Gerrit van der Wal - Academia.edu (original) (raw)

Papers by Gerrit van der Wal

Journal of Medical Ethics, Apr 1, 2000

Non-treatment decisions concerning demented patients are complex: in addition to issues concernin... more Non-treatment decisions concerning demented patients are complex: in addition to issues concerning the health of patients, ethical and legal issues are involved. This paper describes a method for the development of a guideline that clarifies the steps to be taken in the decision making process whether to forgo curative treatment of pneumonia in psychogeriatric nursing home patients. The method of development consisted of seven steps. Step 1 was a literature study from which ethical, juridical and medical factors concerning the patient's health and prognosis were identified. In step 2, a questionnaire was sent to 26 nursing home physicians to determine the relative importance of these factors in clinical practice. In a meeting of nine experienced physicians (step 3), the factors identified in step 2 were confirmed by most of these professionals. To prevent the final guideline being too directive, a concept guideline that included ethical and legal aspects was designed in the form of a "checklist of considerations" (step 4). Experts in the fields of nursing home medicine, ethics and law reviewed and commented on the concept guideline (step 5). The accordingly adapted "checklist of considerations" was tested in a pilot study (step 6), after which all experts endorsed the checklist (step 7). The resulting "checklist of considerations" structures the decision making process according to three primary domains: medical aspects, patient's autonomy, and patient's best interest (see annex at end of paper).

BMC Emergency Medicine, Sep 18, 2009

Background: Several studies on patient safety have shown that a substantial number of patients su... more Background: Several studies on patient safety have shown that a substantial number of patients suffer from unintended harm caused by healthcare management in hospitals. Emergency departments (EDs) are challenging hospital settings with regard to patient safety. There is an increased sense of urgency to take effective countermeasures in order to improve patient safety. This can only be achieved if interventions tackle the dominant underlying causes. The objectives of our study are to examine the nature and causes of unintended events in EDs and the relationship between type of event and causal factor structure. Methods: Study at EDs of 10 hospitals in the Netherlands. The study period per ED was 8 to 14 weeks, in which staff were asked to report unintended events. Unintended events were broadly defined as all events, no matter how seemingly trivial or commonplace, that were unintended and could have harmed or did harm a patient. Reports were analysed with a Root Cause Analysis tool (PRISMA) by an experienced researcher. Results: 522 unintended events were reported. Of the events 25% was related to cooperation with other departments and 20% to problems with materials/equipment. More than half of the events had consequences for the patient, most often resulting in inconvenience or suboptimal care. Most root causes were human (60%), followed by organisational (25%) and technical causes (11%). Nearly half of the root causes was external, i.e. attributable to other departments in or outside the hospital. Conclusion: Event reporting gives insight into diverse unintended events. The information on unintended events may help target research and interventions to increase patient safety. It seems worthwhile to direct interventions on the collaboration between the ED and other hospital departments.

Background: Debates over legalisation of physician-assisted suicide (PAS) or euthanasia often war... more Background: Debates over legalisation of physician-assisted suicide (PAS) or euthanasia often warn of a ''slippery slope'', predicting abuse of people in vulnerable groups. To assess this concern, the authors examined data from Oregon and the Netherlands, the two principal jurisdictions in which physician-assisted dying is legal and data have been collected over a substantial period. Methods: The data from Oregon (where PAS, now called death under the Oregon Death with Dignity Act, is legal) comprised all annual and cumulative Department of Human Services reports 1998-2006 and three independent studies; the data from the Netherlands (where both PAS and euthanasia are now legal) comprised all four government-commissioned nationwide studies of end-of-life decision making (1990, 1995, 2001 and 2005) and specialised studies. Evidence of any disproportionate impact on 10 groups of potentially vulnerable patients was sought. Results: Rates of assisted dying in Oregon and in the Netherlands showed no evidence of heightened risk for the elderly, women, the uninsured (inapplicable in the Netherlands, where all are insured), people with low educational status, the poor, the physically disabled or chronically ill, minors, people with psychiatric illnesses including depression, or racial or ethnic minorities, compared with background populations. The only group with a heightened risk was people with AIDS. While extralegal cases were not the focus of this study, none have been uncovered in Oregon; among extralegal cases in the Netherlands, there was no evidence of higher rates in vulnerable groups. Conclusions: Where assisted dying is already legal, there is no current evidence for the claim that legalised PAS or euthanasia will have disproportionate impact on patients in vulnerable groups. Those who received physician-assisted dying in the jurisdictions studied appeared to enjoy comparative social, economic, educational, professional and other privileges. ''… no matter how carefully any guidelines are framed, assisted suicide and euthanasia will be practiced through the prism of social inequality and bias that characterizes the delivery of services in all segments of our society, including health care. The practices will pose the greatest risks to those who are poor, elderly, members of a minority group, or without access to good medical care.'' New York State Task Force on Life and the Law, 1994 1 ''… the State has an interest in protecting vulnerable groups-including the poor, the elderly, and disabled persons-from abuse, neglect, and mistakes. The Court of Appeals [Ninth Circuit] dismissed the State's concern that disadvantaged persons might be pressured into physician assisted suicide as ludicrous on its face.…We have recognized, however, the real risk of subtle coercion and undue influence in end of life situations …'' US Supreme Court, joint opinion in Washington v Glucksberg (1997) and Vacco v Quill (1997) 2 ''Euthanasia and assisted suicide are opposed by almost every national medical association and prohibited by the law codes of almost all countries. … If euthanasia or assisted suicide or both are permitted for competent, suffering, terminally ill patients, there may be legal challenges … to extend these practices to others who are not competent, suffering or terminally ill. Such extension is the ''slippery slope'' that many fear.'' Canadian Medical Association, 1998 3 ''Both society in general and the medical profession in particular have important duties to safeguard the value of human life. This duty applies especially to the most vulnerable members of society-the sick, the elderly, the poor, ethnic minorities, and other vulnerable persons. In the long run, such persons might come to be further discounted by society, or even to view themselves as unproductive and burdensome, and on that basis, ''appropriate'' candidates for assistance with suicide.'' ''… the ramifications [of legalization] are too disturbing for the … value our society places on life, especially on the lives of disabled, incompetent, and vulnerable persons.''

