Euthanasia and other end-of-life decisions: a mortality follow-back study in Belgium

BACKGROUND: This study compares prevalence and types of medical end-of-life decisions between the Dutch-speaking and French-speaking communities of Belgium. This is the first nationwide study that can make these comparisons and the first measurement after implementation of the euthanasia law (2002). METHODS: We performed a mortality follow-back study in 2005-2006. Data were collected via the nationwide Sentinel Network of General Practitioners, an epidemiological surveillance system representative of all Belgian GPs.Weekly, all GPs reported the medical end-of-life decisions among all non-sudden deaths of patients in their practice. We compared the northern Dutch-speaking (60%) and southern French-speaking communities (40%) controlling for population differences. RESULTS: We analysed 1690 non-sudden deaths. An end-of-life decision with possible life-shortening effect was made in 50% of patients in the Dutch-speaking community and 41% of patients in the French-speaking community (OR 1.4; 95%CI, 1.2 to 1.8). Continuous deep sedation until death occurred in 8% and 15% respectively (OR 0.5; 95%CI, 0.4 to 0.7). Community differences regarding the prevalence of euthanasia or physician-assisted suicide were not significant.Community differences were more present among home/care home than among hospital deaths: non-treatment decisions with explicit life-shortening intention were made more often in the Dutch-speaking than in the French-speaking community settings (OR 2.2; 95%CI, 1.2 to 3.9); while continuous deep sedation occurred less often in the Dutch-speaking community settings (OR 0.5; 95%CI, 0.3 to 0.9). CONCLUSION: Even though legal and general healthcare systems are the same for the whole country, there are considerable variations between the communities in type and prevalence of certain end-of-life decisions, even after controlling for population difference

Dust-penetrated morphology in the high-redshift universe: clues from NGC 922

Results from the Hubble Deep Field (HDF) North and South show a large percentage of high-redshift galaxies whose appearance falls outside traditional classification systems. The nature of these objects is poorly understood, but sub-mm observations indicate that at least some of these systems are heavily obscured (Sanders 2000). This raises the intriguing possibility that a physically meaningful classification system for high-redshift galaxies might be more easily devised at rest-frame infrared wavelengths, rather than in the optical regime. Practical realization of this idea will become possible with the advent of the Next Generation Space Telescope (NGST). In order to explore the capability of NGST for undertaking such science, we present NASA-IRTF and SCUBA observations of NGC 922, a chaotic system in our local Universe which bears a striking resemblance to objects such as HDF 2-86 (z=0.749) in the HDF North. If objects such as NGC 922 are common at high-redshifts, then this galaxy may serve as a local morphological `Rosetta stone' bridging low and high-redshift populations. In this paper we demonstrate that quantitative measures of galactic structure are recoverable in the rest-frame infrared for NGC 922 seen at high redshifts using NGST, by simulating the appearance of this galaxy at redshifts z=0.7 and z=1.2 in rest-frame K'. Our results suggest that the capability of efficiently exploring the rest-wavelength IR morphology of high-z galaxies should probably be a key factor in deciding the final choice of instruments for the NGST.Comment: 7 pages, 12 Figures. Accepted for publication in A&A. Better version of the figures can be found at http://www.inaoep.mx/~puerari/ngs

Towards a standardised approach for evaluating guidelines and guidance documents on palliative sedation: Study protocol

Background: Sedation in palliative care has received growing attention in recent years; and so have guidelines, position statements, and related literature that provide recommendations for its practice. Yet little is known collectively about the content, scope and methodological quality of these materials. According to research, there are large variations in palliative sedation practice, depending on the definition and methodology used. However, a standardised approach to comparing and contrasting related documents, across countries, associations and governmental bodies is lacking. This paper reports on a protocol designed to enable thorough and systematic comparison of guidelines and guidance documents on palliative sedation. Methods and design. A multidisciplinary and international group of palliative care researchers, identified themes and clinical issues on palliative sedation based on expert consultations and evidence drawn from the EAPC (European Association of Palliative Care) framework for palliative sedation and AGREE II (Appraisal Guideline Research and Evaluation) instrument for guideline assessment. The most relevant themes were selected and built into a comprehensive checklist. This was tested on people working closely with practitioners and patients, for user-friendliness and comprehensibility, and modified where necessary. Next, a systematic search was conducted for guidelines in English, Dutch, Flemish, or Italian. The search was performed in multiple databases (PubMed, CancerLit, CNAHL, Cochrane Library, NHS Evidence and Google Scholar), and via other Internet resources. Hereafter, the final version of the checklist will be used to extract data from selected literature, and the same will be compiled, entered into SPSS, cleaned and analysed systematically for publication. Discussion. We have together developed a comprehensive checklist in a scientifically rigorous manner to allow standardised and systematic comparison. The protocol is applicable to all guidelines on palliative sedation, and the approach will contribute to rigorous and systematic comparison of international guidelines on any challenging topic such as this. Results from the study will provide valuable insights into common core elements and differences between the selected guidelines, and the extent to which recommendations are derived from, or match those in the EAPC framework. The outcomes of the study will be disseminated via peer-reviewed journals and directly to appropriate audiences

