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Aim: To explore relatives' needs in terms of bereavement care during euthanasia processes, how healthcare providers respond to these needs, and the degree of commonality between relatives' and healthcare providers' reports. Design: A phenomenological design was employed, utilising reflexive thematic analysis to examine interviews conducted with relatives (N = 19) and healthcare providers (N = 47). Results: Relatives' needs throughout euthanasia processes are presented in five main themes and several subthemes, with similar findings between both sets of participants. Although relatives infrequently communicated their needs explicitly to healthcare providers, they appreciated it when staff proactively met their needs. Healthcare providers aimed to assist with the relatives' grief process by tending to their specific needs. However, aftercare was not consistently offered, but relatives did not have high expectations for professional follow‐up care. Conclusion: Our research offers important directions for healthcare professionals, empowering them to provide needs‐based bereavement care during euthanasia processes. Moreover, it emphasises the importance of recognising the unique needs of relatives and proactively addressing them in the period before the loss to positively contribute to relatives' grief process. Implications for the profession and/or patient care: Insights into relatives' needs in the context of euthanasia. Good practices on how healthcare providers can attend to relatives' needs before, during and after the loss Impact: Current literature and guidelines on needs‐based bereavement care in the context of euthanasia and, more generally, assisted dying, are limited. These findings provide concrete directions for practice in supporting (nearly) bereaved relatives in the context of euthanasia, potentially mitigating adverse health outcomes. Reporting method: Standards for Reporting Qualitative Research (SRQR checklist). Patient or Public contribution: Relatives of deceased cancer patients were involved in the conduct of the study. [ABSTRACT FROM AUTHOR]

Background: Self-assessed will-to-live and self-rated health are associated with long-term survival in community-dwelling older persons but have not been examined in frailer older patients in relation to short-term prognosis. The aim was to explore whether will-to-live and self-rated health are predictive for six-month mortality and can guide ceiling of treatment decisions in hospitalized patients in an acute geriatric ward. We included the Surprise Question as reference, being a well-established clinical tool for short-term prognostication. Methods: This multicentric prospective study included patients of 75 years and older admitted at acute geriatric wards of two Belgian hospitals. Will-to-live and self-rated health were scored on a Likert scale (0–5, 0–4) and assessed by junior geriatricians. The senior geriatricians answered the Surprise Question for clinical judgment of prognosis. Receiver-operator characteristic (ROC) curves were constructed to determine diagnostic accuracy. For time-dependent analysis, Cox regression was performed with adjustment for age and gender. Results: Of 93 included patients in the study, 69 were still alive after six months and 24 died, resulting in a six-month mortality of 26%. The mean age was 86 years (range 75–100), 67% of the patients were women. Median will-to-live and self-rated health were 3 (moderate and good). Both will-to-live and self-rated health were not predictive for six-month mortality (area under the ROC curve [AUC] 0.496, p = 0.951 for will-to-live; 0.447, p = 0.442 for self-rated health) as opposed to Surprise Question (AUC 0.793, p < 0.001). After correction for sex and age, the hazard ratio of six-month mortality was 0.92 for will-to-live (p = 0.667), 0.86 for self-rated health (p = 0.548), and 10.28 for Surprise Question (p < 0.001). Conclusion: Will-to-live and self-rated health are not predictive for six-month mortality in patients admitted to the acute geriatric ward, unlike prognostic tools such as Surprise Question. Clinical Trial Registration Number: B670202100792. [ABSTRACT FROM AUTHOR]

