Een cultuurvergelijkend onderzoek naar behandelbesluiten van artsen met betrekking tot demente verpleeghuispatiënten met pneumonie

A cross-cultural study of physician treatment decisions for demented nursing home patients who develop pneumoniaThis qualitative interview study in the Netherlands and North Carolina (US) found that physician treatment decisions are influenced by contextual differences in physician training and healthcare delivery in the US and the Netherlands. Dutch physicians treating nursing home residents with dementia and pneumonia assumed active, primary responsibility for treatment decisions while US physicians were more passive and deferential to family preferences, even in cases where they considered the families’ wishes inappropriate. Dutch physicians knew their patients well and made treatment decisions based on what they perceived was in the best interest of the patient while US physicians reported limited knowledge of their nursing home patients due to a lack of contact time. Efforts to improve care for patients with poor quality of life who lack decision-making capacity must consider the context of societal values, physician training, and the processes by which physicians negotiate patient and family preferences.     

Who should Decide for the Unrepresented?

Unrepresented patients lack the capacity to make medical decisions for themselves, have no clear documentation of preferences for medical treatment, and have no surrogate decision maker or obvious candidate for that role. There is no consensus about who should serve as the decision maker for these patients, particularly regarding whether to continue or to limit life‐sustaining treatment. Several authors have argued that ethics committees should play this role rather than the patient's treating physician, a common current default. We argue that concerns about the adequacy of physicians as surrogates are either empirically unfounded or apply equally to ethics committees. We suggest that physicians should be the primary decision maker for the unrepresented because of their fiduciary duties toward their patients. As part of the process of fulfilling these duties, they should seek the advice of third parties such as ethic committees; but final end‐of‐life decision‐making for the unrepresented should rest with the treating physician.     

Ethical decision making by Canadian family physicians.

Canadian family physicians were sent questionnaires that asked how they would handle the ethical problems posed by six sample cases and what reasons were relevant to their decisions. The ethical problems concerned how much information to divulge to patients, how extensively a physician should become involved in the lifestyles of patients and how to deal with a possible family problem. The study identified characteristics of family physicians that affect their ethical decision making and tested a theoretical model that regards ethical problems as conflicts between respecting patient autonomy and promoting patient welfare. The varied responses suggested that ethical issues are resolved on a case-by-case, rather than a theoretical, basis. Certification in family medicine was the only characteristic associated with a consistent pattern of responses; certificants were more likely than other physicians to involve patients in decisions.     

Palliative care in dementia and the dismantling of the treatment function of nursing homes

Palliative care is mostly restricted to the terminal phase of incurable illness. According to the WHO revised definition palliative care is specifically directed towards patients and families facing life-threatening illness. This definition is not adequate to orient and direct palliative care policies in non-cancer diseases such as dementia. Although dementia is incurable from the outset, its course is often protracted, resulting in a terminal stage only after several years. This disease trajectory necessitates an alternative palliative approach, implying a proactive attitude of nursing home physicians in facilitating early and timely discussions with patients and their proxies on advance care planning and treatment of complications and concomitant diseases. This, together with their specific training in the treatment of the long-term sequelae of chronic diseases, defines the success of Dutch nursing home medicine in foregoing inappropriate hospital admissions and providing adequate medical care in the nursing home. However, recent reorganisations of nursing home care and its funding threaten to downgrade the quality of medical care for patients with dementia in Dutch nursing homes by focusing unilaterally on welfare ideology and 'marketization' of long term care, thus underestimating the importance of a palliative care policy in dementia.     

