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BackgroundFor GPs to implement early palliative care, the first step is to identify patients with palliative care needs. The surprise question (SQ) is a screening tool that aims to aid this identification; for example, a response of 'no' to the SQ — 'Would you be surprised if this patient would die within a year?' — would suggest palliative care may be needed.AimTo describe setting-specific screening results of patients eligible for early palliative care in family practices, which is defined as patients aged ≥45 years with GPs' responses of 'no' to the SQ.Design & settingA secondary analysis was undertaken using a cross-sectional descriptive study in family practices in five areas in Belgium.MethodGPs were recruited by targeted sampling. As a first part of an implementation research project, participating GPs provided demographic information about themselves and also provided a response to the SQ for all patients who came to the practice in 10 consecutive office days. A summary table describing the sex, age, location of contact (GP surgeries, patients' homes, or nursing homes) of the patients was provided by each GP.ResultsFifty-six GPs provided complete data for the practice summary tables. In total, 9150 patients were described (all ages, all settings), of which 506 patients (6%) had a GP response of 'no' to the SQ. The distribution of SQ-no-as-answer patients per setting was: 152/7659 (2%) patients seen in family practice surgeries; 139/998 (14%) patients seen in their homes; and 215/493 (44%) patients seen in nursing homes.ConclusionThere was a large number of patients with SQ-no-as-answer, with possible palliative care needs. To enhance implementation of early palliative care, future research should compare results of SQ and other screening tools with palliative care symptoms assessments.

Background: Palliative care requires a multidisciplinary care team. General practitioners often ask specialised palliative home care teams for support. Working with specialised nurses offers learning opportunities, also called workplace learning. This can be enhanced by the presence of a learning facilitator. Objectives: To describe the development and evaluation of a training programme for nurses in primary care. The programme aimed to prepare palliative home care team nurses to act as facilitators for general practitioners’ workplace learning. Design: A one-group post-test only design (quantitative) and semi-structured interviews (qualitative) were used. Methods: A multifaceted train-the-trainer programme was designed. Evaluation was done through assignments with individual feedback, summative assessment through videotaped encounters with simulation-physicians and individual interviews after a period of practice implementation. Results: A total of 35 nurses followed the programme. The overall satisfaction was high. Homework assignments interfered with the practice workload but showed to be fundamental in translating theory into practice. Median score on the summative assessment was 7 out of 14 with range 1–13. Interviews revealed some aspects of the training (e.g. incident analysis) to be too difficult for implementation or to be in conflict with personal preferences (focus on patient care instead of facilitating general practitioners’ learning). Conclusion: Training palliative home care team nurses as facilitator of general practitioners’ workplace learning is a feasible but complex intervention. Personal characteristics, interpersonal relationships and contextual variables have to be taken into account. Training expert palliative care nurses to facilitate general practitioners’ workplace learning requires careful and individualised mentoring.

Objective To describe the offer of continuing medical education (CME) in palliative care in Flanders, Belgium and to explore the way providers of CME address the preferences of general practitioners (GP's) towards CME. Methods Questionnaire-survey among official providers of formal CME. Results The response rate was 43%, equally distributed over all 5 provinces of Flanders. Data show large content gaps, an under usage of appropriate educational techniques and an absence of evaluation of the impact of CME on clinical practice. Providers of CME explain how they take the preferences of GP's concerning education in palliative care into account. Conclusions The present offer of CME is insufficient to educate GP's in palliative care. The absence of quality criteria and the lack of coordination between different providers results in an unattractive labyrinth of courses leaving GP's and their patients in the cold. Practice implications A comprehensive offer of CME sessions should be installed in a coordination between all providers. This could render the use of means (logistics and speakers) more efficient. Further research could look into other ways of acquiring palliative care competences such as evaluating the learning effect of GP's working together with specialized palliative home care teams.

The semi-synthetic opioid, buprenorphine, has the general structure of morphine but differs from it in significant ways, both pharmacologically and clinically. A number of long-term studies have shown effective, long-lasting analgesia in moderate to severe cancer and non-cancer pain, including neuropathic pain, with a low incidence of constipation, nausea, dizziness and tiredness. The treatment of moderate to severe chronic pain has improved as a result of the development of new methods of administration of this substance, particularly the introduction of the transdermal drug delivery system, which offers a number of advantages over the usual oral and parenteral routes.A panel of experts specialising in palliative care and pain treatment was convened in November 2007 to discuss their clinical experiences with transdermal buprenorphine and other analgesics. The aim was to provide practical guidance on the treatment of cancer pain with transdermal buprenorphine, particularly when there is a need for increasing pain relief leading to high and increasing doses. A literature search on the use of transdermal buprenorphine was carried out for the panel meeting (based on a search of PubMed to November 2007 - since updated by an additional search for the period to February 2009) and a number of case histories were presented and discussed. This commentary article presents this evidence and the consensus findings of the expert panel.The Panel reached consensus that transdermal buprenorphine was a valuable treatment for chronic cancer pain, including its neuropathic components. A number of general recommendations were made. Large-scale, randomised clinical studies are needed to provide product comparisons on the use of analgesics in the treatment of neuropathic pain although it was recognised that such studies may not be practicable. Data on the treatment of acute and chronic pain should be kept separate in general. Physicians should be made more aware of the problem of hyperalgesic effects of some opioids in long term use. Buprenorphine in contrast has been described to exert an antihyperalgesic effect. The development of analgesic tolerance with some opioids in long term use and the lack of it with buprenorphine requires further studies. The registered dose range of 35-140 microg/h was considered adequate to achieve sufficient pain relief in most patients although some members of the panel presented data showing that increases beyond this dose range provided improved pain relief if slow titration is used. However, it was generally felt that more evidence was needed before this could become generally acceptable.The consensus was that transdermal buprenorphine has a valuable role to play in the treatment of chronic cancer pain because of its efficacy and good safety and tolerability profile, including a low risk of respiratory depression, a lack of immunosuppression and a lack of accumulation in patients with impaired renal function.

