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Liu Y, Semino E, Rietjens J, Payne S. Cancer experience in metaphors: patients, carers, professionals, students - a scoping review. BMJ Support Palliat Care 2024:spcare-2024-004927. [PMID: 38744448 DOI: 10.1136/spcare-2024-004927] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
The use of metaphors to talk about cancer experiences has attracted much research and debate, especially in the case of military metaphors. However, questions remain about what metaphors are used by different populations for different aspects of the cancer experience. This scoping review aims to answer them.We searched PubMed, PsycINFO, CINAHL, Scopus and Web of Science databases. Eligible sources include peer-reviewed scientific research published in English between 2013 and 2023, investigating patterns of metaphor use from adult populations (age ≥18) for cancer-related topics, such as cancer itself, the general experience of being ill, treatment, and people and relationships.Out of 1929 articles identified, 30 met the criteria, spanning over different populations. While most papers focused on cancer in general, some focused on specific cancer types, such as breast cancer. Both spontaneous and elicited data were collected in ten languages: mostly English (N=12), Swedish (N=3) and Arabic (N=3). The identified metaphors were subsumed under various broad categories, including particularly violence and journey. Other categories include education and non-human animate entity for the cancer itself, confinement and deprivation and cleanliness for the general experience of being ill with cancer, Poison and gardening for cancer treatment, and distance for patients' social relationships.It was found that metaphors help to identify how patients describe experiences of vulnerability and empowerment. To provide patient-centred care, clinicians and researchers should avoid blanket conclusions about helpful or unhelpful metaphors, but consider the ways in which different metaphors are used by different populations in different contexts.
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Affiliation(s)
- Yufeng Liu
- Department of Linguistics and English Language, Lancaster University, Lancaster, UK
| | - Elena Semino
- Department of Linguistics and English Language, Lancaster University, Lancaster, UK
| | - Judith Rietjens
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
- Department of Design, Organisation and Strategy, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, the Netherlands
| | - Sheila Payne
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
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Vandenbogaerde I, De Vleminck A, Cohen J, Verkissen MN, Lapeire L, Ingravallo F, Payne S, Wilcock A, Seymour J, Kars M, Grønvold M, Lunder U, Rietjens J, van der Heide A, Deliens L. Advance care planning-family carer psychological distress and involvement in decision making: the ACTION trial. BMJ Support Palliat Care 2024; 13:e807-e811. [PMID: 35177432 DOI: 10.1136/bmjspcare-2020-002744] [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: 10/14/2020] [Accepted: 02/02/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Facilitated advance care planning (ACP) helps family carers' to be aware of patient preferences. It can improve family carers' involvement in decision making and their overall experiences at the end of life, as well as, reduce psychological stress. We investigated the effects of the ACTION Respecting Choices (RC) ACP intervention on the family carers' involvement in decision making in the last 3 months of the patients' life and on the family carers' psychological distress after 3 months of bereavement. METHODS Over six European countries, a sample of 162 bereaved family carers returned a bereavement questionnaire. Involvement in decision making was measured with a single item of the Views of Informal Carers-Evaluation of Services Short Form questionnaire. Psychological distress was measured with the Impact of Event Scale (IES). RESULTS No significant effect was found on family carers involvement in decision making in the last 3 months of the patients' life (95% CI 0.449 to 4.097). However, the probability of involvement in decision making was slightly higher in the intervention arm of the study (89.6% vs 86.7%; OR=1.357). Overall, no statistical difference was found between intervention and control group regarding the IES (M=34.1 (1.7) vs 31.8 (1.5); (95% CI -2.2 to 6.8)). CONCLUSION The ACTION RC ACP intervention showed no significant effect on family carers' involvement in decision making or on subsequent psychological distress. More research is needed about (1) how family carers can be actively involved in ACP-conversations and (2) how to prepare family carers on their role in decision making. TRIAL REGISTRATION NUMBER International Standard Randomised Controlled Trial Number ISRCTN17231.
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Affiliation(s)
- Isabel Vandenbogaerde
- End of Life Care Research Group, Vrije Universiteit Brussel (VUB) & Universiteit Gent, Brussel, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussel, Belgium
- Department of Public Health and Primary Care, Universiteit Gent, Gent, Belgium
| | - Aline De Vleminck
- End of Life Care Research Group, Vrije Universiteit Brussel (VUB) & Universiteit Gent, Brussel, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussel, Belgium
| | - Joachim Cohen
- End of Life Care Research Group, Vrije Universiteit Brussel (VUB) & Universiteit Gent, Brussel, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussel, Belgium
| | - Mariëtte Nadine Verkissen
- End of Life Care Research Group, Vrije Universiteit Brussel (VUB) & Universiteit Gent, Brussel, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussel, Belgium
- Department of Public Health and Primary Care, Universiteit Gent, Gent, Belgium
| | - Lore Lapeire
- Department of Medical Oncology, University Hospital Ghent, Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), University Hospital Ghent, Ghent, Belgium
| | - Francesca Ingravallo
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Sheila Payne
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Andrew Wilcock
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jane Seymour
- School of Nursing and Midwifery, University of Sheffield, Sheffield, UK
| | - Marijke Kars
- Julius Centre/Palliative Care, University Medical Center Utrecht, Utecht, The Netherlands
| | - Mogens Grønvold
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Urska Lunder
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
| | - Judith Rietjens
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Luc Deliens
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussel, Belgium
- Department of Public Health and Primary Care, Universiteit Gent, Gent, Belgium
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Stiggelbout A, Griffioen I, Brands J, Melles M, Rietjens J, Kunneman M, van der Kolk M, van Eijck C, Snelders D. Metro Mapping: development of an innovative methodology to co-design care paths to support shared decision making in oncology. BMJ Evid Based Med 2023; 28:291-294. [PMID: 37236775 PMCID: PMC10579511 DOI: 10.1136/bmjebm-2022-112168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 05/28/2023]
Affiliation(s)
- Anne Stiggelbout
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
- Erasmus School Of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Ingeborg Griffioen
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
- Department of Design, Organisation and Strategy, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands
- Design Studio Panton, Deventer, The Netherlands
| | | | - Marijke Melles
- Department of Human-Centered Design, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands
| | - Judith Rietjens
- Department of Design, Organisation and Strategy, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marleen Kunneman
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
- Knowledge and Evaluation Research Unit, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Marion van der Kolk
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Casper van Eijck
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Dirk Snelders
- Department of Design, Organisation and Strategy, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands
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Driessen HPA, Busschbach JJV, van der Rijt CCD, Elfrink EJ, Raijmakers NJH, van Roij J, Rietjens J, Kranenburg LW. Unmet care needs of patients with advanced cancer and their relatives: multicentre observational study. BMJ Support Palliat Care 2023:spcare-2023-004242. [PMID: 37491145 DOI: 10.1136/spcare-2023-004242] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/05/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVES The care needs of patients with advanced cancer and their relatives change throughout the disease trajectory. This study focused on the care-related problems and needs of patients with advanced cancer and their relatives. This was done from the perspective of centres for information and support. METHODS This cross-sectional study used data from the eQuiPe study: an observational cohort study in which 40 Dutch hospitals participated. All adult patients with a diagnosis of a metastasised tumour and their relatives were eligible. Measures included information on the patients' and relatives' care problems and needs, assessed by the short version of the Problems and Needs in Palliative Care questionnaire. Socioeconomic demographics were also collected. RESULTS 1103 patients with advanced cancer and 831 relatives were included. Both patients (M=60.3, SD=29.0) and relatives (M=59.2, SD=26.6) experienced most problems in the domain of 'psychological issues'. Both patients (M=14.0, SD=24.2) and relatives (M=17.7, SD=25.7) most frequently reported unmet needs within this domain. The most often reported unmet need by patients was 'worrying about the future of my loved ones' (22.0%); for relatives this was 'fear for physical suffering of the patient' (32.8%). There was no clear relationship between socioeconomic demographics and the experienced unmet needs. CONCLUSIONS The most often mentioned unmet needs consisted of fears and worries, followed by a broad range of topics within multiple domains. Centres for information and support may play a role in reducing the unmet needs of (potential) visitors as these centres provide support on a broad range of topics.