A. Rhebergen, C. van Tol-Verhagen en G. van der Wal Dr. A. Kuin is onderzoeker, dr. L. Deliens is... more A. Rhebergen, C. van Tol-Verhagen en G. van der Wal Dr. A. Kuin is onderzoeker, dr. L. Deliens is senior onderzoeker en prof.dr. G. van der Wal is hoogleraar sociale geneeskunde; zij zijn verbonden aan de afdeling Sociale Geneeskunde van het Instituut voor Extramuraal-Geneeskundig Onderzoek (EMGO-Instituut), VU medisch centrum, Amsterdam. Drs. A. Rhebergen is werkzaam bij Delta T Consult, Utrecht. C. van Tol-Verhagen is algemeen directeur van de Stichting Kuria, Amsterdam.

Journal of Clinical Nursing, Nov 12, 2012

Aims and objectives. To examine whether the relationship between specialty and patient safety is ... more Aims and objectives. To examine whether the relationship between specialty and patient safety is mediated by safety culture. Background. Research has shown that patient safety in hospitals varies by specialty. The safety culture among healthcare professionals in hospital units is believed to influence safety performance. If there is a mediation effect of safety culture in the relationship between specialty and safety, then safety culture could explain why units vary in performance. Design. Cross-sectional observational study in 28 units of 20 hospitals in the Netherlands. Units were of three specialties: emergency medicine, surgery and internal medicine. Methods. Safety culture was measured with the Dutch version of the Hospital Survey on Patient Safety Culture with 11 culture dimensions (n = 542; response 56%). Safety outcomes were types of unintended events (six types). Unintended events were collected through staff reporting (n = 1885 events). Data were examined using multilevel regression analysis. Results. The overall safety culture in the units did not mediate the relationship between specialty and the safety outcomes (event types), but three of the 11 dimensions showed significant mediation on one or more event types: non

Patient Safety in Surgery, 2011

Background: We need to know the scale and underlying causes of surgical adverse events (AEs) in o... more Background: We need to know the scale and underlying causes of surgical adverse events (AEs) in order to improve the safety of care in surgical units. However, there is little recent data. Previous record review studies that reported on surgical AEs in detail are now more than ten years old. Since then surgical technology and quality assurance have changed rapidly. The objective of this study was to provide more recent data on the incidence, consequences, preventability, causes and potential strategies to prevent AEs among hospitalized patients in surgical units. Methods: A structured record review study of 7,926 patient records was carried out by trained nurses and medical specialist reviewers in 21 Dutch hospitals. The aim was to determine the presence of AEs during hospitalizations in 2004 and to consider how far they could be prevented. Of all AEs, the consequences, responsible medical specialty, causes and potential prevention strategies were identified. Surgical AEs were defined as AEs attributable to surgical treatment and care processes and were selected for analysis in detail. Results: Surgical AEs occurred in 3.6% of hospital admissions and represented 65% of all AEs. Forty-one percent of the surgical AEs was considered to be preventable. The consequences of surgical AEs were more severe than for other types of AEs, resulting in more permanent disability, extra treatment, prolonged hospital stay, unplanned readmissions and extra outpatient visits. Almost 40% of the surgical AEs were infections, 23% bleeding, and 22% injury by mechanical, physical or chemical cause. Human factors were involved in the causation of 65% of surgical AEs and were considered to be preventable through quality assurance and training. Conclusions: Surgical AEs occur more often than other types of AEs, are more often preventable and their consequences are more severe. Therefore, surgical AEs have a major impact on the burden of AEs during hospitalizations. These findings concur with the results from previous studies. However, evidence-based solutions to reduce surgical AEs are increasingly available. Interventions directed at human causes are recommended to improve the safety of surgical care. Examples are team training and the surgical safety checklist. In addition, specific strategies are needed to improve appropriate use of antibiotic prophylaxis and sustainable implementation of hygiene guidelines to reduce infections.

