hospital discharges, hospice, and home care records). The principal outcome was defined as having 3+ health care setting transitions during the last month of life. The ICPC plans instituted 90-31 days before death represented the main exposure of interest. RESULTS Of the 17,604 patients, 6698 included in an ICPC, although spending in hospital a median number of only two days (interquartile range 1-2), experienced 1+ (59.8%), 2+ (21.1%), or 3+ (5.9%) health care transitions. Among the latter group, the most common trajectory of care is home-hospital-home-hospital (36.0%). The intensity of the ICPC plan showed a marked protective effect toward the event of 3+ health care setting transitions; the effect is already evident from an intensity of at least one home visit/week (odds ratio 0.73; 95% confidence interval 0.62-0.87). CONCLUSION A well-integrated palliative care approach can be effective in further reducing the percentage of patients who spent many days in hospital and/or undergo frequent and inopportune changes of their care setting during their last month of life.
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Affiliation(s)
| | - Maria Rolfini
- Direzione Sanità e Politiche Sociali, Emilia-Romagna Region, Italy
| | - Eliana Ferroni
- Epidemiological System of the Veneto Region, Padova, Italy.
| | - Valentina Savioli
- Servizio Sistema Informativo Sanità e Politiche Sociali, Emilia-Romagna Region, Italy
| | - Nicola Gennaro
- Epidemiological System of the Veneto Region, Padova, Italy
| | | | | | - Franco Figoli
- Palliative Care Unit, Local Health Unit n. 4, Thiene, Italy
| | | | | | | | - Ugo Fedeli
- Epidemiological System of the Veneto Region, Padova, Italy
| | - Mario Saugo
- Epidemiological System of the Veneto Region, Padova, Italy
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14
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Penders YWH, Albers G, Deliens L, Miccinesi G, Vega Alonso T, Miralles M, Moreels S, Van den Block L. End-of-life care for people dying with dementia in general practice in Belgium, Italy and Spain: A cross-sectional, retrospective study. Geriatr Gerontol Int 2017; 17:1667-1676. [PMID: 28060462 DOI: 10.1111/ggi.12948] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 09/06/2016] [Accepted: 09/22/2016] [Indexed: 11/28/2022]
Abstract
AIM To describe and compare end-of-life care for people with mild or severe dementia in general practice in Belgium, Italy and Spain, in terms of place of care, place of death, treatment aims, use of specialized palliative care and communication with general practitioners (GPs). METHODS Cross-sectional retrospective survey was carried out of nationwide networks of GPs in Belgium, Italy and Spain, including patients who died aged 65 years or older in 2009-2011 and were judged by the GP to have had dementia (n = 1623). RESULTS GPs reported a higher proportion of older people with severe dementia in Belgium (55%) than in Spain (46 %) and Italy (45 %), and a higher proportion of patients living in care homes (57% vs 18% and 13%, respectively). A palliative treatment aim was common in the last 3 months of life in all three countries. Specialized palliative care services were provided in 14% (Italy, severe dementia) to 38% (Belgium, severe dementia) of cases. Communication between GP and patient about illness-related topics occurred in between 50% (Italy) and 72% (Belgium) of cases of mild dementia, and 10% (Italy) to 32% (Belgium) of cases of severe dementia. Patient preferences for end-of-life care were known in a minority of cases. Few people (13-15 %) were transferred between care settings in the last week of life. CONCLUSIONS Although overall treatment aims at the end of life are often aligned with a palliative care approach and transfer rates are low, there is room for improvement in end-of-life care for people with dementia in all countries studied, especially regarding early patient-GP communication. Geriatr Gerontol Int 2017; 17: 1667-1676.
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Affiliation(s)
- Yolanda W H Penders
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Gwenda Albers
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Luc Deliens
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Guido Miccinesi
- Clinical and Descriptive Epidemiology Unit, Cancer Prevention and Research Institute, Florence, Italy
| | - Tomás Vega Alonso
- Public Health Directorate, Regional Ministry of Health (Dirección General de Salud Pública, Consellería de Sanidad), Castile and Leon, Valladolid, Spain
| | - Maite Miralles
- Public Health Directorate, Regional Ministry of Health (Dirección General de Salud Pública, Conselleria de Sanitat), Comunitat Valenciana, Valencia, Spain
| | - Sarah Moreels
- Scientific Institute of Public Health (Wetenschappelijk Instituut Volksgezondheid, Institut Scientifique de Santé Publique), Unit of Health Services Research, Brussels, Belgium
| | - Lieve Van den Block
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
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15
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„Der spielt im Moment nicht mehr ganz die Rolle“. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2016; 60:55-61. [DOI: 10.1007/s00103-016-2478-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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16
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Clark J, Gardiner C, Barnes A. International palliative care research in the context of global development: a systematic mapping review. BMJ Support Palliat Care 2016; 8:7-18. [DOI: 10.1136/bmjspcare-2015-001008] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 05/17/2016] [Accepted: 07/14/2016] [Indexed: 01/18/2023]
Abstract
ContextAn increasing amount of health policy is formulated at global level. At this global level, palliative care has attracted support primarily from normative institutions (WHO), not funding agencies. To attract greater global attention from policymakers, it has been argued that an international approach to research is required. However, the extent to which an international approach is being undertaken is unknown.ObjectivesTo systematically identify and thematically synthesise all international palliative care research, defined as research involving two or more countries, or focused on the global level.MethodsFive bibliographic databases (CINAHL, Cochrane Library, ASSIA, Web of Knowledge, Psychinfo) were searched for journal articles relevant to international and global palliative care and end-of-life care. Data were extracted using a piloted extraction form and findings were synthesised.Results184 studies were included, published across 75 different academic journals. Research emanates from and focuses on all world regions and there is increasing focus on the global level. Thematically, there is a high focus on Evaluation (n=53) and views of Stakeholders (n=38). The review revealed a predominantly observational research approach and few interventional studies were identified.ConclusionsInternational palliative care research is a relatively new, but growing field. However, many gaps in the evidence base remain and palliative care research continues to take place outside broader discourses of international development. The relative absence of interventional research demonstrating the effectiveness and cost-effectiveness of palliative care risks limiting the tools with which advocates can engage with international policymakers on this topic.
