F. Elsner

What are the problems in palliative care? Results from a representative survey.

The development of a standardised core documentation for palliative care was initiated in Germany in 1996. Results from previous evaluations have shown the wide variability of the documentation in participating units. A different documentation form was used in 2001 using free text entries to find out what problems palliative care specialists perceive in their patients. Fifty-five of the 83 palliative inpatient units in Germany (66% of the units) as well as one unit each from Austria and Switzerland, documented 1,304 patients in the core documentation in 2001. Inpatient care was continued until death for 531 patients, 604 patients were discharged home and 169 patients were transferred to other places of care. Palliative care treatment effectively reduced mean physical symptom intensity. Mean intensities of psychological and social problems also were reduced although not as much as physical symptom load. Nursing problems were reduced for those patients discharged but not for those who died in the unit. Anxiety and depression were the most frequent psychological problems. Nursing problems were focussed on impairment of mobility and other activities of daily living such as washing, nutrition and drinking. Excessive distress on caregivers and the organisation of home care were the predominant social problems. In conclusion, this representative prospective survey with the majority of palliative care units in Germany showed the high effectiveness of symptom relief. Using the categories identified in this study, checklists were constructed and included in the documentation forms that are currently used for the core documentation project.

Assessing cognition and psychomotor function under long-term treatment with controlled release oxycodone in non-cancer pain patients

Background:  The therapeutic use of opioids can be associated with altered cognition and impaired psychomotor function. Several studies have demonstrated the impact of opioid therapy on psychomotor performance and cognition, but no data exist about the effect of long‐term treatment with controlled release oxycodone (CRO) on driving ability.

What is the profile of palliative care in Germany. Results of a representative survey

Since 1996 a working group of palliative care physicians has been developing a core documentation for palliative facilities. The data on a total of 1304 patients were collected in 2001. Treatment in palliative care units was provided for 531 patients until their death (Pat-V), 604 patients could be discharged home, and 169 patients were transferred to other facilities (Pat-E). Infusion therapy, physical therapy, positioning and mobilization, together with counseling and social services were initiated in more than 30% of the patients, while specific measures such as ascites or pleura puncture were instituted in less than 10%. Chemotherapy, radiotherapy, immunotherapy, urinary catheter, physical therapy, mobilization, positioning, psychotherapy, and social services were documented more frequently in the Pat-E group than in the Pat-V group. Chemotherapy was started in only 35 patients and radiotherapy in only 31 patients while they were in the palliative care unit. Parenteral nutrition, infusion therapy, wound management, and counseling were documented more frequently in the Pat-V group. Advanced directives were available for 9,9% of the patients omission or discontinuation of therapies was documented for 28,1%. Specific indications for the quality of palliative care provided could not be identified with the documentation instruments applied. The core documentation does however furnish data from a representative sample of in-patient palliative care in Germany, which can be used as a comparative data pool for other studies and quality assurance measures.

Tetrahydrocannabinol zur Therapie chronischer Schmerzen

ZusammenfassungEinleitung. Cannabis wurde bereits im vorigen Jahrhundert zur Therapie von Schmerzen eingesetzt. Sein Hauptwirkbestandteil Tetrahydrocannabinol (THC) steht in den letzten Jahren zunehmend in der Diskussion. Bisherige Indikationen waren die Therapie von Übelkeit, Erbrechen, Appetitlosigkeit und Niedergeschlagenheit. Auch zur Behandlung von Schmerzen wird es empfohlen. Erste eigene Erfahrungen mit THC zur Therapie chronischer Schmerzen sollen anhand von 6 Fallberichten dargestellt werden. Methodik. Retrospektiv wurden die Unterlagen von Patienten mit nichttumorbedingten chronischen Schmerzen, die von Februar 1998 bis Januar 2000 in der Schmerzambulanz der Klinik für Anästhesiologie mit THC behandelt worden waren, ausgewertet. Die Effektivität und Verträglichkeit bei analgetischer Indikation wurden retrospektiv untersucht. Ergebnisse. Im Untersuchungszeitraum wurde bei 6 Patienten THC zur Behandlung chronischer Schmerzen eingesetzt. Die Dosierungen lagen zwischen 5–20 mg/Tag. Bei 3 dieser Patienten konnte mit der Gabe von THC eine zufriedenstellende Schmerzreduktion erzielt werden. Bei den anderen 3 Patienten musste bei unzureichender Schmerzreduktion und nicht tolerablen Nebenwirkungen wie Übelkeit, Schwindelgefühl und Müdigkeit THC abgesetzt und die Therapie mit anderen Analgetika fortgeführt werden. Schlussfolgerung. Nach den Erfahrungen dieser retrospektiven Einzelfallbetrachtungen ist die analgetische Wirkung von THC individuell sehr unterschiedlich. Prospektive Untersuchungen sind erforderlich, um den Stellenwert von THC in der Schmerztherapie zu bewerten.AbstractIntroduction. Even in the last century cannabis was used in the treatment of chronic pain. The main active component of cannabis Delta-9-Tetrahydrocannabinol (THC) has been increasingly used in the treatment of nausea, vomiting, loss of appetite and depression. It is also recommended in the treatment of chronic pain. We present our first experiences with THC in the treatment of patients with chronic pain. Methods. All patients treated with THC in the period from February 1998 until January 2000 were evaluated. Pain relief and side effects of THC were examined retrospectively. Results. In the period of investigation 6 patients had been treated with THC because of chronic pain. Dosages between 5 and 20 mg/d had been used. A sufficient pain relief had been achieved in three patients. The other three suffered from intolerable side effects such as nausea, dizziness and sedation without a reduction of pain intensity. In these cases the treatment was continued with other analgesics. Conclusion. This retrospective evaluation of 6 case reports of patients treated with THC showed large individual differences in the effectiveness of THC in pain management. Prospective studies are necessary to evaluate the importance THC in the treatment of chronic pain.