Scandinavian Journal of Work, Environment & Health, Aug 1, 2002

Objectives This study investigates the relationship between physical and psychosocial load at wor... more Objectives This study investigates the relationship between physical and psychosocial load at work and sickness absence due to neck pain. Methods A prospective cohort study with a follow-up period of 3 years (1994-1998) was performed among a working population. At the beginning of the study, physical load at work was quantified by means of video recordings. Work-related psychosocial variables were measured by means of the Job Content Questionnaire. The frequency of sickness absence due to neck pain with a minimal duration of 3 days was assessed on the basis of company registrations during the follow-up period. Altogether 758 workers were included in the analyses. Possible confounding by individual characteristics, physical load, and psychosocial load was studied. Results Work-related neck flexion and neck rotation, low decision authority, and medium skill discretion showed statistically significant increased risks for sickness absence due to neck pain (adjusted rate ratios ranging from 1.6 to 4.2). High quantitative job demands, low skill discretion, and low job security showed nonsignificant increased risks for sickness absence due to neck pain (adjusted rate ratios of 2.0, 1.6 and 1.7, respectively). Work-related sitting, conflicting job demands, supervisor support, and co-worker support did not increase sickness absence due to neck pain. Conclusions Work-related neck flexion, neck rotation, low decision authority, and medium skill discretion are risk factors for sickness absence due to neck pain. There are indications that high job demands, low skill discretion, and low job security are also risk factors for sickness absence due to neck pain.

Tijdschrift voor toezicht, 2011

Zoals ook elders in dit themanummer aan de orde komt, wordt informatie over de kwaliteit van zorg... more Zoals ook elders in dit themanummer aan de orde komt, wordt informatie over de kwaliteit van zorginstellingen en zorgverleners in toenemende mate openbaar gemaakt. Onder andere maakt de Inspectie voor de Gezondheidszorg (IGZ) sinds enkele jaren de namen openbaar van instellingen die onder verscherpt toezicht zijn geplaatst. Komt dat de kwaliteit van de zorg ten goede? In deze opinierubriek legt prof. dr. Gerrit van der Wal, Inspecteur-generaal voor de Gezondheidszorg, uit waarom de IGZ de namen van instellingen met verscherpt toezicht publiceert en welke effecten de IGZ hiermee beoogt te realiseren. Dr. Judith van Erp, criminoloog bij de Erasmus School of Law en auteur van diverse publicaties over openbaarmaking in het toezicht, waaronder het boek Naming en shaming in het markttoezicht (Boom Juridische uitgevers 2009), waarschuwt voor onbedoelde neveneffecten.

Archives of internal medicine, Feb 14, 2000

Background: The growing number of requests for euthanasia or assisted suicide (EAS) makes it impe... more Background: The growing number of requests for euthanasia or assisted suicide (EAS) makes it imperative for health care institutions, such as nursing homes, to have written guidelines on how to handle requests for EAS. The objective of this study was to determine the prevalence of EAS guidelines in Dutch nursing homes and to analyze the content. Methods: Directors of patient care in 324 Dutch nursing homes were asked, by means of a mailed short list of questions, if they had an institutional guideline on EAS and, if so, to provide a copy. Guidelines were analyzed according to a structured list of items based on current jurisprudence, model documents, and opinions of experts. Results: Of the 324 directors, 313 (97%) responded. In 58% of the nursing homes that responded, there existed written guidelines for EAS. Of those guidelines, 74% concerned EAS; in 26%, EAS was integrated in a guideline on terminal care. Of the guidelines, 165 (90%) were based on the policy that EAS is acceptable under specific conditions, and 18 (10%) banned EAS completely. Of the first-mentioned guidelines, 81% described one or more procedures for in-principle objections. In 65% of these guidelines, all official requirements for prudent practice were described. Conclusions: Despite the rapidly growing number of nursing-home guidelines on EAS and the existence of model documents, there is still considerable variation in the guidelines, and they can be improved in many aspects. A basic prerequisite is that the guidelines include all the official requirements for prudent practice.

