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Biomedical subjects

Gerrit van der Wal

Publications and source records attributed to Gerrit van der Wal.

At least 55 records · Page 3Linked to original sources
PubMed2005

Decreasing the number of consultations for minor illnesses of Turkish and Dutch inhabitants of a deprived area in The Netherlands: an intervention study.

OBJECTIVE: The purpose of this study was to assess the effectiveness of GPs personally handing out to their patients booklets about minor ailments and self-limiting health problems (minor illnesses). METHODS: The study was a pre-test-post-test, control group design and took place in seven general practices. The participants were 162 patients (72 Turkish, 70 Dutch and 20 of other nationality) who frequently visit their GP (>5 times a year), living in deprived areas of The Hague. They were recruited in the waiting rooms of participating general practices. GPs personally handed out booklets to their patients about 12 of the most common minor illnesses and explained how to use them. The main outcome measures were consultations for the 12 minor illnesses listed in the booklet, reported by the patients themselves as well as registered in the general practice medical records, and the number of self-reported illnesses the patients suffered from. RESULTS: The results of both the self-report and the medical records show a significant decrease in number of consultations for minor illnesses in the entire research population, Turkish as well as Dutch. The number of self-reported self-limiting health problems of the Dutch increased. CONCLUSION: Due to the non-randomization procedure, some caution with regard to generalization must be taken. The results indicate that distribution by the GP of booklets with tailored information when a patient is ill leads to a reduction in consultations for minor illnesses.

Adult↗
PubMed2005

Medical end-of-life decisions for children in the Netherlands.

BACKGROUND: Most end-of-life decision-making studies have, until now, involved either the general population or newborn infants. OBJECTIVE: To assess the frequency of end-of-life decisions preceding child death and the characteristics of the decision-making process in the Netherlands. METHODS: Two studies were performed. The first was a death certificate study in which all 129 physicians reporting the death of a child aged between 1 and 17 years in the period August to December 2001 received a written questionnaire; the second was an interview study in which face-to-face interviews were held with 63 physicians working in pediatric hospital departments. RESULTS: Some 36% of all deaths of children between the ages of 1 and 17 years during the relevant period were preceded by an end-of-life decision: 12% by a decision to refrain from potentially life-prolonging treatment; 21% by the alleviation of pain or symptoms with a possible life-shortening effect; and 2.7% by the use of drugs with the explicit intention of hastening death. The latter decision was made at the child's request in 0.7% and at the request of the family in 2% of cases. The interview study examined 76 cases of end-of-life decision making. End-of-life decisions were discussed with all 9 competent and 3 partly competent children, with the parents in all cases, with other physicians in 75 cases, and with nurses in 66 cases. CONCLUSIONS: While not inconsiderable, the percentage of end-of-life decisions was lower for children than for adults and newborn infants. Most children are not considered to be able to participate in the decision-making process. Decisions are generally discussed with parents and other caregivers and, if possible, with the child.

Adolescent↗
PubMed2005

Accepting or declining the offer of prenatal screening for congenital defects: test uptake and women's reasons.

OBJECTIVES: Prenatal screening for Down syndrome has become standard practice in many western countries. In the Netherlands, however, prenatal screening tests for congenital defects are not offered routinely. The present study aims to assess test uptake in a large, unselected population of pregnant women, and to give more insight into the decision for or against prenatal screening through nuchal translucency measurement or maternal serum screening. PATIENTS AND METHODS: The study is part of a randomized controlled trial with two groups, each being offered a different prenatal screening test, and a control group. Pregnant women received postal questionnaires at three stages of their pregnancy. RESULTS: Of the women being offered the nuchal translucency measurement or the second trimester maternal serum test, 53 and 38% respectively accepted the test offer. The main reasons for accepting were 'gaining knowledge about the health of the foetus/curiosity' (50%), 'favourable characteristics of the screening test' (18%), and 'increased risk of having a child with DS' (15%). The main reasons for declining were 'unfavourable characteristics of the screening test' (42%), 'not applicable/not necessary' (35%), 'anxiety/uncertainty' (36%), 'adverse characteristics of the invasive tests' (32%), and 'being against abortion' (15%). DISCUSSION: The uptake of prenatal screening was relatively low, and different distributions of reasons were reported, compared to other studies. These differences may be due to the specific Dutch situation in which prenatal screening is not part of standard prenatal care. The question arises as to whether informed decision-making would be reduced if prenatal screening became routinised.

