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BACKGROUND: Respiratory secretions impact negatively on palliative patients. Unfortunately, a gold standard therapy is not yet available. The purpose of this study was to identify which interventions are in use to control respiratory secretions in patients with chronic disease with a poor prognosis and verify their effects on outcomes relevant for palliative care patients. METHODS: A systematic review of the literature with narrative summary was conducted. We searched eight electronic databases in April (6th), 2016. Citation-tracking and reference list searches were conducted. We included randomized controlled trials, crossover trials, observational and qualitative studies regarding interventions for respiratory secretion management in adult patients with chronic diseases that met inclusion criteria indicating short prognosis. RESULTS: Six randomized controlled trials, 11 observational studies, ten crossover trials and one qualitative study were found. Interventions included mechanical insufflation-exsufflation (MIE), expiratory muscle training, manually-assisted cough, tracheotomy, chest physiotherapy, suctioning, air stacking, electrical stimulation of abdominal muscles, nebulized saline, positive expiratory pressure masks, percussive ventilation, high frequency chest wall oscillations. The interventions with most promising benefits to patients in palliative care were manually-assisted cough and mechanical insufflation-exsufflation to promote expectoration and percussive ventilation to improve mucous clearance. CONCLUSION: Therapies, such as manually assisted cough, mechanical insufflation-exsufflation and percussive ventilation, which aim to deal with respiratory secretion, were the most promising treatment for use in palliative care for specific diseases. Nevertheless, the evidence still needs to improve in order to identify which treatment is the best.

Context Sedation is administered to some palliative care patients at the end of their life. Nurses play an important role in this practice. Objectives To systematically review the evidence on nurses' attitudes and practice of end-of-life sedation. Methods We searched eight electronic databases, four key palliative care journals, and reference lists for empirical studies published in English, between 1990 and 2012, on nurses and their attitudes toward and practice of sedation until a patient's death. A total of 10 studies met the inclusion criteria. Results Data were generated from 7515 nurses in four main settings (specialized palliative care unit, home, nursing home, and acute hospital) from seven countries (Belgium, Canada, Japan, The Netherlands, Norway, U.K., and U.S.). On average, the quality of the evidence was good; hence, we analyzed all selected studies. Based on the findings from a previous review, we categorized the emerging themes into: 1) important factors leading to the patient receiving palliative sedation (PS), 2) nurses' attitudes toward PS, and 3) nurses' experience of PS at the end of a patient's life. In general, nurses had a positive but cautious attitude toward the practice of PS. Most saw it as a last resort treatment for relieving suffering and refractory symptoms, and its practice was often influenced by their level of education, expertise, and the roles they played per setting. Conclusion Most nurses administered sedation until death only within the given circumstances because of the anticipatory benefits in controlling refractory symptoms and suffering. Some of them experienced burdens during PS delivery; these could be supported by operational guidelines and task-related training.

Context Sedation is administered to some palliative care patients at the end of their life. Nurses play an important role in this practice. Objectives To systematically review the evidence on nurses' attitudes and practice of end-of-life sedation. Methods We searched eight electronic databases, four key palliative care journals, and reference lists for empirical studies published in English, between 1990 and 2012, on nurses and their attitudes toward and practice of sedation until a patient's death. A total of 10 studies met the inclusion criteria. Results Data were generated from 7515 nurses in four main settings (specialized palliative care unit, home, nursing home, and acute hospital) from seven countries (Belgium, Canada, Japan, The Netherlands, Norway, U.K., and U.S.). On average, the quality of the evidence was good; hence, we analyzed all selected studies. Based on the findings from a previous review, we categorized the emerging themes into: 1) important factors leading to the patient receiving palliative sedation (PS), 2) nurses' attitudes toward PS, and 3) nurses' experience of PS at the end of a patient's life. In general, nurses had a positive but cautious attitude toward the practice of PS. Most saw it as a last resort treatment for relieving suffering and refractory symptoms, and its practice was often influenced by their level of education, expertise, and the roles they played per setting. Conclusion Most nurses administered sedation until death only within the given circumstances because of the anticipatory benefits in controlling refractory symptoms and suffering. Some of them experienced burdens during PS delivery; these could be supported by operational guidelines and task-related training.