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Affiliation(s)
- Helen P A Driessen
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jan J V Busschbach
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Erna J Elfrink
- Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Janneke van Roij
- The Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
- CoRPS - Center of Research on Psychology in Somatic diseases, Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Judith Rietjens
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Design, Organization, and Strategy, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands
| | - Leonieke W Kranenburg
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus Medical Center, Rotterdam, The Netherlands
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5
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Noorlandt H, Stoevelaar R, van Dongen S, Arslan M, Luu N, Kranenburg L, Witkamp E, van der Rijt C, Lorig K, van der Heide A, Rietjens J. Challenges in self-management of persons living with advanced cancer: An exploratory, in-depth interview study. Eur J Cancer Care (Engl) 2022; 31:e13638. [PMID: 35729779 PMCID: PMC9788059 DOI: 10.1111/ecc.13638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 10/06/2021] [Revised: 05/23/2022] [Accepted: 06/06/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To obtain insight in self-management challenges of persons with advanced cancer and factors that influence their self-management. METHODS Exploratory study among persons with advanced cancer. We conducted in-depth interviews and performed an inductive thematic analysis, using open, axial and selective coding. RESULTS We interviewed 33 persons with advanced cancer. Four self-management challenges were identified: (1) Dealing with physical and psychological symptoms and problems. (2) Navigating the illness trajectory, including management of clinical appointments and treatment regimens, end-of-life planning life and 'maintaining normality'. (3) Managing relations with healthcare professionals, including contributing experiential knowledge to medical decision-making. (4) Navigating changes in the social environment. Some participants responded proactively to these challenges, for example, by actively searching for information to obtain an extensive understanding of their illness and (re)scheduling medical appointments for a better fit in their agenda. Self-management strategies seemed to be influenced by patients' personality, life history, moment in the illness trajectory and the social environment. CONCLUSION Self-management challenges of persons with advanced cancer are based largely outside the professional care setting. Self-management strategies in response to these challenges are typically aimed at maintaining a normal life. Self-management support should be tailored to patients' needs and part of trustful partnerships with patients and relatives.
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Affiliation(s)
- Hanna Noorlandt
- Department of Public HealthErasmus MC, Erasmus University Medical CenterRotterdamThe Netherlands
| | - Rik Stoevelaar
- Department of Public HealthErasmus MC, Erasmus University Medical CenterRotterdamThe Netherlands
| | - Sophie van Dongen
- Department of Public HealthErasmus MC, Erasmus University Medical CenterRotterdamThe Netherlands
| | - Muzeyyen Arslan
- Department of Public HealthErasmus MC, Erasmus University Medical CenterRotterdamThe Netherlands
| | - Nancy Luu
- Department of Public HealthErasmus MC, Erasmus University Medical CenterRotterdamThe Netherlands
| | - Leonieke Kranenburg
- Department of Psychiatry, Section Medical Psychology and PsychotherapyErasmus MC, Erasmus University Medical CenterRotterdamThe Netherlands
| | - Erica Witkamp
- Department of Public HealthErasmus MC, Erasmus University Medical CenterRotterdamThe Netherlands,Center of Expertise Innovations in CareRotterdam University of Applied SciencesRotterdamThe Netherlands
| | - Carin van der Rijt
- Department of Medical OncologyErasmus MC, University Medical CenterRotterdamThe Netherlands
| | - Kate Lorig
- Stanford School of MedicineStanfordCaliforniaUSA
| | - Agnes van der Heide
- Department of Public HealthErasmus MC, Erasmus University Medical CenterRotterdamThe Netherlands
| | - Judith Rietjens
- Department of Public HealthErasmus MC, Erasmus University Medical CenterRotterdamThe Netherlands
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6
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Morita T, Kawahara T, Stone P, Sykes N, Miccinesi G, Klein C, Stiel S, Hui D, Deliens L, Heijltjes MT, Mori M, Heckel M, Robijn L, Krishna L, Rietjens J. Intercountry and intracountry variations in opinions of palliative care specialist physicians in Germany, Italy, Japan and UK about continuous use of sedatives: an international cross-sectional survey. BMJ Open 2022; 12:e060489. [PMID: 35459681 PMCID: PMC9036469 DOI: 10.1136/bmjopen-2021-060489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES To explore intercountry and intracountry differences in physician opinions about continuous use of sedatives (CUS), and factors associated with their approval of CUS. SETTINGS Secondary analysis of a questionnaire study. PARTICIPANTS Palliative care physicians in Germany (N=273), Italy (N=198), Japan (N=334) and the UK (N=111). PRIMARY AND SECONDARY OUTCOME MEASURES Physician approval for CUS in four situations, intention and treatment goal, how to use sedatives and beliefs about CUS. RESULTS There were no significant intercountry or intracountry differences in the degree of agreement with statements that (1) CUS is not necessary as suffering can always be relieved with other measures (mostly disagree); (2) intention of CUS is to alleviate suffering and (3) shortening the dying process is not intended. However, there were significant intercountry differences in agreement with statements that (1) CUS is acceptable for patients with longer survival or psychoexistential suffering; (2) decrease in consciousness is intended and (3) choice of neuroleptics or opioids. Acceptability of CUS for patients with longer survival or psychoexistential suffering and whether decrease in consciousness is intended also showed wide intracountry differences. Also, the proportion of physicians who agreed versus disagreed with the statement that CUS may not alleviate suffering adequately even in unresponsive patients, was approximately equal. Regression analyses revealed that both physician-related and country-related factors were independently associated with physicians' approval of CUS. CONCLUSION Variations in use of sedatives is due to both physician- and country-related factors, but palliative care physicians consistently agree on the value of sedatives to aid symptom control. Future research should focus on (1) whether sedatives should be used in patients with longer survival or with primarily psychoexistential suffering, (2) understanding physicians' intentions and treatment goals, (3) efficacy of different drugs and (4) understanding the actual experiences of patients receiving CUS.
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Affiliation(s)
- Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara Hospital, Hamamatsu, Shizuoka, Japan
| | - Takuya Kawahara
- Clinical Research Promotion Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Nigel Sykes
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Guido Miccinesi
- Department of Oncological Network, Prevention and Research Institute-ISPRO, Firenze, Italy
| | - Carsten Klein
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Nürnberg, Germany
| | - Stephanie Stiel
- Institute for General Practice and Palliative Care, Hannover Medical School, Hannover, Germany
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center, University of Texas, Austin, Texas, USA
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| | - Madelon T Heijltjes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Masanori Mori
- Palliative and Supportive care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Maria Heckel
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Lenzo Robijn
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Lalit Krishna
- The Division of Supportive and Palliative Care, National Cancer Center Singapore, National Cancer Center Singapore, Singapore
| | - Judith Rietjens
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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7
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Matthys O, De Vleminck A, Dierickx S, Deliens L, Van Goethem V, Lapeire L, Groenvold M, Lund L, Arnfeldt CM, Sengeloev L, Pappot H, Johnsen AT, Guerin S, Larkin PJ, Jordan C, Connolly M, D'Alton P, Costantini M, Di Leo S, Guberti M, Turola E, van der Heide A, Witkamp E, Rietjens J, van der Wel M, Brazil K, Prue G, Reid J, Scott D, Bristowe K, Harding R, Normand C, May P, Cronin C, Northouse L, Hudson P, Cohen J. Effectiveness of a nurse-delivered (FOCUS+) and a web-based (iFOCUS) psychoeducational intervention for people with advanced cancer and their family caregivers (DIAdIC): study protocol for an international randomized controlled trial. BMC Palliat Care 2021; 20:193. [PMID: 34963453 PMCID: PMC8713043 DOI: 10.1186/s12904-021-00895-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 12/21/2020] [Accepted: 12/10/2021] [Indexed: 11/21/2022] Open
Abstract
Background Worldwide, millions of people with advanced cancer and their family caregivers are experiencing physical and psychological distress. Psychosocial support and education can reduce distress and prevent avoidable healthcare resource use. To date, we lack knowledge from large-scale studies on which interventions generate positive outcomes for people with cancer and their informal caregivers’ quality of life. This protocol describes the DIAdIC study that will evaluate the effectiveness of two psychosocial and educational interventions aimed at improving patient-family caregiver dyads’ emotional functioning and self-efficacy. Methods We will conduct an international multicenter three-arm randomized controlled trial in Belgium, Denmark, Ireland, Italy, The Netherlands, and the United Kingdom. In each country, 156 dyads (936 in total) of people with advanced cancer and their family caregiver will be randomized to one of the study arms: 1) a nurse-led face-to-face intervention (FOCUS+), 2) a web-based intervention (iFOCUS) or 3) a control group (care as usual). The two interventions offer tailored psychoeducational support for patient-family caregiver dyads. The nurse-led face-to-face intervention consists of two home visits and one online video session and the web-based intervention is completed independently by the patient-family caregiver dyad in four online sessions. The interventions are based on the FOCUS intervention, developed in the USA, that addresses five core components: family involvement, optimistic outlook, coping effectiveness, uncertainty reduction, and symptom management. The FOCUS intervention will be adapted to the European context. The primary outcomes are emotional functioning and self-efficacy of the patient and the family caregiver, respectively. The secondary outcomes are quality of life, benefits of illness, coping, dyadic communication, and ways of giving support of the patient and family caregiver. Discussion DIAdIC aims to develop cost-effective interventions that integrate principles of early palliative care into standard care. The cross-country setup in six European countries allows for comparison of effectiveness of the interventions in different healthcare systems across Europe. By focusing on empowerment of the person with cancer and their family caregiver, the results of this RCT can contribute to the search for cost-effective novel interventions that can relieve constraints on professional healthcare. Trial registration Registration on ClinicalTrials.gov on 12/11/2020, identifier NCT04626349. Date and version identifier 20211209_DIAdIC_Protocol_Article. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00895-z.
