Gerd G. Hanekop

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<u20090.01).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.

Emergency calls and need for emergency care in patients looked after by a palliative care team: Retrospective interview study with bereaved relatives.

BackgroundDuring the last stage of life, palliative care patients often experience episodes of respiratory distress, bleeding, pain or seizures. In such situations, caregivers may call emergency medical services leading to unwanted hospital admissions. The study aims to show the influence of our palliative care team to reducing emergency calls by cancer patients or their relatives during the last six month of life.MethodsFifty relatives of deceased patients who had been attended by our palliative care team were randomly selected. Data was obtained retrospectively during a structured interview. In addition to demographic data, the number of emergency calls made during the final six months of the patients life, the reason for the call and the mental compound score (MCS-12) of the caregivers was registered.ResultsForty-six relatives agreed to the interview. Emergency calls were placed for 18 patients (39%) during the final six months of their lives. There were a total of 23 emergency calls. In 16 cases (70%) the patient was admitted to the hospital. Twenty-one (91%) of the calls were made before patients had been enrolled to receive palliative care from the team, and two (9%) were made afterwards. The mean mental compound score of the caregivers at the time of the interview was 41 (range 28–57). There was a lack of correlation between MCS-12 and number of emergency calls.ConclusionEmergency calls were more likely to occur if the patients were not being attended by our palliative care team. Because of the lack of correlation between MCS-12 and the number of emergency calls, the MCS-12 cannot indicate that acutely stressful situations triggered the calls. However, we conclude that special palliative care programs can reduce psychosocial strain in family caregivers. Therefore, the number of emergency calls may be reduced and this fact allows more palliative patients to die at home.

Prehospital emergency treatment of palliative care patients with cardiac arrest: a retrolective investigation.

BackgroundToday, prehospital emergency medical teams (EMTs) are confronted with emergent situations of cardiac arrest in palliative care patients. However, little is known about the out-of-hospital approach in this situation and the long-term survival rate of this specific patient type. The aim of the present investigation was to provide information about the strategic and therapeutic approach employed by EMTs in outpatient palliative care patients in cardiac arrest.MethodsDuring a period of 2xa0years, we retrolectively analysed emergency medical calls with regard to palliative care emergency situations dealing with cardiac arrest. We evaluated the numbers of patients who were resuscitated, the prevalence of an advance directive or other end-of-life protocol, the first responder on cardiac arrest, the return of spontaneous circulation (ROSC) and the survival rate.ResultsEighty-eight palliative care patients in cardiac arrest were analysed. In 19 patients (22%), no resuscitation was started. Paramedics and prehospital emergency physicians began resuscitation in 61 cases (69%) and in 8 cases (9%), respectively. A total of 10 patients (11%) showed a ROSC; none survived after 48xa0h. Advance directives were available in 43% of cases. The start of resuscitation was independent of the presence of an advance directive or other end-of-life protocol.ConclusionsStrategic and therapeutic approaches in outpatient palliative care patients with cardiac arrest differ depending on medical qualification. Although many of these patients do not wish to be resuscitated, resuscitation was started independent of the presence of advance directive. To reduce legal insecurity and to avoid resuscitation and a possible lengthening of the dying process, advance directives and/or “Do not attempt resuscitation” orders should be more readily available and should be adhered to more closely.

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.

Post-mortal bereavement of family caregivers in Germany: a prospective interview-based investigation

