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van Hylckama Vlieg MAM, Pot IE, Visser HPJ, Jong MAC, van der Vorst MJDL, van Mastrigt BJ, Kiers JNA, van den Homberg PPPH, Thijs-Visser MF, Oomen-de Hoop E, van der Heide A, van der Kuy PHM, van der Rijt CCD, Geijteman ECT. Appropriate medication use in Dutch terminal care: study protocol of a multicentre stepped-wedge cluster randomized controlled trial (the AMUSE study). BMC Palliat Care 2024; 23:6. [PMID: 38172930 PMCID: PMC10762916 DOI: 10.1186/s12904-023-01334-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Polypharmacy is common among patients with a limited life expectancy, even shortly before death. This is partly inevitable, because these patients often have multiple symptoms which need to be alleviated. However, the use of potentially inappropriate medications (PIMs) in these patients is also common. Although patients and relatives are often willing to deprescribe medication, physicians are sometimes reluctant due to the lack of evidence on appropriate medication management for patients in the last phase of life. The aim of the AMUSE study is to investigate whether the use of CDSS-OPTIMED, a software program that gives weekly personalized medication recommendations to attending physicians of patients with a limited life expectancy, improves patients' quality of life. METHODS A multicentre stepped-wedge cluster randomized controlled trial will be conducted among patients with a life expectancy of three months or less. The stepped-wedge cluster design, where the clusters are the different study sites, involves sequential crossover of clusters from control to intervention until all clusters are exposed. In total, seven sites (4 hospitals, 2 general practices and 1 hospice from the Netherlands) will participate in this study. During the control period, patients will receive 'care as usual'. During the intervention period, CDSS-OPTIMED will be activated. CDSS-OPTIMED is a validated software program that analyses the use of medication based on a specific set of clinical rules for patients with a limited life expectancy. The software program will provide the attending physicians with weekly personalized medication recommendations. The primary outcome of this study is patients' quality of life two weeks after baseline assessment as measured by the EORTC QLQ-C15-PAL questionnaire, quality of life question. DISCUSSION This will be the first study investigating the effect of weekly personalized medication recommendations to attending physicians on the quality of life of patients with a limited life expectancy. We hypothesize that the CDSS-OPTIMED intervention could lead to improved quality of life in patients with a life expectancy of three months or less. TRIAL REGISTRATION This trial is registered at ClinicalTrials.gov (NCT05351281, Registration Date: April 11, 2022).
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Affiliation(s)
| | - I E Pot
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - H P J Visser
- Department of Internal Medicine, Noordwest Ziekenhuis, Alkmaar, The Netherlands
| | - M A C Jong
- Department of Internal Medicine, Noordwest Ziekenhuis, Alkmaar, The Netherlands
| | - M J D L van der Vorst
- Department of Internal Medicine, Center for Supportive and Palliative Care, Rijnstate Hospital, Arnhem, The Netherlands
| | | | - J N A Kiers
- Family Medicine Network, Nijmegen, The Netherlands
| | | | - M F Thijs-Visser
- Department of Medical Oncology, Ikazia Hospital, Rotterdam, The Netherlands
| | - E Oomen-de Hoop
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - A van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - P H M van der Kuy
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - C C D van der Rijt
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - E C T Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Becqu YN, van der Wel M, Aktan-Arslan M, van AG, Rietjens DJ, van der Heide A, Witkamp E, Watson M. Supportive interventions for family caregivers of patients with advanced cancer: A systematic review. Psychooncology 2023; 32:663-681. [PMID: 36959117 DOI: 10.1002/pon.6126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/25/2023]
Abstract
OBJECTIVE Family caregivers are often intensively involved in palliative and end-of-life cancer care. A variety of interventions to support family caregivers have been developed, differing in target population, modality, and components. We aimed to systematically examine characteristics and the effectiveness of interventions to support family caregivers of patients with advanced cancer. METHODS A systematic review was conducted using Embase, Medline Ovid, Web of Science, Cochrane, Google Scholar, and Cinahl. This review included quantitative studies published from January 2004 until January 2020 reporting on interventions to support family caregivers of patients with advanced cancer in all care settings. RESULTS Out of 7957 titles, 32 studies were included. Twenty-two studies were randomised controlled trials. Interventions were delivered to four target populations: individual family caregivers (n=15), family caregiver-patient dyads (n=11), families (n=2) and peer groups (n=4). Most interventions (n=26) were delivered face-to-face or by phone, two were delivered online. Most interventions included multiple components and were primarily aimed at supporting family caregivers' self-care. Twenty-nine interventions were shown to have beneficial effects on family caregiver outcomes, mostly in the psycho-emotional (n=24), daily functioning (n=13) and social dimension (n=6). Individual interventions were mainly effective in the psycho-emotional dimension, dyad and family interventions in the psycho-emotional and social domain, and group interventions mainly had an effect on daily functioning. CONCLUSIONS Interventions to support family caregivers in advanced cancer care vary widely. Most intervention studies reported beneficial effects for the wellbeing of family caregivers. There is evidence that the target group is associated with beneficial effects on different outcome dimensions. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Yvonne N Becqu
- Erasmus MC afdeling Maatschappelijke GezondheidsZorg, Rotterdam, Netherlands
| | - Maaike van der Wel
- Erasmus MC afdeling Maatschappelijke GezondheidsZorg, Rotterdam, Netherlands
| | | | | | - Driel J Rietjens
- Erasmus MC afdeling Maatschappelijke GezondheidsZorg, Rotterdam, Netherlands
| | - A van der Heide
- Erasmus MC afdeling Maatschappelijke GezondheidsZorg, Rotterdam, Netherlands
| | - Erica Witkamp
- Erasmus MC afdeling Maatschappelijke GezondheidsZorg, Rotterdam, Netherlands
| | - Maggie Watson
- Erasmus MC afdeling Maatschappelijke GezondheidsZorg, Rotterdam, Netherlands
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Vieveen MJM, Yildiz B, Korfage IJ, Witkamp FE, Becqué YN, van Lent LGG, Pasman HR, Zee MS, Onwuteaka-Philipsen BD, van der Heide A, Goossensen A. Meaning-making following loss among bereaved spouses during the COVID-19 pandemic (the CO-LIVE study). Death Stud 2023:1-9. [PMID: 36892091 DOI: 10.1080/07481187.2023.2186979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
This study investigates how individuals construe, understand, and make sense of experiences during the first wave of the COVID-19 pandemic. Seventeen semi-structured interviews were conducted with bereaved spouses focusing on meaning attribution to the death of their partner. The interviewees were lacking adequate information, personalized care, and physical or emotional proximity; these challenges complicated their experience of a meaningful death of their partner. Concomitantly, many interviewees appreciated the exchange of experiences with others and any last moments together with their partner. Bereaved spouses actively sought valuable moments, during and after bereavement, that contributed to the perceived meaning.
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Affiliation(s)
- M J M Vieveen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands
- Master Vitality and Ageing, LUMC, Leiden University Medical Center, The Netherlands
| | - B Yildiz
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - I J Korfage
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - F E Witkamp
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands
- Research Center Innovations in Care, University of Applied Sciences, Rotterdam, The Netherlands
| | - Y N Becqué
- Research Center Innovations in Care, University of Applied Sciences, Rotterdam, The Netherlands
| | - L G G van Lent
- Department of Internal Oncology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - H R Pasman
- Department of Public and Occupational Health, Amsterdam Public Health research institute and Expertise center for Palliative Care, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - M S Zee
- Department of Public and Occupational Health, Amsterdam Public Health research institute and Expertise center for Palliative Care, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - B D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health research institute and Expertise center for Palliative Care, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - A van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - A Goossensen
- University of Humanistic Studies, Universiteit voor Humanistiek, Utrecht, The Netherlands
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Luu KL, Witkamp FE, Nieboer D, Bakker EM, Kranenburg LW, van der Rijt CCD, Lorig K, van der Heide A, Rietjens JAC. Effectiveness of the "Living with Cancer" peer self-management support program for persons with advanced cancer and their relatives: study protocol of a non-randomized stepped wedge study. Palliat Care 2022; 21:107. [PMID: 35692043 PMCID: PMC9188837 DOI: 10.1186/s12904-022-00994-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/30/2022] [Indexed: 11/13/2022] Open
Abstract
Background Persons with advanced cancer and their relatives experience physical, emotional, and psychosocial consequences of the illness. Most of the time, they must deal with these themselves. While peer self-management support programs may be helpful, there is little evidence on their value for this population. We present the research protocol of our SMART study that will evaluate the effectiveness of the “Living with Cancer” peer self-management support program, aimed at improving self-management behaviors, self-efficacy, and health-related quality of life of persons with advanced cancer and their relatives. Methods We will conduct a non-randomized stepped wedge study in the Netherlands. We will include 130 persons with advanced cancer and 32 relatives. Participants can choose to either start the program within 4 weeks after inclusion or after eight to 10 weeks. The “Living with Cancer” is a peer self-management support program, based on the Chronic Disease Self-Management Program. It consists of six 1,5 hours video-conferencing group meetings with eight to 12 participants, preceded by two or three preparatory audio clips with supportive text per session. The program has the following core components: the learning of self-management skills (action-planning, problem-solving, effective communication, and decision-making), discussing relevant themes (e.g. dealing with pain and fatigue, living with uncertainty, and future planning), and sharing experiences, knowledge, and best practices. The primary outcome for both persons with advanced cancer and relatives is self-management behavior assessed by the subscale “constructive attitudes and approaches” of the Health Education Impact Questionnaire. Secondary outcomes are other self-management behaviors, self-efficacy, health-related quality of life, symptoms, depression and anxiety, and loneliness. Participants complete an online questionnaire at baseline, and after eight and 16 weeks. After each session, they complete a logbook about their experiences. Group meetings will be video recorded. Discussion SMART aims to evaluate an innovative program building on an evidence-based self-management program. New features are its use for persons with advanced cancer, the inclusion of relatives, and the video-conferencing format for this population. The use of both quantitative and qualitative analyses will provide valuable insight into the effectiveness and value of this program. Trial registration This study was registered in the Dutch Trial Register on October 2021, identifier NL9806. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-00994-5.
