The attitudes, role & knowledge of mental health nurses towards euthanasia because of unbearable mental suffering in Belgium: A pilot study.

WHAT IS KNOWN ABOUT THE SUBJECT?: Euthanasia because of unbearable mental suffering (UMS euthanasia) has been legal in Belgium since 2002 under strict conditions of careful practice. UMS euthanasia occurs fairly rarely in Belgium, but the frequency has increased substantially over the past few years. Although most mental health nurses play an important role and are supportive of euthanasia in general, their role, attitude and knowledge when it comes to UMS euthanasia were unknown until now. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Most mental health nurses in Belgium appear to be supportive towards UMS euthanasia and where UMS euthanasia is carried out, mental health nurses are often involved in the preceding decision-making process. Mental health nurses critically reflect on the interpretation and application of the legal euthanasia criteria as experienced in their daily work with their patients, and identify several problems. After a rather quiet period in Belgium, the public ethical debate regarding UMS euthanasia has recently been reopened and intensified. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Sufficient attention must be paid to how mental health nurses can be involved in the process of UMS euthanasia. This applies at several levels: legal, healthcare policy, bedside care and education. Specific attention must be paid within the UMS euthanasia process to ensure adequate cooperation between physicians, nurses and patients. There is a need for proper training in: knowledge of psychiatric pathologies and remaining treatment options; communication skills; the legal framework and all its difficulties; transdisciplinary and multicultural approaches; ethical reflection and how nurses handle their own emotions. ABSTRACT: Introduction Euthanasia because of unbearable mental suffering (UMS euthanasia) has been legal in Belgium since 2002, under certain circumstances that govern careful practice. Despite the legal framework, there are specific difficulties and concerns regarding UMS euthanasia. Mental health nurses are often involved in the process, but little is known about their attitudes towards UMS euthanasia, their role and their knowledge. Aim To determine the attitudes, role and knowledge of mental health nurses regarding UMS euthanasia. Methods A cross-sectional survey was performed at a convenience sample of four psychiatric hospitals in Belgium (n = 133) as a pilot study. Self-administered questionnaires were provided to mental health nurses. Results Half the nurses in our sample had been involved at least once in the process of UMS euthanasia. A large majority of mental health nurses were supportive of UMS euthanasia. Nurses show differences in attitudes related to the different psychiatric pathologies of the patients, and in whether or not minors are involved. In some cases, they believed that the mental suffering of psychiatric patients can be unbearable and irreversible and that psychiatric patients can be competent to voluntarily request UMS euthanasia. Nurses stated that they have an important role in the UMS euthanasia process, but also demanded more knowledge and clear guidelines to implement the procedure. Discussion Nurses have a key role regarding UMS euthanasia but face several challenges: the recent process, resistance to a multidisciplinary approach by psychiatrists and an unclear role defined by the legal framework. Nurses do not appear to have a common voice on the topic and the development of clear guidelines appears to be essential. Social recovery can offer a way out of an UMS euthanasia request, but it will not always offer a solution. Implications for Practice Sufficient attention must be paid to how mental health nurses can be involved in the process of UMS euthanasia at various levels: bedside practice, healthcare management, education and policy. A form of systematic cooperation between nurses, physicians and patients can contribute to the utmost careful decision-making process needed in these cases. There is a need for proper training in: knowledge of psychiatric pathologies and remaining treatment options; communication skills; the legal framework and all its difficulties; transdisciplinary and multicultural approaches; ethical reflection and how nurses handle their own emotions.

What influences intentions to request physician-assisted euthanasia or continuous deep sedation?

The increasing prevalence of euthanasia in Belgium has been linked to changing attitudes. Using National health survey data (N = 9651), we investigated Belgian adults' intention to ask a physician for euthanasia or continuous deep sedation in the hypothetical scenario of a terminal illness and examined its connection to sociodemographic and health characteristics. Respectively, 38.3 and 25.8% could envisage asking for euthanasia and continuous deep sedation. Those with very bad to fair subjective health and with depression more likely had an intention to ask for euthanasia, which suggests need for attention in the evaluation of requests from specific patient groups.

Socioeconomic risk factors for hospital admittance due to a suicide attempt in Belgium: a population-based study using administrative data.

