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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 To deliver optimal palliative care, a Care Pathway for Primary Palliative Care (CPPPC) was developed. This CPPPC was implemented by general practitioners (GPs) in territories of five Belgian palliative care networks (2014–2016). Belgian doctors have much therapeutic freedom, and do not commonly follow guidelines. Objectives To assess how palliative care was provided by GPs before the CPPPC and its implementation project were presented publicly. Methods Between 2013 and 2015, seven focus groups with GPs were conducted. Participants included 15 GPs in three French-speaking focus groups and 26 GPs in four Dutch-speaking focus groups, with diversity for age, gender, palliative care experience and practice context. Some GPs implemented the CPPPC later. Results GPs considered each palliative care case unique and disliked strict protocols. However, they expressed a need for peer review and reflective frameworks. GPs felt it is important to identify palliative care patients ‘timely’, but found this difficult. Screening methods help, but are not widely used. GPs struggled most with identifying palliative care needs in non-oncological patients. Bad news breaking was considered difficult. Continuity of care was considered very important. However, advance care planning seemed more widely practised by Dutch-speaking GPs than by French-speaking GPs. The taboo of palliative care provoked emotional discussions. Conclusion Palliative care frameworks which help GPs to deliver ‘tailor-made’ care have more chance to be adopted than strict protocols. GPs should be given education for bad news breaking. Palliative care and advance care planning practices differ locally: guideline dissemination plans should respect these local differences.

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.

Veel huisartsen vinden palliatieve zorg een belangrijk deel van hun taak. Toch zijn er ook barrières bij huisartsen om aan vroegtijdige zorgplanning te doen.

International audience; The number of people in their last years of life with advanced chronic conditions, palliative care needs, and limited life prognosis due to different causes including multi-morbidity, organ failure, frailty, dementia, and cancer is rising. Such people represent more than 1% of the population. They are present in all care settings, cause around 75% of mortality, and may account for up to one-third of total national health system spend. The response to their needs is usually late and largely based around institutional palliative care focused on cancer. There is a great need to identify these patients and integrate an early palliative approach according to their individual needs in all settings, as suggested by the World Health Organization. Several tools have recently been developed in different European regions to identify patients with chronic conditions who might benefit from palliative care. Similarly, several models of integrated palliative care have been developed, some with a public health approach to promote access to all in need. We describe the characteristics of these initiatives and suggest how to develop a comprehensive and integrated palliative approach in primary and hospital care and to design public health and community-oriented practices to assess and respond to the needs in the whole population. Additionally, we report ethical challenges and prognostic issues raised and emphasize the need for research to test the various tools and models to generate evidence about the benefits of these approaches to patients, their families, and to the health system. (C) 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

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.

Background: A multidisciplinary European Association of Palliative Care Taskforce was established to scope the extent of and learn what facilitates and hinders the development of palliative care in the community across Europe. Aim: To document the barriers and facilitators for palliative care in the community and to produce a resource toolkit that palliative care specialists, primary care health professionals or policymakers, service developers, educationalists and national groups more generally could use to facilitate the development of palliative care in their own country. Design: (1) A survey instrument was sent to general practitioners with knowledge of palliative care services in the community in a diverse sample of European countries. We also conducted an international systematic review of tools used to identify people for palliative care in the community. (2) A draft toolkit was then constructed suggesting how individual countries might best address these issues, and an online survey was then set up for general practitioners and specialists to make comments. Iterations of the toolkit were then presented at international palliative care and primary care conferences. Results: Being unable to identify appropriate patients for palliative care in the community was a major barrier internationally. The systematic review identified tools that might be used to help address this. Various facilitators such as national strategies were identified. A primary palliative care toolkit has been produced and refined, together with associated guidance. Conclusion: Many barriers and facilitators were identified. The primary palliative care toolkit can help community-based palliative care services to be established nationally.

Background: Working and learning go hand in hand during interprofessional collaborative practice. Patients' nursing records are designed to record patient care and health status. It is not known whether these records are also used to keep track of interprofessional contacts or interprofessional learning between team members. This study explored the usefulness of patients' nursing records in optimising interprofessional workplace learning for general practitioners. Methods: We utilized a descriptive retrospective chart review. All palliative home care teams of the Dutch speaking part of Belgium were involved. Throughout the year 2010, a representative sample of patient charts was selected. Characteristics of encounters between general practitioners and palliative care nurses were extracted from the charts. Results: Detailed accounts of interprofessional contacts were found in the charts. Palliative care nurses recorded number and type of contacts, topics discussed during contacts and general practitioner's learning activities. Discussion: Palliative care nurses are sensitive and open towards the general practitioners' learning needs. Patients' nursing records provide useful information for interprofessional team discussions on workplace learning. Healthcare professionals should be trained to respond to each other's learning needs.