Palliatieve zorg bij dementie en de ontmanteling van de behandelfunctie van het verpleeghuis

Palliative care in dementia and the dismantlement of nursing home medicinePalliative care is mostly restricted to the terminal phase of incurable illness. According to the WHO revised definition palliative care is specifically directed towards patients and families facing life-threatening illness. This definition is not adequate to orient and direct palliative care policies in non-cancer diseases such as dementia. Although dementia is incurable from the outset, its course is often protracted, resulting in a terminal stage only after several years. This disease trajectory necessitates an alternative palliative approach, implying a proactive attitude of nursing home physicians in facilitating early and timely discussions with patients and their proxies on advance care planning and treatment of complications and concomitant diseases. This, together with their specific training in the treatment of the long term sequelae of chronic diseases, defines the success of Dutch nursing home medicine in foregoing inappropriate hospital admissions and providing adequate medical care in the nursing home. However, recent reorganisations of nursing home care and its funding threaten to downgrade the quality of medical care for patients with dementia in Dutch nursing homes by focusing unilaterally on welfare ideology and ‘marketization’ of long term care, thus underestimating the importance of a palliative care policy in dementia.     

Understanding of elderly patients' resuscitation preferences by physicians and nurses.

We compared the understanding by family physicians and nurses of their elderly outpatients'' preferences for cardiopulmonary resuscitation and mechanical ventilation under 3 scenarios reflecting varying qualities of life. Physicians and nurses correctly predicted patients'' treatment preferences in from 59% to 84% and 53% to 78% of cases, respectively, for the various decisions. For most decisions, neither physicians nor nurses were significantly more accurate in their predictions than expected by chance alone. Moreover, nurses and physicians did not significantly agree with one another in their predictions of patients'' preferences for any of these decisions. These results suggest that while nurses'' and physicians'' perceptions of patients'' preferences for life-sustaining treatment are not necessarily similar, neither nurses nor physicians systematically understand their elderly patients'' resuscitation preferences.     

Factoren die van invloed zijn op het verwijzen van patiënten van het verpleeghuis naar het ziekenhuis

Introduction

Hospitalisation may cause negative effects on elderly patients. Therefore, it is important that referral and admission of older nursing home patients is well-considered. The aim of this study is to investigate the factors that affect the decision making process.

Method

Questionnaire survey among elderly care physicians and physicians following the elderly care physician training program.

Results

Of the 1,540 surveys, 200 were returned (response rate of 13%). Over 60% of the respondents had referred a nursing home patient to the hospital in the previous month. A stay at a geriatric rehabilitation ward, suspicion of a fracture, a good quality of life, a patient’s or family’s wish for referral, no treatment restrictions, and follow-up appointments in the hospital were factors which made referral to the hospital more likely according to the respondents. Medical specialist consultation and the in hospital presence of a physician specialised in geriatric care were considered to be important. Referral was less likely if a patient was diagnosed with dementia, had a low quality of life or had treatment restrictions.

Conclusion

Both patient-related and non-patient-related factors influence hospital referral of nursing home patients. Further research is needed to determine whether these different factors contribute to the different outcomes of a hospital admission, to facilitate proper decision-making for elderly care physicians.

     

Understanding potential barriers and enablers to a perioperative early phase cell therapy trial

Background aimsEarly-phase cell therapy clinical trials depend on patient and physician involvement, yet barriers can impede their participation.MethodsTo optimize engagement for a planned cell therapy trial to prevent perioperative cardiac complications, the authors conducted semi-structured interviews with at-risk patients and physicians who could potentially be involved in the study. The authors used the theoretical domains framework to systematically identify potential barriers and enablers.ResultsForty-one interviews were conducted to reach data saturation, and four overall potential barriers to participation (themes) were identified. Theme 1 emphasizes that patients and physicians need accessible information to better understand the benefits and risks of the novel therapy and trial procedures and to address misconceptions. Theme 2 underscores the need for clarity on whether the trial's primary purpose is safety or efficacy, as this may influence patient and physician decisions. Theme 3 recognizes the resource and logistic realities for patients (e.g., convenient follow-up appointments) and physicians (e.g., personnel to assist in trial procedures, competing priorities). Theme 4 describes the importance of social influences (e.g., physicians and family, peers/colleagues) that may affect decisions to participate and the importance of patient preferences (e.g., availability of physicians to discuss the trial, including caregivers in discussions).ConclusionsProspectively addressing these issues may help optimize feasibility prior to conducting an expensive, resource-intensive trial.     