Opioidwechsel auf transdermales Fentanyl im klinischen Alltag

ZusammenfassungEinleitung: Transdermales Fentanyl gewinnt in der Tumorschmerztherapie zunehmend an Bedeutung. Wir beschreiben die Gründe für eine Umstellung einer Opioidtherapie auf transdermales Fentanyl in einer universitären Schmerzambulanz. Material und Methode: Retrospektiv wurden die Krankenakten der Patienten untersucht, die in unserer Schmerzambulanz mit transdermalem Fentanyl behandelt worden waren. Die Umrechnungsfaktoren wurden aus den Opioiddosierungen vor und nach dem Wechsel ermittelt. Die Schmerzstärke wurde anhand der Numerischen Ratingskala (NRS 0: kein Schmerz, 10: nicht stärker vorstellbarer Schmerz) gemessen. Ergebnisse: Von Oktober 1995 bis Dezember 1997 wurden 101 Patienten mit transdermalem Fentanyl behandelt. 36 dieser Patienten waren schon zum Aufnahmezeitpunkt auf transdermales Fentanyl eingestellt. Von einem weiteren Patienten lagen nur unvollständige Unterlagen vor, so daß die Umstellung auf transdermales Fentanyl bei 64 Patienten ausgewertet werden konnte. Von diesen wurden 53 stationär und 11 ambulant auf transdermales Fentanyl umgestellt. 48% der Patienten waren mit retardiertem Morphin, 17% mit nicht-retardiertem Morphin, 11% mit Buprenorphin, 11% mit Tramadol, 5% mit Levomethadon, 5% mit Tilidin/Naloxon und 3% mit Piritramid vorbehandelt. Gründe für die Umstellung auf transdermales Fentanyl waren die unzureichende Schmerzreduktion (33%), der Wunsch des Patienten nach oraler Medikamentenreduktion (20%), gastrointestinale Nebenwirkungen wie Übelkeit (31%), Erbrechen (13%) und Obstipation (19%), Schluckbeschwerden (27%) oder andere. Eine Reduktion der Nebenwirkungen gaben 10 von 19 Patienten mit dokumentierten Nebenwirkungen an. 12 von 21 Patienten, die wegen unzureichender Schmerzreduktion umgestellt worden waren, berichteten nach Umstellung auf transdermales Fentanyl eine Abnahme der Schmerzintensität. Diskussion: Die Umstellung einer Opioidtherapie auf transdermales Fentanyl führte bei der Hälfte der Patienten entweder zu einer besseren Schmerzreduktion oder zu einer Verminderung der Nebenwirkungen. In der Literatur sind Umrechnungsfaktoren von oralem retardierten Morphin zu transdermalem Fentanyl von 70:1–100:1 beschrieben, was durch unsere Auswertungen bestätigt wird. Umrechnungsfaktoren von anderen Opioiden auf transdermales Fentanyl werden vorgeschlagen.AbstractIntroduction: The use of transdermal fentanyl is gaining in importance in the management of cancer pain. We describe the reasons for switching opioid medication to transdermal fentanyl in a pain management unit. Methods: Case records of patients treated with transdermal fentanyl in our pain clinic were evaluated retrospectively. Conversion ratios were calculated from the opioid dosage before and after conversion. Pain intensities were assessed on a numeric rating scale (NRS 0: no pain, 10: worst pain imaginable). Results: From October 1995 to December 1997 101 patients received transdermal fentanyl. Thirty-six patients had been treated with transdermal fentanyl before admission to our pain clinic, and relevant information was missing for one patient, so 64 patients were evaluated. Opioid therapy was switched to transdermal fentanyl during in-patient treatment for 53 patients and during out-patient treatment for 11 patients. Before conversion patients were treated with slow-release morphine (48%), immediate-release morphine (17%), buprenorphine (11%), tramadol (11%), levomethadone (5%), tilidine/naloxone (5%) and piritramid (3%). Reasons for opioid rotation were inadequate pain relief ( 33%), the patients’ wish to reduce oral medication (20%), gastrointestinal side effects such as nausea (31%), vomiting (13%) and constipation (19%), dysphagia (27%) or others. Reduction of side effects was reported by 10 of 19 patients . In 12 of 21 patients, in whom the medication was switched because of inadequate pain relief, a reduction in pain intensity was reported. Discussion: Conversion to transdermal therapy may readjust the balance between opioid analgesia and side effects. The opioid switch resulted in more pain relief or fewer side effects in half of the patients. A proposed equianalgesic conversion ratio between 70:1 and 100:1 from oral slow-release morphine to transdermal fentanyl can be confirmed by our data. Conversion rates from other opioids to transdermal fentanyl are suggested.

