title: Policies to improve end-of-life decisions in Flemish hospitals: communication, training of health care providers and use of quality assessments.
abstract: BACKGROUND
  The prevalence and implementation of institutional end-of-life policies has been comprehensively studied in Flanders, Belgium, a country where euthanasia was legalised in 2002. Developing end-of-life policies in hospitals is a first step towards improving the quality of medical decision-making at the end-of-life. Implementation of policies through quality assessments, communication and the training and education of health care providers is equally important in improving actual end-of-life practice. The aim of the present study is to report on the existence and nature of end-of-life policy implementation activities in Flemish acute hospitals.
  
  
  METHODS
  A cross-sectional mail survey was sent to all acute hospitals (67 main campuses) in Flanders (Belgium). The questionnaire asked about hospital characteristics, the prevalence of policies on five types of end-of-life decisions: euthanasia, palliative sedation, alleviation of symptoms with possible life-shortening effect, do-not-resuscitate decision, and withdrawing or withholding of treatment, the internal and external communication of these policies, training and education on aspects of end-of-life care, and quality assessments of end-of-life care on patient and family level.
  
  
  RESULTS
  The response rate was 55%. Results show that in 2007 written policies on most types of end-of-life decisions were widespread in acute hospitals (euthanasia: 97%, do-not-resuscitate decisions: 98%, palliative sedation: 79%). While standard communication of these policies to health care providers was between 71% and 91%, it was much lower to patients and/or family (between 17% and 50%). More than 60% of institutions trained and educated their caregivers in different aspects on end-of-life care. Assessment of the quality of these different aspects at patient and family level occurred in 25% to 61% of these hospitals.
  
  
  CONCLUSIONS
  Most Flemish acute hospitals have developed a policy on end-of-life practices. However, communication, training and the education of health care providers about these policies is not always provided, and quality assessment tools are used in less than half of the hospitals.
authors.affiliation: Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.
authors.forename: Ina
authors.initials: I
authors.lastname: D'Haene
authors.forename: Robert H
authors.initials: RH
authors.lastname: Vander Stichele
authors.forename: H Roeline W
authors.initials: HR
authors.lastname: Pasman
authors.forename: Nele Van den
authors.initials: NV
authors.lastname: Noortgate
authors.forename: Johan
authors.initials: J
authors.lastname: Bilsen
authors.forename: Freddy
authors.initials: F
authors.lastname: Mortier
authors.forename: Luc
authors.initials: L
authors.lastname: Deliens