Practice In Belgium Research Articles

Reliability, responsiveness and interpretability of the neck disability index-Dutch version in primary care.

To establish an evidence-based recommendation for the pragmatic use of the Neck Disability Index-Dutch Version (NDI-DV) in primary care based on an assessment of the reliability, the responsiveness, and the interpretability of the NDI-DV. At baseline, the NDI-DV was completed by 337 patients with neck pain presenting to 97 chiropractic clinics in Belgium and the Netherlands. Three months after inclusion, 265 patients provided data to assess the responsiveness and interpretability. Reliability was assessed in 155 patients (retested after 10 days) by calculating the intra-class correlation coefficient for agreement (ICCagreement) and the measurement error (standard error of measurement, SEM), the latter resulting in the smallest detectable change (SDC). The minimal important change (MIC) was assessed by the anchor-based MIC distribution using self-reported perceived recovery as anchor. We tested interpretability by relating SDC to MIC. The ICCagreement was 0.88. The SEMagreement was 1.95 resulting in a SDC of 5.40. The NDI-DV appeared to be responsive, being able to distinguish improved from stable patients with an area under the curve of 0.85. The MIC was 4.50. The NDI-DV has good reliability and responsiveness and may be used in clinical practice in Belgium and the Netherlands. A change score of 5 is important for patients, but has a 7 % chance to be due to measurement error.

Governing education without reform: the power of the example

There is an increasing emphasis today on different forms of evidence-based policy in education. Several authors address the related emergence of new patterns of governing and describe forms of governing by numbers and related practices of governing by comparison. There is, however, less focus on the governmental use of soft evidence such as examples of good practice. Drawing on the analysis of governing practices in Belgium (Flanders) and Europe, this article attempts to examine in detail how soft evidence, among other elements, constitutes the current governing configuration. It is argued that this configuration includes several mechanisms that appear as evident but have far-reaching consequences: imposing spaces of meaning and discussion, deciding on what is within one's control and what is not, making people believe there is no longer something beyond themselves that is an excuse for actual self-improvement. What takes shape as part of techniques of contextualization, personalization, and permanent monitoring is ‘the power of the example’: learning from examples in view of increased performance. The conclusion expresses some concerns about the tendencies toward a manipulative society.

Electronic Monitoring in Belgium: A Penological Analysis of Current and Future Orientations

Electronic monitoring was introduced nationwide in Belgium in 2000 and has expanded ever since. Currently important changes are taking place, radically transforming its operation and nature. The aim of this article is to describe and critically discuss the current shift in EM discourses and practices in Belgium from a penological perspective. We start with a brief sketch of the historical evolution of EM, explaining the penal and political context in which EM emerged and was further established, what goals it was supposed to meet and how these goals and practices shifted. With the new regulations of 2012 and 2013, both the rationale and the technology of EM have further evolved. These recent evolutions will be illustrated and situated in a consideration of the wider transformation of punishment in the community.

Employment loss during economic crisis and suicidal thoughts in Belgium: a survey in general practice

The economic crisis of 2009 led to a wave of corporate reorganisations and bankruptcies, with many dismissals of employees. GPs were confronted with subsequent health consequences. To assess the possible relationship between losing one's job and having suicidal thoughts. A survey of patients aged 18-49 years recruited from GP practices in Belgium in Deurne (Flemish region) and La Louvière (Walloon region) from September to December 2010. Method Anonymous self-administered questionnaire. Of all eligible patients (n = 1818), 831 were offered the questionnaire and 377 completed it (45.4%). More than one in five had been confronted with employment loss in the past year (the responder or someone close losing their job). Almost one in ten had lost their job themselves in the past year. More than one in four had experienced suicidal thoughts and 11.7% had seriously considered ending their life in the past year. In the logistic regression analysis, the following characteristics showed a statistically significant relationship with having suicidal thoughts: being single (odds ratio [OR] = 4.8, 95% confidence interval [CI] = 1.7 to 13.8), not having satisfying social contacts (OR = 5.1, 95% CI = 1.6 to 16.2), having depressive complaints (OR = 18.4, 95% CI = 5.8 to 58.4), and having lost one's employment in the past year (OR = 8.8, 95% CI = 2.0 to 39.3). This study points to a statistically significant relationship between losing one's employment in the past year and having suicidal thoughts. It emphasises the important role of the GP in the continuous and reinforced assessment of suicidal risk in times of recession.