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Affiliation(s)
- K L Luu
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - F E Witkamp
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Center of Expertise Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, the Netherlands
| | - D Nieboer
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - E M Bakker
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - L W Kranenburg
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - C C D van der Rijt
- Department of Medical Oncology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - K Lorig
- Stanford School of Medicine, CA, Stanford, USA
| | - A van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - J A C Rietjens
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Heijltjes MT, van Thiel G, Rietjens J, van der Heide A, de Graeff A, van Delden J. A Response to a Letter of Vivat and Twycrossrs information. J Pain Symptom Manage 2022; 63:e267. [PMID: 34666175 DOI: 10.1016/j.jpainsymman.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 11/24/2022]
Affiliation(s)
- M T Heijltjes
- Julius Center for Health Sciences and Primary Care (M.H., G.V.T., J.V.D.), Utrecht, The Netherlands.
| | - Gjmw van Thiel
- Julius Center for Health Sciences and Primary Care (M.H., G.V.T., J.V.D.), Utrecht, The Netherlands
| | - Jac Rietjens
- Department of Public Health (J.R., A.V.H.), Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A van der Heide
- Department of Public Health (J.R., A.V.H.), Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A de Graeff
- Department of Medical Oncology (A.G.), University Medical Center Utrecht, The Netherlands and Academic Hospice Demeter, De Bilt, The Netherlands
| | - Jjm van Delden
- Julius Center for Health Sciences and Primary Care (M.H., G.V.T., J.V.D.), Utrecht, The Netherlands
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van Dongen SI, Stoevelaar R, Kranenburg LW, Noorlandt HW, Witkamp FE, van der Rijt CCD, van der Heide A, Rietjens JAC. The views of healthcare professionals on self-management of patients with advanced cancer: An interview study. Patient Educ Couns 2022; 105:136-144. [PMID: 34034936 DOI: 10.1016/j.pec.2021.05.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 04/13/2021] [Accepted: 05/12/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Self-management of patients with advanced cancer is challenging. Although healthcare professionals may play a crucial role in supporting these patients, scant scientific attention has been paid to their perspectives. Therefore, we examined healthcare professionals' views on self-management and self-management support in this population. METHODS We conducted qualitative interviews with 27 purposively sampled medical specialists (n = 6), nurse specialists (n = 6), general practitioners (n = 8) and homecare/ hospice nurses (n = 7) in the Netherlands. Transcripts were analysed using thematic analysis. RESULTS Healthcare professionals experienced self-management of patients with advanced cancer to be diverse, dynamic and challenging. They adopted instructive, collaborative and advisory roles in self-management support for this population. Whereas some professionals preferred or inclined towards one role, others indicated to switch roles, depending on the situation. CONCLUSIONS Just like patients with advanced cancer, healthcare professionals differ in their views and approaches regarding self-management and self-management support in this population. Therefore, instructive, collaborative and advisory self-management support roles will all be useful under certain circumstances. PRACTICE IMPLICATIONS Healthcare professionals can support self-management by being aware of their own views and communicating these clearly to their patients and colleagues. Education in self-management support should include self-reflection skills and discuss the relation between self-management and professional care.
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Affiliation(s)
- S I van Dongen
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - R Stoevelaar
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - L W Kranenburg
- Department of Psychiatry, Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - H W Noorlandt
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - F E Witkamp
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands; Faculty of Nursing and Research Centre Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, The Netherlands.
| | - C C D van der Rijt
- Department of Medical Oncology, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - A van der Heide
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - J A C Rietjens
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands.
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7
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Noorlandt HW, Echteld MA, Tuffrey-Wijne I, Festen DAM, Vrijmoeth C, van der Heide A, Korfage IJ. Shared decision-making with people with intellectual disabilities in the last phase of life: A scoping review. J Intellect Disabil Res 2020; 64:881-894. [PMID: 32914520 DOI: 10.1111/jir.12774] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 03/18/2020] [Accepted: 08/18/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Shared decision-making (SDM) is the process in which healthcare professionals and patients jointly discuss and decide which care and treatment policy is to be followed. The importance of SDM is increasingly being recognised across health settings, including palliative care. Little is known about SDM with people with intellectual disabilities (IDs) in the last phase of life. This review aimed to explore to which extent and in which way people with ID in the last phase of life are involved in decision-making about their care and treatment. METHOD In this scoping review, we systematically searched in the Embase, Medline and PsycINFO databases for empirical studies on decision-making with people with ID in the last phase of life. RESULTS Of a total of 281 identified titles and abstracts, 10 studies fulfilled the inclusion criteria. All focused on medical end-of-life decisions, such as foregoing life-sustaining treatment, do-not-attempt-resuscitation orders or palliative sedation. All studies emphasise the relevance of involving people with ID themselves, or at least their relatives, in making decisions at the end of life. Still, only two papers described processes of decision-making in which persons with ID actively participated. Furthermore, in only one paper, best practices and guidelines for decision-making in palliative care for people with ID were defined. CONCLUSION Although the importance of involving people with ID in the decision-making process is emphasised, best practices or guidelines about what this should look like are lacking. We recommend developing aids that specifically support SDM with people with ID in the last phase of life.
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Affiliation(s)
- H W Noorlandt
- Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M A Echteld
- Expertise Centre Caring Society, Avans University of Applied Science, Breda, The Netherlands
- Prisma Foundation, Biezenmortel, The Netherlands
| | - I Tuffrey-Wijne
- Faculty of Health, Social Care and Education Cranmer Terrace, Kingston University & St. George's, University of London, London, UK
| | - D A M Festen
- Department of General Practice, Intellectual Disability Medicine, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - C Vrijmoeth
- Centre for Research and Innovation in Christian Mental Health Care, Eleos/De Hoop GGZ, Amersfoort, Utrecht, The Netherlands
| | - A van der Heide
- Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - I J Korfage
- Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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Zwakman M, Milota MM, van der Heide A, Jabbarian LJ, Korfage IJ, Rietjens JAC, van Delden JJM, Kars MC. Unraveling patients' readiness in advance care planning conversations: a qualitative study as part of the ACTION Study. Support Care Cancer 2020; 29:2917-2929. [PMID: 33001268 PMCID: PMC8062377 DOI: 10.1007/s00520-020-05799-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/22/2020] [Indexed: 10/26/2022]
Abstract
PURPOSE Patients' readiness for advance care planning (ACP) is often considered a prerequisite for starting ACP conversations. Healthcare professionals' uncertainty about patients' readiness hampers the uptake of ACP in clinical practice. This study aims To determine how patients' readiness is expressed and develops throughout an ACP conversation. METHODS A qualitative sub-study into the ACTION ACP conversations collected as part of the international Phase III multicenter cluster-randomized clinical trial. A purposeful sample was taken of ACP conversations of patients with advanced lung or colorectal cancer who participated in the ACTION study between May 2015 and December 2018 (n = 15). A content analysis of the ACP conversations was conducted. RESULTS All patients (n = 15) expressed both signs of not being ready and of being ready. Signs of being ready included anticipating possible future scenarios or demonstrating an understanding of one's disease. Signs of not being ready included limiting one's perspective to the here and now or indicating a preference not to talk about an ACP topic. Signs of not being ready occurred more often when future-oriented topics were discussed. Despite showing signs of not being ready, patients were able to continue the conversation when a new topic was introduced. CONCLUSION Healthcare professionals should be aware that patients do not have to be ready for all ACP topics to be able to participate in an ACP conversation. They should be sensitive to signs of not being ready and develop the ability to adapt the conversation accordingly.
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Affiliation(s)
- M Zwakman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, P.O. Box 85500, 3508, GA, Utrecht, the Netherlands
| | - M M Milota
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, P.O. Box 85500, 3508, GA, Utrecht, the Netherlands
| | - A van der Heide
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - L J Jabbarian
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - I J Korfage
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - J A C Rietjens
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - J J M van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, P.O. Box 85500, 3508, GA, Utrecht, the Netherlands
| | - M C Kars
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, P.O. Box 85500, 3508, GA, Utrecht, the Netherlands.
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Stoevelaar R, Brinkman-Stoppelenburg A, van Bruchem-Visser RL, van Driel AG, Bhagwandien RE, Theuns DAMJ, Rietjens JAC, van der Heide A. Implantable cardioverter defibrillators at the end of life: future perspectives on clinical practice. Neth Heart J 2020; 28:565-570. [PMID: 32548800 PMCID: PMC7596123 DOI: 10.1007/s12471-020-01438-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The implantable cardioverter defibrillator (ICD) is effective in terminating life-threatening arrhythmias. However, in the last phase of life, ICD shocks may no longer be appropriate. Guidelines recommend timely discussion with the patient regarding deactivation of the shock function of the ICD. However, research shows that such conversations are scarce, and some patients experience avoidable and distressful shocks in the final days of life. Barriers such as physicians’ lack of time, difficulties in finding the right time to discuss ICD deactivation, patients’ reluctance to discuss the topic, and the fragmentation of care, which obscures responsibilities, prevent healthcare professionals from discussing this topic with the patient. In this point-of-view article, we argue that healthcare professionals who are involved in the care for ICD patients should be better educated on how to communicate with patients about ICD deactivation and the end of life. Optimal communication is needed to reduce the number of patients experiencing inappropriate and painful shocks in the terminal stage of their lives.
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Affiliation(s)
- R Stoevelaar
- Department of Public Health, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - A Brinkman-Stoppelenburg
- Department of Public Health, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - R L van Bruchem-Visser
- Department of Internal Medicine, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - A G van Driel
- Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
- Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
| | - R E Bhagwandien
- Department of Cardiology, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - D A M J Theuns
- Department of Cardiology, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J A C Rietjens
- Department of Public Health, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - A van der Heide
- Department of Public Health, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
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10
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Zwakman M, Pollock K, Bulli F, Caswell G, Červ B, van Delden JJM, Deliens L, van der Heide A, Jabbarian LJ, Koba-Čeh H, Lunder U, Miccinesi G, Arnfeldt CAM, Seymour J, Toccafondi A, Verkissen MN, Kars MC. Trained facilitators' experiences with structured advance care planning conversations in oncology: an international focus group study within the ACTION trial. BMC Cancer 2019; 19:1026. [PMID: 31672145 PMCID: PMC6822448 DOI: 10.1186/s12885-019-6170-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 09/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In oncology, Health Care Professionals often experience conducting Advance Care Planning (ACP) conversations as difficult and are hesitant to start them. A structured approach could help to overcome this. In the ACTION trial, a Phase III multi-center cluster-randomized clinical trial in six European countries (Belgium, Denmark, Italy, the Netherlands, Slovenia, United Kingdom), patients with advanced lung or colorectal cancer are invited to have one or two structured ACP conversations with a trained facilitator. It is unclear how trained facilitators experience conducting structured ACP conversations. This study aims to understand how facilitators experience delivering the ACTION Respecting Choices (RC) ACP conversation. METHODS A qualitative study involving focus groups with RC facilitators. Focus group interviews were recorded, transcribed, anonymized, translated into English, and thematically analysed, supported by NVivo 11. The international research team was involved in data analysis from initial coding and discussion towards final themes. RESULTS Seven focus groups were conducted, involving 28 of in total 39 trained facilitators, with different professional backgrounds from all participating countries. Alongside some cultural differences, six themes were identified. These reflect that most facilitators welcomed the opportunity to participate in the ACTION trial, seeing it as a means of learning new skills in an important area. The RC script was seen as supportive to ask questions, including those perceived as difficult to ask, but was also experienced as a barrier to a spontaneous conversation. Facilitators noticed that most patients were positive about their ACTION RC ACP conversation, which had prompted them to become aware of their wishes and to share these with others. The facilitators observed that it took patients substantial effort to have these conversations. In response, facilitators took responsibility for enabling patients to experience a conversation from which they could benefit. Facilitators emphasized the need for training, support and advanced communication skills to be able to work with the script. CONCLUSIONS Facilitators experienced benefits and challenges in conducting scripted ACP conversations. They mentioned the importance of being skilled and experienced in carrying out ACP conversations in order to be able to explore the patients' preferences while staying attuned to patients' needs. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number registry 63110516 ( ISRCTN63110516 ) per 10/3/2014.