Background There is a growing need for palliative care. The majority of palliative patients prefer their general practitioner (GP) to organize their palliative home care. General practitioners need a range of competences to perform this task. However, there has been nogeneral description so far of how GPs keep these competences up-to-date. The present study explores current experiences, views and preferences towards training and education in palliative care among GPs, palliative home-care professionals and professionals from organizations who provide training and education. Methods Five focus groups were brought together in Belgium, with a total of 29 participants, including members of the three categories mentioned above. They were analysed using a constant comparison method. Results The analysis revealed that undergraduate education and continuing medical education (CME) while in practice, is insufficient to prepare GPs for their palliative work. Workplace learning (WPL) through collaboration with specialized palliative home-care nurses seems to be a valuable alternative. Conclusions The effectiveness of undergraduate education might be enhanced by adding practical experience. Providers of continuing medical education should look to organize interactive, practice-based and interprofessional sessions. Therefore, teachers need to be trained to run small group discussions. In order to optimize workplace learning, health care professionals should be trained to monitor each other's practice and to provide effective feedback. Further research is needed to clarify which aspects of interprofessional teamwork (e.g. professional hierarchy, agreements on tasks and responsibilities) influence the effectiveness of workplace learning.

Background Palliative care often requires inter-professional collaboration, offering opportunities to learn from each other. General practitioners often collaborate with specialized palliative home care teams. This study seeks to identify what, how and from whom health care professionals learn during this collaboration. Methods Cross-sectional survey in Belgium. All palliative home care teams were invited to participate. General practitioners (n = 267) and palliative care nurses (n = 73) filled in questionnaires. Results General practitioners (GPs) and palliative care nurses learned on all palliative care aspects. Different learning activities were used. Participants learned from all others involved in patient care. The professionals’ discipline influences the content, the way of learning and who learns from whom. Multiple linear regression shows significant but limited association of gender with amount of learning by GPs (M F; p = 0.019; Adj R2 = 0.01). Conclusions This study is the first to reveal what, how and from whom learning occurs during collaboration in palliative care. Training professionals in sharing expertise during practice and in detecting and adequately responding to others’ learning needs, could optimize this way of learning. Electronic supplementary material The online version of this article (doi:10.1186/s12913-014-0501-9) contains supplementary material, which is available to authorized users.

Objective Working alongside specialized palliative care nurses brings about learning opportunities for general practitioners. The views of these nurses toward their role as facilitator of learning is unknown. The aim of this study is to clarify the views and preferences of these nurses toward their role as facilitator of physicians’ learning. Methods Qualitative study based on semi-structured interviews. We interviewed 21 palliative care nurses in Belgium who were trained in the role of learning facilitator. Data were analyzed using Grounded Theory principles. Results First all interviewees shared the conviction that patient care is their core business. Secondly two core themes were defined: nurses’ preferences toward sharing knowledge and their balancing between patient care and team care. Combining these themes yielded a typology of nurses’ behavioral style: the clinical expert-style, the buddy-style, the coach-style and the mediator-style. Conclusions Palliative care nurses’ interpretation of the role as facilitator of general practitioners’ learning diverges according to personal characteristics and preferences. Practice implications Asking clinical expert nurses to become a facilitator of other professional's learning requires personal mentoring during this transition. Nurses’ preferences toward practice behavior should be taken into account.

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.

The article discusses a survey on postgraduate education on palliative care in Belgium in 2007 and the structure for assessment of activities under continuing medical education (CME). The article highlights that the education available to general practitioners (GPs) for improving their palliative care competences does not have centrally managed content or quality. It also mentions the lack of assessment of CME activities, and offers suggestions on how to improve existing CME programs.

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.

Starting with early identification of palliative care patients by general practitioners (GPs), the Care Pathway for Primary Palliative Care (CPPPC) is believed to help primary health care workers to deliver patient- and family-centered care in the last year of life. The care pathway has been pilot-tested, and will now be implemented in 5 Belgian regions: 2 Dutch-speaking regions, 2 French-speaking regions and the bilingual capital region of Brussels. The overall aim of the CPPPC is to provide better quality of primary palliative care, and in the end to reduce the hospital death rate. The aim of this article is to describe the quantitative design and innovative data collection strategy used in the evaluation of this complex intervention. A quasi-experimental stepped wedge cluster design is set up with the 5 regions being 5 non-randomized clusters. The primary outcome is reduced hospital death rate per GPs’ patient population. Secondary outcomes are increased death at home and health care consumption patterns suggesting high quality palliative care. Per research cluster, GPs will be recruited via convenience sampling. These GPs -volunteering to be involved will recruit people with reduced life expectancy and their informal care givers. Health care consumption data in the last year of life, available for all deceased people having lived in the research clusters in the study period, will be used for comparison between patient populations of participating GPs and patient populations of non-participating GPs. Description of baseline characteristics of participating GPs and patients and monitoring of the level of involvement by GPs, patients and informal care givers will happen through regular, privacy-secured web-surveys. Web-survey data and health consumption data are linked in a secure way, respecting Belgian privacy laws. To evaluate this complex intervention, a quasi-experimental stepped wedge cluster design has been set up. Context characteristics and involvement level of participants are important parameters in evaluating complex interventions. It is possible to securely link survey data with health consumption data. By appealing to IT solutions we hope to be able to partly reduce respondent burden, a known problem in palliative care research. ClinicalTrials.gov Identifier: NCT02266069 .