Relatives' needs in terms of bereavement care throughout euthanasia processes: A qualitative study.

AIM: To explore relatives' needs in terms of bereavement care during euthanasia processes, how healthcare providers respond to these needs, and the degree of commonality between relatives' and healthcare providers' reports. DESIGN: A phenomenological design was employed, utilising reflexive thematic analysis to examine interviews conducted with relatives (N = 19) and healthcare providers (N = 47). RESULTS: Relatives' needs throughout euthanasia processes are presented in five main themes and several subthemes, with similar findings between both sets of participants. Although relatives infrequently communicated their needs explicitly to healthcare providers, they appreciated it when staff proactively met their needs. Healthcare providers aimed to assist with the relatives' grief process by tending to their specific needs. However, aftercare was not consistently offered, but relatives did not have high expectations for professional follow-up care. CONCLUSION: Our research offers important directions for healthcare professionals, empowering them to provide needs-based bereavement care during euthanasia processes. Moreover, it emphasises the importance of recognising the unique needs of relatives and proactively addressing them in the period before the loss to positively contribute to relatives' grief process. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Insights into relatives' needs in the context of euthanasia. Good practices on how healthcare providers can attend to relatives' needs before, during and after the loss IMPACT: Current literature and guidelines on needs-based bereavement care in the context of euthanasia and, more generally, assisted dying, are limited. These findings provide concrete directions for practice in supporting (nearly) bereaved relatives in the context of euthanasia, potentially mitigating adverse health outcomes. REPORTING METHOD: Standards for Reporting Qualitative Research (SRQR checklist). PATIENT OR PUBLIC CONTRIBUTION: Relatives of deceased cancer patients were involved in the conduct of the study.

Relatives' Experiences of Being Involved in Assisted Dying: A Qualitative Study.

Recent literature demonstrates an interdependence between relatives and healthcare providers throughout euthanasia processes. Yet, current guidelines and literature scarcely specify the interactions between healthcare providers and bereaved relatives. The aim of this work consisted of providing an insight into bereaved relatives' experiences (1) of being involved in euthanasia processes and (2) of their interactions with healthcare providers before, during, and after the euthanasia. The research process was guided by the principles of constructivist grounded theory. Nineteen Dutch-speaking bereaved relatives of oncological patients, who received euthanasia at home or in a hospital less than 24 months ago, participated via semi-structured interviews. These interviews were conducted between May 2021 and June 2022. Due to the intensity of euthanasia processes, relatives wanted to be involved as early as possible, in order to receive time, space, and access to professionals' support whilst preparing themselves for the upcoming loss of a family member with cancer. Being at peace with the euthanasia request facilitated taking a supportive attitude, subsequently aiding in achieving a serene atmosphere. A serene atmosphere facilitated relatives' grief process because it helped them in creating and preserving good memories. Relatives appreciated support from healthcare providers, as long as overinvolvement on their part was not occurring. This study advocates for a relational approach in the context of euthanasia and provides useful complements to the existing euthanasia guidelines.

SPICT as a predictive tool for risk of 1-year health degradation and death in older patients admitted to the emergency department: a bicentric cohort study in Belgium.

BACKGROUND: Older patients are increasingly showing multi-comorbidities, including advanced chronic diseases. When admitted to the emergency department (ED), the decision to pursue life-prolonging treatments or to initiate a palliative care approach is a challenge for clinicians. We test for the first time the diagnostic accuracy of the Supportive and Palliative Care Indicators Tool (SPICT) in the ED to identify older patients at risk of deteriorating and dying, and timely address palliative care needs. METHODS: We conducted a prospective bicentric cohort study on 352 older patients (≥ 75 years) admitted to two EDs in Belgium between December 2019 and March 2020 and between August and November 2020. SPICT (French version, 2019) variables were collected during the patients' admission to the ED, along with socio-demographic, medical and functional data. The palliative profile was defined as a positive SPICT assessment. Survival, symptoms and health degradation (≥ 1 point in ADL Katz score or institutionalisation and death) were followed at 12 months by phone. Main accuracy measures were sensitivity, specificity and likelihood ratios (LR) as well as cox regression, survival analysis using the Kaplan Meier method, and ordinal regression. RESULTS: Out of 352 patients included in the study (mean age 83 ± 5.5 years, 43% male), 167 patients (47%) had a positive SPICT profile. At one year follow up, SPICT positive patients presented significantly more health degradation (72%) compared with SPICT negative patients (35%, p < 0.001). SPICT positivity was correlated with 1-year health degradation (OR 4.9; p < 0.001). The sensitivity and specificity of SPICT to predict health degradation were 0.65 (95%CI, 0.57-0.73) and 0.72 (95%CI, 0.64-0.80) respectively, with a negative LR of 0.48 (95%CI, 0.38-0.60) and a positive LR of 2.37 (1.78-3.16). The survival time was shorter in SPICT positive patients than in SPICT negative ones (p < 0.001), the former having a higher 1-year mortality rate (HR = 4.21; p < 0.001). CONCLUSIONS: SPICT successfully identifies older patients at high risk of health degradation and death. It can support emergency clinicians to identify older patients with a palliative profile and subsequently initiate a palliative care approach with a discussion on goals of care.