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17
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van Gurp J, van Selm M, Vissers K, van Leeuwen E, Hasselaar J. How outpatient palliative care teleconsultation facilitates empathic patient-professional relationships: a qualitative study. PLoS One 2015; 10:e0124387. [PMID: 25902263 PMCID: PMC4406581 DOI: 10.1371/journal.pone.0124387] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/13/2015] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The problems and needs of advanced cancer patients and proxies normally increase as the disease progresses. Home-based advanced cancer patients and their proxies benefit from collaborations between primary care physicians and hospital-based palliative care specialists when confronted with complex problems in the last phase of life. Telemedicine might facilitate direct, patient-centered communication between patients and proxies, primary care physicians, and specialist palliative care teams (SPCTs). This study focuses on the impact of teleconsultation technologies on the relationships between home-based palliative care patients and hospital-based palliative care specialists. METHODS This work consists of a qualitative study among patients, family members, and caregivers that utilizes long-term direct observations, semi-structured interviews, and open interviews following the observations. RESULTS The analysis of the empirical data resulted in three key concepts that describe the impact of teleconsultation on the patient-professional relationship in palliative homecare: transcending the institutional walls of home and hospital; transparency of teleconsultation technology; and technologized, intimate patient-professional relationships. Teleconsultation offers (1) condensed encounters between home-based palliative care patients and distant professionals, (2) a unique insight into the patients' daily lives for palliative care specialists, and (3) long-term interaction that results in trustful relationships and experiences of intimacy and relief. CONCLUSIONS Teleconsultation fits the practice of home-based palliative care. Teleconsultation can, if well applied, facilitate computer-mediated but empathic patient-palliative care specialist relationships, which enable professional care attuned to the patient's context as well as patient involvement. This article proposes a teleconsultation implementation guide for optimal use of teleconsultation in daily palliative care practice.
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Affiliation(s)
- Jelle van Gurp
- Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Martine van Selm
- Amsterdam School of Communication Research, University of Amsterdam, Amsterdam, Netherlands
| | - Kris Vissers
- Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Evert van Leeuwen
- Department of IQ Healthcare Ethics Section, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jeroen Hasselaar
- Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Medical Center, Nijmegen, Netherlands
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18
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Van den Block L, Pivodic L, Pardon K, Donker G, Miccinesi G, Moreels S, Vega Alonso T, Deliens L, Onwuteaka-Philipsen B. Transitions between health care settings in the final three months of life in four EU countries. Eur J Public Health 2015; 25:569-75. [DOI: 10.1093/eurpub/ckv039] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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19
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Brinkman-Stoppelenburg A, Onwuteaka-Philipsen BD, van der Heide A. Involvement of supportive care professionals in patient care in the last month of life. Support Care Cancer 2015; 23:2899-906. [PMID: 25733001 PMCID: PMC4552770 DOI: 10.1007/s00520-015-2655-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 02/08/2015] [Indexed: 11/28/2022]
Abstract
Background In the last month of life, many patients suffer from multiple symptoms and problems. Professional supportive care involvement may help to alleviate patients’ suffering and provide them with an optimal last phase of life. Purpose We investigated how often palliative care consultants, pain specialists, psychological experts and spiritual caregivers are involved in caring for patients in the last month of life, and which factors are associated with their involvement. Methods Questionnaires were mailed to physicians who had attended the death of a patient from a stratified sample of 8496 deaths that had occurred in 2010 in the Netherlands. The response rate was 74 % (n = 6263). Results A palliative care team or consultant had been involved in the last month of life in 12 % of all patients for whom death was expected; this percentage was 3 % for pain specialists, 6 % for psychologists or psychiatrists and 13 % for spiritual caregivers. Involvement of palliative care or pain specialists was most common in younger patients, in patients with cancer and in patients who died at home. Involvement of psychological or spiritual caregivers was most common in older patients, in females, in patients with dementia and in patients who died in a nursing home. Involvement of supportive caregivers was also associated with the use of morphine and end-of-life decisions. Conclusion Supportive care professionals are involved in end-of-life care in about a quarter of all non-suddenly dying patients. Their involvement is related to the setting where patients die, to the patient’s characteristics and to complex ethical decision-making.
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Affiliation(s)
- Arianne Brinkman-Stoppelenburg
- Department of Public Health, Erasmus Medical Center, University Medical Center Rotterdam, Room NA22-12, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands,
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20
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Ko W, Deliens L, Miccinesi G, Giusti F, Moreels S, Donker GA, Onwuteaka-Philipsen B, Zurriaga O, López-Maside A, Van den Block L. Care provided and care setting transitions in the last three months of life of cancer patients: a nationwide monitoring study in four European countries. BMC Cancer 2014; 14:960. [PMID: 25510507 PMCID: PMC4301937 DOI: 10.1186/1471-2407-14-960] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 12/11/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND This is an international study across four European countries (Belgium[BE], the Netherlands[NL], Italy[IT] and Spain[ES]) between 2009 and 2011, describing and comparing care and care setting transitions provided in the last three months of life of cancer patients, using representative GP networks. METHODS General practitioners (GPs) of representative networks in each country reported weekly all non-sudden cancer deaths (+18y) within their practice. GPs reported medical end-of-life care, communication and circumstances of dying on a standardised questionnaire. Multivariate logistic regressions (BE as a reference category) were conducted to compare countries. RESULTS Of 2,037 identified patients from four countries, four out of five lived at home or with family in their last year of life. Over 50% of patients had at least one transition in care settings in the last three months of life; one third of patients in BE, IT and ES had a last week hospital admission and died there. In the last week of life, a treatment goal was adopted for 80-95% of those having palliation/comfort as their treatment goal. Cross-country differences in end-of-life care provision included GPs in NL being more involved in palliative care (67%) than in other countries (35%-49%) (OR 1.9) and end-of-life topics less often discussed in IT or ES. Preference for place of death was less often expressed in IT and ES (32-34%) than in BE and NL (49-74%). Of all patients, 88-98% were estimated to have distress from at least one physical symptom in the final week of life. CONCLUSION Although palliative care was the main treatment goal for most cancer patients at the end of life in all four countries, frequent late hospital admissions and the symptom burden experienced in the last week of life indicates that further integration of palliative care into oncology care is required in many countries.
