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Objectives: To determine the prognostic value of the Surprise Question (SQ) in older persons. Methods: A multicenter prospective study, including patients aged 75 years or older admitted to acute geriatric (AGU) or cardiology unit (CU). The SQ was answered by the treating physician. Patients or relatives were contacted after 1 year to determine 1-year survival. Logistic regression was used to explore parameters associated with SQ. Summary ROC curves were constructed to obtain the pooled values of sensitivity and specificity based on a bivariate model. Results: The SQ was positive (death within 1 year is no surprise) in 34.7% AGU and 33.3% CU patients (p = 0.773). Parameters associated with a positive SQ were more severe comorbidity, worse functionality, significant weight loss, refractory symptoms and the request for palliative care by patient or family. One-year mortality was, respectively, 24.9% and 20.2% for patients hospitalized on AGU and CU (p = 0.319). There was no difference in sensitivity or specificity, respectively, 64% and 77% (AUC 0.635) for AGU versus 63% and 76% (AUC 0.758) for CU (p = 0.870). A positive SQ is associated with a significant shorter time until death (HR 5.425 (95% CI 3.332–8.834), p < 0.001) independently from the ward. Conclusion: The Surprise Question is moderately accurate to predict 1-year mortality in older persons hospitalized on acute geriatric and cardiologic units.

De nombreuses donnees recentes demontrent qu’une approche palliative precoce, mise en place bien en amont de la fin de vie, apporte des benefices significatifs aux patients cancereux avances. Les patients atteints d’hemopathies malignes ont quant a eux moins souvent et moins vite acces aux structures palliatives que ceux atteints d’autres cancers, et sont traites plus agressivement en fin de vie. Les buts de cet article sont de demontrer que les patients hematologiques pourraient egalement beneficier d’une approche palliative precoce, de tenter de comprendre les freins qui empechent cette approche et de proposer des pistes pour une integration des prises en charge curative et palliative.

Alors que certaines pratiques cliniques, au regard de l'evolution des legislations relatives a la fin de vie, sont ou seront confrontees a "une demande de mort" de la part du patient, le concept de transgression apparait central, tant dans sa nommination que sa prise en compte au coeur de l'action clinique et son evaluation, afin de qualifier les enjeux ethiques d'une possible reponse.

Policy makers and health care payers are concerned about the costs of treating terminal patients. This study was done to measure the costs of treating terminal patients during the final month of life in a sample of Belgian nursing homes from the health care payer perspective. Also, this study compares the costs of palliative care with those of usual care. This multicenter, retrospective cohort study enrolled terminal patients from a representative sample of nursing homes. Health care costs included fixed nursing home costs, medical fees, pharmacy charges, other charges, and eventual hospitalization costs. Data sources consisted of accountancy and invoice data. The analysis calculated costs per patient during the final month of life at 2007/2008 prices. Nineteen nursing homes participated in the study, generating a total of 181 patients. Total mean nursing home costs amounted to 3,243 a,not sign per patient during the final month of life. Total mean nursing home costs per patient of 3,822 a,not sign for patients receiving usual care were higher than costs of 2,456 a,not sign for patients receiving palliative care (p = 0.068). Higher costs of usual care were driven by higher hospitalization costs (p < 0.001). This study suggests that palliative care models in nursing homes need to be supported because such care models appear to be less expensive than usual care and because such care models are likely to better reflect the needs of terminal patients.

Context. In addition to the effectiveness of terminal care, policy makers and health care payers are concerned about the costs of treating terminal patients in a context of spiraling health care costs and limited resources. Objectives. This article aims to review the international literature on the costs of treating terminal patients. Methods. Studies were identified by searching PubMed, Centre for Reviews and Dissemination databases, Cochrane Database, and EconLit, up to April 2009. Studies were included that contrasted costs in different health care settings and that compared palliative care with alternative therapeutic approaches for terminal patients. Results. The few studies that focused on treatment of terminal patients across health care settings showed that hospitalization costs represent the principal component of palliative care costs. In the hospital setting, palliative care tends to be cheaper than usual care or care delivered in units other than the palliative care unit. Palliative care costs depend on patient characteristics, such as diagnosis, status of disease, and age. Also, different care models appear to target different patient groups and offer varied packages of services. Finally, there is some evidence pointing to cost advantages of palliative care at home as compared with alternative care models, although this needs to be corroborated by further research. Conclusion. Different approaches to deliver palliative care are not substitutes of each other and, thus, have different costs. From a cost perspective, hospitals need to pay attention to admitting patients to the palliative care unit at the right time. J Pain Symptom Manage 2010;40:436-448. (C) 2010 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Elderly patients confront doctors and nursing staff with demands for euthanasia. These demands reflect intense suffering in which the psychological aspect plays a dominant role. Such demands should be subjected to a thorough examination as a result of which many will be interpreted as desperate calls for help rather than the deep desire to end everything. Nevertheless, in certain cases, elderly people clearly expect doctors to take action to deliberately put an end to their lives. Such people should be sound of mind, free from constraint and well informed. Their coherent and insistent demands should lead to an interdisciplinary conference intended to clarify the issue for the doctor but without relieving him of the responsibility of his decision whatever that might be. © Fondation Nationale de Gerontologie.