Will-to-live is defined as the psychological expression of one's commitment to life and the desire to continue living. It is an important indicator of subjective wellbeing. This study aimed to assess the will-to-live in frail older hospitalized patients and nursing home residents as well as to evaluate its association with physical frailty, tiredness of life, depression and wish-to-die. Between March and September 2021, we interviewed 186 older adults in six nursing homes and two acute geriatric wards across Belgium. Will-to-live was assessed using a single-item numeric rating scale from 0 to 5. A linear regression analysis was performed to assess the association between will-to-live and frailty (Clinical Frailty Scale) with adjustment for age, gender and setting. Mann-Whitney U test was used to evaluate the association between will-to-live and depression, tiredness of life and wish-to-die. Mean age was 85 (± 6.2) years. Mean score on the Clinical Frailty Scale was five (± 1.5) and four on the will-to-live (± 1.3). No statistical significant association was found between will-to-live and age (p = 0.991), gender (p = 0.272), setting (p = 0.627) and frailty (p = 0.629). Multiple linear regression showed no significant association with Clinical Frailty Scale (p = 0.660), after adjustment for age, gender and setting. Will-to-live was negatively associated with tiredness of life (p = 0.020) and wish-to-die (p < 0.001), but not with depression (p = 0.186). Both nursing home residents and older hospitalized patients expressed a strong or very strong will-to-live. Will-to-live was not associated with physical frailty as measured by the Clinical Frailty Scale. Nursing home residents with a weak will-to-live were more likely to have depressive symptoms. Most nursing home residents with a wish-to-die had also a low will-to-live, although some residents had both a high will-to-live and wish-to-die. [ABSTRACT FROM AUTHOR]

Recent literature demonstrates an interdependence between relatives and healthcare providers throughout euthanasia processes. Yet, current guidelines and literature scarcely specify the interactions between healthcare providers and bereaved relatives. The aim of this work consisted of providing an insight into bereaved relatives' experiences (1) of being involved in euthanasia processes and (2) of their interactions with healthcare providers before, during, and after the euthanasia. The research process was guided by the principles of constructivist grounded theory. Nineteen Dutch-speaking bereaved relatives of oncological patients, who received euthanasia at home or in a hospital less than 24 months ago, participated via semi-structured interviews. These interviews were conducted between May 2021 and June 2022. Due to the intensity of euthanasia processes, relatives wanted to be involved as early as possible, in order to receive time, space, and access to professionals' support whilst preparing themselves for the upcoming loss of a family member with cancer. Being at peace with the euthanasia request facilitated taking a supportive attitude, subsequently aiding in achieving a serene atmosphere. A serene atmosphere facilitated relatives' grief process because it helped them in creating and preserving good memories. Relatives appreciated support from healthcare providers, as long as overinvolvement on their part was not occurring. This study advocates for a relational approach in the context of euthanasia and provides useful complements to the existing euthanasia guidelines. [ABSTRACT FROM AUTHOR]

Background: Older patients are increasingly showing multi-comorbidities, including advanced chronic diseases. When admitted to the emergency department (ED), the decision to pursue life-prolonging treatments or to initiate a palliative care approach is a challenge for clinicians. We test for the first time the diagnostic accuracy of the Supportive and Palliative Care Indicators Tool (SPICT) in the ED to identify older patients at risk of deteriorating and dying, and timely address palliative care needs. Methods: We conducted a prospective bicentric cohort study on 352 older patients (≥ 75 years) admitted to two EDs in Belgium between December 2019 and March 2020 and between August and November 2020. SPICT (French version, 2019) variables were collected during the patients' admission to the ED, along with socio-demographic, medical and functional data. The palliative profile was defined as a positive SPICT assessment. Survival, symptoms and health degradation (≥ 1 point in ADL Katz score or institutionalisation and death) were followed at 12 months by phone. Main accuracy measures were sensitivity, specificity and likelihood ratios (LR) as well as cox regression, survival analysis using the Kaplan Meier method, and ordinal regression. Results: Out of 352 patients included in the study (mean age 83 ± 5.5 years, 43% male), 167 patients (47%) had a positive SPICT profile. At one year follow up, SPICT positive patients presented significantly more health degradation (72%) compared with SPICT negative patients (35%, p < 0.001). SPICT positivity was correlated with 1-year health degradation (OR 4.9; p < 0.001). The sensitivity and specificity of SPICT to predict health degradation were 0.65 (95%CI, 0.57–0.73) and 0.72 (95%CI, 0.64–0.80) respectively, with a negative LR of 0.48 (95%CI, 0.38–0.60) and a positive LR of 2.37 (1.78–3.16). The survival time was shorter in SPICT positive patients than in SPICT negative ones (p < 0.001), the former having a higher 1-year mortality rate (HR = 4.21; p < 0.001). Conclusions: SPICT successfully identifies older patients at high risk of health degradation and death. It can support emergency clinicians to identify older patients with a palliative profile and subsequently initiate a palliative care approach with a discussion on goals of care. [ABSTRACT FROM AUTHOR]

