Ina Otte

“We need to talk!” Barriers to GPs’ communication about the option of physician-assisted suicide and their ethical implications: results from a qualitative study

GPs usually care for their patients for an extended period of time, therefore, requests to not only discontinue a patient’s treatment but to assist a patient in a suicide are likely to create intensely stressful situations for physicians. However, in order to ensure the best patient care possible, the competent communication about the option of physician assisted suicide (PAS) as well as the assessment of the origin and sincerity of the request are very important. This is especially true, since patients’ requests for PAS can also be an indicator for unmet needs or concerns. Twenty-three qualitative semi-structured interviews were conducted to in-depth explore this multifaceted, complex topic while enabling GPs to express possible difficulties when being asked for assistance. The analysis of the gathered data shows three main themes why GPs may find it difficult to professionally communicate about PAS: concerns for their own psychological well-being, conflicting personal values or their understanding of their professional role. In the discussion part of this paper we re-assess these different themes in order to ethically discuss and analyse how potential barriers to professional communication concerning PAS could be overcome.

General Practitioners' Attitudes towards Essential Competencies in End-of-Life Care: A Cross-Sectional Survey

Background Identifying essential competencies in end-of-life care, as well as general practitioners’ (GPs) confidence in these competencies, is essential to guide training and quality improvement efforts in this domain. Aim To determine which competencies in end-of-life care are considered important by GPs, to assess GPs’ confidence in these competencies in a European context and their reasons to refer terminally ill patients to a specialist. Design and Setting Cross-sectional postal survey involving a stratified random sample of 2000 GPs in Switzerland in 2014. Method Survey development was informed by a previous qualitative exploration of relevant end-of-life GP competencies. Main outcome measures were GPs’ assessment of the importance of and confidence in 18 attributes of end-of-life care competencies, and reasons for transferring care of terminally-ill patients to a specialist. GP characteristics associated with main outcome measures were tested using multivariate regression models. Results The response rate was 31%. Ninety-nine percent of GPs considered the recognition and treatment of pain as important, 86% felt confident about it. Few GPs felt confident in cultural (16%), spiritual (38%) and legal end-of-life competencies such as responding to patients seeking assisted suicide (35%) although more than half of the respondents regarded these competencies as important. Most frequent reasons to refer terminally ill patients to a specialist were lack of time (30%), better training of specialists (23%) and end-of-life care being incompatible with other duties (19%). In multiple regression analyses, confidence in end-of-life care was positively associated with GPs’ age, practice size, home visits and palliative training. Conclusions GPs considered non-somatic competencies (such as spiritual, cultural, ethical and legal aspects) nearly as important as pain and symptom control. Yet, few GPs felt confident in these non-somatic competencies. These findings should inform training and quality improvement efforts in this domain, in particular for younger, less experienced GPs.

The utility of standardized advance directives: the general practitioners’ perspective

Advance directives (AD) are written documents that give patients the opportunity to communicate their preferences regarding treatments they do or do not want to receive in case they become unable to make decisions. Commonly used pre-printed forms have different formats. Some offer space for patients to (a) appoint a surrogate decision maker, and/or (b) to determine future medical treatments and/or (c) give a statement of personal values. So far it is unknown which forms GPs preferably use and why they decide to do so. 23 semi-structured interviews with GPs were analysed using content analysis. Interviewees mainly use short templates (to appoint surrogate decision makers) and medium length templates with checkboxes to indicate patients’ preferences in regards to life prolonging measures. Especially when patients faced the progression of a disease, participants use the latter version. Only then, the interviewees remarked, patients are capable to rate concrete situations reliably. GPs also realize the importance of the verbal assessment of patients’ preferences; however they rarely keep a written form of the conversation. Some GPs hand out one or more templates and ask their patients to read and think about them at home with the option to talk to them about it later on, while others prefer their patients to fill them out alone at home. Regardless of template usage, most GPs emphasize that ADs require regular updates. GPs tend to see standardized advance directives mainly as a tool to start a conversation with their patients and to identify their real preferences and values. When the patient is still not facing the progression of an already existing disease it could be sufficient to only appoint a surrogate decision maker instead of creating a full AD. However, in all other situations, appointing a surrogate decision maker should be backed up by a written statement of a patient’s general values. Patients and their relatives should always have the opportunity to ask their GP for medical advice when drafting an AD. It is crucial to regularly verify and update existing ADs within the course of a disease.