Coaching doctors to improve ethical decision-making in adult hospitalised patients potentially receiving excessive treatment: Study protocol for a stepped wedge cluster randomised controlled trial.

BACKGROUND: Fast medical progress poses a significant challenge to doctors, who are asked to find the right balance between life-prolonging and palliative care. Literature indicates room for enhancing openness to discuss ethical sensitive issues within and between teams, and improving decision-making for benefit of the patient at end-of-life. METHODS: Stepped wedge cluster randomized trial design, run across 10 different departments of the Ghent University Hospital between January 2022 and January 2023. Dutch speaking adult patients and one of their relatives will be included for data collection. All 10 departments were randomly assigned to start a 4-month coaching period. Junior and senior doctors will be coached through observation and debrief by a first coach of the interdisciplinary meetings and individual coaching by the second coach to enhance self-reflection and empowering leadership and managing group dynamics with regard to ethical decision-making. Nurses, junior doctors and senior doctors anonymously report perceptions of excessive treatment via the electronic patient file. Once a patient is identified by two or more different clinicians, an email is sent to the second coach and the doctor in charge of the patient. All nurses, junior and senior doctors will be invited to fill out the ethical decision making climate questionnaire at the start and end of the 12-months study period. Primary endpoints are (1) incidence of written do-not-intubate and resuscitate orders in patients potentially receiving excessive treatment and (2) quality of ethical decision-making climate. Secondary endpoints are patient and family well-being and reports on quality of care and communication; and clinician well-being. Tertiairy endpoints are quantitative and qualitative data of doctor leadership quality. DISCUSSION: This is the first randomized control trial exploring the effects of coaching doctors in self-reflection and empowering leadership, and in the management of team dynamics, with regard to ethical decision-making about patients potentially receiving excessive treatment.

Bereavement care and the interaction with relatives in the context of euthanasia: A qualitative study with healthcare providers.

BACKGROUND: A recent review shows an interdependence between healthcare providers and relatives in the context of euthanasia. Belgian guidelines do focus on the role of certain healthcare providers (physicians, nurses, and psychologists), yet they hardly specify bereavement care services before, during and after the euthanasia. PURPOSE: A conceptual model showing underlying mechanisms of healthcare providers' experiences regarding the interaction with and the provision of bereavement care to relatives of cancer patients throughout a euthanasia process. METHODS: 47 semi-structured interviews with Flemish physicians, nurses and psychologists working in hospitals and/or homecare, conducted from September 2020 to April 2022. Transcripts were analyzed using the Constructivist Grounded Theory Approach. RESULTS: Participants experienced the interaction with relatives as very diverse, which can be visualized as a continuum ranging from negative to positive, depending on each unique case. The achieved degree of serenity was the main contributor in determining their position on the aforementioned continuum. To create this serene atmosphere, healthcare providers undertook actions underpinned by two attitudes (wariness and meticulousness), which are guided by different considerations. These considerations can be categorized into three groups: 1) ideas about a good death and its importance, 2) having the situation well under control and 3) self-reassurance. CONCLUSIONS: If relatives were not at peace, most participants said that they deny a request or formulate additional requirements. Moreover, they wanted to ensure relatives can cope with the loss, which was often experienced as intense and time-consuming. Our insights shape needs-based care from healthcare providers' perspective in the context of euthanasia. Future research should explore the relatives' perspective regarding this interaction and the provision of bereavement care. TWEETABLE ABSTRACT: Professionals strive for a serene atmosphere throughout a euthanasia process to ensure relatives can cope with the loss, and the way in which the patient died.