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Affiliation(s)
- M Zwakman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - K Pollock
- Faculty of Medicine and Health Sciences, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - F Bulli
- Oncological network, research and prevention Institute - ISPRO, Florence, Italy
| | - G Caswell
- Faculty of Medicine and Health Sciences, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - B Červ
- University Clinic for Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - J J M van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - L Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - A van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - L J Jabbarian
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - H Koba-Čeh
- University Clinic for Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - U Lunder
- University Clinic for Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - G Miccinesi
- Oncological network, research and prevention Institute - ISPRO, Florence, Italy
| | - C A Møller Arnfeldt
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Palliative Medicine, Bispebjerg and Frederiksberg Hospital, The Research Unit, Copenhagen, Denmark
| | - J Seymour
- University of Sheffield, Sheffield, UK
| | - A Toccafondi
- Oncological network, research and prevention Institute - ISPRO, Florence, Italy
| | - M N Verkissen
- End-of-life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.,Ghent University, Brussels, Belgium
| | - M C Kars
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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11
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Schinkelshoek MS, Fronczek R, Kooy-Winkelaar EMC, Petersen J, Reid HH, van der Heide A, Drijfhout JW, Rossjohn J, Lammers GJ, Koning F. H1N1 hemagglutinin-specific HLA-DQ6-restricted CD4+ T cells can be readily detected in narcolepsy type 1 patients and healthy controls. J Neuroimmunol 2019; 332:167-175. [PMID: 31048269 DOI: 10.1016/j.jneuroim.2019.04.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 04/16/2019] [Accepted: 04/16/2019] [Indexed: 12/15/2022]
Abstract
Following the 2009 H1N1 influenza pandemic, an increased risk of narcolepsy type 1 was observed. Homology between an H1N1 hemagglutinin and two hypocretin sequences has been reported. T cell reactivity to these peptides was assessed in 81 narcolepsy type 1 patients and 19 HLA-DQ6-matched healthy controls. HLA-DQ6-restricted H1N1 hemagglutinin-specific T cell responses were detected in 28.4% of patients and 15.8% of controls. Despite structural homology between HLA-DQ6-hypocretin and -H1N1 peptide complexes, T cell cross-reactivity was not detected. These results indicate that it is unlikely that cross-reactivity between H1N1 hemagglutinin and hypocretin peptides presented by HLA-DQ6 is involved in the development of narcolepsy.
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Affiliation(s)
- M S Schinkelshoek
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands; Sleep Wake Centre SEIN, Achterweg 5, 2103 SW Heemstede, the Netherlands.
| | - R Fronczek
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands; Sleep Wake Centre SEIN, Achterweg 5, 2103 SW Heemstede, the Netherlands
| | - E M C Kooy-Winkelaar
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands
| | - J Petersen
- Infection and Immunity Program, The Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, VIC 3800, Australia; Australian Research Council Centre of Excellence in Advanced Molecular Imaging, Monash University, Clayton, VIC 3800, Australia
| | - H H Reid
- Infection and Immunity Program, The Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, VIC 3800, Australia; Australian Research Council Centre of Excellence in Advanced Molecular Imaging, Monash University, Clayton, VIC 3800, Australia
| | - A van der Heide
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands
| | - J W Drijfhout
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands
| | - J Rossjohn
- Infection and Immunity Program, The Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, VIC 3800, Australia; Australian Research Council Centre of Excellence in Advanced Molecular Imaging, Monash University, Clayton, VIC 3800, Australia; Institute of Infection and Immunity, Cardiff University School of Medicine, Heath Park, Cardiff CF14 4XN, UK
| | - G J Lammers
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands; Sleep Wake Centre SEIN, Achterweg 5, 2103 SW Heemstede, the Netherlands
| | - F Koning
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands
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12
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Zwakman M, Jabbarian LJ, van Delden JJM, van der Heide A, Korfage IJ, Pollock K, Rietjens JAC, Seymour J, Kars MC. Advance care planning: A systematic review about experiences of patients with a life-threatening or life-limiting illness. Palliat Med 2018; 32:1305-1321. [PMID: 29956558 PMCID: PMC6088519 DOI: 10.1177/0269216318784474] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Advance care planning is seen as an important strategy to improve end-of-life communication and the quality of life of patients and their relatives. However, the frequency of advance care planning conversations in practice remains low. In-depth understanding of patients' experiences with advance care planning might provide clues to optimise its value to patients and improve implementation. AIM To synthesise and describe the research findings on the experiences with advance care planning of patients with a life-threatening or life-limiting illness. DESIGN A systematic literature review, using an iterative search strategy. A thematic synthesis was conducted and was supported by NVivo 11. DATA SOURCES The search was performed in MEDLINE, Embase, PsycINFO and CINAHL on 7 November 2016. RESULTS Of the 3555 articles found, 20 were included. We identified three themes in patients' experiences with advance care planning. 'Ambivalence' refers to patients simultaneously experiencing benefits from advance care planning as well as unpleasant feelings. 'Readiness' for advance care planning is a necessary prerequisite for taking up its benefits but can also be promoted by the process of advance care planning itself. 'Openness' refers to patients' need to feel comfortable in being open about their preferences for future care towards relevant others. CONCLUSION Although participation in advance care planning can be accompanied by unpleasant feelings, many patients reported benefits of advance care planning as well. This suggests a need for advance care planning to be personalised in a form which is both feasible and relevant at moments suitable for the individual patient.
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Affiliation(s)
- M Zwakman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Marieke Zwakman, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Stratenum 6.131, PO Box 85500, 3508 GA Utrecht, The Netherlands.
| | - LJ Jabbarian
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - JJM van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A van der Heide
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - IJ Korfage
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - K Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - JAC Rietjens
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - J Seymour
- School of Nursing and Midwifery, University of Sheffield, Sheffield, UK
| | - MC Kars
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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13
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Lokker ME, Swart SJ, Rietjens JAC, van Zuylen L, Perez RSGM, van der Heide A. Palliative sedation and moral distress: A qualitative study of nurses. Appl Nurs Res 2018; 40:157-161. [PMID: 29579492 DOI: 10.1016/j.apnr.2018.02.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/06/2018] [Accepted: 02/12/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Clinical nursing practice may involve moral distress, which has been reported to occur frequently when nurses care for dying patients. Palliative sedation is a practice that is used to alleviate unbearable and refractory suffering in the last phase of life and has been linked to distress in nurses. AIM The aim of this study was to explore nurses' reports on the practice of palliative sedation focusing on their experiences with pressure, dilemmas and morally distressing situations. METHODS In-depth interviews with 36 nurses working in hospital, nursing home or primary care. RESULTS Several nurses described situations in which they felt that administration of palliative sedation was in the patient's best interest, but where they were constrained from taking action. Nurses also reported on situations where they experienced pressure to be actively involved in the provision of palliative sedation, while they felt this was not in the patient's best interest. The latter situation related to (1) starting palliative sedation when the nurse felt not all options to relieve suffering had been explored yet; (2) family requesting an increase of the sedation level where the nurse felt that this may involve unjustified hastening of death; (3) a decision by the physician to start palliative sedation where the patient had previously expressed an explicit wish for euthanasia. CONCLUSIONS Nurses experienced moral distress in situations where they were not able to act in what they believed is the patient's best interest. Situations involving moral distress require nurses to be well informed and able to adequately communicate with suffering patients, distressed family and physicians.
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Affiliation(s)
- M E Lokker
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands; Department of Medical Oncology, Erasmus MC, Rotterdam, The Netherlands.
| | - S J Swart
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - J A C Rietjens
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - L van Zuylen
- Department of Medical Oncology, Erasmus MC, Rotterdam, The Netherlands
| | - R S G M Perez
- Department of Anesthesiology, VUmc, Amsterdam, The Netherlands
| | - A van der Heide
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
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14
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Geijteman ECT, Tempelman MMA, Dees MK, Huisman BAA, Perez RSGM, van Zuylen L, van der Heide A. [Discontinuation of potentially inappropriate medications at the end of life: perspectives from patients, their relatives, and physicians]. Ned Tijdschr Geneeskd 2017; 160:D1084. [PMID: 28181897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To obtain insight into the perspectives of patients, relatives and physicians towards potentially inappropriate medications (PIMs) at the end of life. DESIGN Qualitative interview study. METHOD An analysis of in-depth interviews with 17 patients who were diagnosed as having a life expectancy of less than three months, 12 patient relatives, and 20 medical specialists and 12 general practitioners who cared for them. For analysis we applied the constant comparative method, which forms part of the grounded theory approach. RESULTS Patients and their relatives are prepared to discontinue PIMs. Still, some patients reported that stopping might give them the feeling that their attending physician has already thrown in the towel. Physicians mentioned several reasons for not ceasing PIMs: cessation not considered, low priority, and unknown consequences of discontinuation. Some physicians were concerned that discussing the discontinuation of PIMs with patients could make patients acutely aware of the approach of death, and give patients the impression that they are receiving inferior medical care. If physicians communicate with patients the possibility of discontinuing medications, they seem to emphasize the clinical futility of continuing PIMs in light of the patient's limited life expectancy. CONCLUSION Patients with a limited life expectancy and their relatives may be open to discontinue PIMs; however, in reality this happens rarely. When a physician is of the opinion that it would be of benefit to discontinue certain medications, then the advantages of cessation should be highlighted more in discussions with the patient.
