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Summary: Objectives: To evaluate graduating students '' pharmacological knowledge and calculation skills and describe their self-rated readiness to safe medication care in practice on two nurse educational levels. Additionally, the study describes some characteristics of pharmacology in nurse education in Flanders, Belgium. Methods: Thirty-eight nursing schools (bachelor '' s degree in nursing [N =18] and diploma in nursing [N =20]) were asked to provide details on their pharmacology curriculum and to let their graduating students participate in a cross-sectional survey using the Medication Knowledge and Calculation test in February/March 2009. Results: The 29 participating schools showed a large diversity in pharmacology curricula. Mean scores on the pharmacology section and calculation section were 55% and 66%, respectively, for bachelor '' s degree and 52% and 53% for diploma students. On a scale of 1–10, 27% had a self-rated readiness perception≤5. Results differed significantly between schools. Conclusions: Just before graduation, nursing students '' pharmacological knowledge and calculation skills are limited. Apart from the test results, students did not perceive themselves able to deliver safe medication care in practice. Schools need to address the shortcomings. In practice, awareness is needed regarding possible limitations of the newly graduated. [Copyright &y& Elsevier]

Abstract: Changes in medical practices during transitions in regulating healthcare are rarely investigated. In this study, we investigated changes in medical end-of-life decisions with a possible or certain life-shortening effect (ELDs) that occurred during the legalization process of euthanasia in Belgium. We took representative random samples from deaths reported to registries in Flanders, Belgium in 1998 (n=3999) at the beginning of the process and in 2001 (N=5005), at the end of the process. The reporting physicians received an anonymous mail questionnaire about possible ELDs preceding the death involved. We found no significant shifts in the epidemiology of diseases between 1998 and 2001. The overall incidence of ELDs did not change. The incidence decreased for euthanasia, administering life-ending drugs without patient''s explicit request, and alleviation of pain and symptoms with life-shortening co-intention. Incidence increased for alleviation of pain and symptom without life-shortening intention, and remained stable for non-treatment decisions. All decisions in 2001 were more often discussed with patients, their relatives and nurses. In 2001, continuous deep sedation was reported in 8.3% of deaths. We can conclude that physicians’ end-of-life practices have substantially changed during the short but tumultuous legalization process of euthanasia in Belgium. Although follow-up research is needed to investigate the continuance of these changes, it is important for policy makers to keep in mind that social factors related to transitions in healthcare regulation may play an important role in the physicians’ actual behaviour. [Copyright &y& Elsevier]

Cultural differences are probably an important factor in the considerable variation in antibiotic use between countries. The objective of this study was to explore local cultural differences in the lay perspective on coping with URTD and using antibiotics. We interviewed 30 persons in a Dutch and a Belgian city. Twenty-one were interviewed a second time after 3 months. Between the first and second interview, they noted in a diary all URTD episodes experienced by themselves and their family members (N=69) and how they coped with them. The Dutch participants labelled most URTD episodes as “common cold” or “flu”. The Flemish participants labelled most of their URTD episodes as “bronchitis” and used more antibiotics. Four categories of antibiotic users could be distinguished. Participants with a Protestant background were more sceptical about medicines than those with a Catholic background. A thorough understanding of the cultural context is necessary to design effective campaigns to promote rational antibiotic use. [Copyright &y& Elsevier]

Highlights • 36% of nursing home residents were still alive after 4 years. • Polypharmacy and PIM use were high. • People with dementia and high care dependency died earlier. • No association between polypharmacy or PIM use and survival. Abstract Background Survival in older adults has a high variability. The possible association of length of survival with potentially inappropriate medication (PIM) use remains unclear. Aim To examine the four-year survival rate, the prevalence of polypharmacy and PIM use at admission, and the association between the two, in an inception cohort of newly admitted nursing home residents Methods Data were used from ageing@NH, a prospective observational cohort study in nursing homes. Residents (n = 613) were followed for four years after admission or until death. PIM use was measured at admission, using STOPPFrail. The Kaplan-Meier method was used to estimate survival, using log-rank tests for subgroup analyses. Cox regression analyses was used to explore associations with PIM use and polypharmacy, corrected for covariates Results Mean age was 84, 65% were females. After one, two, three and four years the survival rates were respectively 79%, 60.5%, 47% and 36%. At admission, 47% had polypharmacy and 40% excessive polypharmacy, 11% did not use any PIMs, and respectively 28%, 29%, and 32% used one, two and three or more PIMs. No difference in survival was found between polypharmacy and no polypharmacy, and PIM use and no PIM use at admission. Neither polypharmacy nor PIM use at admission were associated with mortality. Conclusion Residents survived a relatively short time after NH admission. Polypharmacy and PIM use at admission were relatively high in this cohort, although neither was associated with mortality. [ABSTRACT FROM AUTHOR]