De nieuwe redactieadviesraad van het Tijdschrift voor Gerontologie en Geriatrie

It is unknown how often choking occurs in geriatric wards and in nursing homes and what the treatment and outcomes are in regular practice. A questionnaire was sent to Dutch geriatricians (N = 130), nursing home physicians (N = 130), and trainees for these disciplines (N = 215), in order to gain information about the experience, practice and competence of physicians in choking in geriatric and nursing home patients. We also analysed to what extent geriatric and nursing home wards were prepared for accurate handling of choking. The response rate was 30%. More than half of the responders had experienced an episode of food choking at least once in the past five years. The mortality rate in the reported cases was high (30%). The majority of the patients who died of choking had not received the Heimlich-manoeuvre. Physicians who had attended resuscitation training long ago felt as competent to manage a choking episode as physicians that had recently attended resuscitation training. Of all geriatric wards and nursing homes, the majority lacked a guideline on how to handle in acute food choking. Geriatric wards and nursing homes do not seem to be well prepared for acute food choking in several aspects. Despite methodological shortcomings of this study, the results underline the necessity of clarification of the terms used, and development and implementation of guidelines for this important problem.     

Sterven met dementie: wat weten wij ervan?

Dying with dementia: what do we know about it? Death with dementia is increasingly common, yet research on end of life with dementia and end-of-life care for such patients has been sparse. This article reviews recent studies in this area, most of which were done in US nursing homes. Research focused on five domains: prognosis, decision making, treatment, patient’s health and suffering, and family’s circumstances and satisfaction with care. Prognostication focused on developing risk scores for mortality within 6 months or a year, and while decision making was usually studied qualitatively, the other three domains were largely covered by a series of small, retrospective studies. Future direction in research is discussed, including the ongoing CASCADE project in Boston and the Dutch End of Life with Dementia Study (DEOLD). Both of these prospective studies in nursing home residents assess decision making, as well as factors associated with family’s satisfaction and patient suffering. These studies will provide insight into interventions that are most likely to improve end of life care of patients with dementia in the respective countries and elsewhere. Tijdschr Gerontol Geriatr 2007; 38: 288-297     

Preventie en behandeling van osteoporose bij kortdurende revalidatie in het verpleeghuis: een taak voor de verpleeghuisarts

Prevention and treatment of osteoporosis in short stay departments of nursing homes: a nursing home physician’s task. This research shows that nursing home physicians might play an important part in the diagnostics and treatment of vitamin-D deficiency. 96 rehabilitating elderly who had undergone a hip operation were investigated. 36% had a vitamin-D deficiency (vitamin-D<30nmol/l). Vitamin-D deficiency was 53 % in the fracture group and 26 % in the arthritis group. Deficiencies were treated with vitamin-D medication. After the patient’s discharge the general practitioner was sent a questionnaire. The results show that general practitioners agree to nursing home physicians’ investigating vitamin-D deficiencies and to nursing home physicians’ initiating vitamin-D medication in case of a deficiency. The general practitioners themselves do not often investigate vitamin-D deficiency. Tijdschr Gerontol Geriatr 2007; 38:147-153     

Nationwide study of decisions concerning the end of life in general practice in The Netherlands.