Palliative profile, one-year mortality and quality of life in older inpatients according to Be-PICT: a multicenter prospective cohort study.

BACKGROUND: A palliative care approach (PCA), including advanced care planning (ACP), should be considered for patients with limited life expectancy. The Belgian Palliative Care Indicators Tool (Be-PICT) has been released to help identify patients who may benefit from such approach. This study aimed at measuring 1-year mortality and describe the quality of life in older inpatients, according to baseline Be-PICT results. METHODS: Prospective multicentre cohort study in older patients (≥ 75 years) admitted at geriatrics and cardiology wards of four Belgian hospitals. The palliative profile was defined as a positive Be-PICT.1, defined by the presence of its three criteria, i.e. a negative physician's answer to the surprise question 'would you be surprised if this patient dies in the 6-12 next months?', ≥ 1 poor health indicator and ≥ 1 life-limiting condition. RESULTS: Of the 379 patients (50% aged ≥85 years; 51% female), 52 (14%) presented a palliative profile and 83 (23%) died within 1 year. Be-PICT.1 showed the following characteristics to predict 1-year mortality: sensitivity 0.54, specificity 0.83, positive and negative predictive values 0.48 and 0.86, positive and negative likelihood ratios 3.22 and 0.55. The patients with a palliative profile were at higher mortality risk (hazard ratio 4.79 p < 0.001) and 1-year mortality rate (45%). Not using the SQ allowed to improve sensitivity to include a larger number of patients who may benefit from ACP and PCA. CONCLUSIONS: Be-PICT.1 is a simple case-finding tool to identify older inpatients being at high mortality risk and candidates for ACP and PCA.

In-hospital end-of-life care in the old: a retrospective study of intensive care unit use and do-not-resuscitate forms in patients deceased in a Belgian university hospital.

OBJECTIVES: To explore the quality of in-hospital end-of-life care in adult patients with special attention to those 75 years and older and to make a comparison with the situation 10 years ago. METHODS: Data were retrospectively collected on adult patients who deceased at Ghent University Hospital between September 2018 and December 2019. The main outcome measures were 'ICU use' and 'presence of DNR forms on non-ICU units' in the final hospitalization. In order to identify possible risk factors for ICU use, logistic regression was performed. RESULTS: In total, 762 people died, of whom 35% were 75 or older. Just as 10 years ago, one-third (31%) died in the ICU versus 49% of those younger than 75 years (p < 0.001). Of people ≥75 years, 38%, compared to 42% 10 years ago, received an ICU treatment during their final hospitalization. The median length of an ICU stay was 4 versus 3 days 10 years ago. After adjusting for gender, comorbidities and the Charlson Comorbidity Index, factors associated with less ICU use were higher age, active malignancy and dementia (OR 0.838, 0.116 and 0.098 respectively). Seventy-nine percent of older patients on non-ICU wards died with a DNR form (versus 87% 10 years ago). CONCLUSION: Although there was an increase in the presence of DNR forms in the final hospitalization, no significant differences were seen in actual ICU use compared to 10 years ago. Factors associated with less ICU use were higher age, active malignancy and dementia.

Scope of treatment and clinical-decision making in the older patient with COVID-19 infection, a European perspective.

PURPOSE: Older patients were particularly vulnerable to severe COVID-19 disease resulting in high in-hospital mortality rates during the two first waves. The aims of this study were to better characterize the management of older people presenting with COVID-19 in European hospitals and to identify national guidelines on hospital admission and ICU admission for this population. METHODS: Online survey based on a vignette of a frail older patient with Covid-19 distributed by e-mail to all members of the European Geriatric Medicine Society. The survey contained questions regarding the treatment of the vignette patient as well as general questions regarding available services. Additionally, questions on national policies and differences between the first and second wave of the pandemic were asked. RESULTS: Survey of 282 respondents from 28 different countries was analyzed. Responses on treatment of the patient in the vignette were similar from respondents across the 28 countries. 247 respondents (87%) would admit the patient to the hospital, in most cases to a geriatric COVID-19 ward (78%). Cardiopulmonary resuscitation was found medically inappropriate by 85% of respondents, intubation and mechanical ventilation by 91% of respondents, admission to the ICU by 82%, and ExtraCorpular Membrane Oxygenation (ECMO) by 93%. Sixty percent of respondents indicated they would consult with a palliative care specialist, 56% would seek the help of a spiritual counsellor. National guidelines on admission criteria of geriatric patients to the hospital existed in 22 different European countries. CONCLUSION: This pandemic has fostered the collaboration between geriatricians and palliative care specialists to improve the care for older patients with a severe disease and often an uncertain prognosis.

