D. Ruppert

Quality of out-of-hospital palliative emergency care depends on the expertise of the emergency medical team—a prospective multi-centre analysis

BackgroundThe number of palliative care patients who live at home and have non-curable life-threatening diseases is increasing. This is largely a result of modern palliative care techniques (e.g. specialised out-of-hospital palliative medical care services), changes in healthcare policy and the availability of home care services. Accordingly, pre-hospital emergency physicians today are more likely to be involved in out-of-hospital emergency treatment of palliative care patients with advanced disease.MethodsIn a prospective multi-centre study, we analysed all palliative emergency care calls during a 24-month period across four emergency services in Germany. Participating pre-hospital emergency physicians were rated according to their expertise in emergency and palliative care as follows—group 1: pre-hospital emergency physicians with high experience in emergency and palliative medical care, group 2: pre-hospital emergency physicians with high experience in emergency medical care but less experience in palliative medical care and group 3: pre-hospital emergency physicians with low experience in palliative and emergency medical care.ResultsDuring the period of interest, the centres received 361 emergency calls requiring a response to palliative care patients (2.8% of all 12,996 emergency calls). Ten percent of all patients were treated by group 1; 42% were treated by group 2 and 47% were treated by group 3. There was a statistically significant difference in the treatment of palliative care patients (e.g. transfer to hospital, symptom control, end-of-life decision) as a result of the level of expertise of the investigated pre-hospital emergency physicians (p< 0.01).ConclusionsIn Germany, out-of-hospital emergency medical treatment of palliative care patients depends on the expertise in palliative medical care of the pre-hospital emergency physicians who respond to the call. In our investigation, best out-of-hospital palliative medical care was given by pre-hospital emergency physicians who had significant expertise in palliative and emergency medical care. Our results suggest that it may be necessary to take the core principles of palliative care into consideration when conducting out-of-hospital emergency medical treatment of palliative care patients.

Treatment of palliative care emergencies by prehospital emergency physicians in Germany: an interview based investigation

Palliative care medical emergencies as a consequence of advanced cancer account for approximately 3% of all prehospital emergency cases. Therefore, prehospital emergency physicians (EP) are confronted with ‘end of life decisions’. No educational content exists concerning palliative medicine in emergency medicine curricula. Over the course of 6 months, we interviewed 150 EPs about their experiences in ‘end of life decisions’ using a specific questionnaire. The total response rate was 69% (n = 104). Most of the interviewed EPs (89%, n = 93) had been confronted with palliative care medical emergencies and expressed uncertainties in dealing with these difficult situations, especially in the area of psychosocial care of the patients (50%). The emergency treatment of palliative care patients can become a particular challenge for any EP. A large percentage of interviewed EPs felt uncertain about aspects of social care and in the assessment of decisions at the end of life. Further information and training are necessary to amenable EPs to provide adequate patient-oriented care to palliative care patients and their relatives in emergency situations.

Paramedics experiences and expectations concerning advance directives: A prospective, questionnaire-based, bi-centre study:

Background: Advance directives and palliative crisis cards are means by which palliative care patients can exert their autonomy in end-of-life decisions. Aim: To examine paramedics’ attitudes towards advance directives and end-of-life care. Design: Questionnaire-based investigation using a self-administered survey instrument. Setting/participants: Paramedics of two cities (Hamburg and Goettingen, Germany) were included. Participants were questioned as to (1) their attitudes about advance directives, (2) their clinical experiences in connection with end-of-life situations (e.g. resuscitation), (3) their suggestions in regard to advance directives, ‘Do not attempt resuscitation’ orders and palliative crisis cards. Results: Questionnaires were returned by 728 paramedics (response rate: 81%). The majority of paramedics (71%) had dealt with advance directives and end-of-life decisions in emergency situations. Most participants (84%) found that cardiopulmonary resuscitation in end-of-life patients is not useful and 75% stated that they would withhold cardiopulmonary resuscitation in the case of legal possibility. Participants also mentioned that more extensive discussion of legal aspects concerning advance directives should be included in paramedic training curricula. They suggested that palliative crisis cards should be integrated into end-of-life care. Conclusions: Decision making in prehospital end-of-life care is a challenge for all paramedics. The present investigation demonstrates that a dialogue bridging emergency medical and palliative care issues is necessary. The paramedics indicated that improved guidelines on end-of-life decisions and the termination of cardiopulmonary resuscitation in palliative care patients may be essential. Participants do not feel adequately trained in end-of-life care and the content of advance directives. Other recent studies have also demonstrated that there is a need for training curricula in end-of-life care for paramedics.