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Affiliation(s)
- Orphé Matthys
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.
| | - Aline De Vleminck
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Sigrid Dierickx
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Vincent Van Goethem
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Lore Lapeire
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Mogens Groenvold
- Department of Public Health, University of Copenhagen and Palliative Care Research Unit, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Line Lund
- Department of Public Health, University of Copenhagen and Palliative Care Research Unit, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Caroline Moeller Arnfeldt
- Department of Public Health, University of Copenhagen and Palliative Care Research Unit, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Lisa Sengeloev
- Department of Oncology, Herlev Gentofte University Hospital, Herlev, Denmark
| | - Helle Pappot
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Suzanne Guerin
- UCD School of Psychology, University College Dublin, Belfield, Ireland
| | - Philip J Larkin
- Palliative and Supportive Care Service, Chair of Palliative Care Nursing, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Catherine Jordan
- UCD School of Psychology, University College Dublin, Belfield, Ireland
| | - Michael Connolly
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Paul D'Alton
- UCD School of Psychology, University College Dublin, Belfield, Ireland
| | - Massimo Costantini
- Scientific Directorate, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Silvia Di Leo
- Psycho-oncology Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Monica Guberti
- Nursing & Health Care Professions Directorate, Azienda USL-IRCCS, Reggio Emilia, Italy
| | - Elena Turola
- Scientific Directorate, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Agnes van der Heide
- Deparmtent of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Erika Witkamp
- Deparmtent of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Judith Rietjens
- Deparmtent of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Maaike van der Wel
- Deparmtent of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Kevin Brazil
- School of Nursing and Midwifery, Queen's University of Belfast, 97 Lisburn Road, Belfast, Northern Ireland, BT9 7BL, UK
| | - Gillian Prue
- School of Nursing and Midwifery, Queen's University of Belfast, 97 Lisburn Road, Belfast, Northern Ireland, BT9 7BL, UK
| | - Joanne Reid
- School of Nursing and Midwifery, Queen's University of Belfast, 97 Lisburn Road, Belfast, Northern Ireland, BT9 7BL, UK
| | - David Scott
- School of Nursing and Midwifery, Queen's University of Belfast, 97 Lisburn Road, Belfast, Northern Ireland, BT9 7BL, UK
| | - Katherine Bristowe
- King's College London, Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, Cicely Saunders Institute, London, UK
| | - Richard Harding
- King's College London, Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, Cicely Saunders Institute, London, UK
| | - Charles Normand
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland.,Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Peter May
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland.,The Irish Longitudinal Study on Ageing, Dublin, Ireland
| | - Catherine Cronin
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | | | - Peter Hudson
- Centre for Palliative Care, St Vincent's Hospital, Melbourne, Australia.,Vrije University Brussels (VUB), Brussels, Belgium
| | - Joachim Cohen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
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Robijn L, Gijsberts MJ, Pype P, Rietjens J, Deliens L, Chambaere K. Continuous Palliative Sedation Until Death: The Development of a Practice Protocol for Nursing Homes. J Am Med Dir Assoc 2021; 22:1776.e1-1776.e7. [PMID: 33930319 DOI: 10.1016/j.jamda.2021.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 09/19/2020] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Challenges inherent in the practice of continuous palliative sedation until death appear to be particularly pervasive in nursing homes. We aimed to develop a protocol to improve the quality of the practice in Belgian nursing homes. METHODS The development of the protocol was based on the Medical Research Council Framework and made use of the findings of a systematic review of existing improvement initiatives and focus groups with 71 health care professionals [palliative care physicians, general practitioners (GPs), and nursing home staff] identifying perceived barriers to the use of continuous palliative sedation until death in nursing homes. The protocol was then reviewed and refined by another 70 health care professionals (palliative care physicians, geriatricians, GPs, and nursing home staff) through 10 expert panels. RESULTS The final protocol was signed off by expert panels after 2 consultation rounds in which the remaining issues were ironed out. The protocol encompassed 7 sequential steps and is primarily focused on clarification of the medical and social situation, communication with all care providers involved and with the resident and/or relatives, the organization of care, the actual performance of continuous sedation, and the supporting of relatives and care providers during and after the procedure. Although consistent with existing guidelines, our protocol describes more comprehensively recommendations about coordination and collaboration practices in nursing homes as well as specific matters such as how to communicate with fellow residents and give them the opportunity to say goodbye in some way to the person who is dying. CONCLUSIONS AND IMPLICATIONS This study succeeded in developing a practice protocol for continuous palliative sedation until death adapted to the specific context of nursing homes. Before implementing it, future research should focus on developing profound implementation strategies and on thoroughly evaluating its effectiveness.
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Affiliation(s)
- Lenzo Robijn
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Public Health & Primary Care, Ghent University, Ghent, Belgium.
| | - Marie-Jose Gijsberts
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Peter Pype
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium; Department of Public Health & Primary Care, Ghent University, Ghent, Belgium
| | - Judith Rietjens
- Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, the Netherlands
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Public Health & Primary Care, Ghent University, Ghent, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Public Health & Primary Care, Ghent University, Ghent, Belgium
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9
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Robijn L, Deliens L, Scherrens AL, Pauwels NS, Pype P, Rietjens J, Chambaere K. A systematic review of quality improvement initiatives for continuous sedation until death. Palliat Med 2021; 35:670-682. [PMID: 33722107 DOI: 10.1177/0269216321996990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Extensive debate surrounds the practice of continuous sedation until death within end-of-life care. AIM To provide insight into existing initiatives to support the practice of continuous sedation until death and assess their feasibility and effectiveness. DESIGN Systematic review and narrative synthesis, registered on PROSPERO (CRD42020149630). DATA SOURCES Records were searched through MEDLINE, EMBASE, CENTRAL, CINAHL, and Web of Science from inception to April 16 2020. Peer-reviewed studies reporting original data on initiatives to support the practice of continuous sedation were included for review. RESULTS Twenty-one studies met the criteria and were included. Initiatives were focused on assessment tools of consciousness and discomfort (9), the use of guidelines and protocols (8), and expert consultation (3). All initiatives were reported as useful, acceptable, and feasible. Studies on the use of monitoring devices showed that a small proportion of patients were found to be awake, despite the patient being unresponsive according to the observer-based sedation scales. However, the wide range of values of these monitoring devices for comfortable and adequately sedated patients seems to hamper its overall implementation in daily clinical practice. Physicians reported changes in practice conform to guideline recommendations but the shift was modest at best. Expert consultation was regarded as supportive when sufficient expertise is lacking and helpful in avoiding possibly unnecessary sedations. CONCLUSIONS The reviewed initiatives may contribute to improvement of continuous sedation until death, though their evidence base is rather limited. More insight is needed into their feasibility, preconditions for effective implementation and impact in actual practice.
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Affiliation(s)
- Lenzo Robijn
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Luc Deliens
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Anne-Lore Scherrens
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Nele S Pauwels
- Ghent University, Knowledge Management Center Ghent, Ghent, Belgium
| | - Peter Pype
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Judith Rietjens
- Erasmus University Medical Centre, Department of Public Health, Rotterdam, The Netherlands
| | - Kenneth Chambaere
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
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10
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Fahner J, Rietjens J, van der Heide A, Milota M, van Delden J, Kars M. Evaluation showed that stakeholders valued the support provided by the Implementing Pediatric Advance Care Planning Toolkit. Acta Paediatr 2021; 110:237-246. [PMID: 32434275 PMCID: PMC7818164 DOI: 10.1111/apa.15370] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/04/2020] [Accepted: 05/15/2020] [Indexed: 01/22/2023]
Abstract
AIM This study described the development, and pilot evaluation, of the Implementing Pediatric Advance Care Planning Toolkit (IMPACT). METHODS Key elements of paediatric advance care planning (ACP) were defined using a systematic review, a survey of 168 paediatricians and qualitative studies of 13 children with life-limiting conditions, 20 parents and 18 paediatricians. Participants were purposively recruited from six Dutch university hospitals during September 2016 and November 2018. Key elements were translated into intervention components guided by theory. The acceptability of the content was evaluated by a qualitative pilot study during February and September 2019. This focused on 27 children with life-limiting conditions from hospitals, a hospice and home care, together with 41 parents, 11 physicians and seven nurses who cared for them. RESULTS IMPACT provided a holistic, caring approach to ACP, gave children a voice and cared for their parents. It provided information on ACP for families and clinicians, manuals to structure ACP conversations and training for clinicians in communication skills and supportive attitudes. The 53 pilot study participants felt that IMPACT was appropriate for paediatric ACP. CONCLUSION IMPACT was an appropriate intervention that supported a holistic approach towards paediatric ACP, focused on the child's perspective and provided care for their parents.