To explore the legal understanding and attitudes of nurses and physicians in both acute and chronic geriatric care (Flanders, Belgium) regarding euthanasia in the context of tiredness of life in older people. Healthcare providers employed in acute care (59 geriatricians and 75 nurses of acute geriatric wards), as well as chronic care (135 general practitioners (GPs) and 76 nurses employed in nursing homes and home care services) were sent a survey with four case vignettes. For each case vignette, respondents were asked the following questions: (1) 'Does this case fit the due-care criteria of the euthanasia law?', (2) 'Do you consider this person to be tired of life?', (3) 'Can you comprehend this person's euthanasia request?'. In cases of severe and life-limiting physical suffering, where the patient meets the legal criteria for euthanasia in Belgium, only 50% of physicians and nurses are aware of this legal basis. In case of tiredness of life without underlying pathology, nurses showed more comprehension for the euthanasia request compared to physicians (43.0% vs. 10.8%, p < 0.001). Physicians tend to assess the legal base of an euthanasia-request depending on the severity of physical morbidity, whereas nurses show a greater comprehension towards euthanasia-requests even in absence of severe illness. Geriatricians are more reserved regarding performing euthanasia themselves as compared to GPs, regardless of underlying pathology or reason for the euthanasia-request (p < 0.001). The legal understanding and attitude of Flemish physicians and nurses towards tiredness of life and euthanasia in older patients differed to a great extent. This study showed (1) a lack of awareness of the legal basis for euthanasia in the context of ToL among all HCPs, (2) differences in the extent of comprehension between nurses and physicians and (3) differences in willingness to actually perform euthanasia between geriatricians and GPs. So even with the formulation of strict due-care criteria there is still room for interpretation. This creates a gray area and a discussion point between healthcare providers. [ABSTRACT FROM AUTHOR]

Background: To be able to provide high-quality palliative care, there need to be a number of organizational structures available in the nursing homes. It is unclear to what extent such structures are actually present in nursing homes in Europe. We aim to examine structural indicators for quality of palliative care in nursing homes in Europe and to evaluate the differences in terms of availability of and access to palliative care, infrastructure for residents and families, multidisciplinary meetings and quality improvement initiatives. Methods: A PACE cross-sectional study (2015) of nursing homes in Belgium, England, Finland, Italy, the Netherlands and Poland. Nursing homes (N = 322) were selected in each country via proportional stratified random sampling. Nursing home administrators (N = 305) filled in structured questionnaires on nursing home characteristics. Organization of palliative care was measured using 13 of the previously defined IMPACT structural indicators for quality of palliative care covering four domains: availability of and access to palliative care, infrastructure for residents and families, multidisciplinary meetings and quality improvement initiatives. We calculated structural indicator scores for each country and computed differences in indicator scores between the six countries. Pearson's Chi-square test was used to compute the p-value of each difference. Results: The availability of specialist palliative care teams in nursing homes was limited (6.1–48.7%). In Finland, Poland and Italy, specialist advice was also less often available (35.6–46.9%). Up to 49% of the nursing homes did not provide a dedicated contact person who maintained regular contact with the resident and relatives. The 24/7 availability of opioids for all nursing home residents was low in Poland (37.5%). Conclusions: This study found a large heterogeneity between countries in the organization of palliative care in nursing homes, although a common challenge is ensuring sufficient structural access to specialist palliative care services. Policymakers and health and palliative care organizations can use these structural indicators to identify areas for improvement in the organization of palliative care. [ABSTRACT FROM AUTHOR]

