[The listening doctor; appropriate care in the last phase of life]. / De luisterdokter; passende zorg in de laatste levensfase.

In his report 'Everything that can be done should not necessarily be done. Appropriate care in the last phase of life', the chairman of the steering committee of the Royal Dutch Medical Association says: 'I wish that doctors would listen to their patients.' This wish sets the tone of the report, which signals overtreatment in patients' last years of life and advocates a more restrained approach by doctors in this phase. The message is, however, that for this to take place a complete U-turn in modern medical thinking and management is needed.

Cost-effectiveness of neonatal surgery: first greeted with scepticism, now increasingly accepted.

Mortality rates in neonatal surgery have dropped markedly, illustrating the enormous progress made. Yet, new questions have arisen. To mention one, health care budgets have tightened. It follows that the effects of medical interventions should be weighted against their costs. As evidence was particularly sparse, we set out to analyse cost-effectiveness of neonatal surgery. The purpose of this article is to summarise our findings and to review recent studies. Moreover, this article explains the relevance of cost-effectiveness analysis and explores how cost-effectiveness interacts with other determinants of health care priority setting. Our research revealed that treatments for two common diagnostic categories in neonatal surgery (congenital anorectal malformations and congenital diaphragmatic hernia) produce good cost-effectiveness. Other groups also published cost-effectiveness studies in the field of neonatal surgery, although their number is still small. Contemporaneously, the economic aspects of health care have captured the interest of policy makers. Importantly, this is not to say that there are no other factors playing a role in priority setting, foremost among which are ethical questions and arguments of equity. This article concludes that, according to present evidence, neonatal surgery yields good value for money and contributes to equity in health.

The cost-effectiveness of treatment for congenital diaphragmatic hernia.

BACKGROUND/PURPOSE: The cost-effectiveness of medical interventions is becoming an important issue for decision makers. Until recently, evidence of the cost-effectiveness of neonatal surgery was largely lacking. The authors analyzed the cost-effectiveness of neonatal surgery and subsequent treatment for congenital diaphragmatic hernia (CDH). METHODS: Both costs incurred inside and outside the health care sector (eg, out-of-pocket expenses and productivity losses) were included. Quality-adjusted life years (QALYs) were measured using the EuroQol EQ-5D questionnaire. Descriptive quality-of-life data were collected using a disease-specific questionnaire. Both costs and effects basically were measured in a life-time setting. RESULTS: Total costs of treatment average euro 42,658, mainly consisting of costs of the initial hospitalization. Productivity losses in both the patients and their caregivers appear to be minor. Treated CDH patients, even adults, suffer from respiratory difficulties and stomach aches. According to the EQ-5D, however, their quality of life does not differ from the general population, suggesting that these symptoms barely affect overall quality of life. Treatment results in a gain of 17.5 QALYs. Costs per QALY amount to euro 2,434. CONCLUSIONS: Treatment for CDH has favorable cost-effectiveness. Considering the growing importance of cost-effective medicine, these are important and encouraging results. Health economics outlines the inevitability of making choices that directly affect patient care and places relative values on different health care programs. The results of this study provide convincing evidence that treatment for CDH is indeed cost effective.

The legal investigation of a decision not to operate on an infant with Down's syndrome and a duodenal atresia: a report from the Netherlands.

It is well-known that in the Netherlands it has for several years been possible to carry out voluntary euthanasia quite openly, provided certain strict conditions are fulfilled. This situation has arisen because courts in the Netherlands have decided that doctors who end the lives of their patients under these conditions are in a "conflict of duties" situation, and therefore should not be convicted of any criminal offence. It has, however, not been known what view a Netherlands court might take about life and death decisions concerning patients who are not capable of giving consent -- for example, infants. This report briefly outlines my experience in the case of an infant with Down's syndrome and duodenal atresia -- a blockage of the digestive system that must be operated upon if the infant is to survive. A decision was taken not to operate, and this decision resulted in the Netherlands courts considering whether criminal proceedings were justified.