Betreuung von Palliativpatienten in Akutsituationen durch Rettungsassistenten

SummaryBACKGROUND: In recent years outpatient palliative care, even for patients in an advanced state of their disease, has gained importance. Therefore, also paramedics are more often confronted with palliative emergencies, advance directives, and ethical end-of-life issues. Presently in emergency medicine there is undoubtedly a lack of education on palliative medicine and ethical questions for paramedics. METHODS: In a period of six months we questioned 250 paramedics from two German regions (Göttingen and Braunschweig) about their experiences in palliative medicine, palliative emergencies and about their knowledge of advance directives. For these key questions we drew up a specific questionnaire. RESULTS: The response rate in the set period of time amounted to 64.8% (n = 162). Most of the interviewed paramedics (91.4%, n = 148) had been confronted with palliative emergency situations on duty. 47.6% felt uncertain about the correct psychosocial care of the patients. 84% of the paramedics were insecure concerning their knowledge about advance directives. 72.8% had already taken care of patients with advance directives. These advance directives had influenced their therapy decision in 42.8%. CONCLUSION: The emergency treatment of palliative patients can present a particular challenge to paramedics. Most of the interviewed paramedics felt insecure both about the social care and the assessment of legal issues in dealing with advance directives and decisions at the end of life. Therefore emergency medical training apparently needs to be improved in these fields. Further information and training are necessary to guarantee adequate patient-oriented care of palliative patients und their relatives also in emergency situations.ZusammenfassungHINTERGRUND: Die ambulante Versorgung von Palliativpatienten im fortgeschrittenen Stadium ihrer Erkrankung hat in den letzten Jahren an Bedeutung zugenommen. Hierbei kann es aber auch zu häuslichen Akutsituationen kommen, die durch den Rettungsdienst versorgt werden müssen. Rettungsassistenten werden somit auch zunehmend mit Patientenverfügungen, palliativen Notfallbögen und ethischen Fragen am Ende des Lebens konfrontiert. Bisher fehlen in der Ausbildung von Rettungsassistenten Inhalte zu palliativmedizinischen und ethischen Fragestellungen. METHODEN: Wir befragten 250 Rettungsassistenten aus zwei Einsatzbereichen (Göttingen und Braunschweig) bezüglich eigener palliativmedizinischer Aus- bzw. Fortbildungen, der Versorgung palliativmedizinischer Notfallpatienten und ihrer Kenntnisse zu speziellen Fragen bei Patientenverfügungen. Für diese Kernfragen entwickelten wir einen eigenen Interviewbogen. ERGEBNISSE: Die Rücklaufquote der Befragung betrug 64,8% (n = 162). Der größte Teil der befragten Rettungsassistenten (91,4%, n = 148) wurde innerhalb der Einsatztätigkeit schon mit palliativmedizinischen Notfallsituationen konfrontiert. In der Ausbildung wurden palliativmedizinische Fragestellungen bei 8% der Rettungsassistenten thematisiert, während insgesamt 38,9% der befragten Rettungsassistenten vorherige Teilnahmen an palliativmedizinischen Fortbildungen angaben. Unsicherheiten bestanden insbesondere bei der psychosozialen Betreuung der Patienten (47,6%). 84% der befragten Rettungsassistenten schätzten sich in Bezug auf die rechtliche Gültigkeit von Patientenverfügungen als schlecht informiert ein. 72,8% der befragten Rettungsassistenten haben während ihrer Einsatztätigkeit bereits Patienten mit Patientenverfügungen betreut. Eine solche beeinflusste bei 42,8% der Rettungsassistenten die Therapieentscheidung. SCHLUSSFOLGERUNG: Die Notfallversorgung von Palliativpatienten kann für jeden Rettungsassistenten aufgrund notfallmedizinischer Probleme sowie palliativmedizinischer und ethischer Prinzipien zu einer besonderen Herausforderung werden. Ein großer Teil der befragten Rettungsassistenten fühlt sich in der sozialen Betreuung und in der Bewertung rechtlicher Fragen im Umgang mit Patientenverfügungen und Entscheidungen am Ende des Lebens unsicher. Deshalb erscheinen Aufklärung, Fortbildung und Gesetzmäßigkeiten erforderlich, um eine adäquate Versorgung von Palliativpatienten durch Rettungsdienstpersonal in Notfallsituationen zu gewährleisten.BACKGROUND In recent years outpatient palliative care, even for patients in an advanced state of their disease, has gained importance. Therefore, also paramedics are more often confronted with palliative emergencies, advance directives, and ethical end-of-life issues. Presently in emergency medicine there is undoubtedly a lack of education on palliative medicine and ethical questions for paramedics. METHODS In a period of six months we questioned 250 paramedics from two German regions (Göttingen and Braunschweig) about their experiences in palliative medicine, palliative emergencies and about their knowledge of advance directives. For these key questions we drew up a specific questionnaire. RESULTS The response rate in the set period of time amounted to 64.8% (n = 162). Most of the interviewed paramedics (91.4%, n = 148) had been confronted with palliative emergency situations on duty. 47.6% felt uncertain about the correct psychosocial care of the patients. 84% of the paramedics were insecure concerning their knowledge about advance directives. 72.8% had already taken care of patients with advance directives. These advance directives had influenced their therapy decision in 42.8%. CONCLUSION The emergency treatment of palliative patients can present a particular challenge to paramedics. Most of the interviewed paramedics felt insecure both about the social care and the assessment of legal issues in dealing with advance directives and decisions at the end of life. Therefore emergency medical training apparently needs to be improved in these fields. Further information and training are necessary to guarantee adequate patient-oriented care of palliative patients und their relatives also in emergency situations.