Actual and preferred place of death of home-dwelling patients in four European countries: making sense of quality indicators

Background: Dying at home and dying at the preferred place of death are advocated to be desirable outcomes of palliative care. More insight is needed in their usefulness as quality indicators. Our objective is to describe whether " the percentage of patients dying at home'' and "the percentage of patients who died in their place of preference'' are feasible and informative quality indicators. Methods and Findings: A mortality follow-back study was conducted, based on data recorded by representative GP networks regarding home-dwelling patients who died non-suddenly in Belgium (n = 1036), the Netherlands (n = 512), Italy (n = 1639) or Spain (n = 565). "The percentage of patients dying at home'' ranged between 35.3% (Belgium) and 50.6% (the Netherlands) in the four countries, while "the percentage of patients dying at their preferred place of death'' ranged between 67.8% (Italy) and 86.0% (Spain). Both indicators were strongly associated with palliative care provision by the GP (odds ratios of 1.55-13.23 and 2.30-6.63, respectively). The quality indicator concerning the preferred place of death offers a broader view than the indicator concerning home deaths, as it takes into account all preferences met in all locations. However, GPs did not know the preferences for place of death in 39.6% (the Netherlands) to 70.3% (Italy), whereas the actual place of death was known in almost all cases. Conclusion: GPs know their patients' actual place of death, making the percentage of home deaths a feasible indicator for collection by GPs. However, patients' preferred place of death was often unknown to the GP. We therefore recommend using information from relatives as long as information from GPs on the preferred place of death is lacking. Timely communication about the place where patients want to be cared for at the end of life remains a challenge for GPs

Luminous AGB stars in nearby galaxies. A study using Virtual Observatory tools

Aims. This study focuses on very luminous Mbol<-6.0 mag AGB stars with J-Ks>1.5 mag and H-Ks>0.4 mag in the LMC, SMC, M31, and M33 from 2MASS data. Methods.The data were taken from the 2MASS All-Sky Point Source catalogue archive. We used Virtual Observatory tools and took advantage of its capabilities at various stages in the analysis. Results. It is well known that stars with the colors we selected correspond mainly to carbon stars. Although the most luminous AGBs detected here contain a large number of carbon stars,they are not included in existing catalogues produced from data in the optical domain, where they are not visible since they are dust-enshrouded. A comparison of the AGB stars detected with combined near and mid-infrared data from MSX and 2MASS in the LMC shows that 10% of the bright AGB stars are bright carbon stars never detected before and that the other 50% are OH/IR oxygen rich stars, whereas the 40% that remain were not cross-matched. Conclusions. The catalogues of the most luminous AGB stars compiled here are an important complement to existing data. In the LMC, these bright AGB stars are centrally located, whereas they are concentrated in an active star-formation ring in M31. In the SMC and M33, there are not enough of them to draw definite conclusions, although they tend to be centrally located. Their luminosity functions are similar for the four galaxies we studied.Comment: 16 pages, 12 figures, 4 tables (Appendix A), accepted in A&

Dying at home in Belgium: a descriptive GP interview study

<p>Abstract</p> <p>Background</p> <p>While increasing attention is being paid to enabling terminal patients to remain at home until death, limited information is available on the circumstances in which people at home actually die. Therefore this study aims to describe patient characteristics, functional and cognitive status and physical and psychological symptom burden in the last three months of life among Belgian patients dying at home, according to their GPs.</p> <p>Methods</p> <p>In 2005, a nationwide and retrospective interview study with GPs took place on people dying at home in Belgium as reported by Sentinel Network of GPs in Belgium. GPs registered all deaths (patients aged 1 year or more) weekly and were interviewed about all patients dying non-suddenly at home, using face-to-face structured interviews.</p> <p>Results</p> <p>Interviews were obtained on 205 patients (90% response rate). Between the second and third month before death, 55% were fully invalid or limited in self-care. In the last week of life, almost all were fully invalid. Fifty four percent were unconscious at some point during the last week; 46% were fully conscious. Most frequently reported symptoms were lack of energy, lack of appetite and feeling drowsy. Conditions most difficult for GPs to manage were shortness of breath, lack of energy and pain.</p> <p>Conclusions</p> <p>Many people dying at home under the care of their GPs in Belgium function relatively well until the last week of life and cognitive status seems to be preserved until the end in many cases. However, symptoms which GPs find difficult to control still manifest in many patients in the final week of life.</p

