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Compliance With Dutch Guidelines

Jeroen G. J. Hasselaar, MSc; Rob P. B. Reuzel, PhD; Stans C. A. H. H. V. M. Verhagen, MD, PhD; Alexander de Graeff, MD, PhD; Kris C. P. Vissers, MD, PhD, FIPP; Ben J. P. Crul, MD, PhD

Arch Intern Med. 2007;167(11):1166-1171.

Background  Two guidelines addressing palliative sedation have been published in the Netherlands in 2002 and 2003. The objective of the present study is to determine adherence to the guidelines for palliative sedation with regard to prescription. The study is restricted to the practice of continuous deep palliative sedation.

Methods  A structured retrospective questionnaire was administered to 1464 physicians concerning their last case of deep sedation during the past 12 months. Physicians included Dutch hospital specialists, general practitioners, and nursing home physicians.

Results  The response rate was 36%. A total of 43% (95% confidence interval [CI], 37%-49%) of the responding physicians did not adhere to the guidelines. Sources of deviation were the use of basic medication other than a benzodiazepine (30%), which mostly involved morphine, and omissions in adjuvant medication (13%). Nonsignificant positive association was found for consultation of a palliative care expert (odds ratio [OR], 3.86; 95% CI, 0.92-8.87). Significant positive association was found for the physician being a palliative care expert himself or herself (OR, 4.42; 95% CI, 1.42-13.75) and the use of guidelines (OR, 1.74; 95% CI, 1.02-2.98). Treatment of pain symptoms (OR, 2.21; 95% CI, 1.28-3.82), anxiety (OR, 2.32; 95% CI, 1.33-4.06), vomiting (OR, 6.52; 95% CI, 1.08-39.50), and loss of dignity (OR, 3.93; 95% CI, 1.80-8.58) also correlated positively. Treatment of delirium correlated negatively with adherence to the guidelines (OR, 0.22; 95% CI,0.11-0.44).

Conclusions  The rate of 43% noncompliance to the guidelines was mostly owing to the omission of continued antipsychotic treatment for delirium and the use of morphine as the single therapy for the purpose of deep sedation. Future efforts, like better use and knowledge of the guidelines and a larger involvement of consultation teams, should increase adherence to the guidelines.

Author Affiliations: Departments of Anesthesiology, Pain, and Palliative Medicine (Mr Hasselaar and Drs Verhagen, Vissers, and Crul), Medical Technology Assessment (Dr Reuzel), and Oncology (Dr Verhagen), Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands; and Department of Medical Oncology, University Medical Center Utrecht, Utrecht, the Netherlands (Dr de Graeff).

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