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Affiliation(s)
- E C T Geijteman
- *Dit artikel werd eerder in afgeslankte vorm gepubliceerd in Journal of the American Geriatrics Society (2016;64:2602-4) met als titel 'Understanding the continuation of potentially inappropriate medications at the end of life: perspectives from individuals and their relatives and physicians'. Afgedrukt met toestemming
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15
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de Nooijer K, van de Wetering VE, Geijteman ECT, Postma L, Rietjens JAC, van der Heide A. [Written advance euthanasia directives in mentally incompetent patients with dementia: a systematic review of the literature]. Ned Tijdschr Geneeskd 2017; 161:D988. [PMID: 28294929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To present the knowledge, experiences and attitudes of the general population, patients, relatives and health care professionals concerning written advance euthanasia directives in patients who have become mentally incompetent. DESIGN Systematic review of the literature. METHOD We systematically searched Medline, Cochrane Library and Embase for articles published in the period 2002-2016. RESULTS The search yielded 775 articles, of which 11 met the inclusion criteria. Six studies had a quantitative design, four studies had a qualitative design and one a combination of both. Nine articles included patients with advanced dementia, two included patients with Huntington's disease. Patients, their relatives and the general population appear to have limited knowledge about written advance euthanasia directives. However, most of them were open to the practice of euthanasia based on a written advance directive. Few persons and patients had written a euthanasia directive and if they had, it was not always discussed with health care professionals. The majority of health care professionals thought - incorrectly - that euthanasia based on a written advance euthanasia directive is not permitted. Some of them had a positive attitude towards written advance euthanasia directives, and a very small number would be prepared to carry out euthanasia on the basis of a written directive. In practice, there are very few who have actually done so. CONCLUSION There is fairly wide support from the general population and empathy from health care professionals for the idea that euthanasia based on a written advance euthanasia directive of a mentally incompetent patient should be possible. Even so, there is a discrepancy between the expectations of the general population and what health care professionals think they can actually do in this situation.
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Affiliation(s)
- K de Nooijer
- Erasmus MC, afd. Maatschappelijke Gezondheidszorg, Rotterdam
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16
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Brinkman-Stoppelenburg A, Boddaert M, Douma J, van der Heide A. Palliative care in Dutch hospitals: a rapid increase in the number of expert teams, a limited number of referrals. BMC Health Serv Res 2016; 16:518. [PMID: 27663961 PMCID: PMC5035474 DOI: 10.1186/s12913-016-1770-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 09/16/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Palliative care expert teams in hospitals have positive effects on the quality of life and satisfaction with care of patients with advanced disease. Involvement of these teams in medical care is also associated with substantial cost savings. In the Netherlands, professional standards state that each hospital should have a palliative care team by 2017. We studied the number of hospitals that have a palliative care team and the characteristics of these teams. METHODS In April 2015, questionnaires were mailed to key palliative care professionals in all general, teaching and academic hospitals in the Netherlands. Out of 92 hospitals, 74 responded (80 %). RESULTS Seventy-seven percent of all participating hospitals had a palliative care team. Other services, such as outpatient clinics (22 %), palliative care inpatient units (7 %), and palliative day care facilities (4 %) were relatively scarce. The mean number of disciplines that were represented in the teams was 6,5. The most common disciplines were nurses (72 %) and nurse practitioners (54 %), physicians specialized in internal medicine (90 %) or anaesthesiology (75 %), and spiritual caregivers (65 %). In most cases, the physicians did not have labeled hours available for their work as palliative care consultant, whereas nurses and nurse practitioners did. Most teams (77 %) were only available during office hours. Twenty-six percent of the teams could not only be consulted by healthcare professionals but also by patients or relatives. The annual number of consultations for inpatients per year ranged from 2 to 680 (median: 77). On average, teams were consulted for 0.6 % of all patients admitted to the hospitals. CONCLUSION The number of Dutch hospitals with a palliative care team is rapidly increasing. There are substantial differences between teams regarding the disciplines represented in the teams, the procedures and the number of consultations. The development of quality standards and adequate staffing of the teams could improve the quality and effectiveness of the teams.
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Affiliation(s)
- A Brinkman-Stoppelenburg
- Department of Public Health, Erasmus Medical Center, University Medical Center Rotterdam, Room NA22-12, P.O. Box 2040, 3000, Rotterdam, CA, The Netherlands.
| | - M Boddaert
- Netherlands Comprehensive Cancer Organisation (IKNL), Godebaldkwartier 419, 3511DT, Utrecht, The Netherlands
| | - J Douma
- Netherlands Comprehensive Cancer Organisation (IKNL), Godebaldkwartier 419, 3511DT, Utrecht, The Netherlands
| | - A van der Heide
- Department of Public Health, Erasmus Medical Center, University Medical Center Rotterdam, Room NA22-12, P.O. Box 2040, 3000, Rotterdam, CA, The Netherlands
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17
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Otto SJ, Korfage IJ, Polinder S, van der Heide A, de Vries E, Rietjens JAC, Soerjomataram I. Association of change in physical activity and body weight with quality of life and mortality in colorectal cancer: a systematic review and meta-analysis. Support Care Cancer 2014; 23:1237-50. [PMID: 25318696 DOI: 10.1007/s00520-014-2480-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 10/06/2014] [Indexed: 12/24/2022]
Abstract
PURPOSE A systematic review and a meta-analysis were performed to assess the associations between change over time in physical activity and weight and quality of life and mortality in colorectal cancer patients. METHODS The PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched for English language articles published between January 1, 1990 and October 7, 2013. These articles reported results for changes in physical activity and body weight, assessed at pre- to post-diagnosis or at post-diagnosis only. A random effects model was used to analyze pooled quality of life and mortality estimates. RESULTS Seven eligible studies were identified and analyzed. Increased physical activity was associated with higher overall quality of life scores (N = 3 studies; standardized mean difference (SMD) = 0.74, 95 % confidence interval (CI) = 0.66-0.82), reduced disease-specific mortality risk (hazard ratio (HRpooled) = 0.70, 95 % CI = 0.55-0.85), and reduced overall mortality (HRpooled = 0.75, CI = 0.62-0.87) (N = 2 studies). Weight gain was not associated with disease-specific (HRpooled = 1.02, CI = 0.84-1.20) or overall (HRpooled = 1.03, CI = 0.86-1.19) mortality (N = 3 studies). CONCLUSIONS Increased physical activity was associated with improved quality of life, a reduced risk of colorectal cancer, and overall mortality rate. Given the paucity of the literature published on this topic, this finding should be interpreted with caution.
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Affiliation(s)
- S J Otto
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands,
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18
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Bruinsma SM, Brown J, van der Heide A, Deliens L, Anquinet L, Payne SA, Seymour JE, Rietjens JAC. Making sense of continuous sedation in end-of-life care for cancer patients: an interview study with bereaved relatives in three European countries. Support Care Cancer 2014; 22:3243-52. [PMID: 25022759 DOI: 10.1007/s00520-014-2344-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 06/29/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of the study was to explore relatives' descriptions and experiences of continuous sedation in end-of-life care for cancer patients and to identify and explain differences between respondents from the Netherlands, Belgium, and the UK. METHODS In-depth interviews were held between January 2011 and May 2012 with 38 relatives of 32 cancer patients who received continuous sedation until death in hospitals, the community, and hospices/palliative care units. RESULTS Relatives' descriptions of the practice referred to the outcome, to practical aspects, and to the goals of sedation. While most relatives believed sedation had contributed to a 'good death' for the patient, yet many expressed concerns. These related to anxieties about the patient's wellbeing, their own wellbeing, and questions about whether continuous sedation had shortened the patient's life (mostly UK), or whether an alternative approach would have been better. Such concerns seemed to have been prompted by relatives witnessing unexpected events such as the patient coming to awareness during sedation. In the Netherlands and in Belgium, several relatives reported that the start of the sedation allowed for a planned moment of 'saying goodbye'. In contrast, UK relatives discerned neither an explicit point at which sedation was started nor a specific moment of farewell. CONCLUSIONS Relatives believed that sedation contributed to the patient having a good death. Nevertheless, they also expressed concerns that may have been provoked by unexpected events for which they were unprepared. There seems to exist differences in the process of saying goodbye between the NL/BE and the UK.
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Affiliation(s)
- S M Bruinsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands,
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Anquinet L, Rietjens J, van der Heide A, Bruinsma S, Janssens R, Deliens L, Addington-Hall J, Smithson WH, Seymour J. Physicians' experiences and perspectives regarding the use of continuous sedation until death for cancer patients in the context of psychological and existential suffering at the end of life. Psychooncology 2013; 23:539-46. [PMID: 24307235 PMCID: PMC4282582 DOI: 10.1002/pon.3450] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 09/07/2013] [Accepted: 10/21/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The use of continuous sedation until death for terminally ill cancer patients with unbearable and untreatable psychological and existential suffering remains controversial, and little in-depth insight exists into the circumstances in which physicians resort to it. METHODS Our study was conducted in Belgium, the Netherlands, and the UK in hospitals, PCUs/hospices, and at home. We held interviews with 35 physicians most involved in the care of cancer patients who had psychological and existential suffering and had been continuously sedated until death. RESULTS In the studied countries, three groups of patients were distinguished regarding the origin of their psychological and existential suffering. The first group had preexisting psychological problems before they became ill, the second developed psychological and existential suffering during their disease trajectory, and the third presented psychological symptoms that were characteristic of their disease. Before they resorted to the use of sedation, physicians reported that they had considered an array of pharmacological and psychological interventions that were ineffective or inappropriate to relieve this suffering. Necessary conditions for using sedation in this context were for most physicians the presence of refractory symptoms, a short life expectancy, and an explicit patient request for sedation. CONCLUSIONS Physicians in our study used continuous sedation until death in the context of psychological and existential suffering after considering several pharmacological and psychological interventions. Further research and debate are needed on how and by whom this suffering at the end of life should be best treated, taking into account patients' individual preferences.
