title: End-of-life decisions: a cross-national study of treatment preference discussions and surrogate decision-maker appointments.
abstract: BACKGROUND
  Making treatment decisions in anticipation of possible future incapacity is an important part of patient participation in end-of-life decision-making. This study estimates and compares the prevalence of GP-patient end-of-life treatment discussions and patients' appointment of surrogate decision-makers in Italy, Spain, Belgium and the Netherlands and examines associated factors.
  
  
  METHODS
  A cross-sectional, retrospective survey was conducted with representative GP networks in four countries. GPs recorded the health and care characteristics in the last three months of life of 4,396 patients who died non-suddenly. Prevalences were estimated and logistic regressions were used to examine between country differences and country-specific associated patient and care factors.
  
  
  RESULTS
  GP-patient discussion of treatment preferences occurred for 10%, 7%, 25% and 47% of Italian, Spanish, Belgian and of Dutch patients respectively. Furthermore, 6%, 5%, 16% and 29% of Italian, Spanish, Belgian and Dutch patients had a surrogate decision-maker. Despite some country-specific differences, previous GP-patient discussion of primary diagnosis, more frequent GP contact, GP provision of palliative care, the importance of palliative care as a treatment aim and place of death were positively associated with preference discussions or surrogate appointments. A diagnosis of dementia was negatively associated with preference discussions and surrogate appointments.
  
  
  CONCLUSIONS
  The study revealed a higher prevalence of treatment preference discussions and surrogate appointments in the two northern compared to the two southern European countries. Factors associated with preference discussions and surrogate appointments suggest that delaying diagnosis discussions impedes anticipatory planning, whereas early preference discussions, particularly for dementia patients, and the provision of palliative care encourage participation.
authors.affiliation: Department of Public and Occupational Health, EMGO+ Institute, VU University Medical Center, Amsterdam, The Netherlands. n.evans@vumc.nl
authors.forename: Natalie
authors.initials: N
authors.lastname: Evans
authors.forename: H Roeline
authors.initials: HR
authors.lastname: Pasman
authors.forename: Tomás
authors.initials: T
authors.lastname: Vega Alonso
authors.forename: Lieve
authors.initials: L
authors.lastname: Van den Block
authors.forename: Guido
authors.initials: G
authors.lastname: Miccinesi
authors.forename: Viviane
authors.initials: V
authors.lastname: Van Casteren
authors.forename: Gé
authors.initials: G
authors.lastname: Donker
authors.forename: Stefano
authors.initials: S
authors.lastname: Bertolissi
authors.forename: Oscar
authors.initials: O
authors.lastname: Zurriaga
authors.forename: Luc
authors.initials: L
authors.lastname: Deliens
authors.forename: Bregje
authors.initials: B
authors.lastname: Onwuteaka-Philipsen
mesh_terms: D016223:Advance Directives / Q000706:statistics & numerical data; D000368:Aged; D000369:Aged, 80 and over; D001530:Belgium; D003430:Cross-Sectional Studies; D003643:Death; D003657:Decision Making; D005260:Female; D058005:General Practitioners; D006801:Humans; D007558:Italy; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000401:mortality; D009426:Netherlands; D010166:Palliative Care / Q000379:methods; D010358:Patient Participation; D010817:Physician-Patient Relations; D012044:Regression Analysis; D012189:Retrospective Studies; D013030:Spain; D011795:Surveys and Questionnaires; D013727:Terminal Care / Q000706:statistics & numerical data*