Context: According to guideline recommendations, barbiturates and neuromuscular relaxants are the recommended drugs for euthanasia.Objectives: To describe changes over time in drugs used to perform euthanasia and differences in case characteristics according to the drugs used.Methods: Repeated population-based mortality follow-back study among physicians attending a large representative sample of deaths in 1998, 2007, and 2013 in Flanders, Belgium.Results: In 1998, we identified 25 euthanasia cases (1.2% of all deaths), 142 cases in 2007 (2.0% of all deaths), and 349 cases in 2013 (4.6% of all deaths). Use of recommended drugs to perform euthanasia increased from 11.9% of euthanasia cases in 1998 to 55.3% in 2007 and 66.8% in 2013 (P < 0.001). In 2013, cases with recommended drugs compared with nonrecommended drugs more often involved requests expressed both orally and in writing (86.8%/14.1%; P < 0.001), consultation with colleague physicians (93.8%/69.1%; P < 0.001), and administration in the presence of another physician (98.3%/54.3%; P < 0.001), and were more often self-labeled by physicians as euthanasia (95.5%/0.9%; P < 0.001) and reported to the euthanasia review committee (92.3%/3.8%; P < 0.001). Between 2007 and 2013, physicians consistently labeled cases in which nonrecommended drugs were used as palliative sedation (72.8%/78.4%; P = 0.791) or alleviation of pain and symptoms (13.2%/15.0%; P > 0.999).Conclusion: Physicians in Flanders are increasingly using the recommended drugs for euthanasia. This suggests that guidelines and training regarding the conduct and pharmacological aspects of euthanasia may have had important effects on the practice of euthanasia. However, the declining but persisting use of nonrecommended drugs requires further attention. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: The aim of this study was to develop and test the effect of an instrument, Pharmanurse, to facilitate nurse-driven adverse drug reaction (ADR) screening as an input for interdisciplinary medication review in nursing homes. Design: Intervention study with a pre-posttest design Participants: All residents of a convenience sample of 8 nursing homes of more than 80 beds were eligible if they resided at least 1 month in the nursing home and took 4 or more different medications. Residents receiving palliative care were excluded. Intervention: The intervention consisted of interdisciplinary medication review, prepared by nurse observations of potential ADRs using personalized screening lists generated by the Pharmanurse software. Pharmanurse is specifically adapted to use by nurses and to use in nursing homes. Measurements: Outcome parameters were the number of ADRs detected by nurses, ADRs confirmed by general practitioners, and medication changes. After the intervention, health care professionals involved completed a questionnaire to evaluate the value and the feasibility of the intervention. Results: Nurses observed 1527 potential ADRs in 81% of the 418 residents (mean per resident 3.7). Physicians confirmed 821 ADRs in 60% of the residents (mean per resident 2.0). As a result, 214 medication changes were planned in 21% of the residents (mean per resident 0.5) because of ADRs. Health care professionals gave the Pharmanurse intervention a score of 7 of 10 for the potential to improve pharmacotherapy and 83% of the physicians were satisfied about nurses'' screening for ADRs. Conclusions: The Pharmanurse intervention supports nurses in ADR screening and may have the potential to improve pharmacotherapy. [Copyright &y& Elsevier]

Abstract: Context: Death is often preceded by medical decisions that potentially shorten life (end-of-life decisions [ELDs]), for example, the decision to withhold or withdraw treatment. Respect for patient autonomy requires physicians to involve their patients in this decision making. Objectives: The objective of this study was to examine the involvement of advanced lung cancer patients and their families in ELD making and compare their actual involvement with their previously stated preferences for involvement. Methods: Patients with Stage IIIb/IV non-small cell lung cancer were recruited by physicians in 13 hospitals and regularly interviewed between diagnosis and death. When the patient died, the specialist and general practitioner were asked to fill in a questionnaire. Results: Eighty-five patients who died within 18 months of diagnosis were studied. An ELD was made in 52 cases (61%). According to the treating physician, half of the competent patients were not involved in the ELD making, one-quarter shared the decision with the physician, and one-quarter made the decision themselves. In the incompetent patients, family was involved in half of cases. Half of the competent patients were involved less than they had previously preferred, and 7% were more involved. Almost all of the incompetent patients had previously stated that they wanted their family involved in case of incompetence, but half did not achieve this. Conclusion: In half of the cases, advanced lung cancer patients—or their families in cases of incompetence—were not involved in ELD making, despite the wishes of most of them. Physicians should openly discuss ELDs and involvement preferences with their advanced lung cancer patients. [Copyright &y& Elsevier]

