Eberhard Klaschik

Drugs in palliative care: results from a representative survey in Germany

The development of palliative medicine in inpatient units in Germany has been impressive in the last years. As a first step of quality assurance, a core documentation form was developed in 1996. In 2001, 55 of the 83 palliative inpatient units in Germany and one unit each in Switzerland and Austria participated in the third phase of the evaluation of the core documentation. A total of 1304 patients were documented consecutively in the 57 units for a period of up to three months. This study investigates the frequency of drugs used in palliative care units in Germany. During inpatient treatment, the most common drug classes were strong opioids (68% of the patients), nonopioids (59%), corticosteroids (32%), laxatives (31%), antiemetics (27%), gastric protection agents (24%), neuroleptics (19%), sedatives/anxiolytics (18%), antidepressants (16%) and diuretics (15%). These ten drug classes made up for 72% of all prescriptions in the palliative care units. The substances used most frequently were dipyrone (47% of the patients), morphine (42%), fentanyl (28%), dexamethasone (27%), metoclopramide (21%), sodium picosulfate (15%), haloperidol (13%), pantoprazole (11%), macrogol (11%), amtriptyline (11%), furosemide (10%), omeprazole (9%), lactulose (8%), rofecoxib (8%) and lorazepam (7%). The 15 most commonly used drugs accounted for 54% of the prescriptions in the palliative care units in Germany. Drug treatment was related to sex, age and functional status of the patients. Patients who died in a palliative care unit had received significantly more frequent doses of neuroleptics (PB / 0.001), corticosteroids (PB / 0.001), sedatives/anxiolytics (PB / 0.001) and strong opioids (PB / 0.001). This study is the first representative and systematic evaluation of drug treatment in palliative care units in a European country. Many of the ’top 15‘ drugs were drugs included in the list of essential drugs of the World Health Organisation though availability and cultural differences have an effect on the use of drugs, e.g., the high usage of dipyrone in Germany. Age and sex-related differences in drug therapy were seen, and more research is needed to recognize possible undertreatment of symptoms in subgroups of patients, e.g., treatment of depression in older or male patients.

Constipation—modern laxative therapy

It is estimated that one third of the population in Western industrial countries suffers from constipation at least from time to time. Constipation may have somatopathic or functional causes. Furthermore, a great number of substances are known to cause medication-induced constipation, i.e. opioid-induced constipation is caused by linkage of the opioid to opioid receptors in the bowel and the central nerve system. Whenever possible, causal therapy should be undertaken. Patients in palliative care mostly suffer from chronic functional constipation. The treatment consists of basic measures and the application of laxatives. According to their mode of action, they are divided into bulk-forming laxatives, osmotic laxatives, stimulant laxatives, lubricating agents and others. Bulk-forming laxatives are not recommended for use in palliative care patients, for such patients are normally not able to take in the required amount of fluids. Osmotic laxatives are divided into (magnesium) salts, saccharine, alcohols and macrogols. Lactulose is the most popular saccharine laxative. Because of its side effects (flatulence, bloating and abdominal cramping), lactulose is not a laxative of our choice; instead, we prefer to give macrogol. Orally administered, macrogol is not metabolised and pH value and bowel flora remain unchanged. Macrogol hydrates hardened stools, increases stool volume, decreases the duration of colon passage and dilates the bowel wall that then triggers the defecation reflex. Even when given for some time, the effectiveness of macrogol will not decrease. Because of its high effectiveness and commonly good tolerance, macrogol has become the laxative of first choice in palliative care patients with all kinds of chronic constipation, if these patients are able to take in the necessary amount of fluids. From the general medical point of view, lubricating agents have become obsolete. In palliative care patients, however, they are still important laxatives for prophylactic treatment or therapy of constipation. Due to clinical experience, in palliative care a laxative ladder has proven successful.

Is There a Higher Risk of Respiratory Depression in Opioid-Naïve Palliative Care Patients during Symptomatic Therapy of Dyspnea with Strong Opioids?