Background: In particular older people are at risk of mortality due to corona virus disease 2019 (COVID-19). Advance care planning is essential to assist patient autonomy and prevent non-beneficial medical interventions. Aim: To describe early (taken within 72 h after hospital admission) resuscitation orders in oldest-old hospitalized with COVID-19. Setting/participants: A cohort of patients aged 80 years and older admitted to the acute hospital in March and April 2020 with COVID-19 were retrospectively recruited from 10 acute hospitals in Belgium. Recruitment was done through a network of geriatricians. Results: Overall, 766 octogenarians were admitted of whom 49 were excluded because no therapeutic relationship with the geriatrician and six because of incomplete case report form. Early decisions not to consider intensive care admission were taken in 474/711 (66.7%) patients. This subgroup was characterized by significantly higher age, higher number of comorbidities and higher frailty level. There was a significant association between the degree of the treatment limitation and the degree of premorbid frailty (p < 0.001). Overall in-hospital mortality was 41.6% in patients with an early decision not to consider intensive care admission (67.1% in persons who developed respiratory failure vs 16.7% in patients without respiratory failure (p < 0.001)). Of 104 patients without early decision not to consider intensive care admission but who developed respiratory failure, 59 were eventually not transferred to intensive care unit with in-hospital mortality of 25.4%; 45 were transferred to the intensive care unit with mortality of 64.4%. Conclusions: Geriatricians applied all levels of treatment in oldest-old hospitalized with COVID-19. Early decisions not to consider intensive care admission were taken in two thirds of the cohort of whom more than 50% survived to hospital discharge by means of conservative treatment. [ABSTRACT FROM AUTHOR]

Abstract Background and objectives The complex health problems of older persons require that health professionals closely work together, in particular when an acute decline necessitates admission at an acute geriatric unit. These working conditions may cause additional stress in staff. This study aims to identify the relation between interprofessional teamwork, the quality of care and turnover intention in acute geriatric units. Design, setting, participants and methods Perceptions of interprofessional teamwork, quality of care and turnover intention among team members of 55 acute geriatric units were measured using validated questionnaires. A multilevel linear regression model was built for quality of care and logistic regression for turnover intention, with random intercept for acute geriatric unit. Results The overall response rate was 60%. Of the 890 respondents, 71% were nursing professionals, 20% allied health professionals, 5% physicians, and 4% administrative staff. Twenty-three percent reported poor to fair quality of care in their unit; 19% was not sure that patients or families had been given enough means to organise care after discharge. Fifteen percent reported turnover intention (18%, 8%, 9% and 11% among nursing professionals, allied health professionals, physicians and administrative workers respectively, p = 0.005). Higher perceived interprofessional teamwork was related to higher quality of care (estimated coefficient 0.05, p < 0.001) and lower turnover intention in nursing professionals only (estimated OR 0.94, p < 0.001). Conclusion Creating a care environment of good interprofessional teamwork can help acute geriatric units to retain nursing professionals in the job and achieve higher quality of care. [ABSTRACT FROM AUTHOR]

Background Literature depicts differences in ethical decision-making (EDM) between countries and intensive care units (ICU). Objectives To better conceptualise EDM climate in the ICU and to validate a tool to assess EDM climates. Methods Using a modified Delphi method, we built a theoretical framework and a self-assessment instrument consisting of 35 statements. This Ethical Decision-Making Climate Questionnaire (EDMCQ) was developed to capture three EDM domains in healthcare: interdisciplinary collaboration and communication; leadership by physicians; and ethical environment. This instrument was subsequently validated among clinicians working in 68 adult ICUs in 13 European countries and the USA. Exploratory and confirmatory factor analysis was used to determine the structure of the EDM climate as perceived by clinicians. Measurement invariance was tested to make sure that variables used in the analysis were comparable constructs across different groups. Results Of 3610 nurses and 1137 physicians providing ICU bedside care, 2275 (63.1%) and 717 (62.9%) participated respectively. Statistical analyses revealed that a shortened 32-item version of the EDMCQ scale provides a factorial valid measurement of seven facets of the extent to which clinicians perceive an EDM climate: self-reflective and empowering leadership by physicians; practice and culture of open interdisciplinary reflection; culture of not avoiding end-of-life decisions; culture of mutual respect within the interdisciplinary team; active involvement of nurses in end-of-life care and decision-making; active decision-making by physicians; and practice and culture of ethical awareness. Measurement invariance of the EDMCQ across occupational groups was shown, reflecting that nurses and physicians interpret the EDMCQ items in a similar manner. Conclusions The 32-item version of the EDMCQ might enrich the EDM climate measurement, clinicians' behaviour and the performance of healthcare organisations. This instrument offers opportunities to develop tailored ICU team interventions. [ABSTRACT FROM AUTHOR]