Objectives There is growing evidence of the potential effectiveness of advance care planning. Yet important knowledge gaps remain regarding the preconditions for successful implementation of advance care planning in the nursing home setting. We aim to identify the preconditions related to successful advance care planning in the nursing home setting. By specifying those, we would be able to make well-founded choices for the future design and planning of advance care planning intervention programs. Design A systematic review. Data sources PubMed, PsycINFO, EMBASE and CINAHL. Review methods Two authors independently screened publications. One author assessed methodological quality and extracted textual data, which was double-checked for a random sample. We extracted textual data and used thematic synthesis to identify “preconditions”, defined as requirements, conditions and elements necessary to achieve the desired outcome of advance care planning, i.e. attaining concordance between residents' preferences and actual care or treatment received at the end of life. Main findings Based on 38 publications, we identified 17 preconditions at five different levels: resident, family, health-care professional, facility and community. Most preconditions were situated on multiple levels but the majority addressed professionals and the nursing home itself. We summarized preconditions in five domains: to have sufficient knowledge and skills, to be willing and able to participate in advance care planning, to have good relationships, to have an administrative system in place, and contextual factors supporting advance care planning within the nursing home. Conclusion There are multiple preconditions related to successfully implementing advance care planning in the complex nursing home setting that operate at micro, meso and macro level. Future interventions need to address these multiple domains and levels in a whole-system approach in order to be better implementable and more sustainable, while simultaneously target the important role of the health-care professional and the facility itself. [ABSTRACT FROM AUTHOR]

Context: Although the acute hospital setting is not considered to be an ideal place of death, many people are admitted to hospital at the end of life.Objectives: The present study aims to examine the reasons for hospital admissions that result in an expected death and the factors that play a role in the decision to admit to hospital.Methods: This was a survey among family physicians (FPs) about those of their patients who had died nonsuddenly in an acute university hospital setting in Belgium between January and August 2014. Questions were asked about the patient's health situation, care that the patient received before the admission, the circumstances of the hospital admission, the reasons necessitating the admission, and other factors that had played a role in the decision to admit the patient to hospital.Results: We received 245 completed questionnaires (response rate 70%), and 77% of those hospital deaths were considered to be nonsudden. FPs indicated that 55% of end-of-life hospitalizations were for palliative reasons and 26% curative or life-prolonging. Factors such as the patient feeling safer in hospital (35%) or family believing care to be better in hospital (54%) frequently played a role in the end-of-life hospitalization. When patients were admitted with a limited anticipated life expectancy, FPs were more likely to indicate that an inadequate caring capacity of the care setting had played a role in the admission.Conclusion: To reduce the number of hospital deaths, a combination of structural support for out-of-hospital end-of-life care and a more timely referral to out-of-hospital palliative care services may be needed. [ABSTRACT FROM AUTHOR]

Background High drug use and associated adverse outcomes are common in older adults. This study investigates association of medication use with mortality, hospitalisation, and institutionalisation in a cohort of community-dwelling oldest old (aged 80 and over). Methods Baseline data included socio-demographic, clinical, and functional characteristics, and prescribed medications. Medications were coded by the Anatomic Therapeutic Chemical classification. Survival analysis was performed at 18 months after inclusion using Kaplan–Meier, and multivariate analysis with Cox regression to control for covariates. Results Patients’ ( n = 503) mean age was 84.4 years (range 80–102), and 61.2% was female. The median medication use was 5 (0–16). The mortality, hospitalisation, and institutionalisation rate were 8.9%, 31.0%, and 6.4% respectively. The mortality and hospitalisation group had a higher level of multimorbidity and weaker functional profile. Adjusted multivariate models showed an 11% increased hospitalisation rate for every additional medication taken. No association was found between high medication use and mortality, nor with institutionalisation. A higher association for mortality was observed among verapamil/diltiazem users, hospitalisation was higher among users of verapamil/diltiazem, loop diuretics and respiratory agents. Institutionalisation was higher among benzodiazepines users. Conclusion In the community-dwelling oldest old (aged 80 and over), high medication was clearly associated with hospitalisation, independent of multimorbidity. The association with mortality was clear in univariate, but not in multivariate analysis. No association with institutionalisation was found. The appropriateness of the high medication use should be further studied in relation to mortality, hospitalisation, and institutionalisation for this specific age group. [ABSTRACT FROM AUTHOR]