Adult↗
PubMed2005

Physicians' willingness to grant requests for assistance in dying for children: a study of hypothetical cases.

OBJECTIVE: To study the willingness of Dutch physicians to use potentially life-shortening or lethal drugs for severely ill children. STUDY DESIGN: We asked 63 pediatricians about their approach to 10 hypothetical cases of children with cancer. The age of the child (15, 11, or 6 years), the child's (explicit) request, and the opinion of the parents varied. Two hypothetical cases were also presented to 125 general practitioners and 208 clinical specialists. RESULTS: Most pediatricians were willing to increase morphine in all cases. A total of 48% to 60% of pediatricians were willing to use lethal drugs in children at the child's request, when the parents agreed; when parents requested ending of life of their unconscious child, 37% to 42% of pediatricians were willing; 13% to 28% of pediatricians were willing when parents did not agree with their child's request. General practitioners and clinical specialists were as willing as pediatricians to use lethal drugs at the child's request, but less willing to grant a request of parents for their unconscious child. CONCLUSIONS: Many Dutch pediatricians are willing to use potentially life-shortening or lethal drugs for children. The legal limit of 12 years, as the age under which voluntary euthanasia is forbidden, is not fully supported by Dutch physicians.

Adolescent↗
PubMed2005

A comparison of attitudes towards end-of-life decisions: survey among the Dutch general public and physicians.

In The Netherlands, there has been a continuing public debate about the acceptability and regulatory system for medical decision-making concerning the end of life. We studied attitudes of the Dutch general public towards different types of end-of-life decisions in various situations and compared them to attitudes of physicians. Questionnaires were mailed to 1777 members of the Dutch general public (response: 78%). A total of 391 Dutch physicians, including general practitioners, nursing home physicians and clinical specialists, were interviewed in person (response: 81%). In both the survey and physician interviews, questions were asked about attitudes towards active ending of life, terminal sedation, and increasing morphine with premature death as a likely consequence, using hypothetical cases of different patients. By logistic regression analysis, the differences between public and physicians' attitudes were assessed, as well as the associations between attitudes of the general public and their personal characteristics. Acceptance of active ending of life at the request of a terminally ill cancer patient was higher among the general public (85%) than among physicians (64%). For physicians, acceptance decreased to 36% for an incompetent adult, 11% for a patient without a serious disease, and 6% for a patient with dementia. For the general public, these percentages were 63%, 37%, and 62%, respectively. Between both groups, no differences were found in acceptance of terminal sedation and increasing morphine. For the general public, determinants of support for active ending of life were being non-religious, lower education, and having a single household. Acknowledging the observed differences in appreciation of end-of-life decision-making between the general public and physicians is important in doctor-patient communication and in public debate and policymaking. Continued monitoring of practices and informing the general public and policymakers about the clinical and ethical consequences of different types of end-of-life decisions is important.

Adult↗
PubMed2005

Requests for euthanasia or physician-assisted suicide from older persons who do not have a severe disease: an interview study.

OBJECTIVE: To determine how often requests are made for euthanasia and physician-assisted suicide (EAS) in the absence of severe disease and how such requests are dealt with in medical practice in The Netherlands. METHOD: Retrospective interview study. PARTICIPANTS: 125 general practitioners (GPs), 77 nursing home physicians (NHPs), and 208 clinical specialists. RESULTS: In The Netherlands, each year approximately 400 people request EAS, because they are 'weary of life'. Thirty per cent of all physicians have at some time received an explicit request for EAS in the absence of severe disease; 3% of all physicians had granted a request for EAS in such a case. Most requests for EAS to GPs in the absence of severe disease (n = 29) were made by single people aged 80 years and over. While their problems were most frequently of a social nature, 79% had one or more non-severe illnesses. Most GPs refused the request; half of them proposed an alternative treatment, which the patient often refused. Nineteen people who did not receive any treatment persisted in their wish to die; the request for EAS from 5 out of 10 patients who received one or more types of treatment was withdrawn or became less explicit. CONCLUSIONS: Most physicians in The Netherlands refuse requests for EAS in the absence of severe disease. Most patients persist in their request. In an ageing population more research is needed to provide physicians with practical interventions to prevent suicide and to make life bearable and satisfactory for elderly people who wish to die.