Objectives To explore the quality of interprofessional teamwork in acute geriatric care and to build a model of team types. Design Cross-sectional multicenter study. Setting Acute geriatric units in Belgium. Participants Team members of different professional backgrounds. Measurements Perceptions of interprofessional teamwork among team members of 55 acute geriatric units in Belgium were measured using a survey covering collaborative practice and experience, managerial coaching and open team culture, shared reflection and decision-making, patient files facilitating teamwork, members' belief in the power of teamwork, and members' comfort in reporting incidents. Cluster analysis was used to determine types of interprofessional teamwork. Professions and clusters were compared using analysis of variance. Results The overall response rate was 60%. Of the 890 respondents, 71% were nursing professionals, 20% other allied health professionals, 5% physicians, and 4% logistic and administrative staff. More than 70% of respondents scored highly on interprofessional teamwork competencies, consultation, experiences, meetings, management, and results. Fewer than 55% scored highly on items about shared reflection and decision-making, reporting incidents from a colleague, and patient files facilitating interprofessional teamwork. Nurses in this study rated shared reflection and decision-making lower than physicians on the same acute geriatric units ( P < .001). Using the mean score on each of the six areas, four clusters that differed significantly in all areas were identified using hierarchical cluster analysis and scree plot analysis ( P < .001). Conclusion Interprofessional teamwork in acute geriatric units is satisfactory, but shared reflection and decision-making needs improvement. Four types of interprofessional teamwork are identified and can be used to benchmark the teamwork of individual teams. [ABSTRACT FROM AUTHOR]

Aim The aim of this study was to explore how nurses and care-assistants (nursing staff) working in six Flemish nursing homes experience and describe their involvement in grief care. Background Although grief in older people is widely described in literature, less is known about how nursing staff in nursing homes offer and perceive grief care. Design A qualitative research design with elements of constructivist grounded theory was used. Methods Loosely structured face-to-face interviews were done with fourteen nurses and care-assistants. Data were collected from October 2013-March 2014. Interview transcripts were analysed using the Qualitative Analysis Guide of Leuven ( QUAGOL) method with support of NVivo 10. Findings Grief care in nursing homes is characterized by a complex tension between two care dimensions: (1) being involved while keeping an appropriate distance; and (2) being while doing. Nursing staff described key enablers and influencing factors for grief care at the level of both the individual and the organizational context. Conclusion Findings suggest an established personal sensitivity for grief care considered from the nursing staff points of view. Nevertheless, a common denominator was the necessity to further develop a supportive and multidisciplinary grief care policy ingrained in the existing care culture. Suggested components of this grief care policy are: (a) centring attention on non-death-related loss and the cumulative nature of loss in residents; (b) building capacity by means of reflective practices; and (c) the importance of self-care strategies for nursing staff. Furthermore, the findings from this study point towards a need for education and training. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Moral distress (MD) occurs when the health care provider feels certain of the ethical course of action but is constrained from taking that action. The purpose was to examine MD in geriatric nursing care and to identify factors related to MD. Design: Cross-sectional survey. Setting: Twenty nursing homes and 3 acute geriatric wards in Flanders (Belgium). Participants: Participants were 222 nurses providing geriatric care. Measurements: Moral distress was assessed with an 18-item questionnaire, adapted from the Moral Distress Scale. Multivariate linear regression analysis was used to identify key factors (situational, work, and personal factors) related to MD. Results: The response rate was 57%. The frequency score of MD was 1.1 (mean, range 0–4) and the intensity score of MD was 2.3 (mean, range 0–4). Nurses identified situations involving unjustifiable life support (mean product score MPS 4.8), unnecessary tests and treatments (MPS 4.4), and working with incompetent colleagues (MPS 4.3) as causing the most MD. Responding to requests for euthanasia (MPS 0.8) and increasing morphine in an unconscious patient believed to hasten death (MPS 1.2) were least likely to cause MD. The total MD score (sum of the 18 product scores) was significantly higher in nurses with intentional or actual job-leave (mean difference = 15.1, t = –3.5, P = .001). After adjusting for demographic factors, the following factors were independently associated with elevated MD: working in an acute geriatric care setting (as compared with the chronic geriatric care setting), a lack of involvement in end-of-life decisions, a lack of ethical debate, and specific measures of burnout (emotional exhaustion and personal accomplishment). Conclusion: Providing futile and inadequate care contributes to moral distress more than euthanasia and believing to hasten an unconscious patient’s death by increasing morphine in geriatric end-of-life care. Nurses’ moral distress is related to situational and work characteristics as well as to burnout and job-leave. [Copyright &y& Elsevier]