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Affiliation(s)
- Winne Ko
- />End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels and Ghent University, Ghent, Belgium
| | - Luc Deliens
- />End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels and Ghent University, Ghent, Belgium
- />Department of Medical Oncology, University Hospital Ghent, Ghent, Belgium
| | - Guido Miccinesi
- />Clinical and Descriptive Epidemiology Unit, Cancer Prevention and Research Institute, ISPO, Florence, Italy
| | - Francesco Giusti
- />Clinical and Descriptive Epidemiology Unit, Cancer Prevention and Research Institute, ISPO, Florence, Italy
| | - Sarah Moreels
- />Public Health and Surveillance, Scientific Institute of Public Health, Brussels, Belgium
| | - Gé A Donker
- />NIVEL, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Bregje Onwuteaka-Philipsen
- />EMGO Institute for Health and Care Research, Department of Public and Occupational Health, and Palliative Care Expertise Centre, VU University Medical Centre, Amsterdam, the Netherlands
| | - Oscar Zurriaga
- />Health Department, Public Health Directorate General, Valencia, Spain
- />Spanish Consortium for Research in Epidemiology and Public Health, CIBERESP, Barcelona, Spain
| | | | - Lieve Van den Block
- />End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels and Ghent University, Ghent, Belgium
- />Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - on behalf of EURO IMPACT
- />End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels and Ghent University, Ghent, Belgium
- />Department of Medical Oncology, University Hospital Ghent, Ghent, Belgium
- />EMGO Institute for Health and Care Research, Department of Public and Occupational Health, and Palliative Care Expertise Centre, VU University Medical Centre, Amsterdam, the Netherlands
- />Clinical and Descriptive Epidemiology Unit, Cancer Prevention and Research Institute, ISPO, Florence, Italy
- />Public Health and Surveillance, Scientific Institute of Public Health, Brussels, Belgium
- />NIVEL, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
- />Health Department, Public Health Directorate General, Valencia, Spain
- />Spanish Consortium for Research in Epidemiology and Public Health, CIBERESP, Barcelona, Spain
- />Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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21
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De Roo ML, Francke AL, Van den Block L, Donker GA, Alonso JEL, Miccinesi G, Moreels S, Onwuteaka-Philipsen BD, Salvetti A, Deliens L. Hospitalizations of cancer patients in the last month of life: quality indicator scores reveal large variation between four European countries in a mortality follow-back study. BMC Palliat Care 2014; 13:54. [PMID: 25859157 PMCID: PMC4391682 DOI: 10.1186/1472-684x-13-54] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 11/13/2014] [Indexed: 11/17/2022] Open
Abstract
Background Repeated and long hospitalizations of cancer patients at the end of life have been suggested as indicators of low quality of palliative care. Comparing the care delivered between different countries with the help of these quality indicators may identify opportunities to improve practice. Our objective is twofold: firstly, to describe the scores for the existing quality indicators “the percentage of time spent in hospital” and “the proportion of adult patients with more than one hospitalization in the last 30 days of life” in populations of cancer patients in four European countries and to see whether these countries met previously defined performance standards; secondly, to assess whether these scores are related to receiving palliative care from their GP. Methods A mortality follow-back study was conducted, based on data recorded by representative GP networks for samples of cancer patients living at home who died non-suddenly in Belgium (n = 500), the Netherlands (n = 310), Italy (n = 764), and Spain (n = 224). Results The quality indicator score for “the percentage of time spent in hospital” in the last month of life was 14.1% in the Netherlands, 17.7% in Spain, 22.2% in Italy, and 24.6% in Belgium, which means that none of the countries met the performance standard of <10%. For the “proportion of patients with more than one hospitalization in the last 30 days of life”, two countries met the performance standard of <4%: the Netherlands (0.6%) and Italy (3.1%). Spain had a score of 4.0% and Belgium scored 5.4%. When patients received palliative care from their GP, significantly less time was spent in hospital in the last month and fewer hospitalizations took place. Conclusions European countries differ regarding the frequency and duration of hospitalizations of cancer patients in the last month of life. This reflects country-specific differences in the organization of palliative care and highlights the important role of the GP in palliative care provision.
