Carsten Klein

Trends in specialized palliative care for non-cancer patients in Germany--data from the national hospice and palliative care evaluation (HOPE).

INTRODUCTION The proportion of non-cancer patients (NCs) admitted to palliative care (PC) services increases steadily. Nevertheless, little is known not only about their specific problems, needs that have to be met, but also about improvements that have taken place already. This analysis focuses on developments seen in NC management concerning end-of-life care. METHODS The German Hospice and Palliative Care Evaluation (HOPE) is a national long-term quality assurance project providing information on PC patients. Data from yearly evaluation periods between 2007 and 2011 are used to investigate differences between NC patients documented from 2002 to 2005 in symptoms, treatment and general condition. RESULTS The proportion of NC patients increased from 3.5% (147/4182) to 8.1% (558/6854). NC patients, which are now referred to PC services, are younger, show less need for nursing support, die less often during inpatient stay. Overall a greater variety of diagnoses were found and patients suffer from less complex symptoms and problems at admission. CONCLUSIONS Despite the continuously growing number of patients with non-malignant diseases, their number in PC services is still low. As small steps in the right direction have been taken, integrating PC ideas earlier into treatment of chronic diseases to improve quality of life of NCs during the final stages of their diseases will continue to challenge the health care system in terms of workload, need of more staff and further training of medical professionals dealing with NCs in the future.

Fungating Wounds – Multidimensional Challenge in Palliative Care

The management of fungating, malignant wounds is a challenge for the palliative care team. Open, malodorous, poorly healing lesions are obvious signs of underlying disease. In addition, pain and functional impairment remind the patients of their incurable illness. A multidimensional approach is necessary to meet the needs of these patients and to improve quality of life. Although achieving wound closure is rarely a realistic goal, modern techniques of wound management can help to minimize odours and exudates. Specialist knowledge in palliative care is needed to provide adequate pain control. Psychosocial support may help patients to cope with the situation and their limited abilities.

Subcutaneous Administration of Drugs in Palliative Care: Results of a Systematic Observational Study

CONTEXT Especially in palliative care, safe and manageable administration of medication is essential. Subcutaneous drug administration is a possible alternative, when oral intake is hampered. However, evidence for this method is rare. OBJECTIVES This observational study assessed the clinical practice of subcutaneous drug administration, focusing on the evaluation of local reactions or complications to further develop recommendations. METHODS Over 14 months, patients in a specialized inpatient palliative care unit treated by the subcutaneous route were invited to participate in this clinical study. All subcutaneous medications including dosage and volume of injection, type of needles, and injection site were documented. The injection sites were systematically assessed including the subjective perceptions of patients for analysis of patient tolerability and acceptability. T-tests and Chi-squared tests of these variables were performed to calculate group differences between needles with vs. without complications (P < 0.05). RESULTS In 120 patients, 3957 applications were administered via 243 needles. The needles were placed in thighs (38.7%) and upper arms (28.8%). Most frequently used medications were hydromorphone (59.0%), haloperidol (12.3%), and midazolam (8.3%). Complications were diagnosed most often on the third or fourth day of the needle in situ and occurred significantly more often in (fully) active patients and patients transferred or discharged at the end of treatment. The mean time of needle in situ was significantly lower (4.1 vs. 5.0 days) in complication cases than in noncomplication cases (t-test: P = 0.027). CONCLUSION The results of this study acknowledge the clinical practice of subcutaneous administration of medication as a very flexible, broadly feasible, rather safe, and nonburdensome method. Nevertheless, this practice is not free from complications, needs appropriate nursing care, and requires standardized policies and procedures.

Pain Management and Symptom-Oriented Drug Therapy in Palliative Care

Patients with advanced lifelimiting disease often suffer from symptoms that considerably impair their quality of life and that of their families. Palliative care aims to alleviate these symptoms by a multidimensional approach. Pharmacotherapy is an essential component. The objective of this review is to give an overview of symptomoriented drug therapy for the most important symptoms in palliative care. Leading symptoms that affect quality of life include pain, dyspnea, nausea and emesis, weakness and disorientation. Careful examination and history taking help to understand the individual mechanisms underlying these symptoms. Specific pharmacotherapy provides an efficient way to achieve symptom control in the context of palliative care.