International Journal for Quality in Health Care, Jan 11, 2011

Objective. The objective of this study was to analyze the variation in the rates of adverse event... more Objective. The objective of this study was to analyze the variation in the rates of adverse events (AEs), and preventable AEs, between hospitals and hospital departments in order to investigate the room for improvement in reducing AEs at both levels. In addition, we explored the extent to which patient, department and hospital characteristics explain differences in the rates of AEs. Design. Structured retrospective patient record review of hospital admissions. Setting. Twenty-one Dutch hospitals. Population. A representative random sample of 7113 hospital admissions in 2004. Main outcome measures. Variation in AEs, and preventable AEs, between hospitals and hospital departments and the explanatory factors of the variation. Results. The rates of AEs varied between hospitals (P ¼ 0.05) and hospital departments (P , 0.05). The rates of preventable AEs only varied significantly between hospital departments. The clustering of preventable AEs in hospital departments was more than twice that found in hospitals (ICC 9.5 versus 3.5%). The type of hospital explained 35% of the inter-hospital variance in AEs. Patient and department characteristics explained 23% of the inter-department variance in preventable AEs. Conclusions. In addition to interventions to improve the overall patient safety within a hospital, interventions tailored for specific departments are necessary to reduce their patient safety risks. Monitoring and comparing the performance of hospitals should not be limited to the hospital level, but should be extended to the individual department since there can be significant differences in the rates of preventable AEs between different departments within the same hospital.

Pharmacoepidemiology and Drug Safety, 2009

Purpose To examine what pain and adjuvant medication is prescribed in palliative care patients at... more Purpose To examine what pain and adjuvant medication is prescribed in palliative care patients at home in The Netherlands. Methods In a nationwide, representative, prospective study in general practice in The Netherlands, prescribed medication was registered in 95 general practices with a listed population of 374 070 patients. The GPs identified those who received palliative care in a retrospective survey of the 2169 patients who died within the 1-year study period. We analysed the analgesics, laxatives and anti-emetics that were prescribed during the last 3 months of life for these patients. Results The response rate of the survey was 74%. 425 patients received palliative care and 73% of them were prescribed pain medication: 55% a non-opioid analgesic (paracetamol, NSAIDs), 21% a weak opioid (tramadol, codeine), and 51% a strong opioid. Relatively more younger than older patients were prescribed strong opioids, and more cancer than non-cancer patients were prescribed an analgesic. During the last 3 months of life, the proportion of patients prescribed a non-opioid or a weak opioid increased gradually. The proportion of

Family Practice, Jan 17, 2005

Objectives. The objective was to answer the following questions: What is the prevalence of potent... more Objectives. The objective was to answer the following questions: What is the prevalence of potentially work-related diseases in the general practice population? What is the incidence of consulting a GP for a potentially work-related disease? What is the relationship between diseases seen in general practice and work ability? Methods. Cochrane standards and QUOROM principals were used. For this systematic review the available literature was identified in a computerized search of the bibliographical databases Medline, Embase and Osh-rom. A total of 22 publications (24 studies) met the inclusion criteria. Results. In the general practice population high prevalence rates of potentially work-related diseases were found for low back pain, neck pain and shoulder pain. Incidence rates of consulting a GP for a potentially work-related disease were high also. Musculoskeletal disorders were the main reasons for work-related consultations in general practice. Work-related diseases can affect work ability. Conclusions. Work-related diseases are common, given the high incidence and prevalence of potentially work-related diseases found in the general practice population and seen by the GP. This review underlines the important role of GPs in identifying and managing work-related diseases. GPs should consider the work factor and pay special attention to the effects of work on health, because patients often link their work with their illness.

Journal of Medical Ethics, Feb 1, 1999

Objectives-To identify the factors that influence the assessment of reported cases ofphysician-as... more Objectives-To identify the factors that influence the assessment of reported cases ofphysician-assisted death by members of the public prosecution. Design/setting-At the beginning of 1996, during verbal interviews, 12 short case-descriptions were presented to a representative group of 47 members of the public prosecution in the Netherlands. Results-Assessment varied considerably between respondents. Some respondents made more "lenient" assessments than others. Characteristics of the respondents, such as function, personal-life philosophy and age, were not related to the assessment. Case characteristics, ie the presence of an explicit request, life expectancy and the type of suffering, strongly influenced the assessment. Of these characteristics, the presence or absence of an explicit request was the most important determinant of the decision whether or not to hold an inquest. Conclusions-Although the presence of an explicit request, life expectancy and the type of suffering each influenced the assessment, each individual assessment was dependent on the assessor. The resulting danger of legal inequality and legal uncertainty, particularly in complicated cases, should be kept to a minimum by the introduction of some form ofprotocol and consultation in doubtful or boundary cases. The notification procedure already promotes a certain degree of uniformity in the prosecution policy.