At the end of life, some personalized and specialized care is required. The way that general practitioner (GP) visits and palliative care services at the end of life are organized in different countries may impact the frequency of care provision. However, nationwide data on the prevalence of these interventions and comparisons among countries are scarce.

Context Advance care planning (ACP) is an important part of patient-centered palliative care. There have been few nationwide studies of ACP, especially in Europe. Objectives To investigate the prevalence and characteristics of ACP in two European countries and identify the associated factors. Methods A mortality follow-back study was undertaken in 2007 via representative nationwide Sentinel Networks of general practitioners (GPs) in Belgium and The Netherlands using similar standardized procedures. All GPs reported on each non-suddenly deceased patient in their practice. Our main outcome measure was whether or not ACP, that is, an agreement for medical treatment and/or medical decisions in the last phase of life in the case of the patient losing competence, was present. Results Among 1072 non-sudden deaths, ACP was done with 34% of patients and most often related to the forgoing of potential life-prolonging treatments in general (24%). In 8% of cases, ACP was made in consultation with the patient and in writing. In 23% of cases, care was planned with the patient’s family only. Multivariate analysis revealed that ACP was more often made with patients if they were capable of decision making during the last three days of life (odds ratio [OR] 3.86; 95% confidence interval [CI] 2.4–6.1), received treatment aimed at palliation in the last week (OR 2.57; 95% CI 1.6–4.2), had contact with a GP in the last week (OR 2.71; 95% CI 1.7–4.1), died of cancer (OR 1.46; 95% CI 1.1–2.0), or died at home (OR 2.16; 95% CI 1.5–3.0). Conclusion In these countries, ACP is done with approximately one-third of the studied terminally ill patient population. Most agreements are made only verbally, and care also is often planned with family only. ACP relates strongly both to patient factors and to health care measures performed at the very end of life.

Communication is a necessary tool for ensuring the provision of quality patient-centered care for patients who have life-threatening illnesses, and discussing all relevant end-of-life issues should not be limited to cancer patients.

Purpose To examine and compare end-of-life care in patients with cancer dying in Belgium and the Netherlands. Patients and Methods A mortality follow-back study was undertaken in 2008 via representative nationwide sentinel networks of general practitioners (GPs) in Belgium and the Netherlands. By using similar standardized procedures, GPs reported on aspects of end-of-life care and the circumstances of nonsudden death of patients with cancer in their practice. Results Of the 422 reported patients with cancer, most resided at home during the last year of life (Belgium, 91%; the Netherlands, 95%). Death occurred at home in 34% (Belgium) and 61% (the Netherlands) and in the hospital in 29% (Belgium) and 19% (the Netherlands). In the last month of life, end-of-life issues were more often discussed in the Netherlands (88%) than in Belgium (68%). In both countries, physical problems were discussed most often (Belgium, 49%; the Netherlands, 78%) and spiritual issues least often (Belgium, 20%; the Netherlands, 32%). Certain end-of-life treatment preferences were known for 43% (Belgium) and 67% (the Netherlands) of patients. In the last week of life, treatment was most often focused on palliation (Belgium, 94%; the Netherlands, 91%). Physical distress was reported in 84% (Belgium) and 76% (the Netherlands) of patients and psychological distress in 59% and 36%. Most distressing was lack of energy (Belgium, 73%; the Netherlands, 71%) and lack of appetite (Belgium, 61%; the Netherlands, 53%). Two thirds of patients were bedridden (Belgium, 67%; the Netherlands, 69%). Conclusion Although place of death and communication about end-of-life issues differ substantially, a palliative treatment goal is adopted for the vast majority of patients in both countries. However, GPs reported that the majority of patients experienced symptom distress at the end of life, which suggests important challenges remain for improving end-of-life care.