Prognostic value of the Surprise Question for one-year mortality in older patients: a prospective multicenter study in acute geriatric and cardiology units.

OBJECTIVES: To determine the prognostic value of the Surprise Question (SQ) in older persons. METHODS: A multicenter prospective study, including patients aged 75 years or older admitted to acute geriatric (AGU) or cardiology unit (CU). The SQ was answered by the treating physician. Patients or relatives were contacted after 1 year to determine 1-year survival. Logistic regression was used to explore parameters associated with SQ. Summary ROC curves were constructed to obtain the pooled values of sensitivity and specificity based on a bivariate model. RESULTS: The SQ was positive (death within 1 year is no surprise) in 34.7% AGU and 33.3% CU patients (p = 0.773). Parameters associated with a positive SQ were more severe comorbidity, worse functionality, significant weight loss, refractory symptoms and the request for palliative care by patient or family. One-year mortality was, respectively, 24.9% and 20.2% for patients hospitalized on AGU and CU (p = 0.319). There was no difference in sensitivity or specificity, respectively, 64% and 77% (AUC 0.635) for AGU versus 63% and 76% (AUC 0.758) for CU (p = 0.870). A positive SQ is associated with a significant shorter time until death (HR 5.425 (95% CI 3.332-8.834), p < 0.001) independently from the ward. CONCLUSION: The Surprise Question is moderately accurate to predict 1-year mortality in older persons hospitalized on acute geriatric and cardiologic units.

Outcomes of ICU patients with and without perceptions of excessive care: a comparison between cancer and non-cancer patients.

BACKGROUND: Whether Intensive Care Unit (ICU) clinicians display unconscious bias towards cancer patients is unknown. The aim of this study was to compare the outcomes of critically ill patients with and without perceptions of excessive care (PECs) by ICU clinicians in patients with and without cancer. METHODS: This study is a sub-analysis of the large multicentre DISPROPRICUS study. Clinicians of 56 ICUs in Europe and the United States completed a daily questionnaire about the appropriateness of care during a 28-day period. We compared the cumulative incidence of patients with concordant PECs, treatment limitation decisions (TLDs) and death between patients with uncontrolled and controlled cancer, and patients without cancer. RESULTS: Of the 1641 patients, 117 (7.1%) had uncontrolled cancer and 270 (16.4%) had controlled cancer. The cumulative incidence of concordant PECs in patients with uncontrolled and controlled cancer versus patients without cancer was 20.5%, 8.1%, and 9.1% (p < 0.001 and p = 0.62, respectively). In patients with concordant PECs, we found no evidence for a difference in time from admission until death (HR 1.02, 95% CI 0.60-1.72 and HR 0.87, 95% CI 0.49-1.54) and TLDs (HR 0.81, 95% CI 0.33-1.99 and HR 0.70, 95% CI 0.27-1.81) across subgroups. In patients without concordant PECs, we found differences between the time from admission until death (HR 2.23, 95% CI 1.58-3.15 and 1.66, 95% CI 1.28-2.15), without a corresponding increase in time until TLDs (NA, p = 0.3 and 0.7) across subgroups. CONCLUSIONS: The absence of a difference in time from admission until TLDs and death in patients with concordant PECs makes bias by ICU clinicians towards cancer patients unlikely. However, the differences between the time from admission until death, without a corresponding increase in time until TLDs, suggest prognostic unawareness, uncertainty or optimism in ICU clinicians who did not provide PECs, more specifically in patients with uncontrolled cancer. This study highlights the need to improve intra- and interdisciplinary ethical reflection and subsequent decision-making at the ICU.