All health services dealing with the terminally ill are called upon to dispense palliative care. We shall, however, be making a distinction between palliative care services and other forms of services: in fact, the main activity of a palliative care service is palliative medicine, which is dispensed by its trained and experienced personnel. In Belgium, the first specialist palliative care services developed autonomously, and the absence of a planning policy isolated them from the rest of the health system. The Belgian health authorities decided to put an end to this situation by legislation: the laws introduced determine the number, mission and modus operandi of the various palliative care services, as well as the links to be established between them (interaction of the home care support team and the mobile function in hospitals or institutions for the elderly and association for cooperation). The following is a presentation and critical analysis of this legislation.

Background Hospital care plays a major role at the end-of-life. But little is known about the overall size and characteristics of the palliative inpatient population. The aim of our study was to analyse these aspects. Methods We conducted a one-day observational study in 14 randomly selected Belgian hospitals. Patients who met the definition of palliative patients were identified as palliative. Then, information about their socio-demographic characteristics, diagnoses, prognosis, and care plan were recorded and analysed. Results There were 2639 in-patients on the day of the study; 9.4% of them were identified as "palliative". The mean age of the group was 72 years. The primary diagnosis was cancer in 51% of patients and the estimated life expectancy was shorter than 3 months in 33% of patients and longer than 1 year in 28% of patients. The professional caregivers expected for most of the patients (73%), that the treatment would improve patient comfort rather than prolong life. Antibiotics, transfusions, treatments specific to the pathology, and artificial nutrition were administered in 90%, 78%, 57% and 50% of the patients, respectively, but were generally given with a view to controlling the symptoms. Conclusions This analysis presents a first national estimate of the palliative inpatient population. Our results confirm that hospitals play a major role at the end-of-life, with one out of ten inpatients identified as a "palliative" patient. These data also demonstrate the complexity of the palliative population and the substantial diversity of care that they can require.

In addition to the effectiveness of hospital care models for terminal patients, policy makers and health care payers are concerned about their costs. This study aims to measure the hospital costs of treating terminal patients in Belgium from the health care payer perspective. Also, this study compares the costs of palliative and usual care in different types of hospital wards.A multicenter, retrospective cohort study compared costs of palliative care with usual care in acute hospital wards and with care in palliative care units. The study enrolled terminal patients from a representative sample of hospitals. Health care costs included fixed hospital costs and charges relating to medical fees, pharmacy and other charges. Data sources consisted of hospital accountancy data and invoice data.Six hospitals participated in the study, generating a total of 146 patients. The findings showed that palliative care in a palliative care unit was more expensive than palliative care in an acute ward due to higher staffing levels in palliative care units. Palliative care in an acute ward is cheaper than usual care in an acute ward.This study suggests that palliative care models in acute wards need to be supported because such care models appear to be less expensive than usual care and because such care models are likely to better reflect the needs of terminal patients. This finding emphasizes the importance of the timely recognition of the need for palliative care in terminal patients treated in acute wards.

The aim of this study is to ascertain family doctors' opinions of the home care services dispensed by a specialist palliative care team. Fifty-six doctors responded to the questionnaire they had been sent. Ninety-four per cent of them were satisfied with the team's intervention. The highest satisfaction ratings were those for the provision of specialist medical equipment, technical competence and medical support. The lowest ratings were for information coming from the team and for recognition of the practitioner as the primary carer. Among these items, information, regard for the doctor's role and medical support are closely correlated to the practitioners' overall index of satisfaction. The palliative care team answered a mirror questionnaire. It found its availability, its speed of intervention, its technical competence, and its regard for the doctor's role very satisfactory. It was less satisfied with the information, medical support and psychosocial support it provided. Its centres of interest also differed, with the team clearly attributing greater importance to psychosocial support than to technical competence, regard for the role, and information to the practitioner. In conclusion, a survey of this type is a useful and easy way of identifying the aspects that need to be improved on by the palliative care team so as to improve its co-operation with the family physician. But it is of interest only if it forms part of an overall approach whereby, having taken the survey results on board, the team uses them to modify its intervention procedures.

La mise a disposition de moyens destines a soutenir les fonctions vitales oblige le medecin a se questionner sur les traitements et les soins qu’il peut proposer a un malade atteint d’une affection incurable, sur la pertinence de recourir ou de renoncer a ceux qui viseraient a prolonger l’existence. Cet article definit le concept de l’arret therapeutique, en le distinguant du refus de soin, de l’abandon therapeutique et de l’euthanasie. Il rappelle les principes ethiques sur lesquels repose la decision de renoncer a un traitement qui prolonge la vie. Il envisage les difficultes que le medecin pourrait rencontrer lorsqu’il est indecis a l’egard de l’effet benefique de la therapeutique, lorsque le malade est incapable de s’exprimer, lorsqu’il hesite ou lorsqu’il s’oppose a l’avis medical.