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Affiliation(s)
- Jurrianne Fahner
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Judith Rietjens
- Department of Public HealthErasmus Medical CenterRotterdamthe Netherlands
| | | | - Megan Milota
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Johannes van Delden
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Marijke Kars
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtthe Netherlands
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11
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Robijn L, Deliens L, Rietjens J, Pype P, Chambaere K. Barriers in the Decision Making About and Performance of Continuous Sedation Until Death in Nursing Homes. Gerontologist 2020; 60:916-925. [PMID: 31850500 DOI: 10.1093/geront/gnz165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 09/12/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES While decision making about and performance of continuous sedation involve many challenges, they appear to be particularly pervasive in nursing homes. This study aims to identify barriers to the decision making and performance of continuous sedation until death in Flemish nursing homes as experienced by the health care professionals involved. RESEARCH DESIGN AND METHODS Ten focus groups were held with 71 health care professionals including 16 palliative care physicians, 42 general practitioners, and 13 nursing home staff. Discussions were transcribed verbatim and analyzed using a constant comparative approach. RESULTS Perceived barriers concerned factors prior to and during sedation and were classified according to three types: (a) personal barriers related to knowledge and skills including the lack of clarity on what continuous sedation should be used for (linguistic ambiguity) and when and how it should be used (practical ambiguity); (b) relational barriers concerning communication and collaboration both between health care professionals and with family; (c) organizational barriers related to the organization of care in nursing homes where, for example, there is no on-site physician, or where the recommended medication is not always available. DISCUSSION AND IMPLICATIONS The findings suggest there are considerable challenges for sound decision making about and performance of continuous sedation until death in nursing homes. There is a need for multicomponent initiatives that provide guidance in the context of the complexity of a resident's medical situation, the family, and the specific organization of care, which would have the potential to facilitate and improve the decision-making process and performance of continuous sedation in nursing homes.
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Affiliation(s)
- Lenzo Robijn
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| | - Judith Rietjens
- Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, the Netherlands
| | - Peter Pype
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| | - Kenneth Chambaere
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
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12
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van Esch HJ, Lokker ME, Rietjens J, van Zuylen L, van der Rijt CCD, van der Heide A. Understanding relatives' experience of death rattle. BMC Psychol 2020; 8:62. [PMID: 32532332 PMCID: PMC7291713 DOI: 10.1186/s40359-020-00431-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 06/09/2020] [Indexed: 11/12/2022] Open
Abstract
Background Death rattle is a frequently occurring symptom in the last phase of life. The experience of death rattle of relatives has been found to vary. It is unclear if treatment with medication is useful. The most fitting solution for this symptom is still under debate. Aim This study aims to better understand the experience of relatives of their loved ones’ death rattle. Design A qualitative interview study with a phenomenological approach was performed. Data were collected through semi-structured interviews which were audio recorded, transcribed and analyzed using qualitative content analysis. Participants Nineteen family members of 15 patients were interviewed. Results Most relatives had experienced death rattle as a distressing symptom. Concerns about how long the rattling would last resulted in more distress. Experience of death rattle was less fierce when other symptoms such as pain or dyspnea prevailed. Hearing the sound of death rattle sometimes reminded relatives of previously witnessed dying trajectories, which seemed to increase their current level of distress. The experience of death rattle is not always influenced by the amount and quality of information given about the symptom. Conclusion Death rattle is a stressful symptom and the experience of relatives is influenced by more factors than the sound itself. Communication and information alone seem inefficient to address relatives’ distress. The best approach for dealing with this symptom is unclear. Further research needs to show if prophylactically given drugs may be helpful in its prevention.
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Affiliation(s)
- Harriëtte J van Esch
- Department of Medical Oncology, Erasmus MC Cancer Institute, 3000CA, Rotterdam, the Netherlands. .,Laurens Cadenza, Oosterhagen 239, Rotterdam, 3078 CL, the Netherlands. .,Erasmus MC, Department of Public health, Wytema weg 80, Rotterdam, 3015 CN, the Netherlands.
| | - Martine E Lokker
- Erasmus MC, Department of Public health, Wytema weg 80, Rotterdam, 3015 CN, the Netherlands
| | - Judith Rietjens
- Erasmus MC, Department of Public health, Wytema weg 80, Rotterdam, 3015 CN, the Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Erasmus MC Cancer Institute, 3000CA, Rotterdam, the Netherlands
| | - Carin C D van der Rijt
- Department of Medical Oncology, Erasmus MC Cancer Institute, 3000CA, Rotterdam, the Netherlands
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Abstract
ObjectivesThere is increased global focus on advance care planning (ACP) with attention from policymakers, more education programmes, laws and public awareness campaigns.MethodsWe provide a summary of the evidence about what ACP is, and how it should be conducted. We also address its barriers and facilitators and discuss current and future models of ACP, including a wider look at how to best integrate those who have diminished decisional capacity.ResultsDifferent models are analysed, including new work in Wales (future care planning which includes best interest decision-making for those without decisional capacity), Asia and in people with dementia.ConclusionsACP practices are evolving. While ACP is a joint responsibility of patients, relatives and healthcare professionals, more clarity on how to apply best ACP practices to include people with diminished capacity will further improve patient-centred care.
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14
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Franse CB, Zhang X, van Grieken A, Rietjens J, Alhambra-Borrás T, Durá E, Garcés-Ferrer J, van Staveren R, Rentoumis T, Markaki A, Bilajac L, Vasiljev Marchesi V, Rukavina T, Verma A, Williams G, Clough G, Koppelaar E, Martijn R, Mattace Raso F, Voorham AJJ, Raat H. A coordinated preventive care approach for healthy ageing in five European cities: A mixed methods study of process evaluation components. J Adv Nurs 2019; 75:3689-3701. [PMID: 31441529 DOI: 10.1111/jan.14181] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 12/07/2018] [Revised: 07/19/2019] [Accepted: 08/13/2019] [Indexed: 12/14/2022]
Abstract
AIMS To evaluate specific process components of the Urban Health Centres Europe (UHCE) approach; a coordinated preventive care approach aimed at healthy ageing by decreasing falls, polypharmacy, loneliness and frailty among older persons in community settings of five cities in the United Kingdom, Greece, Croatia, the Netherlands and Spain. DESIGN Mixed methods evaluation of specific process components of the UHCE approach: reach of the target population, dose of the intervention actually delivered and received by participants and satisfaction and experience of main stakeholders involved in the approach. METHODS The UHCE approach intervention consisted of a preventive assessment, shared decision-making on a care plan and enrolment in one or more of four coordinated care-pathways that targeted falls, polypharmacy, loneliness and frailty. Quantitative data from a questionnaire and quantitative/qualitative data from logbooks were collected among older persons involved in the approach. Qualitative data from focus groups were collected among older persons, informal caregivers and professionals involved in the approach. Quantitative data were analysed by means of descriptive statistics and multilevel logistic regression models. Qualitative data were analysed through thematic analysis. RESULTS Having limited function was associated with non-enrolment in falls and loneliness care-pathways (both p < .01). The mean rating of the approach was 8.3/10 (SD 1.9). Feeling supported by a care professional and meeting people were main benefits for older persons. Mistrust towards unfamiliar care providers, lack of confidence to engage in care activities and health constraints were main barriers towards engagement in care. CONCLUSIONS Although the UHCE approach was received generally positively, health constraints and psychosocial barriers prevented older person's engagement in care. IMPACT Coordinated preventive care approaches for older community-dwelling persons should address health constraints and psychosocial barriers that hinder older person's engagement in care. TRIAL REGISTRATION ISRCTN registry number is ISRCTN52788952. Date of registration is 13/03/2017.