Studies on the use of BD Vacutainer® SST II™ and RST™ in general practice: investigation of artefactual hyperkalaemia

Current sampling and transport conditions of samples in general practice can result in pseudohyperkalaemia. This study was undertaken to determine, in a general practice setting, whether there is any difference in haemolysis obtained when using BD Vacutainer® Rapid Serum Tubes (BD RST) compared with using BD Vacutainer® SST™ II Advance Blood Collection Tubes (BD SSTII). Blood was collected from 353 patients requiring blood sampling who were attending 31 general practitioner practices in Belgium. For each patient, two BD SSTII tubes and two BD RST tubes were drawn in a randomized order. One of each pair of tubes was inverted five times, the other was not. Serum potassium concentration, serum LDH activity and haemolysis index were measured in each sample. There was no significant difference in measured potassium concentration according to tube type (P = 0.16). Measured LDH activities were 1.7% higher in serum collected into BD SSTII tubes compared to BD RST tubes (P = 0.02). When comparing serum from unmixed BD RST with BD SSTII tubes, there was a slight reduction in the haemolysis index but no significant difference in measured potassium concentration or LDH activity. Risk of hyperkalaemia was 4.8 times higher in serum from tubes that were incompletely filled compared to those that were filled with the correct amount of blood. Both types of blood tubes are suitable for the measurement of serum potassium and LDH in patients from general practice. Tube inversion does not improve the accuracy of either serum potassium or LDH measurement. Blood tubes should be filled to the level recommended by the manufacturer to avoid artefactual increases in measured serum potassium concentration and LDH activity.

AB0584 Safety and efficacy of etanercept in patients with active psoriatic arthritis with peripheral involvement in belgium: 66 months follow-up.

Objectivesto describe the long-term efficacy and types of adverse events (AEs) in psoriatic arthritis (PsA) patients treated with etanercept in a daily clinical setting in Belgium.MethodsThis is a prospective, multi-center,...

Mothering as a citizenship practice: an intersectional analysis of ‘carework’ and ‘culturework’ in non-normative mother–child identities

In this article, a comparative analysis is presented of two ethnographic case studies on mothering practices in Belgium. Interviews with, and participant observation among, both undocumented migrant mothers from the South and Belgian white adoptive mothers of black Ethiopian-born children provide an insight into the way in which mothering plays an important role in the pursuit of citizenship. In our analysis, we draw on critical theorizations of citizenship from feminist, multicultural and globalization perspectives, and of care, intimacy and the affective in order to show how mothering can be viewed as a citizenship practice that transcends boundaries of the private, public and the nation. In their ‘carework’ and ‘culturework’, both undocumented migrant and white adoptive mothers negotiate prevalent ideologies of mothering that are often exclusionary of their own and their children's sense of identity and belonging. Their mothering involves building new networks and strengthening their children's identities in culturally creative ways. We argue that although these mothering practices are embedded in a multiplicity of intersecting privileges and inequalities, within restraints imposed by the nation-state context, this carework attests to the agentic capacity of mothering and its potential to affect politics of inclusion, recognition and changing hegemonic understandings of citizenship and belonging.

Science–policy challenges for biodiversity, public health and urbanization: examples from Belgium

Internationally, the importance of a coordinated effort to protect both biodiversity and public health is more and more recognized. These issues are often concentrated or particularly challenging in urban areas, and therefore on-going urbanization worldwide raises particular issues both for the conservation of living natural resources and for population health strategies. These challenges include significant difficulties associated with sustainable management of urban ecosystems, urban development planning, social cohesion and public health. An important element of the challenge is the need to interface between different forms of knowledge and different actors from science and policy. We illustrate this with examples from Belgium, showcasing concrete cases of human–nature interaction. To better tackle these challenges, since 2011, actors in science, policy and the broader Belgian society have launched a number of initiatives to deal in a more integrated manner with combined biodiversity and public health challenges in the face of ongoing urbanization. This emerging community of practice in Belgium exemplifies the importance of interfacing at different levels. (1) Bridges must be built between science and the complex biodiversity/ecosystem–human/public health–urbanization phenomena. (2) Bridges between different professional communities and disciplines are urgently needed. (3) Closer collaboration between science and policy, and between science and societal practice is needed. Moreover, within each of these communities closer collaboration between specialized sections is needed.