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Affiliation(s)
- Livia Anquinet
- VUB-UGent End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
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Raijmakers N, Witkamp F, Maiorana L, van Zuylen L, van der Heide A, Costantini M. 3014 POSTER Medical and Nursing Interventions in Hospitals in the Last Days of Life of Cancer Patients in Italy and the Netherlands. Eur J Cancer 2011. [DOI: 10.1016/s0959-8049(11)71087-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Efforts to counter the rise in overweight and obesity, such as taxes on certain foods and beverages, limits to commercial advertising, a ban on chocolate drink at schools or compulsory physical exercise for obese employees, sometimes raise questions about what is considered ethically acceptable. There are obvious ethical incentives to these initiatives, such as improving individual and public health, enabling informed choice and diminishing societal costs. Whereas we consider these positive arguments to put considerable effort in the prevention of overweight indisputable, we focus on potential ethical objections against such an effort. Our intention is to structure the ethical issues that may occur in programmes to prevent overweight and/or obesity in order to encourage further debate. We selected 60 recently reported interventions or policy proposals targeting overweight or obesity and systematically evaluated their ethically relevant aspects. Our evaluation was completed by discussing them in two expert meetings. We found that currently proposed interventions or policies to prevent overweight or obesity may (next to the benefits they strive for) include the following potentially problematic aspects: effects on physical health are uncertain or unfavourable; there are negative psychosocial consequences including uncertainty, fears and concerns, blaming and stigmatization and unjust discrimination; inequalities are aggravated; inadequate information is distributed; the social and cultural value of eating is disregarded; people's privacy is disrespected; the complexity of responsibilities regarding overweight is disregarded; and interventions infringe upon personal freedom regarding lifestyle choices and raising children, regarding freedom of private enterprise or regarding policy choices by schools and other organizations. The obvious ethical incentives to combat the overweight epidemic do not necessarily override the potential ethical constraints, and further debate is needed. An ethical framework to support decision makers in balancing potential ethical problems against the need to do something would be helpful. Developing programmes that are sound from an ethical point of view is not only valuable from a moral perspective, but may also contribute to preventing overweight and obesity, as societal objections to a programme may hamper its effectiveness.
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Affiliation(s)
- M ten Have
- Department of Medical Ethics, Erasmus Medical Centre, Rotterdam, the Netherlands.
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Raijmakers N, Fradsham S, van Zuylen L, Mayland C, Ellershaw J, van der Heide A. 3024 POSTER Variation in Attitudes Towards Artificial Hydration at the End of Life -a Systematic Literature Review. Eur J Cancer 2011. [DOI: 10.1016/s0959-8049(11)71097-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Raijmakers N, van Zuylen L, Costantini M, Caraceni A, Clark J, Lundquist G, Voltz R, Ellershaw J, van der Heide A. Artificial nutrition and hydration in the last week of life in cancer patients. A systematic literature review of practices and effects. Ann Oncol 2011; 22:1478-1486. [DOI: 10.1093/annonc/mdq620] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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Buiting HM, van der Heide A, Onwuteaka-Philipsen BD, Rurup ML, Rietjens JAC, Borsboom G, van der Maas PJ, van Delden JJM. Physicians' labelling of end-of-life practices: a hypothetical case study. J Med Ethics 2010; 36:24-29. [PMID: 20026689 DOI: 10.1136/jme.2009.030155] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVES To investigate why physicians label end-of-life acts as either 'euthanasia/ending of life' or 'alleviation of symptoms/palliative or terminal sedation', and to study the association of such labelling with intended reporting of these acts. METHODS Questionnaires were sent to a random, stratified sample of 2100 Dutch physicians (response: 55%). They were asked to label six hypothetical end-of-life cases: three 'standard' cases and three cases randomly selected (out of 47), that varied according to (1) type of medication, (2) physician's intention, (3) type of patient request, (4) patient's life expectancy and (5) time until death. We identified the extent to which characteristics of cases are associated with physician's labelling, with multilevel multivariable logistic regression. RESULTS The characteristics that contributed most to labelling cases as 'euthanasia/ending of life' were the administration of muscle relaxants (99% of these cases were labelled as 'euthanasia/ending of life') or disproportional morphine (63% of these cases were labelled accordingly). Other important factors were an intention to hasten death (54%) and a life expectancy of several months (46%). Physicians were much more willing to report cases labelled as 'euthanasia' (87%) or 'ending of life' (56%) than other cases. CONCLUSIONS Similar cases are not uniformly labelled. However, a physicians' label is strongly associated with their willingness to report their acts. Differences in how physicians label similar acts impede complete societal control. Further education and debate could enhance the level of agreement about what is physician-assisted dying, and thus should be reported, and what not.
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Affiliation(s)
- H M Buiting
- Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
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Rietjens JAC, van Tol DG, Schermer M, van der Heide A. Judgement of suffering in the case of a euthanasia request in The Netherlands. J Med Ethics 2009; 35:502-507. [PMID: 19644009 DOI: 10.1136/jme.2008.028779] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
INTRODUCTION In The Netherlands, physicians have to be convinced that the patient suffers unbearably and hopelessly before granting a request for euthanasia. The extent to which general practitioners (GPs), consulted physicians and members of the euthanasia review committees judge this criterion similarly was evaluated. METHODS 300 GPs, 150 consultants and 27 members of review committees were sent a questionnaire with patient descriptions. Besides a "standard case" of a patient with physical suffering and limited life expectancy, the descriptions included cases in which the request was mainly rooted in psychosocial or existential suffering, such as fear of future suffering or dependency. For each case, respondents were asked whether they recognised the case from their own practice and whether they considered the suffering to be unbearable. RESULTS The cases were recognisable for almost all respondents. For the "standard case" nearly all respondents were convinced that the patient suffered unbearably. For the other cases, GPs thought the suffering was unbearable less often (2-49%) than consultants (25-79%) and members of the euthanasia review committees (24-88%). In each group, the suffering of patients with early dementia and patients who were "tired of living" was least often considered to be unbearable. CONCLUSIONS When non-physical aspects of suffering are central in a euthanasia request, there is variance between and within GPs, consultants and members of the euthanasia committees in their judgement of the patient's suffering. Possible explanations could be differences in their roles in the decision-making process, differences in experience with evaluating a euthanasia request, or differences in views regarding the permissibility of euthanasia.
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Rietjens JAC, Buiting HM, Pasman HRW, van der Maas PJ, van Delden JJM, van der Heide A. Deciding about continuous deep sedation: physicians' perspectives: a focus group study. Palliat Med 2009; 23:410-7. [PMID: 19304807 DOI: 10.1177/0269216309104074] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Although guidelines restrict the use of continuous deep sedation to patients with refractory physical symptoms and a short life-expectancy, its use is not always restricted to these conditions. A focus group study of physicians was conducted to gain more insight in the arguments for and against the use of continuous deep sedation in several clinical situations. Arguments in favour of continuous deep sedation for patients with a longer life-expectancy were that the overall clinical situation is more relevant than life-expectancy alone, and that patients' wishes should be followed. Continuous deep sedation for patients with predominantly emotional/existential suffering was considered appropriate when physicians empathize with the suffering. Further, some physicians indicated that they may consider the use of sedation in the context of a euthanasia request. Arguments were that the option of continuous deep sedation is a better alternative; it may comfort some patients when their thoughts about potential future suffering become unbearable. Further, some considered continuous deep sedation as less burdening or a bother to perform. We conclude that physicians' decision-making about continuous deep sedation is characterized by balancing the interests of patients with their own feelings. Accordingly, the reasons for its use are not unambiguous and need further debate.
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Affiliation(s)
- J A C Rietjens
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
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Buiting HM, Gevers JKM, Rietjens JAC, Onwuteaka-Philipsen BD, van der Maas PJ, van der Heide A, van Delden JJM. Dutch criteria of due care for physician-assisted dying in medical practice: a physician perspective. J Med Ethics 2008; 34:e12. [PMID: 18757612 DOI: 10.1136/jme.2008.024976] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
INTRODUCTION The Dutch Euthanasia Act (2002) states that euthanasia is not punishable if the attending physician acts in accordance with the statutory due care criteria. These criteria hold that: there should be a voluntary and well-considered request, the patient's suffering should be unbearable and hopeless, the patient should be informed about their situation, there are no reasonable alternatives, an independent physician should be consulted, and the method should be medically and technically appropriate. This study investigates whether physicians experience problems with these criteria in medical practice. METHODS In 2006, questionnaires were sent to a random, stratified sample of 2100 Dutch physicians (response rate: 56%). Physicians were asked about problems in their decision-making related to requests for euthanasia or assisted suicide after enforcement of the 2002 Euthanasia Act. RESULTS Of all physicians who had received a request for euthanasia or assisted suicide (75%), 25% had experienced problems in the decision-making with regard to at least one of the criteria of due care. Physicians who had experienced problems mostly indicated to have had problems related to evaluating whether or not the patient's suffering was unbearable and hopeless (79%) and whether or not the patient's request was voluntary or well considered (58%). DISCUSSION Physicians in The Netherlands most frequently reported problems related to aspects in which they have to evaluate the patient's subjective perspective(s). However, it can be questioned whether placing emphasis on these subjective aspects is an adequate fulfilment of the duties imposed on physicians, as laid down in the Dutch Euthanasia Act.
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Affiliation(s)
- H M Buiting
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
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Rurup ML, Onwuteaka-Philipsen BD, van der Heide A, van der Wal G, van der Maas PJ. [Trends in the agents used for euthanasia and the relationship with the number of notifications]. Ned Tijdschr Geneeskd 2006; 150:618-24. [PMID: 16610505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
OBJECTIVE To provide insight into the relationship between the drugs used for euthanasia and its notification. DESIGN Retrospective and descriptive. METHODS By comparing the drugs used for euthanasia according to different components of studies carried out in 1990, 1995 and 2000, insight was obtained into the drugs used in all cases of euthanasia satisfying the definition thereof (death-certificate studies), those cases of euthanasia that, in addition, were defined as such by the physician (physician interviews), and the cases of euthanasia that, in addition, had been reported (reported case studies). RESULTS In 2001, standard drugs for euthanasia were used in 76% of cases and opioids in 23%. Euthanasia with standard drugs was reported in 73% of cases in 1995, and in 71% of cases in 2000, while euthanasia with opioids was reported in 2% and 1% of cases, respectively. The total percentage of euthanasia reported was higher in 2001 than in 1995 (54% versus 44%), since in 2001 euthanasia was apparently performed more often with standard drugs and less with opioids. CONCLUSION An increasing proportion of cases of euthanasia is being carried out with the drugs recommended for this purpose. Euthanasia with opioids was rarely reported. Possibly, physicians did not always consider these cases to be euthanasia.