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Affiliation(s)
- Maaike L De Roo
- Department of Public and Occupational Health, Expertise Center of Palliative Care, VU University Medical Center, EMGO Institute for Health and Care Research, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands
| | - Anneke L Francke
- Department of Public and Occupational Health, Expertise Center of Palliative Care, VU University Medical Center, EMGO Institute for Health and Care Research, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands ; NIVEL, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500 BN Utrecht, the Netherlands
| | - Lieve Van den Block
- Vrije Universiteit Brussel (VUB), End-of-life Care Research Group Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Gé A Donker
- NIVEL, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500 BN Utrecht, the Netherlands
| | - Jose E Lozano Alonso
- Public Health Directorate General, Regional Ministry of Health, Government of Castilla y León, Paseo de Zorrilla 1, 47071 Valladolid, Spain
| | - Guido Miccinesi
- Clinical and Descriptive Epidemiology Unit, Cancer Prevention and Research Institute, ISPO, via Oblate 2, Pal 28/A, 50141 Florence, Italy
| | - Sarah Moreels
- Scientific Institute of Public Health, Public Health and Surveillance, Health Services Research, Juliette Wytsmanstraat 14, 1050 Brussels, Belgium
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Expertise Center of Palliative Care, VU University Medical Center, EMGO Institute for Health and Care Research, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands
| | - Andrea Salvetti
- Italian Society of General Practioners (SIMG), Via del Pignoncino 9-11, 50142 Florence, Italy
| | - Luc Deliens
- Department of Public and Occupational Health, Expertise Center of Palliative Care, VU University Medical Center, EMGO Institute for Health and Care Research, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands ; Vrije Universiteit Brussel (VUB), End-of-life Care Research Group Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium
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22
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Calanzani N, Moens K, Cohen J, Higginson IJ, Harding R, Deliens L, Toscani F, Ferreira PL, Bausewein C, Daveson BA, Gysels M, Ceulemans L, Gomes B. Choosing care homes as the least preferred place to die: a cross-national survey of public preferences in seven European countries. BMC Palliat Care 2014; 13:48. [PMID: 25927972 PMCID: PMC4430987 DOI: 10.1186/1472-684x-13-48] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 10/10/2014] [Indexed: 11/18/2022] Open
Abstract
Background Care homes are increasingly becoming places where people spend the final stages of their lives and eventually die. This trend is expected to continue due to population ageing, yet little is known about public preferences regarding this setting. As part of a larger study examining preferences and priorities for end of life care, we investigated the extent to which care homes are chosen as the least preferred place of death, and the factors associated with this negative preference. Methods We conducted a cross-sectional telephone survey among 9,344 adults from random private households in England, Flanders, Germany, Italy, the Netherlands, Portugal and Spain. We asked participants where they would least prefer to die in a situation of serious illness with less than one year to live. Multivariate binary logistic regressions were used to identify factors associated with choosing care homes as the least preferred place of death in each country. Results Care homes were the most frequently mentioned least preferred place of death in the Netherlands (41.5%), Italy and Spain (both 36.7%) and the second most frequent in England (28.0%), Portugal (25.8%), Germany (23.7%) and Flanders (18.9%). Only two factors had a similar and significant effect on the least preferred place of death in more than one country. In Germany and the Netherlands those doing housework were less likely to choose care homes as their least preferred place (AOR 0.72; 95% CI:0.54-0.96 and AOR 0.68; 95% CI:0.52-0.90 respectively), while those born in the country where the survey took place were more likely to choose care homes (AOR 1.77; 95% CI:1.05-2.99 and AOR 1.74; 95% CI:1.03-2.95 respectively). Experiences of serious illness, death and dying were not associated with the preference. Conclusions Our results suggest it might be difficult to promote care homes as a good place to die. This is an urgent research area in order to meet needs and preferences of a growing number of older people with chronic, debilitating conditions across Europe. From a research perspective and in order to allow people to be cared for and die where they wish, our findings highlight the need to build more in depth evidence on reasons underlying this negative preference. Electronic supplementary material The online version of this article (doi:10.1186/1472-684X-13-48) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Natalia Calanzani
- Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, King's College London, London, SE5 9PJ, UK. .,Centre for Population Health Sciences, University of Edinburgh, Teviot Place, Doorway 1, Edinburgh, EH8 9AG, UK.
| | - Katrien Moens
- Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, King's College London, London, SE5 9PJ, UK.
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium.
| | - Irene J Higginson
- Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, King's College London, London, SE5 9PJ, UK.
| | - Richard Harding
- Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, King's College London, London, SE5 9PJ, UK.
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium. .,VU University Medical Center, EMGO Institute for Health & Care Research, Palliative Care Center of Expertise and Department of Public & Occupational Health, P.O. Box 7057, 1007, MB, Amsterdam, The Netherlands.
| | - Franco Toscani
- Fondazione Lino Maestroni - ONLUS, Istituto di Ricerca in Medicina Palliativa, Via Palestro, 1, 26100, Cremona, Italy.
| | - Pedro L Ferreira
- Centre for Health Studies and Research (CEISUC), Faculty of Economics, University of Coimbra, Av Dias da Silva 165, 3004-512, Coimbra, Portugal.
| | - Claudia Bausewein
- Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, King's College London, London, SE5 9PJ, UK. .,Department of Palliative Medicine, Munich University Hospital, Campus Großhadern, Marchioninistr, 15, Munich, Germany.
| | - Barbara A Daveson
- Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, King's College London, London, SE5 9PJ, UK.
| | - Marjolein Gysels
- Centre for Social Science and Global Health, University of Amsterdam, O.Z. Achterburgwal 185, 1012, DK, Amsterdam, The Netherlands. .,Barcelona Centre for International Health Research (CRESIB - Hospital Clínic - Universitat de Barcelona), Rosselló 132, SA 1ª, Barcelona, 08036, Spain.
| | - Lucas Ceulemans
- University Antwerp Belgium, Campus Drie Eiken, D.R.307, Universiteitsplein 1, 2610, Wilrijk, Antwerp, Antwerp, Belgium.
| | - Barbara Gomes
- Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, King's College London, London, SE5 9PJ, UK.