Prozesse und Interventionen auf den deutschen Palliativstationen

Since 1996 a working group of palliative care physicians has been developing a core documentation for palliative facilities. The data on a total of 1304 patients were collected in 2001. Treatment in palliative care units was provided for 531 patients until their death (Pat-V), 604 patients could be discharged home, and 169 patients were transferred to other facilities (Pat-E). Infusion therapy, physical therapy, positioning and mobilization, together with counseling and social services were initiated in more than 30% of the patients, while specific measures such as ascites or pleura puncture were instituted in less than 10%. Chemotherapy, radiotherapy, immunotherapy, urinary catheter, physical therapy, mobilization, positioning, psychotherapy, and social services were documented more frequently in the Pat-E group than in the Pat-V group. Chemotherapy was started in only 35 patients and radiotherapy in only 31 patients while they were in the palliative care unit. Parenteral nutrition, infusion therapy, wound management, and counseling were documented more frequently in the Pat-V group. Advanced directives were available for 9,9% of the patients omission or discontinuation of therapies was documented for 28,1%. Specific indications for the quality of palliative care provided could not be identified with the documentation instruments applied. The core documentation does however furnish data from a representative sample of in-patient palliative care in Germany, which can be used as a comparative data pool for other studies and quality assurance measures.

Encapsulation of an intrathecal catheter.

A 47-year-old patient with cancer pain underwent implantation of an intrathecal drug delivery device. When the patient suffered from an infection with fever, pain on injection into the catheter and an elevated number of granulocytes in the cerebrospinal fluid 7 weeks later, radiologic examination showed an encapsulation of the catheter tip. Concentrations of morphine and morphine-6-glucuronide in the cerebrospinal fluid suggested transport of morphine into the systemic circulation via the vascularisation of the encapsulating membrane. After antibiotic therapy and removal of the catheter, morphine was administered intravenously with a one to one conversion ratio.

Accompanying evalution of funded projects in palliative medicine of the German Cancer Aid

INTRODUCTION The German Cancer Aid funded 12 regional projects which developed different models of palliative home care. The realization of the projects were concurrently monitored and evaluated. MATERIAL AND METHODS The funded projects were asked to document all patients who were cared for beginning in January 2009 using HOPE (Hospice and palliative survey), MIDOS (Minimal documentation system for palliative patients) and the Barthel index. Documentation was mandatory at the beginning and the end of care as well as when patients changed settings, for example when patients were transferred from a palliative care unit to a palliative home care service. Additionally the projects were visited by an independent observer. RESULTS Overall the 12 projects documented 2,663 patients. Analysis revealed differences between the projects mainly concerning target groups and interventions. DISCUSSION The results of this evaluation can support the discussion about the development of palliative home care in Germany with particular focus on possible interrelations between structures, target groups and possible outcomes of care.

Begleitevaluation des Förderschwerpunkts Palliativmedizin der Deutschen Krebshilfe@@@Accompanying evalution of funded projects in palliative medicine of the German Cancer Aid

INTRODUCTION The German Cancer Aid funded 12 regional projects which developed different models of palliative home care. The realization of the projects were concurrently monitored and evaluated. MATERIAL AND METHODS The funded projects were asked to document all patients who were cared for beginning in January 2009 using HOPE (Hospice and palliative survey), MIDOS (Minimal documentation system for palliative patients) and the Barthel index. Documentation was mandatory at the beginning and the end of care as well as when patients changed settings, for example when patients were transferred from a palliative care unit to a palliative home care service. Additionally the projects were visited by an independent observer. RESULTS Overall the 12 projects documented 2,663 patients. Analysis revealed differences between the projects mainly concerning target groups and interventions. DISCUSSION The results of this evaluation can support the discussion about the development of palliative home care in Germany with particular focus on possible interrelations between structures, target groups and possible outcomes of care.

Begleitevaluation des Förderschwerpunkts Palliativmedizin der Deutschen Krebshilfe

INTRODUCTION The German Cancer Aid funded 12 regional projects which developed different models of palliative home care. The realization of the projects were concurrently monitored and evaluated. MATERIAL AND METHODS The funded projects were asked to document all patients who were cared for beginning in January 2009 using HOPE (Hospice and palliative survey), MIDOS (Minimal documentation system for palliative patients) and the Barthel index. Documentation was mandatory at the beginning and the end of care as well as when patients changed settings, for example when patients were transferred from a palliative care unit to a palliative home care service. Additionally the projects were visited by an independent observer. RESULTS Overall the 12 projects documented 2,663 patients. Analysis revealed differences between the projects mainly concerning target groups and interventions. DISCUSSION The results of this evaluation can support the discussion about the development of palliative home care in Germany with particular focus on possible interrelations between structures, target groups and possible outcomes of care.