Medical and moral considerations regarding complex medical decisions in older patients with multimorbidity: a compact deliberation framework.

In health care for older adults, patients with multimorbidity usually receive the same interventions as those patients without multimorbidity. However, standard curative or life-sustaining treatment options have to be considered carefully in view of the maximally attainable result in older and frail patients. To guide such complex medical decisions, we present a compact deliberation framework that could assist physician(s) in charge of the medical treatment of a specific elderly patient to systematize his own thinking about treatment and decisional responsibilities, in case of an intercurrent disease.The framework includes four questions to be addressed when deciding on a single urgent standard curative or life-sustaining intervention in acute medical problems of an elderly patient with multimorbidity: 1) What is known about the patient's aims and preferences? 2) Will the intervention be effective? 3) Will the intervention support the aims and preferences of the patient? 4) In view of the aims and preferences, will the risks and benefits be in balance?If all four considerations are answered favorably, the intervention will fit patient-centered and appropriate care for frail older patients with multimorbidity.Application to a patient case illustrates how our framework can improve the quality of the shared decision-making process in care for older people and helps clarify medical and moral considerations regarding how to appropriately treat the individual patient.

[Limits to euthanasia]. / Grenzen aan euthanasie.

A recent survey showed that less than half of Dutch physicians would find it conceivable to grant a request for euthanasia from a patient suffering from psychiatric disease or dementia, or who is tired of life. Because of a broader interpretation by the Regional Review Committees of the official criteria for due care, all recent cases of euthanasia in these specific groups of patients had been accepted. In this commentary it is argued that, following recent social developments in the Netherlands (including cuts in provision of care for the elderly and of mental health care, and a narrowed view about end-of-life issues), the official euthanasia criteria for due care are no longer suitable if we are to avoid a 'slippery slope' effect in cases such as those mentioned above. The criteria of a) a voluntary and well-considered request and b) absence of reasonable treatment alternatives are particularly under pressure. A plea is hold for a return to stricter interpretation of the criteria.

Understanding palliative cancer chemotherapy: about shared decisions and shared trajectories.

Most models of patient-physician communication take decision-making as a central concept. However, we found that often the treatment course of metastatic cancer patients is not easy to describe in straightforward terms used in decision-making models but is instead frequently more erratic. Our aim was to analyse these processes as trajectories. We used a longitudinal case study of 13 patients with metastatic colorectal and pancreatic cancer for whom palliative chemotherapy was a treatment option, and analysed 65 semi-structured interviews. We analysed three characteristics of the treatment course that contributed to the 'erraticness' of the course: (1) The treatment (with or without chemotherapy) contained many options; (2) these options were not stable entities to be decided upon, but changed identity over the course of treatment, and (3) contrary to the closure (option X means no option Y, Z, etc.) a decision implies, the treatment course was a continuous process in which options instead remained open. When the treatment course is characterised by these many and changeable options that do not result in closure, the shared decision-making model should take these into account. More attention needs to be paid to the erratic character of the process in which the doctor has to provide continuous information that is related to the changing situation of the patient; also, flexibility in dealing with protocols is warranted, as is vigilance about the overall direction of the process.

Cost issues in new disease-modifying treatments for advanced cancer: in-depth interviews with physicians.

BACKGROUND: The high costs of new disease-modifying, but non-curative, treatments in advanced cancer are increasingly regarded as problematic. Little is known about oncologists' beliefs regarding their ethical obligations for cost considerations about these types of treatments. PARTICIPANTS AND METHODS: This study used in-depth interviews to explore how physicians in The Netherlands view their role regarding the cost of potentially beneficial but expensive drugs, especially for new disease-modifying treatments in advanced cancer. Thirty-six physicians, 19 physicians caring for patients with advanced cancer and 17 physicians participating in four national oncology guideline committees, were interviewed. RESULTS: Physicians identified cost considerations on three levels: individual patient care, hospital policies and national guideline development. Generally, physicians were reluctant to consider costs in individual patient care, believing this compromised their ethical obligations. They did consider costs relevant at the level of hospital policies regarding coverage for drugs. They were divided regarding the role of cost considerations in national practice guideline development. CONCLUSIONS: The distinctive levels of decision-making were understood to be morally relevant as physicians separated their role as direct care provider from that of taking part in decisions about coverage. Because of the fundamental tension between the physician obligation to act in the best interest of the individual patient, the vulnerability of having a life-threatening illness and the inevitability of sharing resources in modern health care, cost considerations will always be problematic for physicians. The roles physicians play at different levels, especially at the levels of hospital policies and national practice guidelines, should further be developed and explicated.

Health care needs in end-stage COPD: a structured literature review.

OBJECTIVE: To give an overview of relevant literature regarding health care needs in end-stage COPD and to identify specific areas where knowledge about needs is still lacking. METHODS: We conducted a structured literature review. We used Bradshaw's classification system. RESULTS: Seventy-seven publications were found. Ten publications were included in the review. The results reported cover a wide range of subjects, all regarded as health care needs. Most reported on 'felt need', i.e. needs that are mentioned by patients themselves. Results on 'normative need' (based on expert judgement) were lacking. CONCLUSION: The literature about the health care needs of patients in the end-stage of COPD is sparse, and there is no commonly accepted definition of health care needs. Looking at the increasing demand for end of life care for COPD patients, there is a clear need for further research on this subject. PRACTICE IMPLICATIONS: We especially need to focus on agreement between experts and professionals so that guidelines can be developed. To attend to the unfulfilled needs of end-stage COPD patients, the delivery of health care should be re-examined carefully.