Chronic venous insufficiency in patients with absence of the inferior vena cava

Up until now, knowledge of absence of the inferior vena cava (AIVC) is limited to case reports and small case series, usually reported shortly after diagnosis. To characterize long-term evolution of outcomes of patients with AIVC, weperformed a survey of current practice in Belgium, TheNetherlands, and Luxembourg (Benelux). Vascular surgeons and phlebologists in the Benelux area were asked to complete a questionnaire on medical history and treatment of each patient in follow-up at their practice with a diagnosis of AIVC. The Benelux survey yielded 35 patients with AIVC, with a follow-up ranging from 0 to 28 years. Their median age was 40 years (range, 14-65 years), and 26 (74%) were male. Diagnosis of AIVC was made in 26 patients at the time of presentation with deep vein thrombosis (DVT). DVT was bilateral in 15 patients and involved one or both iliac veins in 21 (81% of all AIVC patients with acute DVT). Computed tomography scanning was used to detect AIVC in 29 patients. Thrombophilia was present in 16 (46%). The CEAP C classification was C4-6 in 17 right legs (49%) and 15left legs (43%). Unilateral or bilateral ulceration had occurred in 11 patients in the past, and three had active ulceration. Long-term conservative treatment consisted of oral anticoagulant treatment in 28 patients and compression stockings in27. The results of this survey on AIVC illustrate the unfavorable long-term clinical evolution of these patients. They frequently present with advanced stages of chronic venous insufficiency at a relatively young age, with the development of unilateral or bilateral extensive DVT and subsequent moderate to severe post-thrombotic syndrome.

Cultural differences affecting euthanasia practice in Belgium: One law but different attitudes and practices in Flanders and Wallonia

Since 2002, Belgium has had a national law legalising euthanasia. The law prescribes several substantive due care requirements and two procedural due care requirements, i.e. consultation with an independent physician and reporting of euthanasia to a Federal Control Committee. A large discrepancy in reporting rates between the Dutch-speaking (Flanders) and the French-speaking (Wallonia) parts of Belgium has led to speculation about cultural differences affecting the practice of euthanasia in both regions. Using Belgian data from the European Values Study conducted in 2008 among a representative sample of the general public and data from a large-scale mail questionnaire survey on euthanasia of 480 physicians from Flanders and 305 from Wallonia (conducted in 2009), this study presents empirical evidence of differences between both regions in attitudes towards and practice of euthanasia. Acceptance of euthanasia by the general population was found to be slightly higher in Flanders than in Wallonia. Compared with their Flemish counterparts, Walloon physicians held more negative attitudes towards performing euthanasia and towards the reporting obligation, less often labelled hypothetical cases correctly as euthanasia, and less often defined a case of euthanasia having to be reported. A higher proportion of Flemish physicians had received a euthanasia request since the introduction of the law. In cases of a euthanasia request, Walloon physicians consulted less often with an independent physician. Requests were more often granted in Flanders than in Wallonia (51% vs 38%), and performed euthanasia cases were more often reported (73% vs 58%). The study points out some significant differences between Flanders and Wallonia in practice, knowledge and attitudes regarding euthanasia and its legal requirements which are likely to explain the discrepancy between Wallonia and Flanders in the number of euthanasia cases reported. Cultural factors seem to play an important role in the practice of (legal) euthanasia and the extent to which legal safeguards are followed.

Recommendations for the treatment of epilepsy in adult patients in general practice in Belgium: an update.

In 2008, a group of Belgian epilepsy experts published recommendations for antiepileptic drug (AED) treatment of epilepsies in adults and children. Selection of compounds was based on the registration and reimbursement status in Belgium, the level of evidence for efficacy, common daily practice and the personal views and experiences of the authors. In November 2011 the validity of these recommendations was reviewed by the same group of Belgian epilepsy experts who contributed to the preparation of the original paper. The recommendations made in 2008 for initial monotherapy in paediatric patients were still considered to be valid, except for the first choice treatment for childhood absence epilepsy. This update therefore focuses on the treatment recommendations for initial monotherapy and add-on treatment in adult patients. Several other relevant aspects of treatment with AEDs are addressed, including considerations for optimal combination of AEDs (rational polytherapy), pharmacokinetic properties, pharmacodynamic and pharmacokinetic interaction profile, adverse effects, comorbidity, treatment of elderly patients, AED treatment during pregnancy, and generic substitution of AEDs.