Highlights: [•] Process description to create operational rules for electronic INN prescribing. [•] Consistent operational rules to develop a reference database. [•] Insights into difficulties experienced, and remaining limitations. [ABSTRACT FROM AUTHOR]

Abstract: With the explosion of information available on the Web, finding specific medical information in an efficient way has become a considerable challenge. PubMed/MEDLINE offers an alternative to free-text searching on the web, allowing searchers to do a keyword-based search using Medical Subject Headings. However, finding relevant information within a limited time frame remains a difficult task. The current study is based on an error analysis of data from a retrieval experiment conducted at the nursing departments of two Belgian universities and a British university. We identified the main difficulties in query formulation and relevance judgment and compared the profiles of the best and worst performers in the test. For the analysis, a query collection was built from the queries submitted by our test participants. The queries in this collection are all aimed at finding the same specific information in PubMed, which allowed us to identify what exactly went wrong in the query formulation step. Another crucial aspect for efficient information retrieval is relevance judgment. Differences between potential and actual recall of each query offered indications of the extent to which participants overlooked relevant citations. The test participants were divided into “worst”, “average” and “best” performers based on the number of relevant citations they selected: zero, one or two and three or more, respectively. We tried to find out what the differences in background and in search behavior were between these three groups. [Copyright &y& Elsevier]

Abstract: Background: Within the treatment of dementia, management of behavioural and psychological symptoms (BPSD) is a complex component. Purpose: We wanted to offer a pragmatic synthesis of existing specific practice recommendations for managing BPSD, based on agreement among systematically appraised dementia guidelines. Data sources: We conducted a systematic search in MEDLINE and guideline organisation databases, supplemented by a hand search of web sites. Study selection: Fifteen retrieved guidelines were eligible for quality appraisal by the Appraisal of Guidelines Research and Evaluation instrument (AGREE), performed by 2 independent reviewers. Data extraction: From the 5 included guidelines, 18 specific practice recommendations for BPSD were extracted and compared for their level of evidence and strength. Data synthesis: No agreement was found among dementia guidelines for the majority of specific practice recommendations with regard to non-pharmacological interventions, although these were recommended as first-line treatment. Pharmacological specific practice recommendations were proposed as second-line treatment, with agreement for the use of a selection of antipsychotics based on strong supporting evidence, but with guidance for timely discontinuation. Limitations: The appraisal of the level of agreement between guidelines for each specific practice recommendation was complicated by variation in grading systems, and was performed with criteria developed a posteriori. Conclusion: Despite the limited number of recommendations for which agreement was found, guidelines did agree on careful antipsychotic use for BPSD. Adverse events might outweigh the supporting evidence of efficacy, weakening the recommendation. More pivotal trials on the effectiveness of non-pharmacological interventions, as well as guidelines specifically focusing on BPSD, are needed. [Copyright &y& Elsevier]

Background: With the increase of the proportion of old (>80 years), frail people living in long-term care settings, concern about the quality of medication management processes in nursing homes is growing. Objectives: To characterize the organization of medication management processes in Belgian nursing homes. Method: This cross-sectional, observational study of a representative sample of 76 Belgian nursing homes was performed in November and December 2005. The results are based on structured interviews that were conducted with 76 facility directors and 112 head nurses, using 2 questionnaires. Results: A self-reporting medication error system was set up in 69.7% of the nursing homes. Almost all nursing homes had a therapeutic drug formulary, but its use was not compulsory. Medications were mainly delivered from a community pharmacy (82.9%). The role of the pharmacist was often restricted to mere delivery of medications. Medications were not always administered by nurses, but also by care aides (67%) or nursing students (12.5%). The practice of postscription (i.e., prescribing medication after it has been dispensed by the pharmacist) was also found to be quite common (69.9%). Conclusion: This study provides a detailed description of the organization of medication management processes in Belgian nursing homes. Based on these results, problem areas can be identified and, consequently, targeted improvement actions can be investigated and implemented. [Copyright &y& Elsevier]