PURPOSE: This population-based study aims to investigate socio-economic factors, depression and psychosis as independent risk factors for a suicide attempt that requires hospitalization, and estimate the incidence of suicide attempts. METHODS: Individual-level administrative data were analysed that were collected for all members of the Socialist Health Insurance Schemes in Belgium during the period 2011-2013 (N = 3,156,030) in the context of the financing of the health care services provided. Bivariate and multivariate odds ratios were calculated for multiple socio-economic factors, socio-demographic factors and the presence of depression and psychosis. RESULTS: During the study period, 4063 persons were hospitalized due to a suicide attempt. The incidence of suicide attempts with hospital admittance was 48.0/100,000 persons/year. Being unemployed, incapable of work over a shorter or longer period with substitute income, living on social welfare, having an increased healthcare reimbursement, living alone and using antidepressants or antipsychotics were identified as independent factors that contributed to the risk of hospitalization due to a suicide attempt. CONCLUSIONS: Persons from low income groups, however defined, those living alone, or persons using antidepressants or antipsychotics are at an increased risk of attempting suicide and needing hospitalization for it. A social policy that focuses on the improvement of these factors or their consequences may be expected to have a favourable effect on the number of suicide attempts. Funding of mental health care should also better match population needs.

Psychiatric Consultation and Referral of Persons Who Have Attempted Suicide.

BACKGROUND: Persons who have attempted suicide are often admitted to a hospital's emergency department (ED). The risk of them repeating their attempt is lower if they have had access to a psychiatrist in hospital and had been referred to mental health care services. However, the literature suggests this is often lacking. AIMS: To describe perceived barriers to and supportive factors for psychiatric consultation and appropriate referral of suicide attempters in the ED. METHOD: The perspective of the heads of emergency and psychiatry departments in all hospitals with an ED in Brussels-Capital Region was investigated with a qualitative study. Data were obtained with semistructured personal interviews and analyzed in the tradition of content analysis. RESULTS: Eight emergency physicians and 11 psychiatrists participated. Perceived barriers can be summarized as a lack of resources in the ED in terms of psychiatrists, psychiatric beds, and a room for counseling. Intense collaboration between physicians and psychiatrists and integration in a network of mental health services were perceived as being supportive factors. CONCLUSION: According to the heads of department, psychiatric consultation and referral of suicide attempters could be improved by an increase and more even distribution of beds for temporary psychiatric hospitalization in the ED and a more appropriate financing of the psychiatry function in the ED.

Information preferences of the general population when faced with life-limiting illness.

BACKGROUND: Giving the public and the patients good information enables them to make effective choices about their care. This study describes public preferences for both themselves and their relatives on receiving information on end-of-life care topics when faced with a life-limiting illness and to identify associated factors. METHOD: This study used data from the cross-sectional Health Interview Study (HIS) 2008 that collected data from a representative sample (N = 9651) of the Belgian population. RESULTS: Around 82% of respondents wanted to be informed always about diagnosis, chances of cure and available treatments, 77% wanted to be informed on life expectancy, 72% on options regarding palliative care and 67% on possibilities of prolonging or shortening life. Around 55% wanted their relative to be informed always about diagnosis, chances of cure, life expectancy and different treatments available, whereas 50% wanted this in relation to the options regarding palliative care and 46% on the possibilities of prolonging or shortening life. Younger adults, people with more education and people with a regular GP were more likely to want to be informed always. Younger adults and women were less likely to want their relatives to be informed always. CONCLUSION: The majority of the Belgian population wants to be informed always about end-of-life care topics when faced with a life-limiting illness. Physicians should be aware of the desired level of information and tailor information to individual patient preferences. Understanding population preferences may help to tailor patient education and health promotion programmes appropriately.

Attitudes of belgian students of medicine, philosophy, and law toward euthanasia and the conditions for its acceptance.

Euthanasia is legal in Belgium if due care criteria are met, which is judged by committees including physicians, ethicists, and jurists. We examined whether students in these disciplines differ in how they judge euthanasia as an acceptable act. A cross-sectional, anonymous e-mail survey revealed that they have similar attitudes and accept its legalization. Therefore, joint decision-making of physicians, ethicists, and lawyers regarding euthanasia seems to have a common attitudinal base in Belgium. However, they differ to some extent regarding the conditions they put forward for euthanasia being acceptable. Philosophy of life (religion) was an independent predictor of these attitudes.

Labelling of end-of-life decisions by physicians.