THE IMPACT OF TREATMENT WITH RISPERIDONE LONG-ACTING INJECTION ON THE BELGIAN HEALTHCARE SYSTEM: RESULTS FROM A BUDGET IMPACT MODEL

Substantial evidence from randomised clinical trials has demonstrated that long-acting risperidone (RLAI) is efficacious and well tolerated in patients with schizophrenia. Recently, a long-term naturalistic study of treatment practices in Belgium, the electronic Schizophrenia Treatment Adherence Registry (e-STAR), reported that treatment with RLAI is associated with improvements in adherence and long-term outcomes. The present report describes the results of a budget impact model that analysed the Belgian e-STAR data, together with other available data, over a 3-year time horizon, in order to establish the potential impact of treatment with RLAI on total healthcare costs in Belgium. The model framework combined medical resource utilisation with costs of the population of interest in order to quantify the costs, and cost offsets, of RLAI treatment. For the purpose of this budget impact model, it was assumed that among patients who would discontinue their previous antipsychotic medication, 6.7% of patients would be switched to RLAI. The overall cost savings to the Belgian healthcare system were calculated to be € 2.3 million in Year 1, € 3.7 million in Year 2 and € 4.4 million in Year 3. The majority of these cost-savings resulted from the substantial reduction in hospitalisation costs associated with RLAI treatment. This report indicates that improvements in adherence and long-term outcomes previously demonstrated for RLAI treatment in Belgium may result in substantial cost benefits to the country’s healthcare system.

Effect of adenotonsillectomy on the use of respiratory medication

ObjectiveRecurrent tonsillitis and upper respiratory tract obstruction due to adenotonsillar hypertrophy are the most common indications for (adeno)tonsillectomy ((A)TE). Symptoms of upper respiratory tract infection and obstruction can, however, be attributed to lower airway pathology and thus treated with respiratory medication – this is non-antimicrobial medication used for lower respiratory diseases like bronchitis, bronchiolitis, asthma and episodic wheezing. The aim of this study is to investigate the effect of the current (A)TE practice in Belgium on the use of respiratory medication in subjects aged 0–15. MethodsRetrospective data on 11.114 subjects aged 0–15years old who underwent (A)TE from January 1st 2002 until Sept 30th 2003 were retrieved from the database of the Christelijke Mutualiteit, the largest mutual health insurance society in Belgium. We compared the use of respiratory medication 12months before and 12months after (A)TE. ResultsOut of 11.114 subjects, 4.654 received at least one prescription for respiratory medication in the year before and/or after (A)TE. In this subgroup, the median respiratory medication use reduced with 32% in the year after surgery. ConclusionCompared with the year before surgery, the median use of respiratory medication in subjects aged 0–15 drastically reduces in the year after (A)TE. A possible reason for this reduction is that children with upper airway obstruction and infections are often wrongly diagnosed as having lower airway problems.

The Use of Human Milk in the Neonatal Intensive Care Unit: Practices in Belgium and Luxembourg

Human milk remains the preferred feeding for all infants, including premature and sick newborns. However, mother's milk is not sterile, and expressed milk can be a source of commensal and pathogenic microorganisms. Microbiological quality standards for the use of expressed human milk in hospitals are not available, unlike for donor or formula milk. To document current practices for the use of human milk in the neonatal intensive care units (NICU) in Belgium and Luxembourg, both for mother's own milk and donor milk, a questionnaire was sent to all 20 neonatal units. Of the 19 units that completed the survey, 47% perform bacteriological testing of expressed milk. Applied bacterial count limits for the acceptable level of contamination differ among units, for both commensals and pathogens. Only six units have a device for pasteurizing milk at their disposal. Storage time in the refrigerator for fresh milk varies between 24 hours to 7 days before use. Access to donor milk is limited. Routines for handling of human milk differ widely among NICUs in Belgium and Luxembourg. An assessment of current issues through a structured survey is a useful tool in the development of best practice guidelines.

GPs' views in five European countries of interventions to promote prudent antibiotic use

A variety of interventions have been developed to promote a more prudent use of antibiotics by implementing clinical guidelines. It is not yet clear which are most acceptable and feasible for implementation across a wide range of contexts. Previous research has been confined mainly to examining views of individual interventions in a national context. To explore GPs' views and experiences of strategies to promote a more prudent use of antibiotics, across five countries. Qualitative study using thematic and framework analysis in general practices in Belgium, France, Poland, Spain, and the UK. Fifty-two semi-structured interviews explored GPs' views and experiences of strategies aimed at promoting a more prudent use of antibiotics. Interviews were carried out in person or over the telephone, transcribed verbatim, and translated into English where necessary for analysis. Themes were remarkably consistent across the countries. GPs had a preference for interventions that allowed discussion and comparison with local colleagues, which helped them to identify how their practice could improve. Other popular components of interventions included the use of near-patient tests to reduce diagnostic uncertainty, and the involvement of other health professionals to increase their responsibility for prescribing. The study findings could be used to inform future interventions to improve their acceptability to GPs. Consistency in views across countries indicates the potential for development of an intervention that could be implemented on a European scale.