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Reyniers T, Houttekier D, Pasman HR, Stichele RV, Cohen J, Deliens L. The family physician's perceived role in preventing and guiding hospital admissions at the end of life: a focus group study. Ann Fam Med 2014; 12:441-6. [PMID: 25354408 PMCID: PMC4157981 DOI: 10.1370/afm.1666] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Family physicians play a pivotal role in providing end-of-life care and in enabling terminally ill patients to die in familiar surroundings. The purpose of this study was to explore the family physicians' perceptions of their role and the difficulties they have in preventing and guiding hospital admissions at the end of life. METHODS Five focus groups were held with family physicians (N= 39) in Belgium. Discussions were transcribed verbatim and analyzed using a constant comparative approach. RESULTS Five key roles in preventing and guiding hospital admissions at the end of life were identified: as a care planner, anticipating future scenarios; as an initiator of decisions in acute situations, mostly in an advisory manner; as a provider of end-of-life care, in which competency and attitude is considered important; as a provider of support, particularly by being available during acute situations; and as a decision maker, taking overall responsibility. CONCLUSIONS Family physicians face many different and complex roles and difficulties in preventing and guiding hospital admissions at the end of life. Enhancing the family physician's role as a gatekeeper to hospital services, offering the physicians more end-of-life care training, and developing or expanding initiatives to support them could contribute to a lower proportion of hospital admissions at the end of life.
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Affiliation(s)
- Thijs Reyniers
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Dirk Houttekier
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - H Roeline Pasman
- EMGO Institute for Health and Care Research and Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Robert Vander Stichele
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium EMGO Institute for Health and Care Research and Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
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Reyniers T, Houttekier D, Cohen J, Pasman HR, Deliens L. What justifies a hospital admission at the end of life? A focus group study on perspectives of family physicians and nurses. Palliat Med 2014; 28:941-948. [PMID: 24534726 DOI: 10.1177/0269216314522317] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite a majority preferring not to die in hospital and health policies aimed at increasing home death, the proportion of hospital deaths remains high. Gaining insight into professional caregiver perspectives about what justifies them could be helpful in understanding the persistently high rates of such hospital admissions and hospital deaths. AIM To explore the perspectives of nurses from nursing homes, home care and hospitals, and family physicians concerning hospital admissions at the end of life and the circumstances in which they consider them to be justified. DESIGN Focus groups, transcribed verbatim and analysed using a constant comparative approach. SETTING/PARTICIPANTS Five focus groups were held with family physicians (n = 39), two focus groups (n = 16) with nurses from different care settings (nursing home, home care and hospital) and one with nursing home nurses (n = 7) in Belgium. RESULTS Participants indicated that although they considered death at home or in the nursing home of residence the most preferable outcome, there are a number of scenarios that they consider to justify a hospital admission at the end of life: when the patient prefers a hospital admission, when the caring capacity of the care setting is considered to be inadequate and when one of a number of acute medical situations occurs. CONCLUSION A number of situations have been identified in which nurses and family physicians consider a hospital admission to be justified. Adequate advance care planning and improved psychosocial support to both family and professional caregivers could reduce the number of hospital deaths.
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Affiliation(s)
- Thijs Reyniers
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Dirk Houttekier
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - H Roeline Pasman
- EMGO Institute for Health and Care Research and Expertise Center for Palliative Care, Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium EMGO Institute for Health and Care Research and Expertise Center for Palliative Care, Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands
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Brandenbarg D, Roorda C, Groenhof F, Havenga K, Berger MY, de Bock GH, Berendsen AJ. Increased primary health care use in the first year after colorectal cancer diagnosis. Scand J Prim Health Care 2014; 32:55-61. [PMID: 24931639 PMCID: PMC4075017 DOI: 10.3109/02813432.2014.929811] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The view that the general practitioner (GP) should be more involved during the curative treatment of cancer is gaining support. This study aimed to assess the current role of the GP during treatment of patients with colorectal cancer (CRC). DESIGN Historical prospective study, using primary care data from two cohorts. SETTING Registration Network Groningen (RNG) consisting of 18 GPs in three group practices with a dynamic population of about 30,000 patients. SUBJECTS Patients who underwent curative treatment for CRC (n = 124) and matched primary care patients without CRC (reference population; n = 358). MAIN OUTCOME MEASURES Primary healthcare use in the period 1998-2009. FINDINGS Patients with CRC had higher primary healthcare use in the year after diagnosis compared with the reference population. After correction for age, gender, and consultation behaviour, CRC patients had 54% (range 23-92%) more face-to-face contacts, 68% (range 36-108%) more drug prescriptions, and 35% (range -4-90%) more referrals compared with reference patients. Patients consulted their GP more often for reasons related to anaemia, abdominal pain, constipation, skin problems, and urinary infections. GPs also prescribed more acid reflux drugs, laxatives, anti-anaemic preparations, analgesics, and psycholeptics for CRC patients. CONCLUSIONS The GP plays a significant role in the year after CRC diagnosis. This role may be associated with treatment-related side effects and psychological problems. Formal guidelines on the involvement of the GP during CRC treatment might ensure more effective allocation and communication of care between primary and secondary healthcare services.