Symptoomcontrole bij kanker is een uitdaging voor de gezondheidszorg van de eenentwintigste eeuw. In het Cancer Pain programme van de who is de drietraps pijnladder een centraal element: naarmate de pijn intenser wordt, wordt zij behandeld met steeds krachtiger farmaca (voornamelijk opioiden). Deze benadering laat andere behandelingen echter buiten beschouwing, zoals antikankerbehandelingen, chirurgische interventies, nieuwe farmacologische benaderingen en psychologische en aanvullende therapieen. Wij stellen een nieuw, multidimensionaal model voor, gebaseerd op een piramide, dat de symptoomcontrole bij kanker benadert vanuit verschillende invalshoeken en daardoor een werkelijk multimodale en multidisciplinaire behandeling waarborgt. Het model vormt ook de basis voor een meer holistische benadering van de patient, waarin onderzoek, behandeling en evaluatie een geintegreerd geheel vormen. Ons piramidemodel heeft ‘metapiramiden’, nieuwe piramiden afgeleid van elk vlak van de piramide, die een steeds dieper niveau van detaillering mogelijk maken. Het laat zich daardoor gemakkelijk aanpassen aan andere symptomen dan pijn alleen. Wij presenteren vier manieren om dit nieuwe piramidemodel te valideren in termen van aanvaardbaarheid, wetenschappelijke betrouwbaarheid en klinische bruikbaarheid.

The effects of loperamide oxide 1 mg and 2 mg were compared with placebo and with loperamide 2 mg in 261 patients with acute, nonspecific diarrhea. Time to first relief and time to complete relief of diarrhea were statistically significantly shorter in the three active drug groups than in the placebo group. Compared with placebo, neither dosage of loperamide oxide produced a period of posttreatment constipation. Adverse experiences were (nonsignificantly) less frequent for loperamide oxide 1 mg and 2 mg than for either placebo or loperamide 2 mg. These results suggest that loperamide oxide 1 mg is as efficacious as loperamide 2 mg for the treatment of patients with acute, nonspecific diarrhea. Because of its low potential for causing constipating effects and adverse experiences, loperamide oxide 1 mg may be preferred over either loperamide oxide 2 mg or loperamide 2 mg.

There is a growing need for palliative care, with the majority of palliative patients preferring palliative home care from their general practitioner (GP). GPs join specialized palliative home care teams (PHCTs) to perform this task. GPs' views on this collaboration are not known. This study explores the perceptions and preferences of GPs toward interprofessional collaboration. By employing a grounded theory approach, five focus groups were conducted in Flanders, Belgium with a total of 29 participants (professionals from PHCTs; professionals from organizations who provide training and education in palliative care and GPs who are not connected to either of the aforementioned groups). Analysis revealed that GPs considered palliative home care as part of their job. Good relationships with patients and families were considered fundamental in the delivery of high quality care. Factors influencing effective interprofessional collaboration were team competences, team arrangements (responsibilities and task description) and communication. GPs' willingness to share responsibilities with equally competent team members requires further research.

Introduction Ill persons from ethnical minorities are not cared for optimally in our healthcare system. Intercultural mediation aims to improve the accessibility and the quality of care for ethnical minorities. Due to the aging of the first generation of migrants, more and more migrants in Flanders will face an growing need for palliative care. Migrants elderly and palliative services are still rather unknown to each other. So it is not unthinkable that the intercultural mediator can play a significant role when in the future undoubtedly the number of migrant patients with palliative care needs will increase. While in the past interventions of intercultural mediators occurred rather on general wards, they now more often face palliative care. Research question What could be the role of intercultural mediation in providing palliative care in a multicultural society? Research Method This study used a qualitative descriptive method from a phenomenological research perspective where for the thematic analysis the coding paradigm of grounded theory was used. Results Although a palliative care process must always be considered as an individual process, there are nevertheless many cultural differences. Both intercultural mediators and palliative care providers have less experience in guiding and supporting an intercultural palliative care process. The cooperation that currently exists, is considered as positive, although there are still many points waiting for improvement. Conclusion The framework supporting intercultural mediators in guiding a palliative care process, is currently inadequate. This aspect should be paid for more attention in the near future.