Betreuung von Palliativpatienten in Akutsituationen durch Rettungsassistenten@@@Treatment of palliative emergencies by paramedics

SummaryBACKGROUND: In recent years outpatient palliative care, even for patients in an advanced state of their disease, has gained importance. Therefore, also paramedics are more often confronted with palliative emergencies, advance directives, and ethical end-of-life issues. Presently in emergency medicine there is undoubtedly a lack of education on palliative medicine and ethical questions for paramedics. METHODS: In a period of six months we questioned 250 paramedics from two German regions (Göttingen and Braunschweig) about their experiences in palliative medicine, palliative emergencies and about their knowledge of advance directives. For these key questions we drew up a specific questionnaire. RESULTS: The response rate in the set period of time amounted to 64.8% (n = 162). Most of the interviewed paramedics (91.4%, n = 148) had been confronted with palliative emergency situations on duty. 47.6% felt uncertain about the correct psychosocial care of the patients. 84% of the paramedics were insecure concerning their knowledge about advance directives. 72.8% had already taken care of patients with advance directives. These advance directives had influenced their therapy decision in 42.8%. CONCLUSION: The emergency treatment of palliative patients can present a particular challenge to paramedics. Most of the interviewed paramedics felt insecure both about the social care and the assessment of legal issues in dealing with advance directives and decisions at the end of life. Therefore emergency medical training apparently needs to be improved in these fields. Further information and training are necessary to guarantee adequate patient-oriented care of palliative patients und their relatives also in emergency situations.ZusammenfassungHINTERGRUND: Die ambulante Versorgung von Palliativpatienten im fortgeschrittenen Stadium ihrer Erkrankung hat in den letzten Jahren an Bedeutung zugenommen. Hierbei kann es aber auch zu häuslichen Akutsituationen kommen, die durch den Rettungsdienst versorgt werden müssen. Rettungsassistenten werden somit auch zunehmend mit Patientenverfügungen, palliativen Notfallbögen und ethischen Fragen am Ende des Lebens konfrontiert. Bisher fehlen in der Ausbildung von Rettungsassistenten Inhalte zu palliativmedizinischen und ethischen Fragestellungen. METHODEN: Wir befragten 250 Rettungsassistenten aus zwei Einsatzbereichen (Göttingen und Braunschweig) bezüglich eigener palliativmedizinischer Aus- bzw. Fortbildungen, der Versorgung palliativmedizinischer Notfallpatienten und ihrer Kenntnisse zu speziellen Fragen bei Patientenverfügungen. Für diese Kernfragen entwickelten wir einen eigenen Interviewbogen. ERGEBNISSE: Die Rücklaufquote der Befragung betrug 64,8% (n = 162). Der größte Teil der befragten Rettungsassistenten (91,4%, n = 148) wurde innerhalb der Einsatztätigkeit schon mit palliativmedizinischen Notfallsituationen konfrontiert. In der Ausbildung wurden palliativmedizinische Fragestellungen bei 8% der Rettungsassistenten thematisiert, während insgesamt 38,9% der befragten Rettungsassistenten vorherige Teilnahmen an palliativmedizinischen Fortbildungen angaben. Unsicherheiten bestanden insbesondere bei der psychosozialen Betreuung der Patienten (47,6%). 