Pharmacological treatment in the dying geriatric patient: describing use and dosage of opioids in the acute geriatric wards and palliative care units of three hospitals.

PURPOSE: The quality of dying of the older person could be optimized. One of the cornerstones to achieve better symptom control in the dying patient can be the use of opioids. However, little benchmark data concerning the use and dosage of opioids in the terminal phase in older persons are available. METHODS: In this multi-centric retrospective study, we included patients 75 years and older who died on the acute geriatric unit (AGU) and the palliative care unit (PCU) in three hospitals (during a 2-year period). Sudden deaths were excluded. Demographic and clinical variables, and data concerning use and dosage of opioids in the last 72 h before death were collected. RESULTS: Data from 556 patients were collected (38.5% from PCU, 61.5% from AGU). Older patients on the PCU were younger and suffered more frequently from end-stage malignancies. Most older patients on PCU (98.2%) received opioids with a mean dosage of 88.2 mg in 72 h. On the AGU, 75.5% of patients was treated with opioids with a mean dosage of 27.7 mg in 72 h. After adjusting for the variables age, gender and underlying pathology, use of opioids (OR 11.9; 95% CI 2.7-51.7; p = 0.022) and dosage (B 28.8; 95% CI 4.1-53.4; p = 0.001) still differed between the PCU and the AGU. Dosage of opioids was also associated with suffering from cancer or not. CONCLUSIONS: This descriptive benchmark study shows that opioids are given to 75.5% of dying older patients on the AGU at a mean dose of 27.7 mg over the last 72 h versus 98.2% and 88.2 mg, respectively, on the PCU. Further prospective studies including detailed information on symptomatology and more in-depth clinical information on trajectory of dying and cause of death are necessary.

Potentially Inappropriate Treatments at the End of Life in Nursing Home Residents: Findings From the PACE Cross-Sectional Study in Six European Countries.

CONTEXT: Certain treatments are potentially inappropriate when administered to nursing homes residents at the end of life and should be carefully considered. An international comparison of potentially inappropriate treatments allows insight into common issues and country-specific challenges of end-of-life care in nursing homes and helps direct health-care policy in this area. OBJECTIVES: To estimate the prevalence of potentially inappropriate treatments in the last week of life in nursing home residents and analyze the differences in prevalence between countries. METHODS: A cross-sectional study of deceased residents in nursing homes (2015) in six European countries: Belgium (Flanders), England, Finland, Italy, The Netherlands, and Poland. Potentially inappropriate treatments included enteral administration of nutrition, parental administration of nutrition, artificial fluids, resuscitation, artificial ventilation, blood transfusion, chemotherapy/radiotherapy, dialysis, surgery, antibiotics, statins, antidiabetics, new oral anticoagulants. Nurses were questioned about whether these treatments were administered in the last week of life. RESULTS: We included 1384 deceased residents from 322 nursing homes. In most countries, potentially inappropriate treatments were rarely used, with a maximum of 18.3% of residents receiving at least one treatment in Poland. Exceptions were antibiotics in all countries (between 11.3% in Belgium and 45% in Poland), artificial nutrition and hydration in Poland (54.3%) and Italy (41%) and antidiabetics in Poland (19.7%). CONCLUSION: Although the prevalence of potentially inappropriate treatments in the last week of life was generally low, antibiotics were frequently prescribed in all countries. In Poland and Italy, the prevalence of artificial administration of food/fluids in the last week of life was high, possibly reflecting country differences in legislation, care organization and culture, and the palliative care competences of staff.

Can usual gait speed be used as a prognostic factor for early palliative care identification in hospitalized older patients? A prospective study on two different wards.