Recognising patients who will die in the near future is important for adequate planning and provision of end-of-life care. GPs can play a key role in this.

Recognising patients who will die in the near future is important for adequate planning and provision of end-of-life care. GPs can play a key role in this.

Context Advance care planning (ACP) is an important part of patient-centered palliative care. There have been few nationwide studies of ACP, especially in Europe. Objectives To investigate the prevalence and characteristics of ACP in two European countries and identify the associated factors. Methods A mortality follow-back study was undertaken in 2007 via representative nationwide Sentinel Networks of general practitioners (GPs) in Belgium and The Netherlands using similar standardized procedures. All GPs reported on each non-suddenly deceased patient in their practice. Our main outcome measure was whether or not ACP, that is, an agreement for medical treatment and/or medical decisions in the last phase of life in the case of the patient losing competence, was present. Results Among 1072 non-sudden deaths, ACP was done with 34% of patients and most often related to the forgoing of potential life-prolonging treatments in general (24%). In 8% of cases, ACP was made in consultation with the patient and in writing. In 23% of cases, care was planned with the patient’s family only. Multivariate analysis revealed that ACP was more often made with patients if they were capable of decision making during the last three days of life (odds ratio [OR] 3.86; 95% confidence interval [CI] 2.4–6.1), received treatment aimed at palliation in the last week (OR 2.57; 95% CI 1.6–4.2), had contact with a GP in the last week (OR 2.71; 95% CI 1.7–4.1), died of cancer (OR 1.46; 95% CI 1.1–2.0), or died at home (OR 2.16; 95% CI 1.5–3.0). Conclusion In these countries, ACP is done with approximately one-third of the studied terminally ill patient population. Most agreements are made only verbally, and care also is often planned with family only. ACP relates strongly both to patient factors and to health care measures performed at the very end of life.

Communication is a necessary tool for ensuring the provision of quality patient-centered care for patients who have life-threatening illnesses, and discussing all relevant end-of-life issues should not be limited to cancer patients.

Purpose To examine and compare end-of-life care in patients with cancer dying in Belgium and the Netherlands. Patients and Methods A mortality follow-back study was undertaken in 2008 via representative nationwide sentinel networks of general practitioners (GPs) in Belgium and the Netherlands. By using similar standardized procedures, GPs reported on aspects of end-of-life care and the circumstances of nonsudden death of patients with cancer in their practice. Results Of the 422 reported patients with cancer, most resided at home during the last year of life (Belgium, 91%; the Netherlands, 95%). Death occurred at home in 34% (Belgium) and 61% (the Netherlands) and in the hospital in 29% (Belgium) and 19% (the Netherlands). In the last month of life, end-of-life issues were more often discussed in the Netherlands (88%) than in Belgium (68%). In both countries, physical problems were discussed most often (Belgium, 49%; the Netherlands, 78%) and spiritual issues least often (Belgium, 20%; the Netherlands, 32%). Certain end-of-life treatment preferences were known for 43% (Belgium) and 67% (the Netherlands) of patients. In the last week of life, treatment was most often focused on palliation (Belgium, 94%; the Netherlands, 91%). Physical distress was reported in 84% (Belgium) and 76% (the Netherlands) of patients and psychological distress in 59% and 36%. Most distressing was lack of energy (Belgium, 73%; the Netherlands, 71%) and lack of appetite (Belgium, 61%; the Netherlands, 53%). Two thirds of patients were bedridden (Belgium, 67%; the Netherlands, 69%). Conclusion Although place of death and communication about end-of-life issues differ substantially, a palliative treatment goal is adopted for the vast majority of patients in both countries. However, GPs reported that the majority of patients experienced symptom distress at the end of life, which suggests important challenges remain for improving end-of-life care.

