[Death after a fall in patients with advanced dementia: cause of death natural or unnatural?] / Overleden na een val bij gevorderde dementie.

OBJECTIVE: This article describes and discusses the viewpoints of elderly care physicians and municipal coroners regarding the qualification of natural or unnatural deaths of nursing home residents with advanced dementia who fall. DESIGN: A digital questionnaire was sent to all elderly care physicians-in-training and their trainers in the Netherlands, and to all 23 municipal coroners in the Mid-Holland region. METHOD: As well as questions on knowledge of the Dutch law and prognostic figures concerning dementia-related death, the questionnaire described two cases with minimal differences. The respondents were asked if they would issue a certificate of natural death in each case, and if not, would they have preferred to do so. They were also asked to explain their answers. RESULTS: Of the 405 elderly care physicians who responded, 68% and 49%, respectively, would have issued a certificate stating the cause to be natural death in each case, or if they did not they would have preferred to do so. All 15 coroners who filled in the questionnaire came to the conclusion of unnatural death. CONCLUSION: The majority of the elderly care physicians feel that a certificate of natural death can be issued if a fall in a nursing home results in a fracture, as this can be considered as part of the disease process of dementia.

[Data streams and limits to the use of patient data originating in (forensic) mental health care institutions]. / Gegevensstromen en grenzen aan het gebruik van patiëntgegevens van (forensische) jeugdinstellingen.

BACKGROUND: Patient data are not being used soley in the mental health care institutions in which the patients are being treated. Discussion about the legitimacy of using patient data for various purposes is hindered by a lack of clarity about the nature and content of the data streams. AIM: To provide insight into the discrepancy between the purposes of collecting patient data and the purposes for which patient data are being used. METHOD: We reviewed literature on the subject and consulted professionals by means of (open) interviews. RESULTS: Patient data can be divided into four categories, each of which corresponds to the particular purpose for which patient data were acquired or used: clinical, quality and policy, research and 'other purposes'. CONCLUSION: The way in which patient data are handled should depend on the nature and content of the data involved and, above all, on the purposes for which the data have been collected.

Designing a strategy to implement cost-effective blood transfusion management in elective hip and knee arthroplasties: a study protocol.

BACKGROUND: Total hip and knee arthroplasties are two of the most commonly performed procedures in orthopedic surgery. Different blood-saving measures (BSMs) are used to reduce the often-needed allogenic blood transfusions in these procedures. A recent large randomized controlled trial showed it is not cost effective to use the BSMs of erythropoietin and perioperative autologous blood salvage in elective primary hip and knee arthroplasties. Despite dissemination of these study results, medical professionals keep using these BSMs. To actually change practice, an implementation strategy is needed that is based on a good understanding of target groups and settings and the psychological constructs that predict behavior of medical professionals. However, detailed insight into these issuses is lacking. Therefore, this study aims to explore which groups of professionals should be targeted at which settings, as well as relevant barriers and facilitators that should be taken into account in the strategy to implement evidence-based, cost-effective blood transfusion management and to de-implement BSMs. METHODS: The study consists of three phases. First, a questionnaire survey among all Dutch orthopedic hospital departments and independent treatment centers (n = 99) will be conducted to analyze current blood management practice. Second, semistructured interviews will be held among 10 orthopedic surgeons and 10 anesthesiologists to identify barriers and facilitators that are relevant for the uptake of cost-effective blood transfusion management. Interview questions will be based on the Theoretical Domains Interview framework. The interviews will be followed by a questionnaire survey among 800 medical professionals in orthopedics and anesthesiology (400 professionals per discipline) in which the identified barriers and facilitators will be ranked by frequency and importance. Finally, an implementation strategy will be developed based on the results from the previous phases, using principles of intervention mapping and an expert panel. DISCUSSION: The developed strategy for cost-effective blood transfusion management by de-implementing BSMs is likely to reduce costs for elective hip and knee arthroplasties. In addition, this study will lead to generalized knowledge regarding relevant factors for the de-implementation of non-cost-effective interventions and insight in the differences between implementation and de-implementation strategies.

Those famous red pills-Deliberations and hesitations. Ethics of placebo use in therapeutic and research settings.

Placebo fascinates and mystifies. Even with today's medical science we still do not know how and if it works. The use of placebo both in therapy and in research evokes ethical problems that are not easily resolved either. Placebo is intrinsically linked to deception, while veracity is a basic tenet in today's thinking of a doctor-patient relationship. In research ethics placebo, though considered the golden control condition, leads to the question of the therapeutic obligation. This narrative review presents an overview of these ethical questions and offers considerations that are of relevance to daily medical and research practice both in psychiatry and elsewhere.

[Proxy consent and responsibility: professional autonomy and adamant family members]. / Vertegenwoordiging en verantwoordelijkheid. Over medische verantwoordelijkheid en mondige familieleden.

Research into the role of family members in the decision making process concerning medical treatment of incompetent patients in nursing home care, shows that the involvement of a proxy decision maker implies a greater responsibility of the physician. It is the duty of the proxy decision-maker (mostly a family member) to look after the incompetent patient's interests. But it is the physician's duty to decide whether the proxy decision maker indeed fulfills this task. Even so, the physician has the professional responsibility to decide on the medical course of action. Involvement of others (relations and other health care professionals) is of great importance to the answer to the question 'What is good for this patient?' but does not absolve the physician from the obligation to decide professionally what is the right thing to do.

[Dealing with patient dissatisfaction; a professional skill]. / Omgaan met onvrede van patiënten; een professionele vaardigheid.

During the last century the patient-doctor relationship has changed considerably. This change becomes particularly visible when the relationship between the two parties is disturbed. this is usually caused by patient dissatisfaction with the doctor or other workers in the medical profession. Handling dissatisfaction should be part of a doctor's professional skills. The most important advice in dealing with dissatisfaction is to react fast. A doctor should have the good sense to raise the issue for discussion as soon as he/she senses signs of dissatisfaction. If this is not possible and the issue results in a written complaint, the plaintiff can lodge a complaint within the framework of a special law. The complaint is then handled by a complaints committee. Over the past years, mediation has been used increasingly. This procedure has a low threshold, works fast and often results in reconciliation of both parties. If the intervention of a complaints committee is not desired and mediation is not realistic or rejected, the case sometimes progresses to the disciplinary board or civil judge. This often leads to protracted procedures and is stressful to both parties. It is important to prevent these kinds of procedures as much as possible by reacting swiftly and appropriately to signs of dissatisfaction.

[Good medical care at the borderline of mental incompetence]. / Goed hulpverlenerschap aan de grens van de wilsbekwaamheid.

A 73-year-old woman with minor intellectual skills had complaints which suggested a vulvar carcinoma. Despite her refusal she was examined and admitted to hospital, on the basis of good professional care. The psychiatrist examined her and judged her incompetent. For the operation of the diagnosed vulvar carcinoma a court ordered representative was obtained. Two months later she underwent radiotherapy to prevent local complications and pain and a few weeks thereafter she died. Because medical decision-making in a doctor-patient relationship is not always possible decision-making power should be assigned to a third party. That forms the basis of proper medical care.