BMC Family Practice, Dec 1, 2013

Background: Primary care physicians provide palliative home care. In cancer patients dying at hom... more Background: Primary care physicians provide palliative home care. In cancer patients dying at home in the Netherlands (45% of all cancer patients) euthanasia in about one out of every seven patients indicates unbearable suffering. Symptom prevalence, relationship between intensity of symptoms and unbearable suffering, evolvement of symptoms and unbearability over time and quality of unbearable suffering were studied in end-of-life cancer patients in primary care. Methods: 44 general practitioners during three years recruited cancer patients estimated to die within six months. Every two months patients quantified intensity as well as unbearability of 69 symptoms with the State-of-Suffering-V (SOS-V). Also overall unbearable suffering was quantified. The five-point rating scale ranged from 1 (not at all) to 5 (hardly can be worse). For symptoms assessed to be unbearable the nature of the suffering was additionally investigated with open-ended questions. The final interviews were analyzed; for longitudinal evolvement also the pre-final interviews were analyzed. Symptom intensity scores 4 and 5 were defined to indicate high intensity. Symptom unbearability scores 4 and 5 were defined to indicate unbearable suffering. Two raters categorized the qualitative descriptions of unbearable suffering. Results: Out of 148 requested patients 51% participated; 64 patients were followed up until death. The SOS-V was administered at least once in 60 patients (on average 30 days before death) and at least twice in 33 patients. Weakness was the most frequent unbearable symptom (57%). Pain was unbearable in 25%. Pain, loss of control over one's life and fear of future suffering frequently were unbearable (89-92%) when symptom intensity was high. Loss of control over one's life, vomiting and not being able to do important things frequently were unbearable (52-80%) when symptom intensity was low. Unbearable weakness significantly increased between pre-final and final interview. Physical suffering, loss of meaning, loss of autonomy, experiencing to be a burden, fear of future suffering and worrying more frequently occurred in patients suffering unbearably overall.

BMC Health Services Research, Feb 25, 2007

Background: Various international studies have shown that a substantial number of patients suffer... more Background: Various international studies have shown that a substantial number of patients suffer from injuries or even die as a result of care delivered in hospitals. The occurrence of injuries among patients caused by health care management in Dutch hospitals has never been studied systematically. Therefore, an epidemiological study was initiated to determine the incidence, type and impact of adverse events among discharged and deceased patients in Dutch hospitals. Methods/Design: Three stage retrospective patient record review study in 21 hospitals of 8400 patient records of discharged or deceased patients in 2004. The records were reviewed by trained nurses and physicians between August 2005 and October 2006. In addition to the determination of presence, the degree of preventability, and causes of adverse events, also location, timing, classification, and most responsible specialty of the adverse events were measured. Moreover, patient and admission characteristics and the quality of the patient records were recorded. Discussion: In this paper we report on the design of the retrospective patient record study on the occurrence of adverse events in Dutch hospitals. Attention is paid to the strengths and limitations of the study design. Furthermore, alterations made in the original research protocol in comparison with former international studies are described in detail.

Annals of Internal Medicine, Aug 3, 2004

Background: Terminal sedation in patients nearing death is an important issue related to end-of-l... more Background: Terminal sedation in patients nearing death is an important issue related to end-of-life care.

Public Health, Nov 1, 1998

A total of 143 samples of Ugandan mothers' breast milk were analysed by gas chromatography for th... more A total of 143 samples of Ugandan mothers' breast milk were analysed by gas chromatography for the presence and levels of DDT residues. The relationship between the level of DDT in the milk and the mother's age, parity, dietary habits, and place of usual residence were studied. DDT levels in the milk were not signi®cantly related to the mother's age. Mothers nursing their ®rst child had a signi®cantly higher mean DDT level in their milk than those nursing their second child. Furthermore, mothers who resided in the urban area had a signi®cantly higher mean DDT level in their milk than those who resided in the rural area. No statistically signi®cant differences were observed in the mean levels of DDT in the milk samples of vegetarian and non-vegetarian mothers. From the present ®ndings, it could be concluded that milk from mothers nursing the ®rst child and residing in an urban area is a good bioindicator for assessing exposure of lactacting mothers to DDT in Uganda.