Trends in Medical End-of-Life Decision Making in Flanders, Belgium 1998–2001–2007

In 2002, Belgium saw the enactment of 3 laws concerning euthanasia, palliative care, and patient rights that are likely to affect end-of-life decision making. This report examines trends in the occurrence and decision-making process of end-of-life practices in different patient groups since these legal changes. A large-scale retrospective survey in Flanders, Belgium, previously conducted in 1998 and 2001, was repeated in 2007. Questionnaires regarding end-of-life practices and the preceding decision-making process were mailed to physicians who certified a representative sample (N = 6927) of death certificates. The 2007 response rate was 58.4%. In patient groups in which the prevalence of life-ending drug use without explicit patient request has dropped, performance of euthanasia and assisted suicide has increased. The consistent increase in intensified pain and symptom alleviation was found in all patient groups except cancer patients. In 2007, competent patients were slightly more often involved in the discussion of end-of-life practices than in previous years. Over the years, involvement of the patient in decision making was consistently more likely among younger patients, cancer patients, and those dying at home. Physicians consulted their colleagues more often than in previous years for euthanasia and nontreatment decisions. The euthanasia law and emerging palliative care culture have substantially affected the occurrence and decision making for end-of-life practices in Belgium. Efforts are still needed to encourage shared end-of-life decision making, as some patients would benefit from advance care planning.

Effect of Lyophilized Lactobacilli and 0.03 mg Estriol (Gynoflor®) on Vaginitis and Vaginosis with Disrupted Vaginal Microflora: A Multicenter, Randomized, Single-Blind, Active-Controlled Pilot Study

Objectives: To evaluate the efficacy of lyophilized lactobacilli in combination with 0.03 mg estriol when compared to metronidazole in the treatment of bacterial vaginal infections. Setting: Multicenter, randomized, single-blind, active-controlled pilot study in 3 independent gynecological practices in Belgium. Methods: Forty-six, 18- to 50-year-old premenopausal women with a disrupted vaginal flora due to a bacterial vaginal infection (bacterial vaginosis, aerobic vaginitis) were included, provided that fresh phase-contrast microscopy of the vaginal fluid showed lactobacillary flora grade 2B or 3. Patients were given a blinded box with either 12 vaginal tablets of Gynoflor® (study medication) or 6 vaginal suppositories containing 500 mg metronidazole (control medication). Eight efficacy variables were studied to assess the status of the vaginal flora at entry, 3–7 days (control 1), 4–6 (control 2) weeks and 4 months after the end of therapy. Results: At control 1, the combined variables equally improved in the lactobacilli group as in the metronidazole group. At control 2, the lactobacillus preparation showed slightly inferior results when compared to metronidazole. At 4 months, this analysis could not be performed due to low numbers, but analysis of recurrence rate and extra medication needed was not different between both groups. Conclusion: Lyophilized lactobacilli in combination with low-dose estriol are equivalent to metronidazole in the short-term treatment of bacterial vaginal infections, but have less effect after 1 month. Further studies are required to evaluate the long-term efficacy of lactobacilli when applied repeatedly.

The perception of the clinical relevance of the MDS-Home Care(C) tool by trainers in general practice in Belgium

