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J J van Delden

Publications and source records attributed to J J van Delden.

16 recordsLinked to original sources
PubMed2001

The principle of respect for autonomy in the care of nursing home residents.

Respect for autonomy is well known as a core element of normative views on good care. Most often it is interpreted in a liberal way, with a focus on independence and self-determination. In this article we argue that this interpretation is too narrow in the context of care in nursing homes. With the aim of developing an alternative view on respect for autonomy in this setting we described four interpretations and investigated the moral intuitions (i.e. moral judgements) of caregivers regarding these approaches. We found that these caregivers seemed to value different notions relating to respect for autonomy under different circumstances. There was no significant difference in moral judgements between men and women or between doctors and nurses. We conclude that a multidimensional understanding of this principle would best fit this context. We end this article with a description of a modest theory of respect for autonomy in nursing homes.

Adult↗
PubMed2000

[Experiences of guardians of psychogeriatric patients regarding decision not to treat].

OBJECTIVE: To obtain an impression of how representatives of psychogeriatric patients experience their role in non-treatment decisions. DESIGN: Retrospective. METHOD: The names of the 50 most recently deceased patients in psychogeriatric departments of a nursing home and of their representatives were obtained from the register of the nursing home. Of the representatives 28 (67%) agreed to an interview. RESULTS: 24 of the 28 respondents had participated in some form of medical decision-making. There were 34 decisions of which 33 non-treatment decisions. In most cases the decision was to give symptomatic treatment only. In 27 of 34 cases the representative did not regard it as a burden to be involved in the decision-making, on the contrary they considered it self-evident and were pleased to be involved. CONCLUSION: In general, representatives of psychogeriatric nursing home patients did not regard it as a burden to be involved in end-of-life decision-making.

Aged↗
PubMed2000

Guidelines for the use of do-not-resuscitate orders in Dutch hospitals.

OBJECTIVES: To determine the prevalence and analyze the content of guidelines for the use of do-not-resuscitate (DNR) orders in Dutch hospitals. DESIGN: Cross-sectional descriptive study. MEASUREMENTS AND MAIN RESULTS: A questionnaire was mailed to the directors of patient care at all 143 Dutch hospitals. Directors were asked whether their hospitals had guidelines for the use of DNR orders and to provide copies of the guidelines if they did. The content of the guidelines was analyzed with regard to basic assumptions about nonresuscitation, definitions, persons involved in decision-making, advance directives, starting discussions about nonresuscitation, notation, evaluation, and other aspects. Of the 143 hospital directors surveyed, 95% responded. Sixty percent of the hospitals had guidelines for the use of DNR orders and provided copies. The assumption "always resuscitate, unless" was mentioned in 66% of guidelines. In 93% it was stated that patients should be involved in decision-making about nonfutile resuscitation. In 38% it was stated that in principle, living wills were respected in cases of incompetence. The role of proxies was mainly to discuss decisions (58% of guidelines), not to make them. The most frequently mentioned moment for starting a discussion about nonresuscitation was the onset of clinical deterioration of the patient (41%). CONCLUSIONS: It is promising that 60% of Dutch hospitals have developed guidelines for the use of DNR orders. However, current guidelines can be improved in many respects.

Cross-Sectional Studies↗
PubMed1999

Slippery slopes in flat countries--a response.

In response to the paper by Keown and Jochemsen in which the latest empirical data concerning euthanasia and other end-of-life decisions in the Netherlands is discussed, this paper discusses three points. The use of euthanasia in cases in which palliative care was a viable alternative may be taken as proof of a slippery slope. However, it could also be interpreted as an indication of a shift towards more autonomy-based end-of-life decisions. The cases of non-voluntary euthanasia are a serious problem in the Netherlands and they are only rarely justifiable. However, they do not prove the existence of a slippery slope. Persuading the physician to bring euthanasia cases to the knowledge of the authorities is a problem of any euthanasia policy. The Dutch notification procedure has recently been changed to reduce the underreporting of cases. However, many questions remain.

Decision Making↗
PubMed1997

Retrospective study of doctors' "end of life decisions" in caring for mentally handicapped people in institutions in The Netherlands.

OBJECTIVES: To gain insight into the reasons behind and the prevalence of doctors' decisions at the end of life that might hasten a patient's death ("end of life decisions") in institutions caring for mentally handicapped people in the Netherlands, and to describe important aspects of the decisions making process. DESIGN: Survey of random sample of doctors caring for mentally handicapped people by means of self completed questionnaires and structured interviews. SUBJECTS: 89 of the 101 selected doctors completed the questionnaire. 67 doctors had taken an end of life decision and were interviewed about their most recent case. MAIN OUTCOME MEASURES: Prevalence of end of life decisions; types of decisions; characteristics of patients; reasons why the decision was taken; and the decision making process. RESULTS: The 89 doctors reported 222 deaths for 1995. An end of life decision was taken in 97 cases (44%); in 75 the decision was to withdraw or withhold treatment, and in 22 it was to relieve pain or symptoms with opiates in dosages that may have shortened life. In the 67 most recent cases with an end of life decision the patients were mostly incompetent (63) and under 65 years old (51). Only two patients explicitly asked to die, but in 23 cases there had been some communication with the patient. In 60 cases the doctors discussed the decision with nursing staff and in 46 with a colleague. CONCLUSIONS: End of life decisions are an important aspect of the institutionalised care of mentally handicapped people. The proportion of such decisions in the total number of deaths is similar to that in other specialties. However, the discussion of such decisions is less open in the care of mental handicap than in other specialties. Because of distinctive features of care in this specialty an open debate about end of life decisions should not be postponed.