Aged↗
PubMed2005

Withdrawing an explicit request for euthanasia or physician-assisted suicide: a retrospective study on the influence of mental health status and other patient characteristics.

BACKGROUND: Mental health status may be closely related to an instability of intentions toward a premature death, but little is known about such instability following an explicit request for euthanasia or physician-assisted suicide (EAS) and patient characteristics associated with a change of mind. METHOD: A questionnaire was sent to 6596 general practitioners in The Netherlands (response rate 60%). Of these, 1681 provided descriptions of the most recent explicit request for EAS they had received in the preceding 18 months. RESULTS: Symptoms of depression and anxiety were related to a change of mind, but no relationship was found with the total score of the NOSGER Mood Dimension. Multinomial regression analysis revealed that patients who changed their mind had more mental health problems and less mental clarity than those who died by EAS. They also had fewer general health problems, had less unbearable and pointless suffering (according to the physician), were less concerned about loss of dignity and alternative treatment options were more frequently available. A further analysis revealed that mental health problems were more prevalent among patients whose requests were refused than among those who changed their mind. The physicians' evaluations of the reasons why a patient requested EAS were similar to a more objective measure of the patient characteristics. CONCLUSIONS: These findings suggest that mental health status must be carefully assessed, and possible instability of desire must be taken into account in the course of a request for EAS. These results require replication, and future studies should adopt a prospective method.

Anxiety↗
PubMed2005

The last 3 months of life: care, transitions and the place of death of older people.

Many older people die in hospitals, whereas research indicates that they would prefer to die at home. Little is known about the factors associated with place of death. The aim of the present study was to investigate the care received by older people in the last 3 months of their life, the transitions in care and the predictors of place of death. In this population-based study, interviews were held with 270 proxy respondents to obtain data on 342 deceased participants (79% response rate) in the Longitudinal Aging Study Amsterdam. In the last 3 months of life, the utilisation of formal care increased. Half of the community-dwelling older people and their families were confronted with transitions to institutional care, in most cases to hospitals. Women relied less often on informal care only, and were more dependent than men on institutional care. For people who only received informal care, the odds of dying in a hospital were 3.68 times the odds for those who received a combination of formal and informal home care. The chance of dying in a hospital was also related to the geographical region. The authors argue that future research is needed into the association that they found in the present study, i.e. that decedents who received both formal and informal care were more likely to die at home. In view of the differences found in geographical region in relation to place of death, further investigation of regional differences in the availability and accessibility of care is indicated.

Aged↗
PubMed2005

Physicians' experiences with demented patients with advance euthanasia directives in the Netherlands.

OBJECTIVES: To estimate the incidence of (compliance with) advance euthanasia directives of patients suffering from dementia in the Netherlands and to gain knowledge about the experiences of physicians. DESIGN: Retrospective interview study. SETTING: Physicians in the Netherlands. PARTICIPANTS: Four hundred ten physicians. MEASUREMENTS: Physicians were interviewed about their demented patients who had an advance euthanasia directive. Nursing home physicians were interviewed more extensively. RESULTS: Approximately 2,200 demented patients with an advance euthanasia directive die annually after being treated by a physician who knows about this directive. In 76% of such cases, compliance with the directive was discussed, but euthanasia was seldom performed. In two-thirds of the cases of demented nursing home patients with an advance euthanasia directive, the physician was able to identify during the course of the disease a situation for which the patient had intended the directive. One-quarter of the nursing home physicians thought that their most recent patient suffered unbearably to a (very) high degree, and half of them thought that the patient suffered hopelessly to a (very) high degree. In three-quarters of the cases, the relatives did not want the nursing home physician to comply with the directive, but they did want to respect the patient's wishes by forgoing life-prolonging treatment, which occurred in approximately 90% of cases. CONCLUSION: Most nursing home physicians think that the suffering of patients with dementia can be unbearable and hopeless as a consequence of dementia, but most physicians do not consider dementia to be grounds for euthanasia, unless perhaps the patient has an additional illness.

Advance Directives↗
PubMed2005

The last days of life of nursing home patients with and without dementia assessed with the palliative care outcome scale.