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Affiliation(s)
- Carmen B Franse
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Xuxi Zhang
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Amy van Grieken
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Judith Rietjens
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Estrella Durá
- Polibienestar Research Institute, University of Valencia, Valencia, Spain
| | | | | | | | | | - Lovorka Bilajac
- Faculty of Medicine, Department of Social Medicine and Epidemiology, University of Rijeka, Rijeka, Croatia.,Teaching Institute of Public Health Primorsko-Goranska County, Rijeka, Croatia
| | - Vanja Vasiljev Marchesi
- Faculty of Medicine, Department of Social Medicine and Epidemiology, University of Rijeka, Rijeka, Croatia.,Faculty of Health Studies, Department of Public Health, University of Rijeka, Rijeka, Croatia
| | - Tomislav Rukavina
- Faculty of Medicine, Department of Social Medicine and Epidemiology, University of Rijeka, Rijeka, Croatia.,Teaching Institute of Public Health Primorsko-Goranska County, Rijeka, Croatia
| | - Arpana Verma
- Manchester Urban Collaboration on Health, Centre for Epidemiology, Division of Population Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Greg Williams
- Manchester Urban Collaboration on Health, Centre for Epidemiology, Division of Population Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Gary Clough
- Manchester Urban Collaboration on Health, Centre for Epidemiology, Division of Population Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Elin Koppelaar
- Research Centre Innovation in Care, Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
| | - Rens Martijn
- Research Centre Innovation in Care, Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
| | - Francesco Mattace Raso
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Antonius J J Voorham
- Research Centre Innovation in Care, Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
| | - Hein Raat
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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15
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Slockers MT, Nusselder WJ, Rietjens J, van Beeck EF. Unnatural death: a major but largely preventable cause-of-death among homeless people? Eur J Public Health 2019; 28:248-252. [PMID: 29415211 DOI: 10.1093/eurpub/cky002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background We aimed to assess the contribution of specific causes-of-death to excess mortality of homeless persons and to identify differences in cause-specific mortality rates after vs. before implementing social policy measures. Methods We conducted a register based 10-year follow-up study of homeless adults in Rotterdam and calculated the proportion of deaths by cause-of-death in this cohort in the period 2001-2010. We estimated cause-specific mortality among the homeless compared to the general population with Standardized Mortality Ratios. We calculated Hazard Ratios adjusted for age and sex to compare mortality rates by cause-of-death among the homeless in the period after (2006-2010) vs. before (2001-2005) implementing social policy measures. Results Our cohort consisted of 2130 homeless persons with a mean age of 40, 3 years. Unnatural death, cardiovascular disease and cancer were the main causes of death. Compared to the general population of Rotterdam, the homeless had an excess risk of death for all causes. The largest mortality differences with Rotterdam citizens were observed for unnatural death (SMR 14.8, CI 11.5-18.7), infectious diseases (SMR 10.0, CI 5.2-17.5) and psychiatric disorders (SMR 7.7, CI 4.0-13.5). Mortality due to intentional injuries (suicide and homicide) differed significantly between the two study periods (HR 0.45, CI 0.20-0.97). Conclusions Reducing unnatural death should be a target in social policies aimed at improving the health of the homeless. We generated the hypothesis that social policies aimed at housing, work and improved contact with health care could be accompanied by less suicides and homicides within this vulnerable group.
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Affiliation(s)
- Marcel T Slockers
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Wilma J Nusselder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Judith Rietjens
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ed F van Beeck
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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16
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Robijn L, Seymour J, Deliens L, Korfage I, Brown J, Pype P, Van Der Heide A, Chambaere K, Rietjens J. The involvement of cancer patients in the four stages of decision-making preceding continuous sedation until death: A qualitative study. Palliat Med 2018; 32:1198-1207. [PMID: 29667509 DOI: 10.1177/0269216318770342] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Involving patients in decision-making is considered to be particularly appropriate towards the end of life. Professional guidelines emphasize that the decision to initiate continuous sedation should be made in accordance with the wishes of the dying person and be preceded by their consent. AIM To describe the decision-making process preceding continuous sedation until death with particular attention to the involvement of the person who is dying. DESIGN Qualitative case studies using interviews. SETTING/PARTICIPANTS Interviews with 26 physicians, 30 nurses and 24 relatives caring for 24 patients with cancer who received continuous sedation until death in Belgium, the United Kingdom and the Netherlands. RESULTS We distinguished four stages of decision-making: initiation, information exchange, deliberation and the decision to start continuous sedation until death. There was wide variation in the role the patient had in the decision-making process. At one end of the spectrum (mostly in the United Kingdom), the physician discussed the possible use of sedation with the patient, but took the decision themselves. At the other end (mostly in Belgium and the Netherlands), the patient initiated the conversation and the physician's role was largely limited to evaluating if and when the medical criteria were met. CONCLUSION Decision-making about continuous sedation until death goes through four stages and the involvement of the patient in the decision-making varies. Acknowledging the potential sensitivity of raising the issue of end-of-life sedation, we recommend building into clinical practice regular opportunities to discuss the goals and preferences of the person who is dying for their future medical treatment and care.
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Affiliation(s)
- Lenzo Robijn
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,2 Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Jane Seymour
- 3 The School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Luc Deliens
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,2 Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Ida Korfage
- 4 Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, The Netherlands
| | - Jayne Brown
- 5 School of Nursing and Midwifery, De Montfort University, Leicester, UK.,6 Centre for the Promotion of Excellence in Palliative Care, De Montfort University, Leicester, UK
| | - Peter Pype
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,7 Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Agnes Van Der Heide
- 4 Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, The Netherlands
| | - Kenneth Chambaere
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,2 Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Judith Rietjens
- 4 Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, The Netherlands
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17
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Abarshi E, Rietjens J, Robijn L, Caraceni A, Payne S, Deliens L, Van den Block L. International variations in clinical practice guidelines for palliative sedation: a systematic review. BMJ Support Palliat Care 2017; 7:223-229. [PMID: 28432090 DOI: 10.1136/bmjspcare-2016-001159] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [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: 04/15/2016] [Revised: 01/09/2017] [Accepted: 04/01/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Palliative sedation is a highly debated medical practice, particularly regarding its proper use in end-of-life care. Worldwide, guidelines are used to standardise care and regulate this practice. In this review, we identify and compare national/regional clinical practice guidelines on palliative sedation against the European Association for Palliative Care (EAPC) palliative sedation Framework and assess the developmental quality of these guidelines using the Appraisal Guideline Research and Evaluation (AGREE II) instrument. METHODS Using the PRISMA criteria, we searched multiple databases (PubMed, CancerLit, CINAHL, Cochrane Library, NHS Evidence and Google Scholar) for relevant guidelines, and selected those written in English, Dutch and Italian; published between January 2000 and March 2016. RESULTS Of 264 hits, 13 guidelines-Belgium, Canada (3), Ireland, Italy, Japan, the Netherlands, Norway, Spain, Europe, and USA (2) were selected. 8 contained at least 9/10 recommendations published in the EAPC Framework; 9 recommended 'pre-emptive discussion of the potential role of sedation in end-of-life care'; 9 recommended 'nutrition/hydration while performing sedation' and 8 acknowledged the need to 'care for the medical team'. There were striking differences in terminologies used and in life expectancy preceding the practice. Selected guidelines were conceptually similar, comparing closely to the EAPC Framework recommendations, albeit with notable variations. CONCLUSIONS Based on AGREE II, 3 guidelines achieved top scores and could therefore be recommended for use in this context. Also, domains 'scope and purpose' and 'editorial independence' ranked highest and lowest, respectively-underscoring the importance of good reportage at the developmental stage.
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Affiliation(s)
- Ebun Abarshi
- International Observatory on End-of-Life Care, Lancaster, United Kingdom
| | - Judith Rietjens
- Department of Public Health, Erasmus Medical Centre, Rotterdam, The Netherlands.,End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Lenzo Robijn
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Augusto Caraceni
- Fondazione IRCCS Instituto Nazionale dei Tumori, Milan, Italy.,European Palliative Care Research Center, Norwegian University of Science and Technology Trondheim Norway, EAPC Research Network
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster, United Kingdom
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Penders YW, Rietjens J, Albers G, Croezen S, Van den Block L. Differences in out-of-pocket costs of healthcare in the last year of life of older people in 13 European countries. Palliat Med 2017; 31:42-52. [PMID: 27129681 DOI: 10.1177/0269216316647206] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Research on the costs of healthcare provision has so far focused on insurer costs rather than out-of-pocket costs. Out-of-pocket costs may be important to patients making medical decisions. AIM To investigate the self-reported out-of-pocket costs associated with healthcare in the last year of life of older adults in Europe. DESIGN A post-death survey, part of the Survey of Health, Ageing, and Retirement in Europe, completed by proxy respondents in four waves from 2005 to 2012. SETTING/PARTICIPANTS Proxy respondents for 2501 deceased adults of 55 years or over. Data from 13 European countries and four waves from 2005 to 2012 were used. RESULTS The proportion of people with out-of-pocket costs ranged from 21% to 96% in different European Union countries. Out-of-pocket costs ranged from 2% to 25% of median household income. Secondary and institutional care was most often the largest contributor to out-of-pocket costs, with care received in a care home being the most expensive type of care in 11 of 13 countries. Multilevel analyses showed that limitations in more than two activities of daily living (coefficient = 6.47, 95% confidence interval = 1.81-11.14) and a total hospitalization time of 3-6 months (coefficient = 14.66; 95% confidence interval = 0.97-28.35) or more than 6 months (coefficient = 31.01; 95% confidence interval = 11.98-50.15) were associated with higher out-of-pocket costs. In total, 24% of the variance on a country level remained unexplained. CONCLUSION Variation in out-of-pocket costs for healthcare in the last year of life between European countries indicates that countries face different challenges in making healthcare in the last year of life affordable for all.