BACKGROUND: Timely palliative care in frail older persons remains challenging. Scales to identify older patients at risk of functional decline already exist. However, factors to predict short term mortality in older hospitalized patients are scarce. METHODS: In this prospective study, we recruited patients of 75 years and older at the department of cardiology and geriatrics. The usual gait speed measurement closest to discharge was chosen. We used the risk of dying within 1 year as parameter for starting palliative care. ROC curves were used to determine the best cut-off value of usual gait speed to predict one-year mortality. Time to event analyses were assessed by COX regression. RESULTS: On the acute geriatric ward (n = 60), patients were older and more frail (assessed by Katz and iADL) in comparison to patients on the cardiology ward (n = 82); one-year mortality was respectively 27 and 15% (p = 0.069). AUC on the acute geriatric ward was 0.748 (p = 0.006). The best cut-off value was 0.42 m/s with a sensitivity and specificity of 0.857 and 0.643. Slow walkers died earlier than faster walkers (HR 7.456, p = 0.011), after correction for age and sex. On the cardiology ward, AUC was 0.560 (p = 0.563); no significant association was found between usual gait speed and survival time. CONCLUSIONS: Usual gait speed may be a valuable prognostic factor to identify patients at risk for one-year mortality on the acute geriatric ward but not on the cardiology ward.

Top Ten Tips Palliative Care Clinicians Should Know About Cognitive Impairment and Institutional Care.

Most long-term care (LTC) residents are of age >65 years and have multiple chronic health conditions affecting their cognitive and physical functioning. Although some individuals in nursing homes return home after receiving therapy services, most will remain in a LTC facility until their deaths. This article seeks to provide guidance on how to assess and effectively select treatment for delirium, behavioral and psychological symptoms for patients with dementia, and address other common challenges such as advanced care planning, decision-making capacity, and artificial hydration at the end of life. To do so, we draw upon a team of physicians with training in various backgrounds such as geriatrics, palliative medicine, neurology, and psychiatry to shed light on those important topics in the following "Top 10" tips.

Lack of Effect of a Multicomponent Palliative Care Program for Nursing Home Residents on Hospital Use in the Last Month of Life and on Place of Death: A Secondary Analysis of a Multicountry Cluster Randomized Control Trial.

OBJECTIVES: PACE Steps to Success is a 1-year train-the-trainer program aiming to integrate nonspecialist palliative care into nursing homes via staff education and organizational support. In this study, we aimed to explore whether this program resulted in changes in residents' hospital use and place of death. DESIGN: Secondary analysis of the PACE cluster randomized controlled trial (ISRCTN14741671). Data were collected on deaths over the previous 4 months via questionnaires at baseline and postintervention. SETTING AND PARTICIPANTS: Questionnaires were completed by the nurse/care-assistant most involved from 78 nursing homes in 7 European Union countries. MEASURES: We measured number of emergency department visits, hospital admissions, length of hospital stay, and place of death. Baseline and postintervention scores between intervention and control groups were compared, and we conducted exploratory mixed-model analyses. We collected 551 out of 610 questionnaires at baseline and 984 out of 1178 at postintervention in 37 intervention and 36 control homes. RESULTS: We found no statistical significant effects of the program on emergency department visits [odds ratio (OR) = 1.38, P = .32], hospital admissions (OR = 0.98, P = .93), length of hospital stay (geometric mean difference = 0.85, P = .44), or place of death (OR = 1.08, P = .80). CONCLUSIONS AND IMPLICATIONS: We found no effect of the PACE program on either hospital use in the last month of life or place of death. Although this may be related to implementation problems in some homes, the program might also require a more specific focus on managing acute end-of-life situations and a closer involvement of general practitioners or specialist palliative care services to influence hospital use or place of death.

Evaluation of a Palliative Care Program for Nursing Homes in 7 Countries: The PACE Cluster-Randomized Clinical Trial.

