GPs' recognition of death in the foreseeable future and diagnosis of a fatal condition: a national survey

Background: Nowadays, palliative care is considered as a care continuum that may start early in the course of the disease. In order to address the evolving needs of patients for palliative care in time, GPs should be aware in good time of the diagnosis and of the imminence of death. The aim of the study was to gain insight into how long before a non-sudden death the diagnosis of the disease ultimately leading to death is made and on what kind of information the diagnosis is based. In addition, we aimed to explore when, and based on what kind of information, GPs become aware that death of a patient will be in the foreseeable future. Methods: A written questionnaire focusing on the GPs' experiences with their last patient who died non-suddenly was sent to a random representative sample of 850 GPs in the Netherlands. Results: The data were analysed of the 297 GPs who responded. 76% of the reported cases were cancer patients and 24% were patients with another non-sudden cause of death. The diagnosis was made only in the last week of life for 15% of the non-cancer patients and 1% of the patients with cancer. GPs were most likely to have been informed of the diagnosis by the medical specialist, although particularly in the case of non-cancer patients GPs also relied on their own assessment of the diagnosis or on other information sources. The GP remained unaware that the patient would die in the foreseeable future until the last week of life in 26% of the non-cancer group, while this was the case for only 6% of the cancer patients. GP's awareness was most likely to be based on the GP's own observations of problems and/or symptoms. Conclusions: The GP often only becomes aware of a fatal diagnosis and of death in the foreseeable future at a late stage in the disease trajectory, particularly in the case of non-cancer patients. It can be assumed that if the diagnosis and the nearing death are only recognised at a late stage, palliative care is either started at a very late stage or not at all

Burden for family carers at the end of life : a mixed-method study of the perspectives of family carers and GPs

Background: Since many patients spend most of the time at home at the end of life, this may affect the burden for family carers and constitute a risk factor for the patients' hospitalisation. This study aimed to explore family carers' burden in the final three months of the patient's life, from the perspective of both carers and general practitioners (GPs), and to assess whether family burden, as defined by the GP, is associated with hospitalisation. Methods: A cross-sectional nationwide survey among GPs and family carers was performed. Participants were 194 GPs and 74 family carers of patients who died non-suddenly. Additionally, in-depth interviews were conducted with 18 family carers. For the quantitative analyses descriptive statistics, weighted Kappa and multivariate logistic regression analysis was performed. For the qualitative part thematic analysis was conducted. Results: The proportion of family carers experiencing a fairly heavy or severe burden increased significantly from 32% (second and third months before death) to 66% (one week before death). Most carers (95%) felt an emotional burden and 29% felt a physical burden in the final week. Three-quarters of carers did not perceive their burden as a problem because caring often felt rewarding. No significant association was found between the characteristics of family caregivers or professional care and the degree of family caregiver burden. Also, there was no significant evidence that patients of family carers for whom the GP assessed a fairly heavy to severe burden, were more likely to be hospitalised. Conclusions: The different overall assessment of family carers' burden between GPs and family carers and the increasing emotional and physical burden of family carers towards the end constitute relevant information for GPs that will help them understand and anticipate carers' personal needs

GPs views on transfer of information about terminally ill patients to the out-of-hours co-operative

<p>Abstract</p> <p>Background</p> <p>In the Netherlands, the increase in of out-of-hours care that is provided by GP co-operatives is challenging the continuity of care for the terminally ill in general practice. Aim of this study is to investigate the views of general practitioners (GPs) on the transfer of information about terminally ill patients to the GP co-operatives. GPs were asked to give their view from two different perspectives: as a GP in their daily practice and as a locum in the GP co-operative.</p> <p>Methods</p> <p>Retrospective web based questionnaire sent to all 424 GPs in the Amsterdam region.</p> <p>Results</p> <p>With a response rate of 42%, 177 physicians completed the questionnaire. Transfer of information to the GP co-operative about most of their terminally ill patients was reported by 82% of the GPs and 5% did not do so for any of their patients. A faster than foreseen deterioration of the patient's situation was the most frequently reported reason for not transferring information.</p> <p>Of those who transferred information to the GP co-operative, more than 95% reported that they provided information about the diagnosis and terminally ill status of the patient. Information about medication, patient wishes regarding treatment, and prognosis was reported by respectively 90%, 87%, and 74% of the GPs. Less than 50% of the GPs reported that they transferred information about the patient's awareness of both the diagnosis and the prognosis, about the psychosocial context, and intolerances.</p> <p>In their role as locum, over 90% of the GPs wanted to receive information about the diagnosis, the terminally ill status of the patient, the medication and the patient's wishes regarding treatment.</p> <p>Conclusions</p> <p>Although most GPs reported that they transferred information about their terminally ill patients to the GP co-operative, the content of this information varies considerably. Only 21% of the GPs, working out of hours as a locum, were satisfied with the quality of the information transferred.</p

