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Objectives: The aim of the study was to develop a whole medical system healthcare program as an alternative for group-oriented guidelines and as a basis for future studies on safety and (cost) effects. Mild to moderately severe depressive disorders were chosen as an illustrative example. Design: Literature surveys, monodisciplinary expert interviews, and multidisciplinary panel discussions were employed to describe the whole medical system, its important elements, and the way the important elements are integrated in daily practice. Results: The treatment of depressive disorders consists of four separate treatment phases in which 10 specific treatment goals are identified. Different disciplines may contribute to each goal. This gives an opportunity for the individualization of care. Within each discipline multiple options per goal are identified which leads to additional possibilities to individualize care. Conclusions: Individualized healthcare for patients with mild to moderately severe depressive disorders can be described in terms of treatment goals and treatment options to allow for personalization. The program may serve as the basis for future measurement of quality, cost effectiveness, and safety of provided care. [ABSTRACT FROM AUTHOR]

Background: Three important elements of the World Health Organization (WHO) definition of palliative care are: 1) it includes patients who may have cure or life prolongation as treatment aims besides palliative care; 2) it is not exclusively for cancer patients; and 3) it includes attention to the medical, psychological, social, and spiritual needs of the patients and their families. Case managers (nurses with expertise in palliative care) may assist generalist primary care providers in delivery of good palliative care. Objectives: This study investigates the referral of patients to case managers in primary care with regard to the three elements mentioned: diagnosis, treatment aims, and needs as reflected in reasons given for referral. Methods: In this cross-sectional survey in primary care among case managers and referrers to case management, case managers completed questionnaires for 687 patients; referrers completed 448 (65%). Results: Most patients referred have a combination of treatment aims (69%). Life expectancy and functional status of patients are lower for those with a treatment aim of palliation. Almost all (96%) of those referred are cancer patients. A need for psychosocial support is frequently given as a reason for referral (66%) regardless of treatment aim. Conclusions: Referrals to case managers reflect two of three elements of the WHO definition. Mainly, patients are referred for support complementary to medical care, and relatively early in their disease trajectory. However, most of those referred are cancer patients. Thus, to fully reflect the definition, broadening the scope to reach other patient groups is important. [ABSTRACT FROM AUTHOR]

Background: Many people with dementia die in long-term care settings. These patients may benefit from a palliative care goal, focused on comfort. Admission may be a good time to revisit or develop care plans. Objective: To describe care goals in nursing home patients with dementia and factors associated with establishing a comfort care goal. Design: We used generalized estimating equation regression analyses for baseline analyses and multinomial logistic regression analyses for longitudinal analyses. Setting: Prospective data collection in 28 Dutch facilities, mostly nursing homes (2007-2010; Dutch End of Life in Dementia study, DEOLD). Results: Eight weeks after admission (baseline), 56.7% of 326 patients had a comfort care goal. At death, 89.5% had a comfort care goal. Adjusted for illness severity, patients with a baseline comfort care goal were more likely to have a religious affiliation, to be less competent to make decisions, and to have a short survival prediction. Their families were less likely to prefer life-prolongation and more likely to be satisfied with family-physician communication. Compared with patients with a comfort care goal established later during their stay, patients with a baseline comfort care goal also more frequently had a more highly educated family member. Conclusions: Initially, over half of the patients had a care goal focused on comfort, increasing to the large majority of the patients at death. Optimizing patient-family-physician communication upon admission may support the early establishing of a comfort care goal. Patient condition and family views play a role, and physicians should be aware that religious affiliation and education may also affect the (timing of) setting a comfort care goal. [ABSTRACT FROM AUTHOR]