Importance: High-quality evidence on how to improve palliative care in nursing homes is lacking. Objective: To investigate the effect of the Palliative Care for Older People (PACE) Steps to Success Program on resident and staff outcomes. Design, Setting, and Participants: A cluster-randomized clinical trial (2015-2017) in 78 nursing homes in 7 countries comparing PACE Steps to Success Program (intervention) with usual care (control). Randomization was stratified by country and median number of beds in each country in a 1:1 ratio. Interventions: The PACE Steps to Success Program is a multicomponent intervention to integrate basic nonspecialist palliative care in nursing homes. Using a train-the-trainer approach, an external trainer supports staff in nursing homes to introduce a palliative care approach over the course of 1 year following a 6-steps program. The steps are (1) advance care planning with residents and family, (2) assessment, care planning, and review of needs and problems, (3) coordination of care via monthly multidisciplinary review meetings, (4) delivery of high-quality care focusing on pain and depression, (5) care in the last days of life, and (6) care after death. Main Outcomes and Measures: The primary resident outcome was comfort in the last week of life measured after death by staff using the End-of-Life in Dementia Scale Comfort Assessment While Dying (EOLD-CAD; range, 14-42). The primary staff outcome was knowledge of palliative care reported by staff using the Palliative Care Survey (PCS; range, 0-1). Results: Concerning deceased residents, we collected 551 of 610 questionnaires from staff at baseline and 984 of 1178 postintervention in 37 intervention and 36 control homes. Mean (SD) age at time of death ranged between 85.22 (9.13) and 85.91 (8.57) years, and between 60.6% (160/264) and 70.6% (190/269) of residents were women across the different groups. Residents' comfort in the last week of life did not differ between intervention and control groups (baseline-adjusted mean difference, -0.55; 95% CI, -1.71 to 0.61; P = .35). Concerning staff, we collected 2680 of 3638 questionnaires at baseline and 2437 of 3510 postintervention in 37 intervention and 38 control homes. Mean (SD) age of staff ranged between 42.3 (12.1) and 44.1 (11.7) years, and between 87.2% (1092/1253) and 89% (1224/1375) of staff were women across the different groups. Staff in the intervention group had statistically significantly better knowledge of palliative care than staff in the control group, but the clinical difference was minimal (baseline-adjusted mean difference, 0.04; 95% CI, 0.02-0.05; P < .001). Data analyses began on April 20, 2018. Conclusions and Relevance: Residents' comfort in the last week of life did not improve after introducing the PACE Steps to Success Program. Improvements in staff knowledge of palliative care were clinically not important. Trial Registration: ISRCTN Identifier: ISRCTN14741671.

Cancer patients' experiences of communicating and dealing with their older parents: A qualitative study.

PURPOSE: In 2017 almost 25,000 Belgians between 40 and 60 years (38% of new diagnoses) were diagnosed with cancer. With increasing life expectancy the chance augments that these patients still have older parents alive. This implies that oncology care should also take into account the impact cancer may have on (the relationship with) older parents. The purpose of this study was to explore how cancer patients communicate and deal with their older parents during the illness trajectory. METHOD: Semi-structured interviews were conducted with 11 cancer patients. Interview transcripts were analysed using the principles of the constructivist Grounded Theory Approach. RESULTS: Depending on the situation, the time frame and the person the patients are talking about, cancer patients oscillate between perspectives (I, They and We). A common denominator in all three perspectives is silence fuelled by different forms of solicitude (self-protection and other-protection). This solicitude underpins the cancer patients' communicative behaviours and ways of relating towards their parents. CONCLUSIONS: Present findings underline the importance of health care providers considering the often hidden complexity of giving information and talking about feelings. Nurses' strategies must be designed not to harm the existing mechanism of solicitude and the diligent management of the patients' relationship with their parents. Conversations about functionality of avoiding certain topics and the impetus behind certain communicative patterns should be put forward instead of consensually advising open communication.

Opioid, antipsychotic and hypnotic use in end of life in long-term care facilities in six European countries: results of PACE.

Background: Opioids, antipsychotics and hypnotics are recommended for comfort care in dying. We studied their prescription during the last 3 days in residents deceased in the long-term care facility (LTCF). Methods: In a retrospective, cross-sectional survey in Belgium, England, Finland, Italy, the Netherlands and Poland, LTCFs, selected by proportional stratified random sampling, reported all deaths over the previous 3 months. The nurse most involved in the residents' care reviewed the chart for opioid, antipsychotic and hypnotic prescription, cause of death and comorbidities. Multivariable logistic regression was performed to adjust for resident characteristics. Results: Response rate was 81.6%. We included 1079 deceased residents in 322 LCTFs. Opioid prescription ranged from 18.5% (95% CI: 13.0-25.8) of residents in Poland to 77.9% (95% CI: 69.5-84.5) in the Netherlands, antipsychotic prescription from 4.8% (95% CI: 2.4-9.1) in Finland to 22.4% (95% CI: 14.7-32.4) in Italy, hypnotic prescription from 7.8% (95% CI: 4.6-12.8) in Finland to 47.9% (95% CI: 38.5-57.3) in the Netherlands. Differences in opioid, antipsychotic and hypnotic prescription between countries remained significant (P < 0.001) when controlling for age, gender, length of stay, cognitive status, cause of death in multilevel, multivariable analyses. Dying from cancer showed higher odds for receiving opioids (OR 3.51; P < 0.001) and hypnotics (OR 2.10; P = 0.010). Conclusions: Opioid, antipsychotic and hypnotic prescription in the dying phase differed significantly between six European countries. Further research should determine the appropriateness of their prescription and refine guidelines especially for LTCF residents dying of non-cancer diseases.