PACE Steps to Success is a 1-year train-the-trainer program aiming to integrate nonspecialist palliative care into nursing homes via staff education and organizational support. In this study, we aimed to explore whether this program resulted in changes in residents' hospital use and place of death. Secondary analysis of the PACE cluster randomized controlled trial (ISRCTN14741671). Data were collected on deaths over the previous 4 months via questionnaires at baseline and postintervention. Questionnaires were completed by the nurse/care-assistant most involved from 78 nursing homes in 7 European Union countries. We measured number of emergency department visits, hospital admissions, length of hospital stay, and place of death. Baseline and postintervention scores between intervention and control groups were compared, and we conducted exploratory mixed-model analyses. We collected 551 out of 610 questionnaires at baseline and 984 out of 1178 at postintervention in 37 intervention and 36 control homes. We found no statistical significant effects of the program on emergency department visits [odds ratio (OR) = 1.38, P =.32], hospital admissions (OR = 0.98, P =.93), length of hospital stay (geometric mean difference = 0.85, P =.44), or place of death (OR = 1.08, P =.80). We found no effect of the PACE program on either hospital use in the last month of life or place of death. Although this may be related to implementation problems in some homes, the program might also require a more specific focus on managing acute end-of-life situations and a closer involvement of general practitioners or specialist palliative care services to influence hospital use or place of death. [ABSTRACT FROM AUTHOR]

Objectives To validate a newly developed multiple symptom self-assessment tool in nursing homes. Design Thirty prevalent symptoms identified in the literature were classified by a 2-round Delphi procedure to a top 10 of the most relevant, burdensome symptoms. Because no existing symptom scale fully covered this top 10, we developed a new scale, consisting of a horizontal numerical scale for the top 10 symptoms, with the possibility to add and rate 3 other symptoms. This scale was validated. Setting and participants Hundred seventy-four participants, mean age 85 (±5.94) years, were recruited from 7 nursing homes (86%) and 3 acute geriatric wards (14%). Methods To test the construct validity, participants with and without a palliative status were enrolled. Participants completed the Symptom Assessment to Improve Symptom Control for Institutionalized Elderly (SATISFIE) scale on day 0 and day 1 (intrarater reliability). Nurses completed the scale on day 0 (inter-rater reliability). Descriptive statistics described the characteristics of the study population and symptom scores. Differences in symptom scores between palliative and nonpalliative participants were analyzed with the Mann-Whitney U test. Intrarater and inter-rater reliability were calculated by means of an intraclass correlation coefficient. Factor analysis searched for possible symptom clusters. Feasibility was evaluated by measuring the assessment time and by providing a questionnaire for the nurses. Results In the nonpalliative group (n = 130), the highest self-rated median scores were pain on day 1 [median 3, interquartile range (IQR) 0–5] and pain on day 2. In the palliative group (n = 44), the highest median self-rated scores were fatigue on day 1 [median 5 (IQR 0–6)], lack of energy on day 1 and 2 [both median 5 (IQR 0–8)]; and depressed feeling on day 2 [median 3 (IQR 0–5)]. Nurse assessments median scores were the highest for depressed feeling [median 5 (IQR 1–7)], fatigue [median 4.5 (IQR 0–6.5)], and lack of energy, [median 3 (IQR 0–6)] in the palliative group. In the nonpalliative group, none of the median scores was 3 or more. Intraclass correlation coefficients for intrarater reliability varied between 0.65 and 0.89 and for inter-rater reliability (patients-nurses) between 0.18 and 0.63. Mean assessment time for nurses was 2.0 minutes [standard deviation (SD) = 1.01]. For participants, it decreased from 10.5 minutes (SD = 5.41) at the first assessment to 7.5 minutes (SD = 3.72) at the second assessment. Nurses determined the SATISFIE instrument to be useful, applicable in daily practice, and sufficiently comprehensible for the patients. Conclusions The SATISFIE scale is a valid and feasible instrument for regular, multiple symptom assessment in institutionalized older persons. [ABSTRACT FROM AUTHOR]