OBJECTIVE Dyspnea is a highly prevalent symptom in palliative care patients. Opioids are the first-line therapy for symptomatic relief of dyspnea. However, respiratory depression is still a feared side effect of therapy with WHO III opioids. The risk of respiratory depression in opioid-naïve patients and in patients pretreated with strong opioids during symptomatic therapy of dyspnea was investigated in palliative care patients. PATIENTS AND METHODS Twenty-seven patients were included in a prospective, nonrandomized study. All patients suffered from moderate to severe dyspnea. Transcutaneous measurement (earlobe sensor) of carbon dioxide partial pressure (tcpaCO(2)), pulse oximetry oxygen saturation (SaO(2)), and pulse frequency (PF) were monitored with SenTec Digital Monitor (SenTec AG, Therwill, CH). The following monitoring data were compared: baseline recording for 15 minutes, and 30, 60, 90, and 120 minutes after opioid application. RESULTS The data obtained with transcutaneous measurement showed that there were no significant differences between the groups of opioid-naïve patients and those pretreated with strong opioids with regard to tcpaCO(2) increase or SaO(2) decrease after the first opioid application. Neither SaO(2) decreased significantly nor tcpaCO(2) increased significantly after the initial opioid application, which means there was no opioid-induced respiratory depression. The first opioid application, however, resulted in a significant decrease in the intensity of dyspnea and respiratory rate. CONCLUSIONS No higher risk of respiratory depression and increase in tcpaCO2 in opioid-naïve palliative care patients, compared to patients pretreated with strong opioids, during symptomatic therapy of dyspnea with strong opioids could be found.

Management of constipation in palliative care patients.

Purpose of reviewConstipation is a common symptom in palliative care patients that can generate considerable suffering due to both unpleasant physical symptoms and psychological preoccupations that may arise. There is uncertainty about the choice from varying recommendations for management of constipation and a varying clinical practice in palliative care settings. The purpose of the review is to evaluate the current recommendations of therapy guidelines and to determine the effectiveness of laxative administration for the management of constipation in palliative care patients. Recent findingsRecent findings in the literature include an updated version of the Rome criteria and related information on the functional gastrointestinal disorders, as well as information on opioid antagonists. Knowledge of the role of definitions, causes of constipation and the pathophysiology of opioid-induced constipation must be given a high priority in the treatment of patients receiving opioids. Diagnosis and therapy of constipation, therefore, should relate to findings in clinical investigation. SummaryThe treatment of constipation in palliative care is based on inadequate experimental evidence, such that there are insufficient randomized controlled trial data. Recommendations for laxative use can be related to efficacy. Particularly in patients with advanced-stage tumor disease this must be undertaken with careful consideration of their physical activity and dietary needs.

Management of constipation in palliative care patients undergoing opioid therapy: is polyethylene glycol an option?

This study assessed the efficacy of laxative use for treatment of constipation in patients receiving opioid therapy, with special attention to polyethylene glycol 3350/electrolyte solution (PEG-ES). Computerized data from 206 patients were analyzed using descriptive statistics. Subgroups were analyzed using confirmatory statistics. Constipation occurred in 42.7 percent of patients. Laxatives were administered to 74.3 percent of these patients using a standardized step scheme, with good results in 78.4 percent. As a therapy for constipation, the combined administration of PEG-ES, sodium picosulphate, and liquid paraffin proved most effective, although statistical analysis yielded no significance. Early use of PEG-ES using a step scheme holds promise for treatment of opioid-related constipation in palliative care patients, although further investigation is warranted.

Undergraduate training in palliative medicine in Germany: what effect does a curriculum without compulsory palliative care have on medical students’ knowledge, skills and attitudes?

Introduction: The effect of a curriculum without compulsory courses in palliative medicine on students’ knowledge, kills and attitudes towards the care of dying patients and decisions at the end of life was investigated. Methods: In a cross sectional, questionnaire based survey at the medical school of Bonn 1st, 3rd and 5th year students had to grade their knowledge and skills in items concerning palliative medicine. Attitudes towards end of life decisions were queried. Results: The return rate was 78%. Significant increase in self estimation of certainty comparing 1st to 5th year students were detected for the items distinction between palliative and curative medicine (p <0.001), symptom control (p <0.001), pain management (p =0.001) and communication (p =0.036). No significant differences were recorded for the items accompaniment of dying patients, breaking bad news and integration of spiritual aspects. The low overall certainty is reflected in poor knowledge. A significant decrease of the approval for euthanasia by request was evident (p =0.012). Discussion: A medical curriculum without compulsory course does increase confidence in some of the core competencies in palliative care, but the overall results at the end of the training are poor. The WHO claims that palliative care has to be “compulsory in courses leading to a basic professional qualification” has still to be fulfilled in Germany. This study can serve as a baseline to evaluate the effect of mandatory courses in palliative care.

Bowel function during pain therapy with oxycodone/naloxone prolonged-release tablets in patients with advanced cancer

Background:  The World Health Organization (WHO) step‐III opioids are often required right from the start of pain therapy in order to achieve sufficient symptom control. Bowel dysfunction, particularly constipation, is one of the most frequent and persistent side effects of opioid therapy, and it is known to cause considerable distress in many patients. The aim of the study was to evaluate whether patients with advanced cancer and moderate to severe cancer pain will benefit from treatment with oxycodone/naloxone prolonged‐release tablets (OXN), with particular regard to constipation.