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Affiliation(s)
- Daan Brandenbarg
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Carriene Roorda
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Feikje Groenhof
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Klaas Havenga
- Department of Surgery, Division of Abdominal Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marjolein Y. Berger
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Geertruida H. de Bock
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Annette J. Berendsen
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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De Korte-Verhoef MC, Pasman HRW, Schweitzer BP, Francke AL, Onwuteaka-Philipsen BD, Deliens L. Burden for family carers at the end of life; a mixed-method study of the perspectives of family carers and GPs. BMC Palliat Care 2014; 13:16. [PMID: 24678941 PMCID: PMC3974231 DOI: 10.1186/1472-684x-13-16] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 03/25/2014] [Indexed: 11/10/2022] Open
Abstract
Background Since many patients spend most of the time at home at the end of life, this may affect the burden for family carers and constitute a risk factor for the patients’ hospitalisation. This study aimed to explore family carers’ burden in the final three months of the patient’s life, from the perspective of both carers and general practitioners (GPs), and to assess whether family burden, as defined by the GP, is associated with hospitalisation. Methods A cross-sectional nationwide survey among GPs and family carers was performed. Participants were 194 GPs and 74 family carers of patients who died non-suddenly. Additionally, in-depth interviews were conducted with 18 family carers. For the quantitative analyses descriptive statistics, weighted Kappa and multivariate logistic regression analysis was performed. For the qualitative part thematic analysis was conducted. Results The proportion of family carers experiencing a fairly heavy or severe burden increased significantly from 32% (second and third months before death) to 66% (one week before death). Most carers (95%) felt an emotional burden and 29% felt a physical burden in the final week. Three-quarters of carers did not perceive their burden as a problem because caring often felt rewarding. No significant association was found between the characteristics of family caregivers or professional care and the degree of family caregiver burden. Also, there was no significant evidence that patients of family carers for whom the GP assessed a fairly heavy to severe burden, were more likely to be hospitalised. Conclusions The different overall assessment of family carers’ burden between GPs and family carers and the increasing emotional and physical burden of family carers towards the end constitute relevant information for GPs that will help them understand and anticipate carers’ personal needs.
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Affiliation(s)
- Maria C De Korte-Verhoef
- Department of Public and Occupational Health & Expertise Center Palliative Care VUmc, EMGO Institute for Health and Care Research, VU University medical center (VUmc), P,O, Box 7057, 1007, MB Amsterdam, The Netherlands.
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Pivodic L, Pardon K, Van den Block L, Van Casteren V, Miccinesi G, Donker GA, Alonso TV, Alonso JL, Aprile PL, Onwuteaka-Philipsen BD, Deliens L. Palliative care service use in four European countries: a cross-national retrospective study via representative networks of general practitioners. PLoS One 2013; 8:e84440. [PMID: 24386381 PMCID: PMC3875565 DOI: 10.1371/journal.pone.0084440] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 11/22/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Due to a rising number of deaths from cancer and other chronic diseases a growing number of people experience complex symptoms and require palliative care towards the end of life. However, population-based data on the number of people receiving palliative care in Europe are scarce. The objective of this study is to examine, in four European countries, the number of people receiving palliative care in the last three months of life and the factors associated with receiving palliative care. METHODS Cross-national retrospective study. Over two years (2009-2010), GPs belonging to representative epidemiological surveillance networks in Belgium, the Netherlands, Italy, and Spain registered weekly all deaths of patients (≥ 18 years) in their practices and the care they received in the last three months of life using a standardized form. Sudden deaths were excluded. RESULTS We studied 4,466 deaths. GPs perceived to have delivered palliative care to 50% of patients in Belgium, 55% in Italy, 62% in the Netherlands, and 65% in Spain (p<.001). Palliative care specialists attended to 29% of patients in the Netherlands, 39% in Italy, 45% in Spain, and 47% in Belgium (p<.001). Specialist palliative care lasted a median (inter-quartile range) of 15 (23) days in Belgium to 30 (70) days in Italy (p<.001). Cancer patients were more likely than non-cancer patients to receive palliative care in all countries as were younger patients in Italy and Spain with regard to specialist palliative care. CONCLUSIONS Although palliative care is established in the countries studied, there are considerable differences in its provision. Two potentially underserved groups emerge non-cancer patients in all countries and older people in Italy and Spain. Future research should examine how differences in palliative care use relate to both patient characteristics and existing national health care policies.
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Affiliation(s)
- Lara Pivodic
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Koen Pardon
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Viviane Van Casteren
- Scientific Institute of Public Health (Wetenschappelijk Instituut Volksgezondheid, Institut Scientifique de Santé Publique), Unit of Health Services Research, Brussels, Belgium
| | - Guido Miccinesi
- Clinical and Descriptive Epidemiology Unit, Cancer Prevention and Research Institute, Florence, Italy
| | - Gé A. Donker
- Dutch Sentinel General Practice Network, NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Tomás Vega Alonso
- Public Health General Directorate, Regional Ministry of Health (Dirección General de Salud Pública, Consejería de Sanidad), Castile and Leon, Valladolid, Spain
| | - José Lozano Alonso
- Public Health General Directorate, Regional Ministry of Health (Dirección General de Salud Pública, Consejería de Sanidad), Castile and Leon, Valladolid, Spain
| | - Pierangelo Lora Aprile
- Italian Society of General Medicine (Società Italiana di Medicina Generale), Florence, Italy
| | - Bregje D. Onwuteaka-Philipsen
- Department of Public and Occupational Health, EMGO+ Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
- Department of Public and Occupational Health, EMGO+ Institute, VU University Medical Center, Amsterdam, The Netherlands
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Cohen-Almagor R. First do no harm: pressing concerns regarding euthanasia in Belgium. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2013; 36:515-21. [PMID: 23859807 DOI: 10.1016/j.ijlp.2013.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
This article is concerned with the practice of euthanasia in Belgium. Background information is provided; then major developments that have taken place since the enactment of the Belgian Act on Euthanasia are analysed. Concerns are raised about (1) the changing role of physicians and imposition on nurses to perform euthanasia; (2) the physicians' confusion and lack of understanding of the Act on Euthanasia; (3) inadequate consultation with an independent expert; (4) lack of notification of euthanasia cases, and (5) organ transplantations of euthanized patients. Some suggestions designed to improve the situation and prevent abuse are offered.