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Affiliation(s)
- Yolanda Wh Penders
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Judith Rietjens
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,2 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Gwenda Albers
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Simone Croezen
- 2 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.,3 The Netherlands Institute for Social Research (SCP), The Hague, The Netherlands
| | - Lieve Van den Block
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
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19
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Robijn L, Cohen J, Rietjens J, Deliens L, Chambaere K. Trends in Continuous Deep Sedation until Death between 2007 and 2013: A Repeated Nationwide Survey. PLoS One 2016; 11:e0158188. [PMID: 27337064 PMCID: PMC4918927 DOI: 10.1371/journal.pone.0158188] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 06/10/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Continuous deep sedation until death is a highly debated medical practice, particularly regarding its potential to hasten death and its proper use in end-of-life care. A thorough analysis of important trends in this practice is needed to identify potentially problematic developments. This study aims to examine trends in the prevalence and practice characteristics of continuous deep sedation until death in Flanders, Belgium between 2007 and 2013, and to study variation on physicians' degree of palliative training. METHODS Population-based death certificate study in 2007 and 2013 in Flanders, Belgium. Reporting physicians received questionnaires about medical practices preceding the patient's death. Patient characteristics, clinical characteristics (drugs used, duration, artificial nutrition/hydration, intention and consent), and palliative care training of attending physician were recorded. We posed the following question regarding continuous deep sedation: 'Was the patient continuously and deeply sedated or kept in a coma until death by the use of one or more drugs'. RESULTS After the initial rise of continuous deep sedation to 14.5% in 2007 (95%CI 13.1%-15.9%), its use decreased to 12.0% in 2013 (95%CI 10.9%-13.2%). Compared with 2007, in 2013 opioids were less often used as sole drug and the decision to use continuous deep sedation was more often preceded by patient request. Compared to non-experts, palliative care experts more often used benzodiazepines and less often opioids, withheld artificial nutrition/hydration more often and performed sedation more often after a request from or with the consent of the patient or family. CONCLUSION Worldwide, this study is the first to show a decrease in the prevalence of continuous deep sedation. Despite positive changes in performance and decision-making towards more compliance with due care requirements, there is still room for improvement in the use of recommended drugs and in the involvement of patients and relatives in the decision-making process.
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Affiliation(s)
- Lenzo Robijn
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Joachim Cohen
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Judith Rietjens
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Kenneth Chambaere
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
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20
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Affiliation(s)
- Judith Rietjens
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Ida Korfage
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
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21
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Robijn L, Chambaere K, Raus K, Rietjens J, Deliens L. Reasons for continuous sedation until death in cancer patients: a qualitative interview study. Eur J Cancer Care (Engl) 2015; 26. [PMID: 26515814 DOI: 10.1111/ecc.12405] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2015] [Indexed: 11/28/2022]
Abstract
End-of-life sedation, though increasingly prevalent and widespread, remains a highly debated medical practice in the context of palliative medicine. This qualitative study aims to look more specifically at how health care workers justify their use of continuous sedation until death and which factors they report as playing a part in the decision-making process. In-depth interviews were held with 28 physicians and 22 nurses of 27 cancer patients in Belgium who had received continuous sedation until death in hospitals, palliative care units or at home. Our findings indicate that medical decision-making for continuous sedation is not only based on clinical indications but also related to morally complex issues such as the social context and the personal characteristics and preferences of individual patient and their relatives. The complex role of non-clinical factors in palliative sedation decision-making needs to be further studied to assess which medically or ethically relevant arguments are underlying daily clinical practice. Finally, our findings suggest that in some cases continuous sedation was resorted to as an alternative option at the end of life when euthanasia, a legally regulated option in Belgium, was no longer practically possible.
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Affiliation(s)
- L Robijn
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - K Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - K Raus
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Bioethics Institute Ghent, Department of Philosophy and Moral Science, Ghent University, Ghent, Belgium
| | - J Rietjens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - L Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
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22
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Seymour J, Rietjens J, Bruinsma S, Deliens L, Sterckx S, Mortier F, Brown J, Mathers N, van der Heide A. Seymour et al. Palliative sedation: Improvement of guidelines necessary, but not sufficient: A reply. Palliat Med 2015; 29:481. [PMID: 25896072 DOI: 10.1177/0269216315570414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Jane Seymour
- School of Health Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Judith Rietjens
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Sophie Bruinsma
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Sigrid Sterckx
- Bioethics Institute Ghent, Ghent University, Ghent, Belgium Department of Philosophy and Moral Sciences, Vrije Universiteit Brussel, Brussels, Belgium
| | - Freddy Mortier
- Department of Philosophy and Moral Sciences, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jayne Brown
- School of Nursing and Midwifery, De Montfort University, Leicester, UK
| | - Nigel Mathers
- Academic Unit of Primary Medical Care, University of Sheffield, Northern General Hospital, Sheffield, UK
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23
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Seymour J, Rietjens J, Bruinsma S, Deliens L, Sterckx S, Mortier F, Brown J, Mathers N, van der Heide A. Using continuous sedation until death for cancer patients: a qualitative interview study of physicians' and nurses' practice in three European countries. Palliat Med 2015; 29:48-59. [PMID: 25062816 PMCID: PMC4266692 DOI: 10.1177/0269216314543319] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Extensive debate surrounds the practice of continuous sedation until death to control refractory symptoms in terminal cancer care. We examined reported practice of United Kingdom, Belgian and Dutch physicians and nurses. METHODS Qualitative case studies using interviews. SETTING Hospitals, the domestic home and hospices or palliative care units. PARTICIPANTS In all, 57 Physicians and 73 nurses involved in the care of 84 cancer patients. RESULTS UK respondents reported a continuum of practice from the provision of low doses of sedatives to control terminal restlessness to rarely encountered deep sedation. In contrast, Belgian respondents predominantly described the use of deep sedation, emphasizing the importance of responding to the patient's request. Dutch respondents emphasized making an official medical decision informed by the patient's wish and establishing that a refractory symptom was present. Respondents employed rationales that showed different stances towards four key issues: the preservation of consciousness, concerns about the potential hastening of death, whether they perceived continuous sedation until death as an 'alternative' to euthanasia and whether they sought to follow guidelines or frameworks for practice. CONCLUSION This qualitative analysis suggests that there is systematic variation in end-of-life care sedation practice and its conceptualization in the United Kingdom, Belgium and the Netherlands.
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Affiliation(s)
- Jane Seymour
- School of Health Sciences, Sue Ryder Care Centre for the Study of Supportive, Palliative and End of Life Care, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Judith Rietjens
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Sophie Bruinsma
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Sigrid Sterckx
- Bioethics Institute Ghent, Ghent University, Ghent, Belgium Department of Philosophy and Moral Sciences, Vrije Universiteit Brussel, Brussels, Belgium
| | - Freddy Mortier
- Bioethics Institute Ghent, Ghent University, Ghent, Belgium
| | - Jayne Brown
- School of Nursing and Midwifery, Center for the Promotion of Excellence in Palliative Care, De Montfort University, Leicester, UK
| | - Nigel Mathers
- Academic Unit of Primary Medical Care, Northern General Hospital, University of Sheffield, Sheffield, UK
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Seale C, Raus K, Bruinsma S, van der Heide A, Sterckx S, Mortier F, Payne S, Mathers N, Rietjens J, Addington-Hall J, Anquinet L, Brown J, Bruinsma S, Deliens L, Mathers N, Mortier F, Payne S, Raus K, Rietjens J, Seale C, Seymour J, Smithson WH, Sterckx S, Janssens R, van der Heide A. The language of sedation in end-of-life care: The ethical reasoning of care providers in three countries. Health (London) 2014; 19:339-54. [DOI: 10.1177/1363459314555377] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The application of ethically controversial medical procedures may differ from one place to another. Drawing on a keyword and text-mining analysis of 156 interviews with doctors and nurses involved in end-of-life care (‘care providers’), differences between countries in care providers’ ethical rationales for the use of sedation are reported. In the United Kingdom, an emphasis on titrating doses proportionately against symptoms is more likely, maintaining consciousness where possible. The potential harms of sedation are perceived to be the potential hastening of social as well as biological death. In Belgium and the Netherlands, although there is concern to distinguish the practice from euthanasia, rapid inducement of deep unconsciousness is more acceptable to care providers. This is often perceived to be a proportionate response to unbearable suffering in a context where there is also greater pressure to hasten dying from relatives and others. This means that sedation is more likely to be organised like euthanasia, as the end ‘moment’ is reached, and family farewells are organised before the patient is made unconscious for ever. Medical and nursing practices are partly responses to factors outside the place of care, such as legislation and public sentiment. Dutch guidelines for sedation largely tally with the practices prevalent in the Netherlands and Belgium, in contrast with those produced by the more international European Association for Palliative Care whose authors describe an ethical framework closer to that reportedly used by UK care providers.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Judith Rietjens
- Erasmus MC, Netherlands; Ghent University & Vrije Universiteit Brussel, Belgium
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25
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Abarshi E, Rietjens J, Caraceni A, Payne S, Deliens L, Van Den Block L. Towards a standardised approach for evaluating guidelines and guidance documents on palliative sedation: study protocol. BMC Palliat Care 2014; 13:34. [PMID: 25028571 PMCID: PMC4099031 DOI: 10.1186/1472-684x-13-34] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [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: 11/22/2013] [Accepted: 06/26/2014] [Indexed: 11/20/2022] Open
Abstract
Background Sedation in palliative care has received growing attention in recent years; and so have guidelines, position statements, and related literature that provide recommendations for its practice. Yet little is known collectively about the content, scope and methodological quality of these materials. According to research, there are large variations in palliative sedation practice, depending on the definition and methodology used. However, a standardised approach to comparing and contrasting related documents, across countries, associations and governmental bodies is lacking. This paper reports on a protocol designed to enable thorough and systematic comparison of guidelines and guidance documents on palliative sedation. Methods and design A multidisciplinary and international group of palliative care researchers, identified themes and clinical issues on palliative sedation based on expert consultations and evidence drawn from the EAPC (European Association of Palliative Care) framework for palliative sedation and AGREE II (Appraisal Guideline Research and Evaluation) instrument for guideline assessment. The most relevant themes were selected and built into a comprehensive checklist. This was tested on people working closely with practitioners and patients, for user-friendliness and comprehensibility, and modified where necessary. Next, a systematic search was conducted for guidelines in English, Dutch, Flemish, or Italian. The search was performed in multiple databases (PubMed, CancerLit, CNAHL, Cochrane Library, NHS Evidence and Google Scholar), and via other Internet resources. Hereafter, the final version of the checklist will be used to extract data from selected literature, and the same will be compiled, entered into SPSS, cleaned and analysed systematically for publication. Discussion We have together developed a comprehensive checklist in a scientifically rigorous manner to allow standardised and systematic comparison. The protocol is applicable to all guidelines on palliative sedation, and the approach will contribute to rigorous and systematic comparison of international guidelines on any challenging topic such as this. Results from the study will provide valuable insights into common core elements and differences between the selected guidelines, and the extent to which recommendations are derived from, or match those in the EAPC framework. The outcomes of the study will be disseminated via peer-reviewed journals and directly to appropriate audiences.