ZusammenfassungHINTERGRUND: Unterstützende Aspekte ambulanter Palliativdienste umfassen medizinische, psychologische und spirituelle Bedürfnisse von Patienten und ihren betreuenden Angehörigen. Die Zielsetzung der vorliegenden Arbeit ist die Untersuchung der postmortalen Trauerverarbeitung betreuender Angehöriger. METHODIK: In der Studie wurde der Einfluss eines ambulanten Palliativdienstes auf die postmortale Trauerverarbeitung von 50 betreuenden Angehörigen verstorbener Patienten untersucht. Die Interviews wurden mithilfe eines für die Untersuchung erstellten Fragebogens in Bezug auf die validierten Kriterien von Prigerson, Horowitz sowie der Definition nach ICD-10 zur Trauerverarbeitung erstellt. Eingeschlossen wurden alle Personen im Alter von über 18 Jahren, die den Patienten während seiner Krankheit überwiegend betreuten. ERGEBNISSE: Es konnten insgesamt 46 betreuende Angehörige entsprechend der definierten Kriterien in die Untersuchung eingeschlossen werden. Gemäß den Kriterien von Prigerson, Horowitz sowie nach ICD-10 wurde bei bis zu 30% der Untersuchten eine komplizierte Trauerverarbeitung festgestellt. Bezüglich der drei Kriterien konnte kein statistisch signifikanter Unterschied festgestellt werden (P > 0,05). Ebenfalls konnte unter Berücksichtigung des Alters, des Geschlechts der Angehörigen, der Art der Tumorerkrankung, der Dauer der Erkrankung oder der Qualitätsempfindung der Betreuung durch den ambulanten Palliativdienst kein statistisch signifikanter Unterschied der Trauerverarbeitung bzw. des Risikos für eine pathologische Trauerreaktion ermittelt werden (P > 0,05). Insgesamt waren 97% der Angehörigen mit der Betreuung durch den Palliativdienst zufrieden. SCHLUSSFOLGERUNG: Die Ergebnisse unserer Untersuchung lassen vermuten, dass die Unterstützung betreuender Angehöriger das Risiko einer pathologischen Trauerreaktion vermindern kann. Eine sorgsame Exploration möglicher Faktoren, die auf eine pathologische Trauerreaktion deuten, ist in der Betreuung von besonderer Bedeutung. Unterstützende spezialisierte ambulante palliativmedizinische Hilfsangebote sind zu empfehlen, um zahlreiche Probleme zu reduzieren und die Trauerreaktion positiv zu beeinflussen. Deshalb scheint es notwendig, Hilfe sowohl vor als auch nach dem Tod eines Patienten anzubieten, um die Trauerverarbeitung positiv beeinflussen zu können.SummaryBACKGROUND: Care aspects of outpatient palliative-care teams involve the medical, psychological, and spiritual needs of patients and their caregivers. The objective of our study was to examine the post-mortal bereavement of family caregivers. METHODS: The investigation was based on interviews with 50 family caregivers of 50 palliative-care patients assessed by a palliative-care team. Each caregiver was interviewed using interview sheets (mixed method designs) in accordance with three groups of validated criteria for complicated grief: Prigerson, Horowitz, and ICD-10. RESULTS: Forty-six family caregivers of terminally ill patients participated in the study. Complicated grief existed in up to 30% of the caregivers, based on the three sets of criteria. There was no significant difference (P > 0.05) among the three groups and no significant differences were found (P > 0.05) in relation to age, sex, psychosocial distress, primary cancer disease, and duration of illness or quality of care. Overall, 97% of the care-giving relatives were satisfied with the help given by the palliative-care team. CONCLUSION: The results of the study suggest that care from a specialized palliative-care team providing psychological and social support may reduce the risk of complicated grief. Careful exploration of possible risk factors for complicated grief is important for optimal care. Our study shows that healthcare providers play an important role in helping family caregivers to manage the multiple burdens and the grieving reaction. Family-focused grief therapy may prevent complicated grieving reactions.

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.BACKGROUNDnIn 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.nnnMETHODSnIn 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.nnnRESULTSnThe 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%.nnnCONCLUSIONnThe 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.

International recommendations for outpatient palliative care and prehospital palliative emergencies - a prospective questionnaire-based investigation.

BackgroundTo determine the international recommendations and current practices for the treatment and prevention of palliative emergencies. The primary goal of the study was to gather information from experts on their nationally practised concepts.MethodsOne hundred and fifty self-report surveys were distributed by email to selected leading experts (palliative and emergency medical care) in Europe, North and South America, Africa, Asia, and Australia. An expert in this context was defined as an author of an article that was ranked by three reviewers as relevant to outpatient palliative and emergency medical .ResultsThe total response rate was 61% (nu2009=u200992 experts). Survey responses were obtained from 35 different countries. The following standards in the treatment of palliative emergencies were recommended: (1) early integration of “Palliative Care Teams” (PCTs) and basic outpatient palliative care systems, (2) end-of-life discussions, (3) defined emergency medical documents, drug boxes, and “Do not attempt resuscitation” orders and (4) emergency medical training (physicians and paramedics).ConclusionsThis study detected structurally and nationally differences in outpatient palliative care regarding the treatment of palliative emergencies. Accordingly, these differences should be discussed and adapted to the respective specifications of individual single countries. A single established outpatient palliative emergency medical care concept may be the basis for an overall out-of-hospital palliative care system.

Midterm results after arterial switch operation for transposition of the great arteries: a single centre experience