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Affiliation(s)
- M L Rurup
- VU Medisch Centrum, Instituut voor Extramuraal Geneeskundig Onderzoek, afd Sociale Geneeskunde, Amsterdam.
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van der Heide A, Onwuteaka-Philipsen BD, van Delden JJM, Gevers JKM, van der Maas PJ, van der Wal G. [Fourth evaluation of the law on the review of termination of life on request and assisted suicide (Euthanasia Act)]. Ned Tijdschr Geneeskd 2005; 149:2187-9. [PMID: 16223080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
This fall, an extensive study will start to evaluate the Dutch Euthanasia Act. This law was enacted in 2002. According to this law, physicians must report cases of euthanasia and physician-assisted suicide. The cases are then judged by regional euthanasia review committees consisting of a lawyer, a physician and an ethicist. Only if they conclude that the case does not meet the requirements for prudent practice, it will be sent to the public prosecutor. The study will be focused on the practice of medical end-of-life decision-making, the functioning and effects of the Euthanasia Act, and opinions of physicians about the scope of the law and the demarcation between different end-of-life decisions. The study will comprise 4 sub-studies: a judicial evaluation, a death certificate study, a survey among physicians and a panel study among physicians, nurses, members of euthanasia review committees, lawyers and ethicists. This study is the fourth in a row of nationwide studies into end-of-life practices that have been performed since 1990. The previous studies contributed to the public debate about medical care at the end of life and to the development of policy in this field. It is expected that this study, by providing up-to-date information on and insight into end-of-life care in the Netherlands, will do the same.
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Affiliation(s)
- A van der Heide
- Erasmus MC, afd Maatschappelijke Gezondheidszorg, Rotterdam.
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Vrakking AM, van der Heide A, Onwuteaka-Philipsen BD, Keij-Deerenberg IM, van der Maas PJ, van der Wal G. [No conspicuous changes in the practice of medical end-of-life decision-making for neonates and infants in the Netherlands in 2001 as compared to 1995]. Ned Tijdschr Geneeskd 2005; 149:2047-51. [PMID: 16184946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVE To establish whether the practice of end-of-life decision-making for neonates and infants under the age of 1 in the Netherlands in 2000 was different from that in 1995. DESIGN Retrospective descriptive and comparative study. METHODS In both years, all deaths of children under the age of one year that took place in August-November (1995: n = 338; 2001: n = 347) were studied. The response rate was 96% in 1995 and 84% in 2001. The questionnaires which were sent to the physicians who reported the deaths, included structured questions about whether or not death had been preceded by end-of-life decisions, i.e. decisions to withhold or withdraw potentially life-prolonging treatment or to administer (potentially) life-shortening drugs, and questions about the decision-making process. RESULTS The proportion of end-of-life decisions increased slightly from 62% to 68% of all deaths in the first year of life, but the difference was not statistically significant. The large majority of these decisions involved withholding or withdrawing life-sustaining treatment. The frequency of decisions to actively terminate the life of an infant who was not dependent on life-sustaining treatment remained stable at 1%. The proportion of decisions that had been discussed with the parents increased slightly, from 91% in 1995 to 97% in 2001; similar percentages of the decisions had been discussed with other physicians. The percentage of decisions that had been discussed with the nursing staff decreased from 40 in 1995 to 28 in 2001. CONCLUSION The findings suggest that the practice of end-of-life decision-making in neonatology was rather stable between 1995 and 2001. The frequency of the active termination of life had not increased, despite the new euthanasia regulation in the Netherlands.
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Affiliation(s)
- A M Vrakking
- Erasmus MC, afd. Maatschappelijke Gezondheidszorg, Rotterdam.
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Voogt E, van der Heide A, van Leeuwen AF, Visser AP, Cleiren MPHD, Passchier J, van der Maas PJ. Positive and negative affect after diagnosis of advanced cancer. Psychooncology 2005; 14:262-73. [PMID: 15386769 DOI: 10.1002/pon.842] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Anxiety and depression are studied thoroughly in patients with advanced cancer. However, little is known about the nature of mood disorders in this stage of the disease. We studied positive and negative affect in patients who have had a diagnosis of advanced cancer, and examined how these are related to anxiety and depression, and to other patient and care factors. One hundred and five patients filled out a written questionnaire and were interviewed personally. The PANAS positive affect scores were lower than those in the general population, but the negative affect scores were fairly similar. We found a rather low prevalence of depression (13%) and anxiety (8%) as measured by the HADS. The emotional problems patients mentioned most frequently were anxiety about metastases (26%), the unpredictability of the future (18%) and anxiety about physical suffering (15%). Both positive and negative affect were most strongly related to patient's sense of meaning and peace. We conclude that distinguishing positive and negative affect enhances the understanding of psychological distress of patients with advanced cancer, that seems to be mainly caused by low levels of positive affect. Several theories are discussed to explain this finding, that may contribute to efforts to improve care for these patients.
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Affiliation(s)
- E Voogt
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, Netherlands.
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Abstract
The issue of the allocation of resources in health care is here to stay. The goal of this study was to explore the views of physicians on several topics that have arisen in the debate on the allocation of scarce resources and to compare these with the views of policy makers. We asked physicians (oncologists, cardiologists, and nursing home physicians) and policy makers to participate in an interview about their practices and opinions concerning factors playing a role in decision making for patients in different age groups. Both physicians and policy makers recognised allocation decisions as part of their reality. One of the strong general opinions of both physicians and policy makers was the rejection of age discrimination. Making allocation decisions as such seemed to be regarded as a foreign entity to the practice of medicine. In spite of the reluctance to make allocation decisions, physicians sometimes do. This would seem to be only acceptable if it is justified in terms of the best interests of the patient from whom treatment is withheld.
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Affiliation(s)
- J J M van Delden
- Department of Public Health, Erasmus MC, Rotterdam, Netherlands.
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van der Heide A. Workshop 18: End-of-life decision making in 6 European countries. Eur J Public Health 2003. [DOI: 10.1093/eurpub/13.suppl_2.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
OBJECTIVE To investigate the emotional feelings reported by physicians in The Netherlands after having performed euthanasia or other medical end-of-life decisions. DESIGN Nationwide interview study in The Netherlands, November 1995 through February 1996. PARTICIPANTS AND SETTING A random sample of 405 physicians (general practitioners, nursing home physicians, and clinical specialists). MAIN OUTCOME MEASURES Subsequent feelings of physicians about their most recent cases (if any) of euthanasia, assisted suicide, life-ending without an explicit request from the patient, and alleviation of pain and other symptoms with high doses of opioids. RESULTS The response rate was 89%. In 52% of all cases of hastening death, physicians had feelings of comfort afterwards, which included feelings of satisfaction in 44% and of relief in 13%. Feelings of discomfort were reported in 42%, most frequently referred to as emotional (28%) or burdensome (25%). Feelings of discomfort were highest for euthanasia (75%; P<0.000). 95% of physicians were willing to perform euthanasia or assisted suicide again in similar situations. Afterwards, 5% had doubts, but none had regrets, about performing euthanasia. CONCLUSIONS Hastening the death of a patient evokes different feelings among physicians. Although performing euthanasia is often experienced as burdensome and emotional, granting the ultimate wish of a competent patient may also give physicians a feeling of having contributed to the quality of the dying process.
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Affiliation(s)
- I Haverkate
- Vrije Universiteit Medical Centre, Institute for Research in Extramural Medicine, Department of Social Medicine, Amsterdam, The Netherlands.
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Onwuteaka-Philipsen BD, Pasman HR, Kruit A, van der Heide A, Ribbe MW, van der Wal G. Withholding or withdrawing artificial administration of food and fluids in nursing-home patients. Age Ageing 2001; 30:459-65. [PMID: 11742773 DOI: 10.1093/ageing/30.6.459] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND withholding or withdrawing artificial administration of food and fluids, especially in incompetent patients, has been the subject of turbulent discussions. Insight into this practice may be useful in the debate, and also in the development of guidelines. OBJECTIVES to gain insight into the frequency and circumstances of forgoing artificial administration of food and fluids in nursing homes. DESIGN we sent a written questionnaire to the nursing-home physicians of a stratified sample of 6060 people who died in the Netherlands in 1995, and interviewed a random sample of 74 nursing-home physicians. SETTING Dutch nursing homes. MAIN OUTCOME MEASURES incidence of withholding or withdrawing artificial administration of food, patient characteristics and features of the decision-making process. RESULTS in 23% of deaths in nursing homes, artificial administration of food and fluids were foregone. In two-thirds of cases, life was shortened by 1 week at most. The decision was almost always discussed with competent patients. In the case of incompetent patients, the decision was almost always discussed with the patient's relatives. Frequently mentioned considerations in the decision were: the patient's (presumed) wish, low quality of life, no prospect of improvement and the desire not unnecessarily to prolong life. CONCLUSIONS artificial administration of food and fluids is one of the most frequently forgone treatments in nursing homes. In general, the physician involves the patient or the patient's relatives and the nursing staff in the decision-making. In most cases, the nursing-home physicians thought that the decision to forgo artificial administration of food and fluids improved the patient's quality of dying.
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Affiliation(s)
- B D Onwuteaka-Philipsen
- Institute for Research in Extramural Medicine, Department of General Practice, Nursing Home Medicine and Social Medicine, Vrije Universiteit Amsterdam, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.
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van der Wal G, van der Maas PJ, Onwuteaka-Philipsen BD, van der Heide A. [New research on the practice, reporting and reviewing of euthanasia and other medical end-of-life decisions, 2001/2002]. Ned Tijdschr Geneeskd 2001; 145:1802-6. [PMID: 11582645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
In the second half of 2001, an extensive study will start which will evaluate the review procedure for euthanasia in the Netherlands. Since the end of 1998, euthanasia has to be reviewed by regional review committees, which include a physician and an ethicist, in addition to a legal expert. The aim of this study is to examine whether the reporting procedure meets the aim and whether there are any points which require improvement. This study follows on from those carried out in 1990/1991 and 1995/1996, which investigated euthanasia and other medical end-of-life decisions (assisted suicide, termination of life without the patient's explicit request, treatment of pain and symptoms with a possible life-shortening effect, and forgoing potentially life-prolonging treatment). The study consists of an analysis of cases of death (in which the numbers and nature of various medical end-of-life decisions will be established), physician interviews (to gain insight into the context in which medical end-of-life decisions are made), a study of reported cases (to give an overview of doctors' experiences with the review committees), and a study carried out amongst the general public (around 1,500 Dutch adults will be given a written questionnaire about their opinions concerning medical end-of-life decisions and the reporting procedure). In addition to this Dutch study, a European study subsidized by the European Commission is being carried out which will examine attitudes and experiences regarding medical end-of-life decisions in six European countries (Belgium, Denmark, Italy, the Netherlands, Sweden and Switzerland). This will, for the first time, enable a true comparison to be made between the Netherlands and other countries in terms of euthanasia and other medical end-of-life decisions.