UNLABELLED: The aim of this study was to assess the Palliative care Outcome Scale (POS) for terminally ill nursing home (NH) patients in the Netherlands. METHODS: A prospective observational study of patients with a life-expectancy of six weeks or less in 16 Dutch NHs. NH staff rated the patient characteristics and measured palliative care with the POS, including items on physical, psychosocial, informational, spiritual and practical aspects. RESULTS: POS nonscores (not applicable; unknown) were mainly found in the psychosocial and spiritual domains, particularly in patients with dementia. Mean scores for non-demented patients and patients with dementia were favourable for the majority of the POS items. CONCLUSION: According to the NH staff, fairly good quality care was provided, but the psychosocial and spiritual aspects of care need to be addressed more in the last days of the dying NH patient's life. The results indicate that the POS is an appropriate instrument to assess not only cancer patients, but also non-cancer and (moderately) severely demented patients.

Aged↗
PubMed2005

Quality of life change and response shift in patients admitted to palliative care units: a pilot study.

This pilot study was carried out to determine to what extent patients admitted to palliative care units (PCUs) in The Netherlands maintained good levels of individual quality of life (QoL), and to what extent response shift - a measure of adaptation - influenced QoL at the end of life. Two components of response shift were measured: reconceptualization (exchanging important areas of life) and value change (changing the perceived importance of important areas of life). Twenty patients admitted to PCUs were interviewed at one week, three weeks, and five weeks after admission. Results show that individual QoL was high and remained stable over the three measurement points. The individual QoL of patients who did not reconceptualize or did not change values was higher than the individual QoL of patients who did. The current pilot data need to be corroborated with data from additional respondents.

Adaptation, Psychological↗
PubMed2005

Differences between terminally ill cancer patients who died after euthanasia had been performed and terminally ill cancer patients who did not request euthanasia.

Palliative care, directed at improving the quality of life of terminally ill patients, is generally not aimed at any form of postponing or hastening death. It is possible that high quality palliative care could prevent requests for euthanasia. However, empirical evidence on this issue is scarce. In a national survey of end-of-life medical decisions in The Netherlands the subject of care at the end of life has been addressed. Data on terminally ill cancer patients who died after their request was granted and euthanasia had been performed were compared with those of terminally ill cancer patients who did not request euthanasia. The results show that the prevalence and severity of symptoms e.g., pain, feeling unwell, nausea, was higher in patients who died after their request was granted and euthanasia had been performed. No differences concerning the treatment of symptoms or the care provided were found between the two groups. The results suggest that the practice of euthanasia is mainly related to the patient's suffering.

Adult↗
PubMed2004

Striving for quality or length at the end-of-life: attitudes of the Dutch general public.

Questionnaires were mailed to 1777 members of the Dutch public (response: 78%), measuring to what extent respondents appreciate life-prolonging treatment, even if it would seriously impair their quality of life. The association between these attitudes and personal characteristics and initiatives to engage in advance care planning was analyzed. About one third of the respondents prefers quality of life at the expense of survival, another third prefers length of life regardless of impaired quality, whereas the remaining third did not express a clear attitude towards quality or length of life. People who were younger, male, having children, having religious beliefs, and without a history of serious illness were more likely to strive for length, whereas the reverse associations were found for striving for quality. The latter was related to undertaking initiatives to engage in advance care planning. Awareness of differences in attitudes towards life-prolonging treatment within the public may improve communication about appropriate end-of-life care.

Adult↗
PubMed2004

Symptoms, treatment and "dying peacefully" in terminally ill cancer patients: a prospective study.

GOALS: The aims of this study were to describe the symptoms, their treatment during the final months of life of terminally ill cancer patients and to assess characteristics of the dying process. PATIENTS AND METHODS: We used a prospective study design. From a representative sample of physicians who participated in a study of end-of-life decision making, we asked whether they were treating a patient with cancer whose treatment was no longer aimed at cure, whose life expectancy was probably longer than 1 week but no longer than 3 months and who would probably continue to be treated by the same physician until their death; 85 physicians completed a monthly questionnaire until patients' deaths. RESULTS: Patients were confronted with an increasing amount of symptoms during the final months of their life. Fatigue, loss of appetite, dependency and feeling unwell were the most prevalent symptoms. Physical symptoms were more often treated than psychosocial symptoms. The number of medical disciplines involved in the patient's care decreased in the period before death, but the number of informal caregivers increased; 73% of patients died peacefully. A peaceful death was impeded by feelings of anxiety and loneliness but promoted by the involvement of children in their patients' care. CONCLUSION: The results give insight into the nature of suffering and factors related to the dying process of terminally ill cancer patients. Attention to psychosocial well-being and to the need to be with loved ones appears to be essential for patients' quality of life.