OBJECTIVES: Potentially life-shortening medical end-of-life practices (end-of-life decisions (ELDs)) remain subject to conceptual vagueness. This study evaluates how physicians label these practices by examining which of their own practices (described according to the precise act, the intention, the presence of an explicit patient request and the self-estimated degree of life shortening)they label as euthanasia or sedation. METHODS: We conducted a large stratified random sample of death certificates from 2007 (N=6927).The physicians named on the death certificate were approached by means of a postal questionnaire asking about ELDs made in each case and asked to choose the most appropriate label to describe the ELD. Response rate was 58.4%. RESULTS: In the vast majority of practices labelled as euthanasia, the self-reported actions of the physicians corresponded with the definition in the Belgian euthanasia legislation; practices labelled as palliative or terminal sedation lack clear correspondence with definitions of sedation as presented in existing guidelines. In these cases, an explicit life-shortening intention by means of drug administration was present in 21.6%, life shortening was estimated at more than 24 h in 51% and an explicit patient request was absentin 79.7%. DISCUSSION: Our results suggest that, unlike euthanasia,the concept of palliative or terminal sedation covers abroad range of practices in the minds of physicians. This ambiguity can be a barrier to appropriate sedation practice and indicates a need for better knowledge of the practice of palliative sedation by physicians.

Depression and parkinsonism in older Europeans: results from the EURODEP concerted action.

OBJECTIVE: The prevalence rate of depression among patients with Parkinson's disease (PD) has been estimated at 25%, although prevalence figures range between 7-76%. Relatively few studies on PD and depression are based on random samples in the general population. Some depressive symptoms can also be understood as symptoms of parkinsonism, and the current study aims to describe which 'overlap' symptoms can be identified in a community sample. METHODS: Data are employed from the EURODEP collaboration. Nine study centres, from eight western European countries, provided data on depression (most GMS-AGECAT), depressive symptoms (EURO-D items and anxiety), parkinsonism (self-report of PD or clinical signs of PD), functional disability and dementia diagnosis. RESULTS: Data were complete for 16 313 respondents, aged 65 and older; 306 (1.9%) reported or had signs of parkinsonism. The rate of depression was about twice as high among respondents with parkinsonism (unadjusted Odds Ratio 2.44, 95% Confidence Interval 1.88-3.17), also among those without functional disability. 'Overlap' symptoms between parkinsonism and depression, were represented by motivation and concentration problems, appetite problems and especially the symptom of fatigue (energy loss). However, principal component analysis showed that these 'overlap' symptoms loaded on different factors of the EURO-D scale. CONCLUSIONS: As among clinical patients with PD, depression is highly common in community dwelling older people with parkinsonism, even among those without functional disability. Although fatigue did not strongly relate to motivational symptoms, both types of 'overlap' symptoms possibly trigger a final common pathway towards a full depressive syndrome.

Service use in family caregivers of persons with dementia in Belgium: psychological and social factors.

This study aims to investigate whether selected social and psychological characteristics of family caregivers of persons with dementia are related to community-based service use in Belgium. Two aspects were distinguished in service utilisation: volume (number of contacts) and diversity (number of services). Within a selected region, dementia caregivers were traced via the detection of persons with dementia known to community health or social services. A probability diagnosis was made with the Geriatric Mental State and the computer algorithm AGECAT. Family caregivers of persons with dementia (N = 168) were interviewed at home by means of a structured questionnaire. Data were analysed with multiple regression analysis. Co-residence, a positive attitude towards home service use, and increased problem-solving coping were found to be direct predictors of increased diversity of services used, whereas a lower burden of behaviour problems, living apart, and increased avoidance coping were found to be direct predictors of increased volume of service use. Care recipients' behaviour problems and functional status were not found to be related to service use. The results suggest that social and psychological factors have a larger impact on service use in family caregivers of persons with dementia, compared to objective or subjective burden. Interventions to increase awareness of relevant services, to improve attitudes towards their use and support problem-solving coping in family caregivers may be considered to increase the use of appropriate services.

Introduction of assistive devices: home nurses' practices and beliefs.

AIMS: This paper reports a study describing home nurses' intention and current practices regarding introducing assistive devices, and investigating whether their practice is related to social cognitive factors (attitudes, subjective norms and self-efficacy). BACKGROUND: Home nurses not only care for patients in particular medical domains, but also educate and guide them towards more independence. Patients with age-related disabilities in mobility and self-care might benefit from the use of assistive devices. A home nurse might be the first and only person to discuss the disability and use of an assistive device. Therefore, home nurses' beliefs about the introduction of assistive devices could affect their daily practices. METHODS: A cross-sectional study was conducted with a convenience sample of 64 home nurses chosen from a random sample of home nursing departments. The home nurses completed a self-administered questionnaire. The Theory of Planned Behaviour framework was used to develop the social cognitive measures regarding each of the six steps distinguished in the introduction of assistive devices. RESULTS: Home nurses had positive attitudes and high levels of intention, subjective norm and self-efficacy towards most steps of the decision process to introduce assistive devices. In a multiple linear regression analysis, attitude and self-efficacy predicted intention to introduce assistive devices to older clients with disabilities. Intention was correlated to home nurses' current practices. CONCLUSIONS: The findings suggest that conditions are present to involve home nurses more explicitly in the introduction of assistive devices to their patients. Social cognitive factors should be taken into account when developing interventions that aim to support home nurses to do this.