OBJECTIVE--To gain insight into decisions made in general practice about the end of life. DESIGN--Study I: interviews with 405 physicians. Study II: analysis of death certificates with data obtained on 5197 cases in which decisions about the end of life may have been made. Study III: prospective study with doctors from study I: questionnaires used to collect information about 2257 deaths. The information was representative for all deaths in the Netherlands. RESULTS--Over two fifths of all patients in the Netherlands die at home. General practitioners took fewer decisions about the end of life than hospital doctors and doctors in nursing homes (34%, 40%, and 56% of all dying patients, respectively). Specifically, decisions to withhold or withdraw treatment to prolong life were taken less often. Euthanasia or assisted suicide, however, was performed in 3.2% of all deaths in general practice compared with 1.4% in hospital practice. In over half of the cases concerning pain relief or non-treatment general practitioners did not discuss the decision with the patient, mostly because of incapacity of the patient, but in 20% of cases for "paternalistic" reasons. Older general practitioners discussed such decisions less often with their patients. Colleagues were consulted more often if the general practitioner worked in group practice. CONCLUSION--Differences in work situation between general practitioners and hospital doctors and differences between the group of general practitioners contribute to differences in the number and type of decisions about the end of life as well as in the decision making process.     

Doing what the patient orders: maintaining integrity in the doctor-patient relationship

No profession has undergone as much scrutiny in the past several decades as that of medicine. Indeed, one might well argue that no profession has ever undergone so much change in so short a time. An essential part of this change has been the growing insistence that competent, adult patients have the right to decide about the course of their own medical treatment. However, the familiar and widely accepted principle of patient self-determination entails a corollary that has received little attention in the growing literature on the ethics of physician-patient relations: if patients are to direct the course of their own medical treatment, then physicians are at least sometimes to be guided in their actions on behalf of patients by values that are not, and may even be incompatible with, their own values. Unless it is supposed that it would be best if physicians were simply to accommodate any and all patient requests, a possibility I consider and reject in this paper, there are bound to be numerous instances of legitimate moral conflict between the preferences of physicians and patients. In this paper, I examine the implications of this sort of moral conflict from the standpoint of the integrity of the physician....I have also considered the common practice of patient referral from the standpoint of physician integrity, and asked whether a physician who refuses to treat a patient as a matter of conscience can consistently refer the patient to another physician for the same treatment....     

Reconstructive breast surgery: referring physician knowledge and learning needs

Despite the positive impact that reconstructive breast surgery can have on a woman's quality of life, the percentage of eligible candidates that have this procedure remains surprisingly low. The authors hypothesized that this may be attributable to inadequate knowledge, inadequate information, and/or misinformation available to physicians caring for these patients. A needs assessment of primary care physicians, general surgeons, oncologists, and plastic surgeons was conducted to determine referring physicians' current level of knowledge of reconstructive breast surgery and to discover potential learning needs. This comprised a survey, focus groups, and individual interviews. Referring physicians rated their own knowledge of reconstructive breast surgery as low. Plastic surgeons rated their referring physicians' knowledge as even lower. Specific learning needs were identified, as large discrepancies between referring physicians' self-reported knowledge of individual breast reconstruction topics and their own opinion of their relevance were revealed. In addition, despite evidence to the contrary, more than one-third of referring physicians indicated a belief that a breast reconstruction delayed the detection of local cancer recurrence and adversely interfered with adjuvant oncologic therapy. This lack of knowledge and misinformation may be negatively affecting patient referrals to plastic surgeons, as more than one-third of referring physicians and 90 percent of plastic surgeons believed that eligible candidates were not being offered referrals because of inadequate referring physician knowledge of this topic. Furthermore, patients older than 49 years were not being referred despite the fact that plastic surgeons would consider these patients as potential surgical candidates. Referring physician gender affected both referral patterns and perceived importance of reconstructive breast surgery. Finally, personal beliefs and past experiences played a role both in physicians' decisions to refer patients and in patients' decisions to have breast reconstructions. These deficiencies in information, knowledge, and learning needs should be addressed by educational interventions during residency training and through continuing education endeavors.     

Early detection and treatment of hyperlipidemia: physician practices in Canada.