Life threatening illness in popular movies-a first descriptive analysis

In the last two decades, public attention towards illness, dying and death has evolved. In particular, advance care planning, living wills, end-of-life care, and autonomy are increasingly discussed. How this change in public awareness has influenced the presentation of dying and death in cinema needs clarification. Over a one year period, November 2011 until October 2012, a systematic search was conducted to identify movies dealing with incurable diseases produced in 1991–2010 35 movies could be identified and were analyzed in detail and investigated the presentation of illness and death. The number of movies focusing on terminal illness, dying, and death has increased since 1991. The total number of movies that made the yearly German Federal Film Board (FFA) hit list and included a focus on terminal illness, dying, and death increased from 1991 (1 movie) to 2011 (6 movies). The gender of the main characters suffering from terminal illness was distributed equally; three movies portrayed terminally ill children. More than one third of the terminally ill characters died in hospital. The terms “palliative” or “hospice care” were not mentioned once in any films. The number of movies dealing with terminal illness continues to increase and a considerable audience has shown interest in these films. Due to a limited true-to-life performance in the films, a presentation closer to reality could be a major public educational resource.

Palliative sedation in Germany: factors and treatment practices associated with different sedation rate estimates in palliative and hospice care services

BackgroundClinical practice of Palliative Sedation (PS) varies between institutions worldwide and sometimes includes problematic practices. Little available research points at different definitions and frameworks which may contribute to uncertainty of healthcare professionals in the application of PS. This analysis investigates what demographic factors and characteristics of treatment practices differ between institutions with high versus low sedation rates estimates in Palliative and Hospice Care in Germany.MethodsData sets from 221 organisations from a prior online survey were separated into two sub-groups divided by their estimated sedation rate A) lower/equal to 16% (n = 187; 90.8%) and B) higher than 16% (n = 19; 9.2%) for secondary analysis. Demographic factors and characteristics of PS treatment practices between the two groups were compared using T-Tests and Chi2/ Fisher Exact Tests and considered significant (*) at two-sided p < .05.ResultsOrganisations in group B report that they discuss PS for a higher proportion of patients (38.5%/10.2%, p < 0.000**), rate agitation more often as an indications for PS (78.9%/ 53.5%, p = 0.050*), and are more likely to use Lorazepam (63.2%/ 37.4%, p = 0.047*), Promethazin (26.3%/ 9.6%, p = 0.044*), and (Es-)Ketamin (31.6%/ 12.8%, p = 0.039*) than representatives in group A. Both groups differ significantly in their allocation of three case scenarios to different types of PS.ConclusionsBoth definitions and patterns of clinical practice between palliative and hospice care representatives show divergence, which may be influenced one by another. A comprehensive framework considering conceptual, clinical, ethical, and legal aspects of different definitions of PS could help to better distinguish between different types and nuances of PS.

SOP – Umgang mit multiresistenten Erregern auf der Palliativstation

Onkologe 2017 · 23:303–310 DOI 10.1007/s00761-017-0197-7 Online publiziert: 8. März 2017

Praxis der ambulanten parenteralen Schmerztherapie

Jede Behandlung im palliativmedizinischen Bereich muss dem Anspruch genugen, fur den Patienten so wenig belastend wie moglich zu sein. Aus diesem Grund sind invasive Therapieverfahren, wie die parenterale (subkutan oder intravenos applizierte) Schmerztherapie, nicht als Verfahren der ersten Wahl zu sehen. Sie kommen dann zum Einsatz, wenn eine orale oder transdermale Schmerztherapie nicht mehr suffizient durchgefuhrt werden kann oder nicht mehr effektiv ist. Neben den medizinischen Aspekten werden im Folgenden auch einige organisatorische Voraussetzungen fur eine erfolgreiche ambulante Patientenversorgung behandelt.