Open Access Research article

Policies to improve end-of-life decisions in Flemish hospitals: communication, training of health care providers and use of quality assessments

Ina D'Haene12*, Robert H Vander Stichele1, H Roeline W Pasman3, Nele Van den Noortgate4, Johan Bilsen2, Freddy Mortier5 and Luc Deliens23

Author Affiliations

1 Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium

2 End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium

3 Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands

4 Department of Geriatrics, Ghent University Hospital, Ghent, Belgium

5 Bioethics Institute Ghent, Ghent University, Ghent, Belgium

For all author emails, please log on.

BMC Palliative Care 2009, 8:20  doi:10.1186/1472-684X-8-20

Published: 30 December 2009



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.


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.


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.


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.