84% der befragten Rettungsassistenten schätzten sich in Bezug auf die rechtliche Gültigkeit von Patientenverfügungen als schlecht informiert ein. 72,8% der befragten Rettungsassistenten haben während ihrer Einsatztätigkeit bereits Patienten mit Patientenverfügungen betreut. Eine solche beeinflusste bei 42,8% der Rettungsassistenten die Therapieentscheidung. SCHLUSSFOLGERUNG: Die Notfallversorgung von Palliativpatienten kann für jeden Rettungsassistenten aufgrund notfallmedizinischer Probleme sowie palliativmedizinischer und ethischer Prinzipien zu einer besonderen Herausforderung werden. Ein großer Teil der befragten Rettungsassistenten fühlt sich in der sozialen Betreuung und in der Bewertung rechtlicher Fragen im Umgang mit Patientenverfügungen und Entscheidungen am Ende des Lebens unsicher. Deshalb erscheinen Aufklärung, Fortbildung und Gesetzmäßigkeiten erforderlich, um eine adäquate Versorgung von Palliativpatienten durch Rettungsdienstpersonal in Notfallsituationen zu gewährleisten.BACKGROUND In recent years outpatient palliative care, even for patients in an advanced state of their disease, has gained importance. Therefore, also paramedics are more often confronted with palliative emergencies, advance directives, and ethical end-of-life issues. Presently in emergency medicine there is undoubtedly a lack of education on palliative medicine and ethical questions for paramedics. METHODS In a period of six months we questioned 250 paramedics from two German regions (Göttingen and Braunschweig) about their experiences in palliative medicine, palliative emergencies and about their knowledge of advance directives. For these key questions we drew up a specific questionnaire. RESULTS The response rate in the set period of time amounted to 64.8% (n = 162). Most of the interviewed paramedics (91.4%, n = 148) had been confronted with palliative emergency situations on duty. 47.6% felt uncertain about the correct psychosocial care of the patients. 84% of the paramedics were insecure concerning their knowledge about advance directives. 72.8% had already taken care of patients with advance directives. These advance directives had influenced their therapy decision in 42.8%. CONCLUSION The emergency treatment of palliative patients can present a particular challenge to paramedics. Most of the interviewed paramedics felt insecure both about the social care and the assessment of legal issues in dealing with advance directives and decisions at the end of life. Therefore emergency medical training apparently needs to be improved in these fields. Further information and training are necessary to guarantee adequate patient-oriented care of palliative patients und their relatives also in emergency situations.