Multiple transitions between care settings in the last phase of life could jeopardize continuity of care and overall end-of-life patient care. Using a mortality follow-back study, we examined the nature and prevalence of transitions between Dutch care settings in the last 3 months of life, and identified potential characteristics associated with them. During the 2-year study period, 690 registered patients died 'totally expectedly and non-suddenly'. These made 709 transitions in the last 3 months, which involved a hospital two times out of three, and covered 43 distinct care trajectories. The most frequent trajectory was home-to-hospital (48%). Forty-six percent experienced one or more transitions in their last month of life. Male gender, multi-morbidities, and absence of GP awareness of a patient's wish for place of death were associated with having a transition in the last 30 days of life; age of or = 7 days. Although the majority of the 'totally expected and non-sudden' deaths occurred at home, transitions to hospitals were relatively frequent. To minimize abrupt or frequent transitions just before death, timely recognition of the palliative phase of dying is important.

Provision of adequate care for the oldest old is increasingly crucial, given the current ageing trends. This study explores differences in end-of-life care of the oldest (≥85 years) versus the younger (65-84 years) old; testing the hypothesis that age could be an independent correlate of receiving specialised palliative care services (SPCS), having palliative-centred treatment and dying in a preferred place.

To improve the quality of end-of-life care, general practitioner (GP) awareness of where their patients prefer to die is important. To examine GP awareness of patients' preferred place of death (POD), associated patient- and care-related characteristics, and the congruence between preferred and actual POD in The Netherlands, a mortality follow-back study was conducted between January 2005 and December 2006. Standardized registration forms were used to collect data on all nonsudden deaths (n=637) by means of the Dutch Sentinel Network, a nationally representative network of general practices. Forty-six percent of patients had GPs who were not aware of their preferred POD. Of those whose GPs were aware, 88% had preferred to die in a private or care home, 10% in a hospice or palliative care unit, and 2% in a hospital. GPs were informed by the patients themselves in 84% of cases. Having financial status "above average," a life-prolongation or palliative care goal, and using specialist palliative care services were associated with higher GP-awareness odds. Four-fifth of patients with known preferred POD died there. There is a potential for improving GP awareness of patients' preferred POD. Such awareness is enhanced when palliation is an active part of end-of-life care. The hospital is the POD least preferred by dying patients.

Cancer patients have generally requested for euthanasia and assisted suicide (EAS) more frequently than others. However, different terminal cancers are accompanied by different clinical courses. This study seeks to explore the relationship, if any, between EAS requesters and cancer types, as relates to the provision of end-of-life care in the Netherlands.

Cancer patients have generally requested for euthanasia and assisted suicide (EAS) more frequently than others. However, different terminal cancers are accompanied by different clinical courses. This study seeks to explore the relationship, if any, between EAS requesters and cancer types, as relates to the provision of end-of-life care in the Netherlands.

To improve the quality of end-of-life care, general practitioner (GP) awareness of where their patients prefer to die is important. To examine GP awareness of patients' preferred place of death (POD), associated patient- and care-related characteristics, and the congruence between preferred and actual POD in The Netherlands, a mortality follow-back study was conducted between January 2005 and December 2006. Standardized registration forms were used to collect data on all nonsudden deaths (n=637) by means of the Dutch Sentinel Network, a nationally representative network of general practices. Forty-six percent of patients had GPs who were not aware of their preferred POD. Of those whose GPs were aware, 88% had preferred to die in a private or care home, 10% in a hospice or palliative care unit, and 2% in a hospital. GPs were informed by the patients themselves in 84% of cases. Having financial status "above average," a life-prolongation or palliative care goal, and using specialist palliative care services were associated with higher GP-awareness odds. Four-fifth of patients with known preferred POD died there. There is a potential for improving GP awareness of patients' preferred POD. Such awareness is enhanced when palliation is an active part of end-of-life care. The hospital is the POD least preferred by dying patients.