comprehensive geriatric assessment has been advocated as an effective way to first identify multidimensional needs and second to establish priorities for organizing an individual health care plan for community-dwelling elderly. This paper reports on the perception of an internationally evaluated assessment system for use in community care programmes, the Minimal Data Set-Home Care (MDS-HC), by a group of experienced GP trainers. the primary study aim was to determine the perception of a standardized home care assessment system (MDS-HC) by GP trainers in terms of acceptability, perceived clinical relevance, care planning empowerment and valorization of the GP. sixty-five first-year GP trainees were educated about the MDS-HC and the use of a first version of an electronic interface. Each trainee included two elderly patients, based on strict inclusion criteria. Prior to the assessment, GP trainers and trainees were invited to complete together a basic medical record on the basis of their knowledge of the included patients. Next, the collected data, covering the multiple domains by MDS-HC, were introduced in the electronic interface by the trainee. Based on the collected data for each patient, a series of clinical assessment protocols (CAP's) were generated. Afterwards, these CAP's were critically discussed with the trainer. To investigate how the application of the MDS-HC was perceived, a 21 Likert-type item scale was drawn up based on four dimensions regarding the tool. the perception questionnaire had a good internal consistency (Cronbach's alpha 0.93). The first version of the electronic interface was considered not 'user-friendly' enough and the introduction of data time-consuming. The perception of the GP's about the overall clinical relevance of the MDS-HC was found to have little added value for the GP in the establishment of a personal management plan. many developments in health care result in an increasing demand for a standardized home care assessment system. In Belgium, the federal public health service advised to promote the MDS-HC for use in the community setting. In this study, it appears that its added value was not perceived by this sample of 37 experienced GP trainers as an empowering tool in term of management of the patient and valorization of the role of GP.

Excess of mortality in patients with chest pain peaks in the first 3 days period after the incident and normalizes after 1 month

Background. Patients presenting with chest pain have a 5% chance of experiencing a coronary event. These patients are at risk of mortality and should be recognized and referred to secondary care.Aim. To determine the relationship between referral type and mortality in patients with chest pain.Methods. The design of the study is an observational study. The setting of the study is a sentinel network of general practices in Belgium, covering 1.6% of the total population. The subjects are 1558 consecutive patients consulting with chest pain in 2003. Descriptive analyses report the standardized mortality ratios. We used the Belgian population of 1999 as the reference population and as the standard population.Results. The standardized mortality ratios of 3 days were 151.0 [95% confidence interval (CI): 82.3–250.3] for the urgent referred group, 45.5 (95% CI: 12.4–116.0) for non-urgent and 13.6 (95% CI: 1.7–49.4) for the non-referred group. The standardized ratios of 1 month were, respectively, 27.6 (95% CI: 18.0–40.4), 6.7 (95% CI: 2.5–14.6) and 4.7 (95% CI: 1.9–9.7). The standardized ratios of 2–12 months were normal for the urgent referral group (1.3; 95% CI: 0.7–2.2) and for the non-urgent referral group (1.0; 95% CI: 0.5–1.9) and even less in the non-referred group (0.4; 95% CI: 0.2–0.9).Conclusions. Mortality in the first 3 days and first month after consulting for chest pain is very high. There is a marked trend in mortality according to the referral type—urgently referred, non-urgently referred and not referred—suggesting risk stratification by the GP. After 1 month, mortality normalizes for all groups, suggesting that the surviving patients are well treated and the condition causing the chest pain no longer influences survival compared to the general population.

Physician reports of medication use with explicit intention of hastening the end of life in the absence of explicit patient request in general practice in Belgium

BackgroundAlthough the incidence of the use of life-ending drugs without explicit patient request has been estimated in several studies, in-depth empirical research on this controversial practice is nonexistent. Based on face-to-face interviews with the clinicians involved in cases where patients died following such a decision in general practice in Belgium, we investigated the clinical characteristics of the patients, the decision-making process, and the way the practice was conducted.MethodsMortality follow-back study in 2005-2006 using the nationwide Sentinel Network of General Practitioners, a surveillance instrument representative of all GPs in Belgium. Standardised face-to-face interviews were conducted with all GPs who reported a non-sudden death in their practice, at home or in a care home, which was preceded by the use of a drug prescribed, supplied or administered by a physican without an explicit patient request.ResultsOf the 2690 deaths registered by the GPs, 17 were eligible to be included in the study. Thirteen interviews were conducted. GPs indicated that at the time of the decision all patients were without prospect of improvement, with persistent and unbearable suffering to a (very) high degree in nine cases. Twelve patients were judged to lack the competence to make decisions. GPs were unaware of their patient's end-of-life wishes in nine cases, but always discussed the practice with other caregivers and/or the patient's relatives. All but one patient received opioids to hasten death. All GPs believed that end-of-life quality had been "improved considerably".ConclusionsThe practice of using life-ending drugs without explicit patient request in general practice in Belgium mainly involves non-competent patients experiencing persistent and unbearable suffering whose end-of-life wishes can no longer be ascertained. GPs do not act as isolated decision-makers and they believe they act in the best interests of the patient. Advance care planning could help to inform GPs about patients' wishes prior to their loss of competence.