International Psychogeriatrics

Research Article

Advance directives and physicians’ orders in nursing home residents with dementia in Flanders, Belgium: prevalence and associated outcomes

An Vandervoorta1 c1, Lieve van den Blocka1a2 c1, Jenny T. van der Steena3, Robert Vander Stichelea1a4, Johan Bilsena1a5 and Luc Deliensa1a3

a1 End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium

a2 Department of Family Medicine, Vrije Universiteit Brussel, Brussels, Belgium

a3 EMGO Institute for Health and Care Research and Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands

a4 Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium

a5 Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium


Background: Advance care planning (ACP) is an important element of high-quality care in nursing homes, especially for residents having dementia who are often incompetent in decision-making toward the end of life. The aim of this study was describe the prevalence of documented ACP among nursing home residents with dementia in Flanders, Belgium, and associated clinical characteristics and outcomes.

Methods: All 594 nursing homes in Flanders were asked to participate in a retrospective cross-sectional postmortem survey in 2006. Participating homes identified all residents who had died over the last two months. A structured questionnaire was mailed to the nurses closely involved in the deceased resident's care regarding the diagnosis of dementia and documented care planning, i.e. advance patient directives, authorization of a legal representative, and general practitioners’ treatment orders (GP orders).

Results: In 345 nursing homes (58% response rate), nurses identified 764 deceased residents with dementia of whom 62% had some type of documented care plan, i.e. advance patient directives in 3%, a legal representative in 8%, and GP orders in 59%. Multivariate logistic regression showed that the presence of GP orders was positively associated with receiving specialist palliative care in the nursing home (OR 3.10; CI, 2.07–4.65). Chances of dying in a hospital were lower if there was a GP order (OR 0.38; CI, 0.21–0.70).

Conclusions: Whereas GP orders are relatively common among residents with dementia, advance patient directives and a legal representative are relatively uncommon. Nursing home residents receiving palliative care are more likely to have a GP order. GP orders may affect place of death.

(Received September 22 2011)

(Revised October 12 2011)

(Revised January 11 2012)

(Accepted January 17 2012)

(Online publication February 27 2012)


c1 Correspondence should be addressed to: An Vandervoort or Prof. Dr. Lieve Van den Block, End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Jette, Brussels, Belgium. Phone: +32-(0)2 477 49 01, +32-(0)2 477 47 57 or +32-(0)2 477 43 10; Fax: +32-(0)2 477 47 11. Email: or