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Affiliation(s)
- Ebun Abarshi
- International Observatory on End-of-Life Care, Lancaster University, Lancaster LA1 4YG, UK
| | - Judith Rietjens
- Department of Public Health, Erasmus Medical Centre, Rotterdam, The Netherlands ; End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Augusto Caraceni
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy ; European Palliative Care Research Center, Trondheim Norway, EAPC Research Network, Milan, Italy
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster University, Lancaster LA1 4YG, UK
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Vrije Universiteit Brussel (VUB), Brussels, Belgium ; Vrije University Medical Center, EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
| | - Lieve Van Den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Vrije Universiteit Brussel (VUB), Brussels, Belgium ; Department of Family Medicine, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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26
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Papavasiliou EE, Chambaere K, Deliens L, Brearley S, Payne S, Rietjens J, Vander Stichele R, Van den Block L, Zeger DG, Sarah B, Augusto C, Joachim C, Anneke F, Richard H, Irene J H, Stein K, Karen L, Guido M, Bregje OP, Koen P, Roeline P, Sophie P, Sheila P, Luc D. Physician-reported practices on continuous deep sedation until death: A descriptive and comparative study. Palliat Med 2014; 28:491-500. [PMID: 24718896 DOI: 10.1177/0269216314530768] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Research on continuous deep sedation until death has focused on estimating prevalence and describing clinical practice across care settings. However, evidence on sedation practices by physician specialty is scarce. AIMS To compare and contrast physician-reported practices on continuous deep sedation until death between general practitioners and medical specialists. DESIGN/PARTICIPANTS A secondary analysis drawing upon data from a large-scale, population-based, retrospective survey among physicians in Flanders, Belgium in 2007. Symptom prevalence and characteristics of sedation (drugs used, artificial nutrition and hydration administered, intentions, and decision-making) were measured. RESULTS Response rate was 58.4%. The frequency of continuous deep sedation until death among all deaths was 11.3% for general practitioners and 18.4% for medical specialists. General practitioners reported significantly higher rates of severity and mean intensity of pain, delirium, dyspnea, and nausea in the last 24 h of life for sedated patients and a higher number of severe symptoms than medical specialists. No differences were found between groups in the drugs used, except in propofol, reported only by medical specialists (in 15.8% of all cases). Artificial nutrition and hydration was withheld or withdrawn in 97.2% of general practitioner and 36.2% of medical specialist cases. Explicit life-shortening intentions were reported by both groups (for 3%-4% of all cases). Continuous deep sedation until death was initiated without consent or request of either the patient or the family in 27.9% (medical specialists) and 4.7% (general practitioners) of the cases reported. CONCLUSION Considerable variation, often largely deviating from professional guidelines, was observed in physician-reported performance and decision-making, highlighting the importance of providing clearer guidance on the specific needs of the context in which continuous deep sedation until death is to be performed.
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Affiliation(s)
| | - Kenneth Chambaere
- End-of-life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Sarah Brearley
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
| | - Sheila Payne
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
| | - Judith Rietjens
- End-of-life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Robert Vander Stichele
- Heymans Institute of Pharmacology, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Lieve Van den Block
- End-of-life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
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27
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Raus K, Anquinet L, Rietjens J, Deliens L, Mortier F, Sterckx S. Factors that facilitate or constrain the use of continuous sedation at the end of life by physicians and nurses in Belgium: results from a focus group study. J Med Ethics 2014; 40:230-234. [PMID: 22893573 DOI: 10.1136/medethics-2012-100571] [Citation(s) in RCA: 11] [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: 06/01/2023]
Abstract
Continuous sedation at the end of life (CS) is the practice whereby a physician uses sedatives to reduce or take away a patient's consciousness until death. Although the incidence of CS is rising, as of yet little research has been conducted on how the administration of CS is experienced by medical practitioners. Existing research shows that many differences exist between medical practitioners regarding how and how often they perform CS. We conducted a focus group study to find out which factors may facilitate or constrain the use of continuous sedation by physicians and nurses. The participants often had clear ideas on what could affect the likelihood that sedation would be used. The physicians and nurses in the focus groups testified that the use of continuous sedation was facilitated in cases where a patient has a very limited life expectancy, suffers intensely, makes an explicit request and has family members who can cope with the stress that accompanies sedation. However, this 'paradigm case' was considered to occur only rarely. Furthermore, deviations from the paradigm case were said to be sometimes due to physicians initiating the discussion on CS too late or not initiating it at all for fear of inducing the patient. Deviations from the paradigm case may also occur when sedation proves to be too difficult for family members who are said to sometimes pressure the medical practitioners to increase dosages and speed up the sedation.
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Affiliation(s)
- Kasper Raus
- End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel, Ghent, Belgium
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28
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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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Pardon K, Chambaere K, Pasman HRW, Deschepper R, Rietjens J, Deliens L. Trends in end-of-life decision making in patients with and without cancer. J Clin Oncol 2013; 31:1450-7. [PMID: 23478055 DOI: 10.1200/jco.2012.44.5916] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Because of cancer's high symptom burden and specific disease course, patients with cancer are more likely than other patients to face end-of-life decisions that have possible or certain life-shortening effects (ELDs). This study examines the incidence of ELDs in patients with cancer compared with patients without cancer and the trends in ELD incidence from 1998-2007. PATIENTS AND METHODS A nationwide death certificate study in Flanders, Belgium, was conducted in 2007, analogous to one completed in 1998. Physicians who had signed selected death certificates (n = 6,927) were sent a questionnaire. RESULTS The response rate was 58.4%. Nonsudden deaths were studied. Intensified symptom alleviation occurred more in patients with cancer than in those without (53.8% v 31.7%; P < .001) as did euthanasia (6.8% v 0.9%; P < .001). There was no difference between groups in nontreatment decisions and life-ending acts without patient's explicit request. Patients with cancer were less involved in the end-of-life decision-making process than patients without cancer (69.7% v 83.5%; P = .001). From 1998 to 2007, ELD incidence has increased in patients with cancer (+6.7%) and even more in patients without cancer (+14.9%) because of an increase in intensified symptom alleviation. In patients with cancer, euthanasia rates increased strongly and life-ending acts without the patient's explicit request decreased. CONCLUSION The higher ELD incidence in patients with cancer compared with those without is probably related to differences in disease trajectories and access to end-of-life care. During the period from 1998 to 2007, when euthanasia was legalized and palliative care intensified, overall ELDs increased, including those as a result of symptom alleviation and euthanasia, with a decrease in life-ending acts without explicit request.
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Affiliation(s)
- Koen Pardon
- End-of-life Care Research Group, Ghent University and Vrije Universiteit Brussels, Laarbeeklaan 103, 1090 Brussels, Belgium.
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Abstract
BACKGROUND Most studies that have investigated the practice of palliative sedation have focused on physicians' practices and attitudes. OBJECTIVE The aim of this study was to explore relatives' experiences with palliative sedation and to gain more insight in positive and negative elements in their evaluation of palliative sedation. DESIGN Focus groups and individual interviews. SETTING Various care settings in the Netherlands. SUBJECTS A total of 14 relatives of patients who received palliative sedation until death participated. RESULTS Most relatives evaluated the provision of palliative sedation of their dying family member positively. Positive experiences were related to: the beneficial impact of palliative sedation on the patient's suffering, the opportunity that was offered to prepare for the patient's death, their involvement in the decision-making and care for the patient, and the pleasant care environment. However, the majority of the relatives were unsatisfied with one or more aspects of how information was being provided for. Some relatives were frustrated about the fact that nurses were not authorized to make decisions about the care for the patient and about the absence of physicians during weekends. None of the relatives mentioned the loss of the ability to communicate with the patient during the sedation and the possibility of "hastening death" as disadvantages of palliative sedation. CONCLUSION Relatives tend to evaluate the provision of palliative sedation to their severely suffering family member positively because it contributes to a peaceful dying process. However, relatives indicated discontent with how information was being provided and with the communication in general.
