Friedemann Nauck

Implementing the cross-disciplinary subject of palliative medicine (Q13) against the backdrop of recent changes of the legal framework using University Medical School Gottingen as an example.

Palliative care for patients with advanced and progressive diseases has recently become an integrated and compulsory part of undergraduate training in Germany. Up until now, undergraduate teaching in this cross-disciplinary medical field varied and therefore problems during the implementation process with regard to formal aspects and teaching content are to be expected. This contribution summarizes the new legislative framework for palliative care as an independent specialty in undergraduate medical training and describes format, content and problems of the current implementation process at the University Medical School Göttingen, in order to provide advice and support for other faculties.

Outpatient and Inpatient Structures: What Does It Need to Integrate Palliative Care Services?

How to organise comprehensive cancer care from the onset of metastatic disease to the end of life is debated. Arguments exist for full integration of palliative services into general oncology care, and some studies have shown that oncologists having insight and knowledge about palliative care result in improved collaboration and early referral (Kaasa 2013). There is strong evidence underscoring the importance of integrating palliative care across the trajectory of cancer (Shin and Temel 2013; Bakitas et al. 2009; Alt-Epping et al. 2012). Recommendations for such integration have been made by oncological societies, among others, the American Society of Clinical Oncology (Smith et al. 2012), and by authors of comprehensive review articles on this matter (Gaertner et al. 2013; Greer et al. 2013). These include triangular cooperation between cancer specialists, primary care services and specialist palliative care teams; communication, congruity and continuity of care; and coordination, cooperation contracts and collegiality. A qualitative study among oncologists showed that they believed that integrating palliative care enhanced patient care, complemented their own practice and enabled them to ‘share the load’ (Bakitas et al. 2013).

Implementierung eines Klinischen Ethikkomitees

An der Universitatsmedizin Gottingen (UMG) wurde im Herbst 2010 ein Klinisches Ethikkomitee gegrundet. Damit reiht Gottingen sich in die vor allem im vergangenen Jahrzehnt stetig gewachsene Anzahl universitarer Kliniken ein, die ein solches Gremium an ihrem Hause einrichten (vgl. Frewer et al. 2008; Dorries 2010).

Selbstbestimmung braucht Vertrauen – Entscheidungsfindung am Lebensende

Bereits Norbert Elias macht in seinem Aufsatz ‚Uber die Einsamkeit der Sterbenden in unseren Tagen‘ (1983) darauf aufmerksam, dass die allmahliche Verdrangung des Todes ein Phanomen moderner hochzivilisierter Gesellschaften sei. Durch den stetig voranschreitenden medizinischen Fortschritt, die steigende Lebenserwartung und die Moglichkeiten durch Praventivmasnahmen Krankheiten vorzubeugen, habe der Tod mit der Zeit an Bedrohlichkeit verloren. Die Vorstellung vom Tod sei haufig an ein Bild ‚friedlichen‘ Sterbens gebunden (ebd. 75).

The Final Phase

Palliative care aims to improve the quality of life of patients and their families facing life-threatening illness. An overall treatment strategy not only includes prevention, assessment, and treatment of pain and other symptoms but also integrates psychological, social, emotional, and spiritual problems of the patient and his/her relatives. The large majority of patients being managed in palliative medicine are suffering from incurable, far-advanced, and progressive cancer. Pain is the major source of anxiety and distress at the end of life, particularly in cases of end-stage cancer. As in any stage of the disease, cancer pain treatment requires standardized guidelines adapted to the WHO’s three-step ladder of cancer pain relief (WHO 1996). Burdens and suffering of patients and relatives should be minimized, and physical, psychosocial, and spiritual symptoms must be treated even in the terminal phase.

Emergencies in Oncology and Crises in Palliative Care

It belongs to the distinguishing features of cancer that its disease trajectory and its causative treatment implicate numerous critical situations and emergencies that lead to life-threatening situations, and in a significant proportion of patients, these emergencies (instead of the tumour manifestations themselves) will be life-limiting. Therefore, the care of patients suffering from cancer as well as the respective anticancer treatment requires profound expertise in oncology and in emergency care.