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Referral to palliative care in COPD and other chronic diseases: a population-based study. Respir Med 2013; 107:1731-9. [PMID: 23810150 DOI: 10.1016/j.rmed.2013.06.003] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 05/29/2013] [Accepted: 06/03/2013] [Indexed: 11/24/2022]
Abstract
AIM To describe how patients with COPD, heart failure, dementia and cancer differ in frequency and timing of referral to palliative care services. METHODS We performed a population-based study with the Sentinel Network of General Practitioners in Belgium. Of 2405 registered deaths respectively 5%, 4% and 28% were identified as from COPD, heart failure or cancer and 14% were diagnosed with severe dementia. GPs reported use and timing of palliative care services and treatment goals in the final three months of life. RESULTS Patients with COPD (20%) were less likely than those with heart failure (34%), severe dementia (37%) or cancer (60%) to be referred to palliative care services (p < 0.001). The median days between referral and death was respectively 10, 12, 14 and 20. Patients with COPD who were not referred more often received treatment with a curative or life-prolonging goal and less often with a palliative or comfort goal than did the other patients who were not referred. CONCLUSION Patients with COPD are underserved in terms of palliative care compared to those with other chronic life-limiting diseases. Awareness of palliative care as an option for patients with COPD needs to increase in palliative care services, physicians and the general public.
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Van den Block L, Onwuteaka-Philipsen B, Meeussen K, Donker G, Giusti F, Miccinesi G, Van Casteren V, Alonso TV, Zurriaga O, Deliens L. Nationwide continuous monitoring of end-of-life care via representative networks of general practitioners in Europe. BMC FAMILY PRACTICE 2013; 14:73. [PMID: 23731938 PMCID: PMC3751186 DOI: 10.1186/1471-2296-14-73] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Accepted: 05/28/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although end-of-life care has become an issue of great clinical and public health concern in Europe and beyond, we lack population-based nationwide data that monitor and compare the circumstances of dying and care received in the final months of life in different countries. The European Sentinel GP Networks Monitoring End of Life Care (EURO SENTIMELC) study was designed to describe and compare the last months of life of patients dying in different European countries. We aim to describe how representative GP networks in the EURO SENTIMELC study operate to monitor end of life care in a country, to describe used methodology, research procedures, representativity and characteristics of the population reached using this methodology. METHODS Nationwide representative Networks of General Practitioners (GPs)--ie epidemiological surveillance systems representative of all GPs in a country or large region of a country--in Belgium, The Netherlands, Italy and Spain continuously registered every deceased patient (>18 year) in their practice, using weekly standardized registration forms, during two consecutive years (2009-2010). RESULTS A total of 6858 deaths were registered of which two thirds died non-suddenly (from 62% in The Netherlands to 69% in Spain), representative for the GP populations in the participating countries. Of all non-sudden deaths, between 32% and 44% of deaths were aged 85 or older; between 46% and 54% were female, and between 23% and 49% died at home. Cancer was cause of death in 37% to 53% of non-sudden death cases in the four participating countries. CONCLUSION Via the EURO SENTI-MELC methodology, we can build a descriptive epidemiological database on end-of-life care provision in several EU countries, measuring across setting and diseases. The data can serve as baseline measurement to compare and monitor end-of-life care over time. The use of representative GP networks for end-of-life care monitoring has huge potential in Europe where several of these networks are operational.
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Current World Literature. Curr Opin Support Palliat Care 2012; 6:543-52. [DOI: 10.1097/spc.0b013e32835ad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Current World Literature. Curr Opin Support Palliat Care 2012; 6:402-16. [DOI: 10.1097/spc.0b013e3283573126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rurup ML, Smets T, Cohen J, Bilsen J, Onwuteaka-Philipsen BD, Deliens L. The first five years of euthanasia legislation in Belgium and the Netherlands: description and comparison of cases. Palliat Med 2012; 26:43-9. [PMID: 21775411 DOI: 10.1177/0269216311413836] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Netherlands and Belgium legalized euthanasia in 2002. AIM In this study we describe and compare cases of reported euthanasia and physician-assisted suicide in the first 5 years of legislation. DESIGN/SETTING/PARTICIPANTS The databases of the cases reported in Belgium and the Netherlands were made available by the review committees. We compared characteristics of all cases reported between September 2002-December 2007. RESULTS In the Netherlands 10,319 cases were reported, in Belgium 1917. Gender and age distributions were similar in both countries. Most patients suffered from cancer (83-87%), but patients more often suffered from diseases of the nervous system in Belgium (8.3% vs. 3.9%). In the Netherlands, reported euthanasia more often occurred at home compared with Belgium (81% vs. 42%), where it occurred more often in hospital (52% vs. 9%). In the Netherlands, all cases were based on the oral request of a competent patient. In Belgium, 2.1% of the reported cases was based on an advance directive. CONCLUSIONS We conclude that countries debating legislation must realise that the rules and procedures for euthanasia they would agree upon and the way they are codified or not into law may influence the practice that develops once the legislation is effected or what part of that practice is reported.
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Affiliation(s)
- Mette L Rurup
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands
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Meeussen K, Van den Block L, Echteld MA, Boffin N, Bilsen J, Van Casteren V, Abarshi E, Donker G, Onwuteaka-Philipsen B, Deliens L. End-of-Life Care and Circumstances of Death in Patients Dying As a Result of Cancer in Belgium and the Netherlands: A Retrospective Comparative Study. J Clin Oncol 2011; 29:4327-34. [DOI: 10.1200/jco.2011.34.9498] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Purpose To examine and compare end-of-life care in patients with cancer dying in Belgium and the Netherlands. Patients and Methods A mortality follow-back study was undertaken in 2008 via representative nationwide sentinel networks of general practitioners (GPs) in Belgium and the Netherlands. By using similar standardized procedures, GPs reported on aspects of end-of-life care and the circumstances of nonsudden death of patients with cancer in their practice. Results Of the 422 reported patients with cancer, most resided at home during the last year of life (Belgium, 91%; the Netherlands, 95%). Death occurred at home in 34% (Belgium) and 61% (the Netherlands) and in the hospital in 29% (Belgium) and 19% (the Netherlands). In the last month of life, end-of-life issues were more often discussed in the Netherlands (88%) than in Belgium (68%). In both countries, physical problems were discussed most often (Belgium, 49%; the Netherlands, 78%) and spiritual issues least often (Belgium, 20%; the Netherlands, 32%). Certain end-of-life treatment preferences were known for 43% (Belgium) and 67% (the Netherlands) of patients. In the last week of life, treatment was most often focused on palliation (Belgium, 94%; the Netherlands, 91%). Physical distress was reported in 84% (Belgium) and 76% (the Netherlands) of patients and psychological distress in 59% and 36%. Most distressing was lack of energy (Belgium, 73%; the Netherlands, 71%) and lack of appetite (Belgium, 61%; the Netherlands, 53%). Two thirds of patients were bedridden (Belgium, 67%; the Netherlands, 69%). Conclusion Although place of death and communication about end-of-life issues differ substantially, a palliative treatment goal is adopted for the vast majority of patients in both countries. However, GPs reported that the majority of patients experienced symptom distress at the end of life, which suggests important challenges remain for improving end-of-life care.