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Affiliation(s)
- Sophie Bruinsma
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
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Swart SJ, van der Heide A, Brinkkemper T, van Zuylen L, Perez R, Rietjens J. Continuous palliative sedation until death: practice after introduction of the Dutch national guideline. BMJ Support Palliat Care 2012; 2:256-63. [DOI: 10.1136/bmjspcare-2011-000063] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Seymour J, Rietjens J, Brown J, van der Heide A, Sterckx S, Deliens L. The perspectives of clinical staff and bereaved informal care-givers on the use of continuous sedation until death for cancer patients: The study protocol of the UNBIASED study. BMC Palliat Care 2011; 10:5. [PMID: 21375747 PMCID: PMC3056823 DOI: 10.1186/1472-684x-10-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 03/04/2011] [Indexed: 11/29/2022] Open
Abstract
Background A significant minority of dying people experience refractory symptoms or extreme distress unresponsive to conventional therapies. In such circumstances, sedation may be used to decrease or remove consciousness until death occurs. This practice is described in a variety of ways, including: 'palliative sedation', 'terminal sedation', 'continuous deep sedation until death', 'proportionate sedation' or 'palliative sedation to unconsciousness'. Surveys show large unexplained variation in incidence of sedation at the end of life across countries and care settings and there are ethical concerns about the use, intentions, risks and significance of the practice in palliative care. There are also questions about how to explain international variation in the use of the practice. This protocol relates to the UNBIASED study (UK Netherlands Belgium International Sedation Study), which comprises three linked studies with separate funding sources in the UK, Belgium and the Netherlands. The aims of the study are to explore decision-making surrounding the application of continuous sedation until death in contemporary clinical practice, and to understand the experiences of clinical staff and decedents' informal care-givers of the use of continuous sedation until death and their perceptions of its contribution to the dying process. The UNBIASED study is part of the European Association for Palliative Care Research Network. Methods/Design To realize the study aims, a two-phase study has been designed. The study settings include: the domestic home, hospital and expert palliative care sites. Phase 1 consists of: a) focus groups with health care staff and bereaved informal care-givers; and b) a preliminary case notes review to study the range of sedation therapy provided at the end of life to cancer patients who died within a 12 week period. Phase 2 employs qualitative methods to develop 30 patient-centred case studies in each country. These involve interviews with staff and informal care-givers closely involved in the care of cancer patients who received continuous sedation until death. Discussion To our knowledge, this is one of the few studies which seek to take a qualitative perspective on clinical decision making surrounding the use of continuous sedation until death and the only one which includes the perspectives of nurses, physicians, as well as bereaved informal care-givers. It has several potential strengths, weaknesses, opportunities and threats associated with the specific design of the study, as well as with the sensitive nature of the topic and the different frameworks for ethical review in the participating countries.
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Affiliation(s)
- Jane Seymour
- School of Nursing, Midwifery and Physiotherapy, University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK.
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Voorhees J, Rietjens J, Onwuteaka-Philipsen B, Deliens L, Cartwright C, Faisst K, Norup M, Miccinesi G, van der Heide A. Discussing prognosis with terminally ill cancer patients and relatives: a survey of physicians' intentions in seven countries. Patient Educ Couns 2009; 77:430-436. [PMID: 19850436 DOI: 10.1016/j.pec.2009.09.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2008] [Revised: 09/07/2009] [Accepted: 09/11/2009] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To determine the extent to which physicians in different countries intend to inform terminal patients and relatives about prognosis, and to identify physician characteristics associated with an active approach to such discussions. METHODS In the context of a European research project, a study on disclosing prognosis was conducted in seven countries. A written questionnaire with questions regarding hypothetical cases and actual practices was sent to physicians from specialties involved in the care of dying patients. RESULTS 10,139 questionnaires were studied. The response rate was greater than 50% in all countries except Italy (39%). The percentage of physicians who indicated that they would actively inform competent patients of their prognosis varied between countries from 52% in Italy to 99% in Sweden. For informing relatives of incompetent patients, rates were higher, ranging from 86% in Denmark to 98% in Australia. Younger physician age and training in palliative care were associated with an active intention to discuss prognosis. CONCLUSION Physicians' intentions to discuss prognosis with patients and families vary largely across countries. Physician age and training in palliative care may also affect intentions. PRACTICE IMPLICATIONS Continuing training should focus on improving physicians' ability to communicate responsibly about prognosis with patients and families.
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Affiliation(s)
- Jennifer Voorhees
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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Buiting H, van Delden J, Onwuteaka-Philpsen B, Rietjens J, Rurup M, van Tol D, Gevers J, van der Maas P, van der Heide A. Reporting of euthanasia and physician-assisted suicide in the Netherlands: descriptive study. BMC Med Ethics 2009; 10:18. [PMID: 19860873 PMCID: PMC2781018 DOI: 10.1186/1472-6939-10-18] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Accepted: 10/27/2009] [Indexed: 11/25/2022] Open
Abstract
Background An important principle underlying the Dutch Euthanasia Act is physicians' responsibility to alleviate patients' suffering. The Dutch Act states that euthanasia and physician-assisted suicide are not punishable if the attending physician acts in accordance with criteria of due care. These criteria concern the patient's request, the patient's suffering (unbearable and hopeless), the information provided to the patient, the presence of reasonable alternatives, consultation of another physician and the applied method of ending life. To demonstrate their compliance, the Act requires physicians to report euthanasia to a review committee. We studied which arguments Dutch physicians use to substantiate their adherence to the criteria and which aspects attract review committees' attention. Methods We examined 158 files of reported euthanasia and physician-assisted suicide cases that were approved by the review committees. We studied the physicians' reports and the verdicts of the review committees by using a checklist. Results Physicians reported that the patient's request had been well-considered because the patient was clear-headed (65%) and/or had repeated the request several times (23%). Unbearable suffering was often substantiated with physical symptoms (62%), function loss (33%), dependency (28%) or deterioration (15%). In 35%, physicians reported that there had been alternatives to relieve patients' suffering which were refused by the majority. The nature of the relationship with the consultant was sometimes unclear: the consultant was reported to have been an unknown colleague (39%), a known colleague (21%), otherwise (25%), or not clearly specified in the report (24%). Review committees relatively often scrutinized the consultation (41%) and the patient's (unbearable) suffering (32%); they had few questions about possible alternatives (1%). Conclusion Dutch physicians substantiate their adherence to the criteria in a variable way with an emphasis on physical symptoms. The information they provide is in most cases sufficient to enable adequate review. Review committees' control seems to focus on (unbearable) suffering and on procedural issues.
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Affiliation(s)
- Hilde Buiting
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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Rietjens J, van Delden J, Onwuteaka-Philipsen B, Buiting H, van der Maas P, van der Heide A. Continuous deep sedation for patients nearing death in the Netherlands: descriptive study. BMJ 2008; 336:810-3. [PMID: 18344245 PMCID: PMC2292332 DOI: 10.1136/bmj.39504.531505.25] [Citation(s) in RCA: 142] [Impact Index Per Article: 8.9] [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: 11/04/2022]
Abstract
OBJECTIVES To study the practice of continuous deep sedation in 2005 in the Netherlands and compare it with findings from 2001. DESIGN Questionnaire study about random samples of deaths reported to a central death registry in 2005 and 2001. SETTING Nationwide physician study in the Netherlands. PARTICIPANTS Reporting physicians received a questionnaire about the medical decisions that preceded the patient's death; 78% (n=6860) responded in 2005 and 74% (n=5617) in 2001. MAIN OUTCOME MEASURES Characteristics of continuous deep sedation (attending physician, types of patients, drugs used, duration, estimated effect on shortening life, palliative consultation). Requests for euthanasia. RESULTS The use of continuous deep sedation increased from 5.6% (95% confidence interval 5.0% to 6.2%) of deaths in 2001 to 7.1% (6.5% to 7.6%) in 2005, mostly in patients treated by general practitioners and in those with cancer (in 2005, 47% of sedated patients had cancer v 33% in 2001). In 83% of cases sedation was induced by benzodiazepines, and in 94% patients were sedated for periods of less than one week until death. Nine per cent of those who received continuous deep sedation had previously requested euthanasia but their requests were not granted. Nine per cent of the physicians had consulted a palliative expert. CONCLUSIONS The increased use of continuous deep sedation for patients nearing death in the Netherlands and the limited use of palliative consultation suggests that this practice is increasingly considered as part of regular medical practice.
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Affiliation(s)
- Judith Rietjens
- Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, Netherlands.
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