Evaluation of the Clinical Effectiveness of Physiotherapeutic Management of Lymphoedema in Palliative Care Patients

OBJECTIVE Lymphoedema is a common sequela of cancer or its treatment that affects lymph node drainage. The physiotherapist, as member of the multiprofessional team in palliative care, is one of the keys to successful rehabilitation and management of patients with cancer and non-malignant motoneuron disease such as amyotrophic lateral sclerosis and palliative care needs. The aim of the study was to evaluate the frequency and effect of manual lymphatic drainage in palliative care patients with lymphoedema in a far advanced stage of their disease. METHODS Retrospective study (reflexive control design) of data of the 208 patients admitted to our palliative care unit from January 2007 to December 2007. Demographic and disease-related data (diagnosis, symptoms, Karnofsky performance status and effect of manual lymphatic drainage interventions) were documented and compared. STATISTICS mean ± SD, median; Wilcoxons test. RESULTS Of the 208 patients, 90 who reported symptom load due to lymphoedema were included; 67 (74.4%) had pain, 23 (25.6%) dyspnoea due to progredient trunk oedema. Mean age 65.5 ± 13.0 years; 33 (36.7%) male; Karnofsky index 50% (30-80%), mean length of stay 15.6 ± 8.0 days. The mean number of physiotherapeutic treatment interventions was 7.0 ± 5.8. Manual lymphatic drainage was well tolerated in 83 (92.2%) patients; 63 of 67 (94.0%) patients showed a clinically relevant improvement in pain, and 17 of 23 (73.9%) in dyspnoea. CONCLUSIONS The majority of the patients showed a clinical improvement in the intensity of symptoms after manual lymphatic drainage.

Attitudes toward active euthanasia among medical students at two German universities

AimThere has been an ongoing debate about a legalisation of active euthanasia (AE) in Germany. Palliative care education in German medical schools seeks to foster and cultivate a negative attitude toward AE, but little is known about its effectiveness in this respect. The aim of this study was to assess attitudes toward AE among students with and without palliative medicine tuition (PMT).MethodsThe link to an anonymised online questionnaire was sent out to 1,092 third, fifth and sixth year medical students (YMS) in August–November 2006 at two German universities: university one (U1) with compulsory and additional optional PMT and university two (U2) without any PMT. Thirteen questions addressed active, passive or indirect euthanasia and physician-assisted suicide (statistic: mean ± SD (range), Wilcoxon, Whitney U Test, significance p < 0.05).ResultsResponse rate was 17.5%; 59.2% of the questionnaires were returned from U1 and 40.8% from U2; 28.3% of the students were male. Whereas 50% of third YMS at U1 and 36.7% at U2 favoured a legalisation of AE, this was true for 22.4% sixth YMS at U1 and 35.7% at U2. At U1, the number of students who would want to make use of AE for themselves decreased considerably (70%-44.9%) but less at U2; main reasons were ‘unbearable suffering’ and ‘circumstances that lack dignity’. Of all students, 21.1% at U1 and 37.2% at U2 could imagine to perform AE in patients, even though 72.6% at U1 and 78.2% at U2 think its legalisation would promote misuse.ConclusionsThe high proportion of pro-AE attitudes gives reason to reconsider both ‘standard’ and palliative medicine tuition for medical students.

[Palliative medicine--definitions and principles].

Zum ThemaSeit den Anfängen der Medizin gehören die Linderung der Beschwerden und die Begleitung des Kranken zu den Aufgaben des Arztes. Mit den zunehmenden Möglichkeiten, Krankheiten heilen zu können, gerieten diese Aspekte ärztlichen Handelns in den Hintergrund, und erst die 90er Jahre des abgelaufenen 20. Jahrhunderts waren geprägt durch eine zunehmende dynamische Entwicklung unterschiedlicher palliativmedizinischer Dienste, die diese Aufgaben wieder in den Vordergrund stellten. Inzwischen wird die Palliativmedizin auch von denjenigen als ein wichtiges Thema angesehen, die dies noch vor wenigen Jahren für unnötig hielten.Die vorliegende Arbeit gibt eine Übersicht über die Situation der Palliativmedizin in Deutschland, beschreibt die bisherigen Definitionen der unterschiedlichen Organisationsformen und versucht Unterschiede und Gemeinsamkeiten darzulegen.