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Affiliation(s)
- Koen Meeussen
- Koen Meeussen, Lieve Van den Block, Johan Bilsen, and Luc Deliens, Ghent University and Vrije Universiteit Brussel; Nicole Boffin and Viviane Van Casteren, Scientific Institute of Public Health, Brussels, Belgium; Michael A. Echteld, Ebun Abarshi, Bregje Onwuteaka-Philipsen, and Luc Deliens, Vrije Universiteit Medical Centre, Amsterdam; and Gé Donker, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Lieve Van den Block
- Koen Meeussen, Lieve Van den Block, Johan Bilsen, and Luc Deliens, Ghent University and Vrije Universiteit Brussel; Nicole Boffin and Viviane Van Casteren, Scientific Institute of Public Health, Brussels, Belgium; Michael A. Echteld, Ebun Abarshi, Bregje Onwuteaka-Philipsen, and Luc Deliens, Vrije Universiteit Medical Centre, Amsterdam; and Gé Donker, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Michael A. Echteld
- Koen Meeussen, Lieve Van den Block, Johan Bilsen, and Luc Deliens, Ghent University and Vrije Universiteit Brussel; Nicole Boffin and Viviane Van Casteren, Scientific Institute of Public Health, Brussels, Belgium; Michael A. Echteld, Ebun Abarshi, Bregje Onwuteaka-Philipsen, and Luc Deliens, Vrije Universiteit Medical Centre, Amsterdam; and Gé Donker, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Nicole Boffin
- Koen Meeussen, Lieve Van den Block, Johan Bilsen, and Luc Deliens, Ghent University and Vrije Universiteit Brussel; Nicole Boffin and Viviane Van Casteren, Scientific Institute of Public Health, Brussels, Belgium; Michael A. Echteld, Ebun Abarshi, Bregje Onwuteaka-Philipsen, and Luc Deliens, Vrije Universiteit Medical Centre, Amsterdam; and Gé Donker, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Johan Bilsen
- Koen Meeussen, Lieve Van den Block, Johan Bilsen, and Luc Deliens, Ghent University and Vrije Universiteit Brussel; Nicole Boffin and Viviane Van Casteren, Scientific Institute of Public Health, Brussels, Belgium; Michael A. Echteld, Ebun Abarshi, Bregje Onwuteaka-Philipsen, and Luc Deliens, Vrije Universiteit Medical Centre, Amsterdam; and Gé Donker, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Viviane Van Casteren
- Koen Meeussen, Lieve Van den Block, Johan Bilsen, and Luc Deliens, Ghent University and Vrije Universiteit Brussel; Nicole Boffin and Viviane Van Casteren, Scientific Institute of Public Health, Brussels, Belgium; Michael A. Echteld, Ebun Abarshi, Bregje Onwuteaka-Philipsen, and Luc Deliens, Vrije Universiteit Medical Centre, Amsterdam; and Gé Donker, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Ebun Abarshi
- Koen Meeussen, Lieve Van den Block, Johan Bilsen, and Luc Deliens, Ghent University and Vrije Universiteit Brussel; Nicole Boffin and Viviane Van Casteren, Scientific Institute of Public Health, Brussels, Belgium; Michael A. Echteld, Ebun Abarshi, Bregje Onwuteaka-Philipsen, and Luc Deliens, Vrije Universiteit Medical Centre, Amsterdam; and Gé Donker, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Gé Donker
- Koen Meeussen, Lieve Van den Block, Johan Bilsen, and Luc Deliens, Ghent University and Vrije Universiteit Brussel; Nicole Boffin and Viviane Van Casteren, Scientific Institute of Public Health, Brussels, Belgium; Michael A. Echteld, Ebun Abarshi, Bregje Onwuteaka-Philipsen, and Luc Deliens, Vrije Universiteit Medical Centre, Amsterdam; and Gé Donker, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Bregje Onwuteaka-Philipsen
- Koen Meeussen, Lieve Van den Block, Johan Bilsen, and Luc Deliens, Ghent University and Vrije Universiteit Brussel; Nicole Boffin and Viviane Van Casteren, Scientific Institute of Public Health, Brussels, Belgium; Michael A. Echteld, Ebun Abarshi, Bregje Onwuteaka-Philipsen, and Luc Deliens, Vrije Universiteit Medical Centre, Amsterdam; and Gé Donker, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Luc Deliens
- Koen Meeussen, Lieve Van den Block, Johan Bilsen, and Luc Deliens, Ghent University and Vrije Universiteit Brussel; Nicole Boffin and Viviane Van Casteren, Scientific Institute of Public Health, Brussels, Belgium; Michael A. Echteld, Ebun Abarshi, Bregje Onwuteaka-Philipsen, and Luc Deliens, Vrije Universiteit Medical Centre, Amsterdam; and Gé Donker, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
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