Knowing the diagnosis and counselling the relatives of a person with dementia: the perspective of home nurses and home care workers in Belgium.

Home nurses and home care workers share the care for a person with dementia with family caregivers, and are confronted with their needs for medical and service-related information, for advice on how to cope with the behaviour changes, and for emotional support. The first objective of the present study was to describe some of the conditions for effective counselling, such as the perception that knowing the diagnosis has positive consequences for the formal caregivers. A second objective was to describe the formal caregivers' counselling practice, and ascertain its relationship with the psychological variables of attitudes, self-efficacy and subjective norm. A postal questionnaire was sent to 287 home nurses and 1259 home care workers in a defined region of Belgium; the questionnaire was returned by 169 home nurses (58.9% response) and 665 home care workers (52.8% response). The Theory of Planned Behaviour was the organising framework which underpinned the development of the instruments. Only the 168 home nurses and 601 home care workers reporting experience with caregiving to people with dementia were included in the analysis. Formal caregivers indicated that knowing the diagnosis was important, but it could facilitate or hinder caregiving. They were able to describe behavioural characteristics which are indicative of dementia, but only in a limited way, and their strategies to uncover the diagnosis were also limited. Formal caregivers reported that they supported family members emotionally, advised about communication with the person with dementia and informed family caregivers about services. However, providing family caregivers with information about dementia lagged behind these forms of support. In general, nurses scored higher than home care workers. Multiple linear regression analysis was used to investigate the relationships between self-reported practice and the concepts of the model. In both professions, attitudes and self-efficacy were found to be strong independent predictors, and the implications for practice are discussed.

Clinical practice guidelines to improve shared decision-making about assistive device use in home care: a pilot intervention study.

This study examines whether clinical practice guidelines (CPG) for the introduction of assistive devices (ADs) in home care improve shared decision-making about AD use and modify its social-cognitive correlates. Data were collected in an intervention study with quasi-experimental design. Questionnaires were obtained from 116 home nurses and home care workers and their 140 clients with disabilities. Significant differences between intervention and control group revealed that implementation of CPG improved home nurses' and home care workers' self-reported practice: the number of intervention methods they applied increased, and the methods were applied with increased intensity. Nurses' attitudes towards introducing ADs in a shared decision-making process decreased in both intervention group and control group over time. Clients' reports about caregivers' practice showed a minor concurrence with the reports of the caregivers themselves. The complexity of the CPG and a substantial time investment were reported as the main barriers to involving clients in shared decision-making through the experimental CPG. Nevertheless, CPG hold promise for shared decision-making between formal caregivers and community-dwelling persons with disabilities concerning AD use. The findings suggest that these CPG can structure communication between caregiver and client, and can support caregivers in facilitating clients' self-determination concerning coping with their disabilities.

National context of healthcare, economy and religion, and the association between disability and depressive symptoms in older Europeans: results from the EURODEP concerted action.

Associations between disability and depression have been shown to be consistent across cultures among middle-aged adults. In later life the association between disability and depression is much more substantial and may be amenable to influences by health care facilities as well as economic and sociocultural factors. Fourteen community-based studies on depression in later life in 11 western European countries contribute to a total study sample of 22,570 respondents aged 65 years or older. Measures are harmonised for depressive symptoms (EURO-D scale) and disability. Using multilevel modelling to control for the stratified data structure we examined whether the association between disability and depressive symptoms is modified by national health care and mental health care availability, national economic circumstances, demographic characteristics and religious tradition. The association between depressive symptoms and disability is attenuated by health care expenditure and availability of mental health care and also by gross domestic product; it was more pronounced in countries with high levels of orthodox religious beliefs. Higher levels of depressive symptoms are found in countries with a larger gross domestic product (per capita) and higher health care expenses but are interpreted with care because of measurement differences between the centres. The findings from this contextual perspective indicate that general and mental health care should be geared to one another wherever possible.

Depression among older people in Europe: the EURODEP studies.