Perception of inappropriate cardiopulmonary resuscitation by clinicians working in emergency departments and ambulance services: The REAPPROPRIATE international, multi-centre, cross sectional survey.

INTRODUCTION: Cardiopulmonary resuscitation (CPR) is often started irrespective of comorbidity or cause of arrest. We aimed to determine the prevalence of perception of inappropriate CPR of the last cardiac arrest encountered by clinicians working in emergency departments and out-of-hospital, factors associated with perception, and its relation to patient outcome. METHODS: A cross-sectional survey was conducted in 288 centres in 24 countries. Factors associated with perception of CPR and outcome were analyzed by Cochran-Mantel-Haenszel tests and conditional logistic models. RESULTS: Of the 4018 participating clinicians, 3150 (78.4%) perceived their last CPR attempt as appropriate, 548 (13.6%) were uncertain about its appropriateness and 320 (8.0%) perceived inappropriateness; survival to hospital discharge was 370/2412 (15.3%), 8/481 (1.7%) and 8/294 (2.7%) respectively. After adjusting for country, team and clinician's characteristics, the prevalence of perception of inappropriate CPR was higher for a non-shockable initial rhythm (OR 3.76 [2.13-6.64]; P < .0001), a non-witnessed arrest (2.68 [1.89-3.79]; P < .0001), in older patients (2.94 [2.18-3.96]; P < .0001, for patients >79 years) and in case of a "poor" first physical impression of the patient (3.45 [2.36-5.05]; P < .0001). In accordance, non-shockable and non-witnessed arrests were both associated with lower survival to hospital discharge (0.33 [0.26-0.41]; P < 0.0001 and 0.25 [0.15-0.41]; P < 0.0001, respectively), as were older patient age (0.25 [0.14-0.44]; P < 0.0001 for patients >79 years) and a "poor" first physical impression (0.26 [0.19-0.35]; P < 0.0001). CONCLUSIONS: The perception of inappropriate CPR increased when objective indicators of poor prognosis were present and was associated with a low survival to hospital discharge. Factoring clinical judgment into the decision to (not) attempt CPR may reduce harm inflicted by excessive resuscitation attempts.

The palliative care knowledge of nursing home staff: The EU FP7 PACE cross-sectional survey in 322 nursing homes in six European countries.

BACKGROUND: The provision of high-quality palliative care in nursing homes (NHs) is a major challenge and places demands on the knowledge and skills of the staff. AIM: This study assesses the palliative care knowledge of staff in NHs in Europe. DESIGN: Cross-sectional study using structured survey Setting/participants: Nurses and care assistants working in 322 representative samples of NHs in Belgium, the Netherlands, England, Finland, Poland and Italy. Palliative care knowledge is measured with the Palliative Care Survey. Scores on the scales range between 0 and 1; higher scores indicate more knowledge. RESULTS: A total of 3392 NH-staff were given a questionnaire, and 2275 responded (67%). Knowledge of basic palliative care issues ranged between 0.20 in Poland (95% confidence interval (CI) 0.19; 0.24) and 0.61 in Belgium (95% CI 0.59; 0.63), knowledge of physical aspects that can contribute to pain ranged between 0.81 in Poland (95% CI 0.79; 0.84) and 0.91 in the Netherlands (95% CI 0.89; 0.93), and knowledge of psychological reasons that can contribute to pain ranged between 0.56 in England (95% CI 0.50; 0.62) and 0.87 in Finland (95% CI 0.83; 0.90). Factors associated with knowledge were country, professional role and having undertaken formal training in palliative care. CONCLUSIONS: Knowledge of nurses and care assistants concerning basic palliative care issues appears to be suboptimal in all participating countries, although there is substantial heterogeneity. Education of nursing staff needs to be improved across, but each country may require its own strategy to address the unique and specific knowledge gaps.