BackgroundThe arterial switch operation (ASO) has become the surgical approach of choice for d-transposition of the great arteries (d-TGA). There is, however an increased incidence of midterm and longterm adverse sequelae in some survivors. In order to evaluate operative risk and midterm outcome in this population, we reviewed patients who underwent ASO for TGA at our centre.MethodsIn this retrospective study 52 consecutive patients with TGA who underwent ASO between 04/1991 and 12/1999 were included. To analyze the predictors for mortality and adverse events (coronary stenoses, distortion of the pulmonary arteries, dilatation of the neoaortic root, and aortic regurgitation), a multivariate analysis was performed. The follow-up time was ranged from 1–10u2009years (mean 5u2009years, cumulative 260 patient-years).ResultsAll over mortality rate was 15.4% and was only observed in the early postoperative period till 1994. The predictors for poor operative survival were low APGAR-score, older age at surgery, and necessity of associated surgical procedures. Late re-operations were necessary in 6 patients (13.6%) and included a pulmonary artery patch enlargement due to supravalvular stenosis (nu2009=u20093), coronary revascularisation due to coronary stenosis in a coronary anatomy type E, aortic valve replacement due to neoaortic valve regurgitation (nu2009=u20092), and patch-plasty of a pulmonary vein due to obstruction (nu2009=u20091). The dilatation of neoaortic root was not observed in the follow up.ConclusionsASO remains the procedure of choice for TGA with acceptable early and late outcome in terms of overall survival and freedom of reoperation. Although ASO is often complex and may be associated with morbidity, most patients survived without major complications even in a small centre.

Notärztliche Behandlung akuter Schmerzexazerbationen bei ambulanten Palliativpatienten in Deutschland

ZusammenfassungHintergrundAkute Schmerzexazerbationen sind bei ambulanten Palliativpatienten mit Tumorerkrankungen (fehlender kurativer Therapieansatz) im Verlauf ihrer Erkrankung ein häufiges akutes Symptom. Die präklinische Therapie solcher Symptome muss oftmals durch Notärzte geleistet werden. Bisher beinhaltet die notfallmedizinische Ausbildung jedoch nur selten Themen zur Tumorschmerztherapie und zum Umgang mit Patienten am Lebensende.MethodenInnerhalb von 24xa0Monaten wurden retrospektiv und multizentrisch alle Notarzteinsätze (4xa0Notarztstandorte) bei Palliativpatienten mit Tumorerkrankungen mit der Einsatzdiagnose akute Schmerzexazerbation ausgewertet.ErgebnisseInsgesamt 17xa0Palliativpatienten mit akuten Schmerzsyndromen konnten identifiziert werden (4,6% aller Einsätze bei Palliativpatienten während des definierten Untersuchungszeitraums). Bei 10xa0Patienten wurde präklinisch keine Linderung der Beschwerden erreicht und 15xa0Patienten wurden zur weiteren Therapie in eine Klinik eingewiesen. Ein ambulanter Palliativdienst (APD) wurde in zwei Situationen durch den Notarzt informiert, so dass eine patientenorientierte Versorgung in der Folge möglich war.SchlussfolgerungDie akute Schmerzexazerbation bei ambulanten Palliativpatienten stellt im notfallmedizinischen Einsatz insgesamt eher eine Seltenheit dar. Trotzdem kann sich eine derartige Situation für die betroffenen Patienten und deren Angehörige dramatisch entwickeln. In der präklinischen Versorgung ist in solchen Situationen eine adäquate und schnelle Hilfe durch palliativmedizinisch erfahrene Notärzte oder spezialisierte APD notwendig, damit der Patient in der Folge zu Hause verbleiben kann und eine oftmals nicht gewünschte Klinikeinweisung unterbleibt. In diesem Zusammenhang ist es sinnvoll, die Versorgungsstruktur spezialisierter APD auszubauen und die notfallmedizinische Ausbildung von Ärzten um tumorschmerztherapeutische und palliativmedizinische Themen zu erweitern.AbstractBackgroundBreakthrough cancer pain is a symptom often reported by out-of-hospital palliative care patients in an advanced stage of cancer. Therefore, prehospital emergency physicians (EP) may be confronted with the acute care of breakthrough pain in palliative care patients in a home-care setting. Up to now, there is a lack of specialized out-of-hospital palliative care teams. There is also a lack of concepts for emergency care of palliative patients at the end of their lives given their specific symptoms.MethodsOver a 24xa0month period all emergency medical missions for patients with breakthrough cancer pain (four emergency medical systems) were retrospectively investigated. Only services for palliative care patients with cancerous diseases were included (diagnosis of breakthrough pain).ResultsThe primary service diagnosis of breakthrough pain in palliative care patients occurred 17xa0times within the defined period (4.6% of all emergency medical missions for palliative patients during the defined time period). After emergency therapy 15xa0of these patients were admitted into hospital. In 10xa0cases no adequate relief by pain therapy was possible. A specialized palliative care team (PCT) was integrated into the out-of-hospital therapy 2xa0times by an EP.ConclusionsConcerning the emergency medical setting, breakthrough cancer pain in palliative care patients seems to be rare. However, such a situation can dramatically develop for patients and care-giving relatives. Therefore, an adequate and fast cancer pain therapy is necessary to allow the patient to stay at home after such an acute situation. The use of specialized outpatient PCT to support emergency situations motivated by palliative care patients should be encouraged. Basic principles of cancer pain therapy and palliative medical care (end-of-life care) should be integrated into emergency medical curricula to comply with the ethical principles of medical treatment at the end of life.