We surveyed primary care physicians in Canada to determine their current practices regarding the detection and treatment of hyperlipidemia in asymptomatic adults 20 years of age or more and to determine the role of selected patient characteristics (age, sex and the presence of coronary heart disease [CHD] risk factors) in their management decisions. The self-administered questionnaire was completed by 428 of 804 family physicians and general practitioners. The proportion of physicians who reported having tested at least 50% of their adult patients varied from 29% to 85% and was related to the number of CHD risk factors present and the patient''s age. The proportion of respondents who reported starting dietary or drug therapy among patients with a cholesterol level of 6.2 mmol/L or less increased as the number of CHD risk factors increased and was not related to patient age or sex. According to the factors examined our results suggest that primary care physicians in Canada select patients for screening and treatment mainly on the basis of CHD risk factors present and that their approach is more conservative than that recommended by the Canadian and US consensus conferences.     

A report from Japan: choices of Japanese patients in the face of disagreement

Background: Patients in different countries have different attitudes toward self-determination and medical information. Little is known how much respect Japanese patients feel should be given for their wishes about medical care and for medical information, and what choices they would make in the face of disagreement.
Methods: Ambulatory patients in six clinics of internal medicine at a university hospital were surveyed using a self-administered questionnaire.
Results: A total of 307 patients participated in our survey. Of the respondents, 47% would accept recommendations made by physicians, even if such recommendations were against their wishes; 25% would try to persuade their physician to change their recommendations; and 14% would leave their physician to find a new one.
Seventy-six percent of the respondents thought that physicians should routinely ask patients if they would want to know about a diagnosis of cancer, while 5% disagreed; 59% responded that physicians should inform them of the actual diagnosis, even against the request of their family not to do so, while 24% would want their physician to abide by their family's request and 14% could not decide. One-third of the respondents who initially said they would want to know the truth would yield to the desires of the family in a case of disagreement.
Interpretations: In the face of disagreement regarding medical care and disclosure, Japanese patients tend to respond in a diverse and unpredictable manner. Medical professionals should thus be prudent and ask their patients explicitly what they want regarding medical care and information.     

Whether or not to treat pneumonia curatively in (demented) psychogeriatric patients: evaluation of a guideline for nursing home physicians

A guideline was developed to support decision-making about whether or not to treat pneumonia curatively in psychogeriatric (demented) nursing home patients. This guideline was developed as a 'checklist of considerations', primarily of the ethical and legal aspects of decision-making. Nursing home physicians used and evaluated the list. The list's acceptance was assessed by measuring the frequency of the list's use, and judgements of the list's contents and 'usefulness'. The list was used in 50 out of 58 participating nursing homes, in 47% of the 489 psychogeriatric patients in whom pneumonia occurred. The list was found somewhat to very useful to support decision-making in 47% of 107 individual patients. For the targeted patient category as a whole, 85% of 48 physicians who were asked retrospectively (one physician per home) found the list somewhat to very useful. The content of the list was judged favourably. In conclusion, the nursing home physicians accepted the considerations of the checklist as a basis for decision-making on whether or not to treat pneumonia curatively in psychogeriatric patients. In the future, the format of the list can be adapted for use in diverse clinical situations. Suggestions are provided to increase user friendliness and usefulness.     

The impact of reporting cases of euthanasia in Holland: a patient and family perspective

In 1991 the Dutch government released the results of the first national investigation into the nature and extent of decisions concerning end of life including euthanasia. A significant finding was that most cases of euthanasia were not reported. This prompted us to ask what effect, if any, not reporting caused. More specifically, we asked whether reporting has a positive or negative impact on the experiences of friends or relatives of patients who have received euthanasia. In cases of euthanasia, complications of both process and experience can deter from a minimally complicated death. These difficulties arise when either the family or physician does not perceive the freedom to disclose euthanasia openly. On the basis of interviews with family members and patients, we illustrate that they generally benefit from reporting. Our premise is that reporting fosters open discussion of euthanasia. We further suggest physicians and society benefit from a milieu of openness initiated by reporting cases of euthanasia.