The New Perspective challenge to Luther

New Perspective scholars challenge Protestant interpretations of Paul. It used to be the case, they state, that Protestants assumed that Paul was to Judaism as Luther was to Medieval Catholicism. Both men supposedly reacted against legalistic religions and championed grace-based faiths. However, in 1977, E.P. Sanders wrote Paul and Palestinian Judaism, arguing that Judaism is not a legalistic but a grace-based faith. Assuming that Sanders is correct, New Perspectivists claim that Paul’s and Luther’s theologies and experiences were thus not parallel. Hence, Luther misunderstood Paul. Additionally, New Perspectivists challenge Protestant understandings of ‘justification’. In New Perspective thought, Paul uses the term ‘justification’ primarily to describe how people, particularly Gentiles, join the church Christians without following Jewish ritual laws. ‘Justification’, then, does not describe how people ‘stay in’ the covenant and receive salvation, as Protestants think. However, this article maintains that while New Perspectivists have some knowledge of Paul and Judaism, they are much less knowledgeable regarding Luther, Medieval Catholicism and Luther’s reaction to it. Greater scrutiny of these latter areas reveals large difficulties with New Perspective arguments. In addition, a review of relevant passages from Paul’s letters demonstrates that Protestants have not misunderstood Paul’s use of the term ‘justification’. Many Pauline passages show that when Paul discusses justification he is also thinking about ‘staying in’, not just ‘getting in’ the covenant

Adverse effects of extra-articular corticosteroid injections: a systematic review

<p>Abstract</p> <p>Background</p> <p>To estimate the occurrence and type of adverse effects after application of an extra-articular (soft tissue) corticosteroid injection.</p> <p>Methods</p> <p>A systematic review of the literature was made based on a PubMed and Embase search covering the period 1956 to January 2010. Case reports were included, as were prospective and retrospective studies that reported adverse events of corticosteroid injection. All clinical trials which used extra-articular corticosteroid injections were examined. We divided the reported adverse events into major (defined as those needing intervention or not disappearing) and minor ones (transient, not requiring intervention).</p> <p>Results</p> <p>The search yielded 87 relevant studies:44 case reports, 37 prospective studies and 6 retrospective studies. The major adverse events included osteomyelitis and protothecosis; one fatal necrotizing fasciitis; cellulitis and ecchymosis; tendon ruptures; atrophy of the plantar fat was described after injecting a neuroma; and local skin effects appeared as atrophy, hypopigmentation or as skin defect. The minor adverse events effects ranged from skin rash to flushing and disturbed menstrual pattern. Increased pain or steroid flare after injection was reported in 19 studies. After extra-articular injection, the incidence of major adverse events ranged from 0-5.8% and that of minor adverse events from 0-81%. It was not feasible to pool the risk for adverse effects due to heterogeneity of study populations and difference in interventions and variance in reporting.</p> <p>Conclusion</p> <p>In this literature review it was difficult to accurately quantify the incidence of adverse effects after extra-articular corticosteroid injection. The reported adverse events were relatively mild, although one fatal reaction was reported.</p

Defect Diagnostics of Scribing Failures and Cu-Rich Debris in Cu(In,Ga)Se2_2 Thin-Film Solar Modules With Electroluminescence and Thermography

We study the appearance of both scribing failures and Cu-rich debris, formed during Cu(In,Ga)Se2 (CIGS) coevaporation, in electroluminescence (EL) and dark lock-in thermography (DLIT) images. We observe that for most of the defect types, there is a characteristic appearance of EL and DLIT that allows reliable diagnostics. We also point to defect scenarios where different defects appear similar. With regard to scribing defects, we find that the reliability of defect identification increases with the length of the line interruption, while for Cu-rich debris, we find that the geometrical size and position within the cell significantly determine its defect appearance and, therefore, the ability to diagnose it

Out-of-hours palliative care provided by GP co-operatives in the Netherlands: a focus group study

Background: In the Netherlands, out-of-hours primary care has been re-organized from small on-call rota groups to large-scale GP co-operatives. However, out-of-hours palliative care is an area of concern. According to studies in the UK, the transfer of information about terminally ill patients to GP co-operatives seems to be poor, resulting in care that is often inadequate. Our aim was to investigate the experiences of GPs in the Netherlands about the quality of out-of-hours palliative care provided by GP co-operatives, and to identify elements of care that might need to be improved. Methods : Setting: General practice. Design: Qualitative study, using three focus group discussions, analysed in a qualitative descriptive approach. Results : GPs participating in the focus groups, considered the quality of out-of-hours palliative care that is provided by GP co-operatives to be meagre. The service provided by the co-operatives was designed for acute medical problems, rather than for palliative care needs. The GPs reported three major problems: (1) lack of adequate information at the GP out-of-hours service; (2) lack of anticipatory care during office hours; and (3) absence of a palliative care policy in the GP co-operatives. Conclusions : Although GP co-operatives are capable of providing continuity in palliative care, improvements could be achieved if GPs and GP co-operatives address the problems mentioned above