Nitrogen forms affect root structure and water uptake in the hybrid poplar

The study analyses the effects of two different forms of nitrogen fertilisation (nitrate and ammonium) on root structure and water uptake of two hybrid poplar (Populus maximowiczii x P. balsamifera) clones in a field experiment. Water uptake was studied using sap flow gauges on individual proximal roots and coarse root structure was examined by excavating 18 whole-root systems. Finer roots were scanned and analyzed for architecture. Nitrogen forms did not affect coarse-root system development, but had a significant effect on fine-root development. Nitrate-treated trees presented higher fine:coarse root ratios and higher specific root lengths than control or ammonium treated trees. These allocation differences affected the water uptake capacity of the plants as reflected by the higher sapflow rate in the nitrate treatment. The diameter of proximal roots at the tree base predicted well the total root biomass and length. The diameter of smaller lateral roots also predicted the lateral root mass, length, surface area and the number of tips. The effect of nitrogen fertilisation on the fine root structure translated into an effect on the functioning of the fine roots forming a link between form (architecture) and function (water uptake)

Frequency and properties of bars in cluster and field galaxies at intermediate redshifts

We present a study of large-scale bars in field and cluster environments out to redshifts of ~0.8 using a final sample of 945 moderately inclined disk galaxies drawn from the EDisCS project. We characterize bars and their host galaxies and look for relations between the presence of a bar and the properties of the underlying disk. We investigate whether the fraction and properties of bars in clusters are different from their counterparts in the field. The total optical bar fraction in the redshift range z=0.4-0.8 (median z=0.60), averaged over the entire sample, is 25% (20% for strong bars). For the cluster and field subsamples, we measure bar fractions of 24% and 29%, respectively. We find that bars in clusters are on average longer than in the field and preferentially found close to the cluster center, where the bar fraction is somewhat higher (~31%) than at larger distances (~18%). These findings however rely on a relatively small subsample and might be affected by small number statistics. In agreement with local studies, we find that disk-dominated galaxies have a higher optical bar fraction (~45%) than bulge-dominated galaxies (~15%). This result is based on Hubble types and effective radii and does not change with redshift. The latter finding implies that bar formation or dissolution is strongly connected to the emergence of the morphological structure of a disk and is typically accompanied by a transition in the Hubble type. (abridged)Comment: 17 pages, accepted for publication in A&

The involvement of cancer patients in the four stages of decision-making preceding continuous sedation until death: A qualitative study

BACKGROUND: Involving patients in decision-making is considered to be particularly appropriate towards the end of life. Professional guidelines emphasize that the decision to initiate continuous sedation should be made in accordance with the wishes of the dying person and be preceded by their consent. AIM: To describe the decision-making process preceding continuous sedation until death with particular attention to the involvement of the person who is dying. DESIGN: Qualitative case studies using interviews. SETTING/PARTICIPANTS: Interviews with 26 physicians, 30 nurses and 24 relatives caring for 24 patients with cancer who received continuous sedation until death in Belgium, the United Kingdom and the Netherlands. RESULTS: We distinguished four stages of decision-making: initiation, information exchange, deliberation and the decision to start continuous sedation until death. There was wide variation in the role the patient had in the decision-making process. At one end of the spectrum (mostly in the United Kingdom), the physician discussed the possible use of sedation with the patient, but took the decision themselves. At the other end (mostly in Belgium and the Netherlands), the patient initiated the conversation and the physician's role was largely limited to evaluating if and when the medical criteria were met. CONCLUSION: Decision-making about continuous sedation until death goes through four stages and the involvement of the patient in the decision-making varies. Acknowledging the potential sensitivity of raising the issue of end-of-life sedation, we recommend building into clinical practice regular opportunities to discuss the goals and preferences of the person who is dying for their future medical treatment and care

Rings and bars: unmasking secular evolution of galaxies

Secular evolution gradually shapes galaxies by internal processes, in contrast to early cosmological evolution which is more rapid. An important driver of secular evolution is the flow of gas from the disk into the central regions, often under the influence of a bar. In this paper, we review several new observational results on bars and nuclear rings in galaxies. They show that these components are intimately linked to each other, and to the properties of their host galaxy. We briefly discuss how upcoming observations, e.g., imaging from the Spitzer Survey of Stellar Structure in Galaxies (S4G), will lead to significant further advances in this area of research.Comment: Invited review at "Galaxies and their Masks", celebrating Ken Freeman's 70-th birthday, Sossusvlei, Namibia, April 2010. To be published by Springer, New York, editors D.L. Block, K.C. Freeman, & I. Puerari; minor change