Adult↗
PubMed2004

Physician reports of terminal sedation without hydration or nutrition for patients nearing death in the Netherlands.

BACKGROUND: Terminal sedation in patients nearing death is an important issue related to end-of-life care. OBJECTIVE: To describe the practice of terminal sedation in the Netherlands. DESIGN: Face-to-face interviews. SETTING: The Netherlands. PARTICIPANTS: Nationwide stratified sample of 482 physicians; 410 responded and 211 of these reported characteristics of their most recent terminal sedation case. MEASUREMENTS: Physician reports of frequency of terminal sedation (defined as the administration of drugs to keep the patient in deep sedation or coma until death, without giving artificial nutrition or hydration), characteristics of the decision-making process, drugs used, the estimated life-shortening effect, and frequency of euthanasia discussions. RESULTS: Of respondents, 52% (95% CI, 48% to 57%) had ever used terminal sedation. Of the 211 most recent cases, physicians used terminal sedation to alleviate severe pain in 51% of patients (CI, 44% to 58%), agitation in 38% (CI, 32% to 45%), and dyspnea in 38% (CI, 32% to 45%). Physicians reported discussing with patients the decision to use deep sedation in 59% of the 211 most recent cases (CI, 52% to 66%) and the decision to forgo artificial nutrition or hydration in 34% (CI, 28% to 41%). Hastening death was partly the intention of the physician in 47% (CI, 41% to 54%) of cases and the explicit intention in 17% (CI, 13% to 22%) of cases. LIMITATIONS: The generalizability of physician reports about their most recent cases to all terminal sedation cases is uncertain. In addition, the findings are subject to recall bias and may not apply to other geographic settings. CONCLUSIONS: Terminal sedation precedes a substantial number of deaths in the Netherlands. In about two thirds of most recently reported cases, physicians indicated that in addition to alleviating symptoms, they intended to hasten death.

Benzodiazepines↗
PubMed2004

Implementation of the project 'Support and Consultation on Euthanasia in The Netherlands' (SCEN).

OBJECTIVE: In the project 'Support and Consultation on Euthanasia in The Netherlands' (SCEN), general practitioners (GPs) receive training in formal consultation and in giving expert advice to colleagues who have questions about euthanasia and physician-assisted suicide (EAS). This study describes the way in which this project was implemented in The Netherlands and how it was received by GPs. METHOD: In the period from April 2000 to December 2002, all GPs in the districts in which SCEN had been implemented received a written post-test questionnaire a year and a half after the start of the project. Registration forms were also filled in by the SCEN physicians and the GPs who contacted SCEN. The post-test questionnaire was returned by 60% of the GPs (n = 3614), and registration forms were returned by 86% (n = 3337) of the GPs who contacted SCEN. RESULTS: The gradual nation-wide implementation of SCEN was completed within the 4-year study period. Almost all GPs were familiar with the project (99%) and most GPs knew what they could contact SCEN for. Most GPs felt supported by the presence of SCEN, and most GPs also had a positive attitude towards consultation and SCEN. GPs who had received an explicit request for EAS, or had performed EAS, often consulted SCEN physicians (71 and 85%, respectively). Reasons for contacting SCEN were: independence (60%), expertise (58%), and accessibility/availability of a consultant (45%). Reasons for not contacting SCEN were: enough other possibilities for counselling and consultation (48%) only at the beginning of the decision-making process (36%), and sufficient knowledge about EAS (22%). Most GPs intended to use SCEN in the future (96%). CONCLUSION: The implementation of SCEN has been successful, according to the four steps for successful implementation: awareness, attitude, use and future use. In this respect, linking up with existing networks and good organisation may play an important role. Furthermore, GPs consider it important to have a facility like SCEN which they can contact concerning EAS.

Attitude of Health Personnel↗