Adolescent↗
PubMed1995

Withdrawal or withholding of treatment at the end of life. Results of a nationwide study.

BACKGROUND: Decisions to withhold or withdraw treatment (nontreatment decisions) become increasingly important because they have to be made more frequently and more explicitly. This nationwide study provides information on the occurrence and background of these nontreatment decisions. METHODS: Three studies were undertaken: interviews with 405 physicians, 5197 answered questionnaires concerning deceased persons, and information about 2257 deaths collected by a prospective study. RESULTS: Of all deaths, 30% appeared to be sudden and unexpected. In 39% of all nonsudden deaths, a nontreatment decision was made. This percentage varied by specialty (28% to 55%). Nontreatment decisions were made more often in older female patients. The decisions were made at the explicit request of the patient (19%), after discussion with the patient or after a previous wish (22%), or without any involvement of the patient (59%). Of this last group, 87% of patients were not competent at the time of the decision. In 24% of cases of nontreatment, life was shortened by at least a week. Of all physicians interviewed, 56% had changed their attitude since the beginning of their practice, most of them toward more nontreatment decisions at the end of life. CONCLUSIONS: Nontreatment decisions are made frequently in medical practice. Most often the physician has to weigh medical and nonmedical burdens and benefits. For this to be done properly, the patient should be involved whenever possible. Other requirements are optimal palliative treatment, better prognostic knowledge, consultation of other specialists, and the absence of defensive motives.

Adolescent↗
PubMed1994

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.

Aged↗
PubMed1993

Life-terminating acts without explicit request of patient.

In the Dutch nationwide study on medical decisions concerning the end of life (MDEL) life-terminating acts without the explicit request of the patient (LAWER) were noted in 0.8% of all deaths. We present here quantitative information and a discussion of the main issues raised by LAWER. In 59% of LAWER the physician had some information about the patient's wish; in 41% discussion on the decision would no longer have been possible. In LAWER patients tend to be younger and more likely to be male and to have cancer than in non-acute deaths generally. The physician (specialist or general practitioner) knew the patient on average 2.4 years and 7.2 years, respectively. Life was shortened by between some hours and a week at most in 86%. In 83% the decision has been discussed with relatives and in 70% with a colleague. In nearly all cases, according to the physician, the patient was suffering unbearably, there was no chance of improvement, and palliative possibilities were exhausted. MDEL probably will increase in number in future but interviews with Dutch physicians suggest a possible fall in LAWER, even though there will always be some situations in which a well-considered LAWER decision may have to be made.

Adolescent↗
PubMed1993

[Managing psychogeriatric patients who stopped eating].

We carried out a small survey among 22 interviewees working as physicians (n = 11) or as nurses (n = 11) in a nursing home. The questions concerned the last case they had seen of a psychogeriatric patient who did not eat any more, and the decision-making process. 35 patients were described to us: 13 in whom feeding was continued (mostly by drip) and 22 in which it was withheld. It appeared that the withholding of artificial feeding was the more common decision. If feeding was continued it was usually a time-limited trial. The decision-making process appeared to be careful and elaborate. Among the reasons to withhold feeding was the thought that the patient did not wish to live any more and was showing this by refusing to eat. Formal criteria for determining mental (in)competence were not used, however. When patients died after discontinuation of feeding, the dying process mostly was peaceful (15/17); five of the 22 patients in whom feeding was discontinued spontaneously resumed eating.

Aged↗
PubMed1993

Deciding not to resuscitate in Dutch hospitals.

The use of do not resuscitate (DNR) orders in Dutch hospitals was studied as part of a nationwide study on medical decisions concerning the end of life. DNR decisions are made in 6 per cent of all admissions, and 61 per cent of all in-hospital deaths were preceded by a DNR decision. We found that in only 14 per cent of the cases had the patients been involved in the DNR decision (32 per cent of competent patients). The concept of futility is analysed as these findings are discussed. We conclude that determining the effectiveness of resuscitation is a medical judgement whereas determining the proportionality (burden/benefit ratio) of it requires a discussion between doctor and patient (or his or her surrogates). Since the respondents in the cases without patient involvement gave many reasons for their decision that went beyond determining effectiveness, we conclude that more patient involvement would have been desirable.

Death Certificates↗