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Affiliation(s)
- G van der Wal
- Vrije Universiteit Medisch Centrum, afd. Sociale Geneeskunde, Instituut voor Extramuraal Geneeskundig Onderzoek, Van der Boechorststraat 7, 1081 BT Amsterdam
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Abstract
The role of undiagnosed psychiatric disorders in patients requesting euthanasia is an important ethical and professional issue. From June, 1997, until June, 1999, we included a psychiatric consultation as part of our standard procedure for handling euthanasia requests. Of 22 cancer patients who requested euthanasia at short notice: ten had their longstanding and well-considered wish for euthanasia granted; six were denied euthanasia because they did not have such a wish; five were denied because of psychiatric problems; and one was granted the wish despite minor psychiatric symptoms. Our findings suggest that a psychiatrist should be consulted if the treatment team has doubts about a patient's state of mind.
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Abstract
OBJECTIVE To describe the frequency, background, and impact of decisions to give analgesic or other drugs that may, intentionally or unintentionally, shorten the life-span of severely ill neonates. SETTING The Netherlands. DESIGN Retrospective, cross-sectional study. PATIENTS Questionnaires were mailed in The Netherlands to physicians reporting 338 consecutive deaths of infants under 1 yr of age from August through November 1995. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Questions were asked about medical end-of-life decisions preceding the death of the infant and about the decision-making process. Potentially life-shortening drugs, mostly opioids, were given in 37% of all deaths. The estimated effect in terms of the shortening of life was <1 wk in 72% of all patients in whom the administration of potentially life-shortening drugs had been the most important end-of-life decision. Most decisions to administer such drugs were discussed with parents and colleagues. The decisions were discussed regarding virtually all patients in whom the physician had intended to hasten death; doses of opioids tended to be larger in this group. CONCLUSIONS The frequency with which drugs that may shorten life are administered before the death of severely ill infants confirms the important role of modern medicine in dying in neonatology. Most physicians caring for neonates feel that palliative medication may be warranted in dying infants, even if it shortens life. A distinction between intentionally ending life and providing adequate terminal care by alleviating pain or other symptoms, which is important in moral and judicial terms, is probably not easily made for some of these patients.
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Affiliation(s)
- A van der Heide
- Department of Public Health, Erasmus University Rotterdam, The Netherlands
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Groenewoud JH, van der Heide A, Onwuteaka-Philipsen BD, Willems DL, van der Maas PJ, van der Wal G. Clinical problems with the performance of euthanasia and physician-assisted suicide in The Netherlands. N Engl J Med 2000; 342:551-6. [PMID: 10684914 DOI: 10.1056/nejm200002243420805] [Citation(s) in RCA: 133] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND METHODS The characteristics and frequency of clinical problems with the performance of euthanasia and physician-assisted suicide are uncertain. We analyzed data from two studies of euthanasia and physician-assisted suicide in The Netherlands (one conducted in 1990 and 1991 and the other in 1995 and 1996), with a total of 649 cases. We categorized clinical problems as technical problems, such as difficulty inserting an intravenous line; complications, such as myoclonus or vomiting; or problems with completion, such as a longer-than-expected interval between the administration of medications and death. RESULTS In 114 cases, the physician's intention was to provide assistance with suicide, and in 535, the intention was to perform euthanasia. Problems of any type were more frequent in cases of assisted suicide than in cases of euthanasia. Complications occurred in 7 percent of cases of assisted suicide, and problems with completion (a longer-than-expected time to death, failure to induce coma, or induction of coma followed by awakening of the patient) occurred in 16 percent of the cases; complications and problems with completion occurred in 3 percent and 6 percent of cases of euthanasia, respectively. The physician decided to administer a lethal medication in 21 of the cases of assisted suicide (18 percent), which thus became cases of euthanasia. The reasons for this decision included problems with completion (in 12 cases) and the inability of the patient to take all the medications (in 5). CONCLUSIONS There may be clinical problems with the performance of euthanasia and physician-assisted suicide. In The Netherlands, physicians who intend to provide assistance with suicide sometimes end up administering a lethal medication themselves because of the patient's inability to take the medication or because of problems with the completion of physician-assisted suicide.
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Affiliation(s)
- J H Groenewoud
- Department of Public Health, Erasmus University, Rotterdam, The Netherlands.
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Groenewoud JH, van der Heide A, Kester JG, de Graaff CL, van der Wal G, van der Maas PJ. A nationwide study of decisions to forego life-prolonging treatment in Dutch medical practice. Arch Intern Med 2000; 160:357-63. [PMID: 10668838 DOI: 10.1001/archinte.160.3.357] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Decisions to withhold or withdraw life-prolonging treatment in terminally ill patients are common in some areas of medical practice. Information about the frequency and background of these decisions is generally limited to specific clinical settings. This article describes the practice of withholding or withdrawing life-prolonging treatment in the Netherlands. METHODS Questionnaires were sent to the attending physicians of a stratified sample of 6060 of all 43002 cases of death in the Netherlands from August 1 through November 30, 1995. The questions concerned the treatments foregone, the patient characteristics, and the decision-making process. The response rate was 77%. RESULTS A nontreatment decision was made in 30% (95% confidence interval, 28%-31%) of all deaths in the Netherlands in 1995; this is an increase compared with 28% (95% confidence interval, 26%-29%) in 1990; in 20% of all deaths, this decision was the most important end-of-life decision. Artificial nutrition or hydration and antibiotics were the treatments most frequently foregone, each accounting for 25% of cases in which a nontreatment decision was made. Nursing-home physicians withheld or withdrew treatment more often than clinical specialists or general practitioners in 52%, 35%, and 17% of all deaths they were involved with, respectively. Of the patients in whom a nontreatment decision was the most important end-of-life decision, 26% were competent; of those, 93% were involved in the decision making. In 17% of patients, the nontreatment decision was made without being discussed with the patient or the patient's relatives and without knowledge of the patient's wishes. Life was shortened by an estimated 24 hours or less in 42% and 1 month or more in 8% of patients. CONCLUSIONS Decisions to forego life-prolonging treatment are frequently made end-of-life decisions in the Netherlands and may be increasing. Most of these decisions do not involve high-technology treatments, and the consequences, in terms of shortening of life, are relatively small.
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Affiliation(s)
- J H Groenewoud
- Department of Public Health, Erasmus University, Rotterdam, The Netherlands.
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Abstract
In a large percentage of the infants who die in the neonatal intensive care setting, an end-of-life decision was made before death, usually a decision to forego life-sustaining treatment. This was confirmed in a recent study in The Netherlands that showed also that a minority of cases include the administration of drugs to hasten death, usually in patients with severe congenital multiple or central nervous system anomalies. Over 80% of Dutch pediatricians support this option under certain conditions. Almost all pediatricians are of the opinion that these cases have to be subject to public review, but they favor review by a committee of independent medical, judicial, and ethical professionals rather than by the public prosecutor. A discussion group on this subject recently made a proposal for such a reviewing procedure to the Dutch governmental authorities and described the requirements concerning end-of-life decisions in neonatal medicine. Proper handling of ethical aspects of medical treatment including review and feedback after end-of-life decisions can contribute to high standards of quality of care.
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Affiliation(s)
- L A Kollée
- Department of Neonatology, University Hospital of Nijmegen, The Netherlands
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van der Heide A, van der Maas PJ, van der Wal G, Kollée LA, de Leeuw R, Holl RA. The role of parents in end-of-life decisions in neonatology: physicians' views and practices. Pediatrics 1998; 101:413-8. [PMID: 9481006 DOI: 10.1542/peds.101.3.413] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE End-of-life decisions for newborn infants are usually made with the consent of parents as well as physicians, but may occasionally involve disagreement about which decision is in the best interest of the child. Our study was aimed at providing an empirical background for the ethical discussion on the parent's versus the physician's role in decision-making. METHODS We conducted face-to-face interviews with a stratified sample of pediatricians. The response rate was 99%. The most recent decisions in newborn infants to hasten death or not prolong life and the most recent cases in which such decisions were not made because either the parents or the physician objected were comprehensively discussed. RESULTS Decisions to hasten death or not prolong life were usually made after discussing it with parents and did not occur while parents were known to disagree. Situations in which an end-of-life decision was not made because parents did not consent predominantly involved infants with complications of prematurity (24%) or perinatal asphyxia (40%), whereas situations in which parents requested an end-of-life decision that was not acceded to by the pediatrician involved Down syndrome as the main diagnosis in 43% and as a concurrent diagnosis in 21%. Pediatricians afterwards often expressed feelings of discontent about situations in which there had been disagreement with parents. CONCLUSIONS The opinion of parents about which medical decision is in the best interest of their child is for pediatricians only decisive in case it invokes the continuation of treatment. The principle of preserving life is abandoned only when the physician feels sufficiently sure that the parents agree that such a course of action is in the best interest of the child.
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Affiliation(s)
- A van der Heide
- Department of Public Health, Erasmus University, Rotterdam, The Netherlands
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van der Heide A, Muller MT, Kester JG, Groenewoud JH, van der Wal G, van der Maas PJ. [Frequency of decisions to forgo (artificial) administration of food and fluids at life's end]. Ned Tijdschr Geneeskd 1997; 141:1918-24. [PMID: 9550738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine the frequency and characteristics of decisions to forgo (artificial) feeding and hydration with hastening of death as a possible result. DESIGN Retrospective, descriptive study. SETTING The Netherlands. METHODS Data were collected from questionnaires mailed to physicians attending 6060 deaths identified from death certificates dating from August through November 1995 (response rate: 77%). RESULTS Decisions to forgo feeding and hydration preceded 8% of all deaths studied; for deaths attended by nursing home physicians this percentage was 23%, for deaths attended by general practitioners and specialists it was 4%. In 68% of all these death cases, the patients had been 80 years of age or over, and 76% of them had been partly or completely incompetent. The non-treatment decision had been discussed with relatives in 82% of all cases, and in 89% of the death cases attended by nursing home physicians. These patients had had (possibly) life-shortening medication less frequently than other patients for whom a medical decision concerning the end of life had been made. CONCLUSION Decisions to forgo (artificial) feeding and hydration were made relatively often by nursing home physicians, and rarely by general practitioners and specialists. These decisions were usually but not always made after discussion with relatives. There were no indications that these decisions entailed a great deal of suffering for the patients.