Emergency outpatient palliative care in acute situations by paramedics

SummaryBACKGROUND: In recent years outpatient palliative care, even for patients in an advanced state of their disease, has gained importance. Therefore, also paramedics are more often confronted with palliative emergencies, advance directives, and ethical end-of-life issues. Presently in emergency medicine there is undoubtedly a lack of education on palliative medicine and ethical questions for paramedics. METHODS: In a period of six months we questioned 250 paramedics from two German regions (Göttingen and Braunschweig) about their experiences in palliative medicine, palliative emergencies and about their knowledge of advance directives. For these key questions we drew up a specific questionnaire. RESULTS: The response rate in the set period of time amounted to 64.8% (n = 162). Most of the interviewed paramedics (91.4%, n = 148) had been confronted with palliative emergency situations on duty. 47.6% felt uncertain about the correct psychosocial care of the patients. 84% of the paramedics were insecure concerning their knowledge about advance directives. 72.8% had already taken care of patients with advance directives. These advance directives had influenced their therapy decision in 42.8%. CONCLUSION: The emergency treatment of palliative patients can present a particular challenge to paramedics. Most of the interviewed paramedics felt insecure both about the social care and the assessment of legal issues in dealing with advance directives and decisions at the end of life. Therefore emergency medical training apparently needs to be improved in these fields. Further information and training are necessary to guarantee adequate patient-oriented care of palliative patients und their relatives also in emergency situations.ZusammenfassungHINTERGRUND: Die ambulante Versorgung von Palliativpatienten im fortgeschrittenen Stadium ihrer Erkrankung hat in den letzten Jahren an Bedeutung zugenommen. Hierbei kann es aber auch zu häuslichen Akutsituationen kommen, die durch den Rettungsdienst versorgt werden müssen. Rettungsassistenten werden somit auch zunehmend mit Patientenverfügungen, palliativen Notfallbögen und ethischen Fragen am Ende des Lebens konfrontiert. Bisher fehlen in der Ausbildung von Rettungsassistenten Inhalte zu palliativmedizinischen und ethischen Fragestellungen. METHODEN: Wir befragten 250 Rettungsassistenten aus zwei Einsatzbereichen (Göttingen und Braunschweig) bezüglich eigener palliativmedizinischer Aus- bzw. Fortbildungen, der Versorgung palliativmedizinischer Notfallpatienten und ihrer Kenntnisse zu speziellen Fragen bei Patientenverfügungen. Für diese Kernfragen entwickelten wir einen eigenen Interviewbogen. ERGEBNISSE: Die Rücklaufquote der Befragung betrug 64,8% (n = 162). Der größte Teil der befragten Rettungsassistenten (91,4%, n = 148) wurde innerhalb der Einsatztätigkeit schon mit palliativmedizinischen Notfallsituationen konfrontiert. In der Ausbildung wurden palliativmedizinische Fragestellungen bei 8% der Rettungsassistenten thematisiert, während insgesamt 38,9% der befragten Rettungsassistenten vorherige Teilnahmen an palliativmedizinischen Fortbildungen angaben. Unsicherheiten bestanden insbesondere bei der psychosozialen Betreuung der Patienten (47,6%). 84% der befragten Rettungsassistenten schätzten sich in Bezug auf die rechtliche Gültigkeit von Patientenverfügungen als schlecht informiert ein. 72,8% der befragten Rettungsassistenten haben während ihrer Einsatztätigkeit bereits Patienten mit Patientenverfügungen betreut. Eine solche beeinflusste bei 42,8% der Rettungsassistenten die Therapieentscheidung. SCHLUSSFOLGERUNG: Die Notfallversorgung von Palliativpatienten kann für jeden Rettungsassistenten aufgrund notfallmedizinischer Probleme sowie palliativmedizinischer und ethischer Prinzipien zu einer besonderen Herausforderung werden. Ein großer Teil der befragten Rettungsassistenten fühlt sich in der sozialen Betreuung und in der Bewertung rechtlicher Fragen im Umgang mit Patientenverfügungen und Entscheidungen am Ende des Lebens unsicher. Deshalb erscheinen Aufklärung, Fortbildung und Gesetzmäßigkeiten erforderlich, um eine adäquate Versorgung von Palliativpatienten durch Rettungsdienstpersonal in Notfallsituationen zu gewährleisten.BACKGROUND In recent years outpatient palliative care, even for patients in an advanced state of their disease, has gained importance. Therefore, also paramedics are more often confronted with palliative emergencies, advance directives, and ethical end-of-life issues. Presently in emergency medicine there is undoubtedly a lack of education on palliative medicine and ethical questions for paramedics. METHODS In a period of six months we questioned 250 paramedics from two German regions (Göttingen and Braunschweig) about their experiences in palliative medicine, palliative emergencies and about their knowledge of advance directives. For these key questions we drew up a specific questionnaire. RESULTS The response rate in the set period of time amounted to 64.8% (n = 162). Most of the interviewed paramedics (91.4%, n = 148) had been confronted with palliative emergency situations on duty. 47.6% felt uncertain about the correct psychosocial care of the patients. 84% of the paramedics were insecure concerning their knowledge about advance directives. 72.8% had already taken care of patients with advance directives. These advance directives had influenced their therapy decision in 42.8%. CONCLUSION The emergency treatment of palliative patients can present a particular challenge to paramedics. Most of the interviewed paramedics felt insecure both about the social care and the assessment of legal issues in dealing with advance directives and decisions at the end of life. Therefore emergency medical training apparently needs to be improved in these fields. Further information and training are necessary to guarantee adequate patient-oriented care of palliative patients und their relatives also in emergency situations.