The data from nine centres in Europe which had used the Geriatric Mental Scale (GMS) AGECAT were analysed to compare prevalence of diagnoses in subjects aged 65 years and over living in the community. Levels of depressive illness were: Iceland 8.8%, Liverpool 10.0%; Zaragoza 10.7%; Dublin 11.9%; Amsterdam 12.0%; Berlin 16.5%; London 17.3%; Verona 18.3% and Munich 23.6%. Taking all levels of depression, five high (Amsterdam, Berlin, Munich, London and Verona) and four low (Dublin, Iceland, Liverpool, Zaragoza) scoring centres were identified. Meta-analysis of all 13,808 subjects yielded a mean level of depression of 12.3% (95% CI 11.8-12.9), 14.1% for women (95% CI 13.5-14.8) and 8.6% for men (95% CI 7.9-9.3). Symptom levels varied between centres: 40% of the total study population in Amsterdam reported depressive mood against only 26% in Zaragoza. To incorporate studies from other centres using other methods for depression identification, the EURO-D scale was developed from 12 items of the GMS and validated against other scales and expert diagnosis. A two factor solution emerged, an 'affective suffering factor' and a 'motivation factor'. The EURO-D scale was applied to 14 population based surveys. Depression score tended to increase with age unlike levels of prevalence of depression. Large between centre differences were evident in levels of depression unexplained by age, gender or marital status. These data show that depressive illness defined as suitable for intervention is common among older people in Europe. Opportunities for effective treatment are almost certainly being lost. Levels of depressive symptoms vary significantly between high and low scoring centres, prompting the next phase of this study, an examination of risk factors in Europe.

Are cognitive impairment and depressive mood associated with increased service utilisation in community-dwelling elderly people?

The healthcare and social services utilisation of elderly people with mental disorders has not been sufficiently described, although such knowledge could indicate directions for preventive and curative interventions, and suggest unmet service needs. The aim of the present study was to examine cognitive impairment and depressive mood as correlates of specific healthcare and social services utilisation of community-dwelling elderly people. A randomly selected population sample of 1134 community-dwelling individuals aged 65 years and over living in a defined area were interviewed at home. Cognitive impairment was measured by the Mini Mental State Examination and depressive mood by the Centre for Epidemiologic Studies -- Depression scale. Cognitive impairment and depressive mood were related to the number of home care services used, and to the utilisaton of every specific healthcare and social service. After controlling for confounding variables (i.e. age, sex, education, co-residence and disabilities), service utilisation was still predicted by depressive mood, but not by cognitive impairment. Interventions to prevent and cure depressive mood should be considered to decrease the service needs of community-dwelling elderly people. Unmet service needs are suggested since cognitive impairment does not result in increased service utilisation.

Awareness among community-dwelling elderly of assistive devices for mobility and self-care and attitudes towards their use.

The researchers conducted a survey by personal interview of elderly people (75 +years) receiving home nursing (N= 117) in Belgium to investigate the extent of their awareness and perceptions of the existing supply of assistive devices for mobility and selfcare (ADs). A new scale has been developed to measure the possession and the awareness of ADs, the Assistive Devices Awareness Scale. The researchers identified important gaps regarding the awareness of ADs, despite their widespread usefulness and their commercial availability. Even persons with specific disabilities were not necessarily aware of the ADs available to assist with their particular problems. Nevertheless, the elderly persons presented positive attitudes regarding the possibility of using devices as a partial substitute for care and advocated participation in financing the purchase of ADs. Opinions regarding the effect of using ADs on feelings of loneliness differed quite extensively. Most people who were receiving home nursing already possessed ADs. These elderly people perceived mainly positive consequences from using the ADs they already possessed. Linear forward regression analysis revealed that for the elderly clients of home nursing services, the possession of devices is correlated with the extent to which there is a growing need for care, people are aware of the existing devices and people perceive the consequences of using ADs as positive. Implications for future research are discussed.

A social-cognitive model to predict the use of assistive devices for mobility and self-care in elderly people.

PURPOSE: To provide insight into the contribution of psychological variables in understanding use and nonuse of assistive devices (ADs) for self-care and mobility. DESIGN AND METHODS: A survey on a representative sample of 491 community-dwelling elderly people in Flanders was conducted. A theoretical model of the factors predicting the use of ADs was tested with path analysis. RESULTS: The possession and use of 32 ADs were found to be bivariately related to intention to use ADs, awareness of ADs, attitude toward AD use, subjective norm regarding AD use, self-efficacy concerning AD use, and socio-demographic characteristics. In regression analyses the intention to use ADs was found to be related to self-efficacy concerning AD use, attitude toward AD use, and subjective norm regarding AD use. IMPLICATIONS: This study suggests that a social-cognitive model of human behavior can be helpful in explaining the use of ADs. The model can suggest measures to be developed aiming to improve the introduction of ADs.