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Affiliation(s)
- A van der Heide
- Erasmus Universiteit, Instituut Maatschappelijke Gezondheidszorg, Rotterdam
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van der Heide A, van der Maas PJ, van der Wal G, de Graaff CL, Kester JG, Kollée LA, de Leeuw R, Holl RA. Medical end-of-life decisions made for neonates and infants in the Netherlands. Lancet 1997; 350:251-5. [PMID: 9242802 DOI: 10.1016/s0140-6736(97)02315-5] [Citation(s) in RCA: 104] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Advances in neonatal intensive care have lowered the neonatal death rate. There are still some severely ill neonates and infants, however, for whom the application of all possible life-prolonging treatment modalities may be questioned. METHODS We did two studies in the Netherlands. In the first we sent questionnaires to physicians who had attended 338 consecutive deaths (August-November, 1995) within the first year of life (death-certificate study), and in the second we interviewed 31 neonatologists or paediatric intensive-care specialists and 35 general paediatricians. The response rates were 88% and 99%, respectively. FINDINGS In the death-certificate study, 57% of all deaths had been preceded by a decision to forgo life-sustaining treatment; this decision was accompanied by the administration of potentially life-shortening drugs to alleviate pain or other symptoms in 23%, and by the administration of drugs with the explicit aim of hastening death in 8%. A drug was given explicitly to hasten death to neonates not dependent on life-sustaining treatment in 1% of all death cases. No chance of survival was the main motive in 76% of all end-of-life decisions, and a poor prognosis was the main motive in 18%. The interview study showed that parents had been involved in making 79% of decisions. The physicians consulted colleagues about 88% of decisions. Most paediatricians favoured formal review of medical decisions by colleagues together with ethical or legal experts. INTERPRETATION Death among neonates and infants is commonly preceded by medical end-of-life decisions. Most Dutch paediatricians seem to find prospects for survival and prognostic factors relevant in such decisions. Public control by a committee of physicians, paediatricians, ethicists, and legal experts is widely endorsed by paediatricians.
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Affiliation(s)
- A van der Heide
- Department of Public Health, Erasmus University Rotterdam, Netherlands.
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Groenewoud JH, van der Maas PJ, van der Wal G, Hengeveld MW, Tholen AJ, Schudel WJ, van der Heide A. Physician-assisted death in psychiatric practice in the Netherlands. N Engl J Med 1997; 336:1795-801. [PMID: 9187071 DOI: 10.1056/nejm199706193362506] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND In 1994 the Dutch Supreme Court ruled that in exceptional instances, physician-assisted suicide might be justifiable for patients with unbearable mental suffering but no physical illness. We studied physician-assisted suicide and euthanasia in psychiatric practice in the Netherlands. METHODS In 1996, we sent questionnaires to 673 Dutch psychiatrists - about half of all such specialists in the country - and received 552 responses from the 667 who met the study criteria (response rate, 83 percent). We estimated the annual frequencies of requests for physician-assisted suicide by psychiatrists and actual instances of assistance. RESULTS Of the respondents, 205 (37 percent) had at least once received an explicit, persistent request for physician-assisted suicide and 12 had complied. We estimate there are 320 requests a year in psychiatric practice and 2 to 5 assisted suicides. Excluding those who had ever assisted, 345 of the respondents (64 percent) thought physician-assisted suicide because of a mental disorder could be acceptable, including 241 who said they could conceive of instances in which they themselves would be willing to assist. The most frequent reasons for refusing were the belief that the patient had a treatable mental disorder, opposition to assisted suicide in principle, and doubt that the suffering was unbearable or hopeless. Most, but not all, patients who had been assisted by their psychiatrists in suicide had both a mental disorder and a serious physical illness, often in a terminal phase. Thirty percent of the respondents had been consulted at least once by a physician in another specialty about a patient's request for assisted death. The annual number of such consultations was estimated at 310, about 3 percent of the estimated 9700 requests for euthanasia or physician-assisted suicide in medical practice. CONCLUSIONS Explicit requests for physician-assisted suicide are not uncommon in psychiatric practice in the Netherlands, but these requests are rarely granted. Psychiatric consultation for medical patients who request physician-assisted death is relatively rare.
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Affiliation(s)
- J H Groenewoud
- Department of Public Health, Erasmus University, Rotterdam, The Netherlands
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van Jaarsveld CH, van der Heide A. [Favorable results of early 2nd-stage medication in rheumatoid arthritis]. Ned Tijdschr Geneeskd 1997; 141:732-6. [PMID: 9213790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To compare the effects of treatment with and without 'slow-acting antirheumatic drugs' (SAARDs) for patients with recent-onset rheumatoid arthritis (RA). DESIGN Open randomized clinical trial. SETTING Outpatient clinics of six medical centers, the Netherlands. METHOD The study population consisted of 304 consecutive patients with recently diagnosed RA. A therapeutic strategy with delayed introduction of a SAARD was compared with a strategy comprising early start of SAARD treatment. Primary endpoints were functional disability, pain, joint score, erythrocyte sedimentation rate and progression of radiological abnormalities at 12 months. RESULTS Four of the five endpoints improved statistically significantly more in the early-SAARD group than in the non-SAARD group; radiological abnormalities progressed at an equal rate in the two groups. Adverse reactions remained at an acceptable level and were the same in the two groups. CONCLUSION Early introduction of a SAARD was more beneficial than a therapeutic strategy with delayed introduction of a SAARD for patients with recently diagnosed RA.
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Affiliation(s)
- C H van Jaarsveld
- Academisch Ziekenhuis, afd. Reumatologie en Klinische Immunologie, Utrecht
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van der Maas PJ, van der Wal G, Haverkate I, de Graaff CL, Kester JG, Onwuteaka-Philipsen BD, van der Heide A, Bosma JM, Willems DL. Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med 1996; 335:1699-705. [PMID: 8929370 DOI: 10.1056/nejm199611283352227] [Citation(s) in RCA: 429] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND In 1991 a new procedure for reporting physician-assisted deaths was introduced in the Netherlands that led to a tripling in the number of reported cases. In 1995, as part of an evaluation of this procedure, a nationwide study of euthanasia and other medical practices concerning the end of life was begun that was identical to a study conducted in 1990. METHODS We conducted two studies, the first involving interviews with 405 physicians (general practitioners, nursing home physicians, and clinical specialists) and the second involving questionnaires mailed to the physicians attending 6060 deaths that were identified from death certificates. The response rates were 89 percent and 77 percent, respectively. RESULTS Among the deaths studied, 2.3 percent of those in the interview study and 2.4 percent of those in the death-certificate study were estimated to have resulted from euthanasia, and 0.4 percent and 0.2 percent, respectively, resulted from physician-assisted suicide. In 0.7 percent of cases, life was ended without the explicit, concurrent request of the patient. Pain and symptoms were alleviated with doses of opioids that may have shortened life in 14.7 to 19.1 percent of cases, and decisions to withhold or withdraw life-prolonging treatment were made in 20.2 percent. Euthanasia seems to have increased in incidence since 1990, and ending of life without the patient's explicit request to have decreased slightly. For each type of medical decision except those in which life-prolonging treatment was withheld or withdrawn, cancer was the most frequently reported diagnosis. CONCLUSIONS Since the notification procedure was introduced, end-of-life decision making in the Netherlands has changed only slightly, in an anticipated direction. Close monitoring of such decisions is possible, and we found no signs of an unacceptable increase in the number of decisions or of less careful decision making.
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Affiliation(s)
- P J van der Maas
- Department of Public Health, Erasmus University Rotterdam, the Netherlands
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van der Heide A, Jacobs JW, Bijlsma JW, Heurkens AH, van Booma-Frankfort C, van der Veen MJ, Haanen HC, Hofman DM, van Albada-Kuipers GA, ter Borg EJ, Brus HL, Dinant HJ, Kruize AA, Schenk Y. The effectiveness of early treatment with "second-line" antirheumatic drugs. A randomized, controlled trial. Ann Intern Med 1996; 124:699-707. [PMID: 8633829 DOI: 10.7326/0003-4819-124-8-199604150-00001] [Citation(s) in RCA: 293] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To compare two therapeutic strategies for patients with recent-onset rheumatoid arthritis. DESIGN Open, randomized clinical trial. SETTING Outpatient clinics of six clinical centers. PATIENTS 238 consecutive patients with recently diagnosed rheumatoid arthritis. INTERVENTIONS Delayed or immediate introduction of treatment with slow-acting antirheumatic drugs (SAARDs). MEASUREMENTS Primary end points were functional disability, pain, joint score, and erythrocyte sedimentation rate at 6 and 12 months and progression of radiologic abnormalities at 12 months. RESULTS Statistically significant advantages at 12 months for patients receiving the SAARD strategy (immediate treatment with SAARDs) with regard to all primary end points that may be clinically important are indicated by the differences in improvements from baseline and their 95% CIs. These differences were 0.3 (95% CI, 0.2 to 0.6) for disability (range, 0 to 3), 10 mm (CI, 1 to 19 mm) for pain (range, 0 to 100 mm), 39 (CI, 4 to 74) for joint score (range, 0 to 534), and 11 mm/h (CI, 3 to 19 mm/h) for erythrocyte sedimentation rate (range, 1 to 140 mm/h), all in favor of SAARD treatment. The SAARD strategy also appears to be advantageous at 6 months. Radiologic abnormalities progressed at an equal rate in the SAARD and the non-SAARD groups; the difference in progression (range, 0 to 448) was 1 (CI, -3 to 5). Analyses were based on the intention-to-treat principle and thus included 29% of patients in the non-SAARD group who discontinued the non-SAARD treatment strategy; treatment was usually discontinued because of insufficient effectiveness. The SAARD strategy including two alternative SAARDs could not be continued by 8% of patients, usually because of adverse reactions. CONCLUSIONS Early introduction of SAARDs may be more beneficial than delayed introduction for patients with recently diagnosed rheumatoid arthritis.
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Affiliation(s)
- A van der Heide
- Department of Public Health, Faculty of Medicine, Erasmus University, Rotterdam, The Netherlands
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