Medizin trifft Ökonomie. Werkstattbericht zu einem interprofessionellen Lehrprojekt

Die sich stetig wandelnden Wechselbeziehungen zwischen medizinischem Ethos, ärztlicher Professionalität und neuen, ökonomisch orientierten Anreizstrukturen im Gesundheitswesen stehen gegenwärtig im Zentrum des medizinethischen Interesses (vgl. etwa [4, 5]). Der Umgang mit einem zunehmend wirtschaftlich geprägten Arbeitsumfeld wird bisher allerdings nur selten explizit zum Gegenstand von Lehrveranstaltungen des Medizinstudiums gemacht. Da wirtschaftliche Aspekte in der ärztlichen Tätigkeit eine bedeutende Rolle spielen, ist aus medizinethischer Sicht jedoch eine offene und reflektierte Auseinandersetzung mit möglichen Spannungen zwischen den „traditionellen“ ärztlichen Aufgaben und „neuen“ ökonomischen Herausforderungen wünschenswert, um die unkritische Übernahme von vorgelebten Verhaltensmustern zu vermeiden und einen Fatalismus zu verhindern, der sich angesichts von als übermächtig empfundenen wirtschaftlichen Zwängen zum Teil bereits während des Studiums einstellt. Die komplexe und zunehmend spezialisierte Patientenversorgung im modernen Gesundheitswesen erfordert weiterhin eine enge Kooperation von Ärzten1 mit nicht-ärztlichen Gesundheitsberufen. Im Bereich der Lehre wird daher zunehmend die Forderung nach

Entwicklungsstand von klinischer Ethikberatung in der Psychiatrie

OBJECTIVE The aim of this article is to assess the level of development of clinical ethics consultation in psychiatric institutions in North Rhine-Westphalia. METHODS Survey among medical directors, directors of nursing and administrative directors of all psychiatric acute clinics and forensic psychiatric hospitals in North Rhine-Westphalia. RESULTS 113 persons working in psychiatric acute clinics responded (response rate: 48 %) and 13 persons working in forensic psychiatric hospitals (response rate 62 %). We received at least one response from 89 % of all psychiatric acute clinics and from 100 % of all forensic psychiatric hospitals. 92 % of the responding psychiatric acute clinics and 29 % of the responding forensic psychiatric hospitals have already implemented clinical ethics consultation. CONCLUSION Clinical ethics consultation is more widespread in psychiatric institutions than was hitherto assumed. Future medical ethics research should therefore give greater attention to the methodology and the quality of clinical ethics consultation in psychiatric practice.Ziel der Studie Erhebung von Daten zur Verbreitung und zum Entwicklungsstand von klinischer Ethikberatung in psychiatrischen Institutionen in Nordrhein-Westfalen. Methodik Umfrage unter Arztlichen Direktoren, Pflege- und Verwaltungsdirektoren aller psychiatrischen Akutkrankenhauser und Masregelvollzugskliniken in Nordrhein-Westfalen. Ergebnisse Aus 89 % aller psychiatrischen Akutkrankenhauser und 100 % aller Masregelvollzugskliniken liegt mindestens ein Fragebogen vor. 92 % der antwortenden psychiatrischen Akutkrankenhauser und 29 % der Masregelvollzugskliniken halten Strukturen der klinischen Ethikberatung vor. Schlussfolgerung Strukturen der klinischen Ethikberatung sind in psychiatrischen Institutionen weiter verbreitet als bislang in der Forschung angenommen.

Requirements for the implementation of open door policies in acute psychiatry from a mental health professionals’ and patients’ view: a qualitative interview study

BackgroundTreating legally committed patients on open, instead of locked wards is controversially discussed and the affected stakeholders (patients, mental health professionals) have ambiguous views on the benefits and disadvantages. The study aims to assess the opinions and values of relevant stakeholders with regard to the requirements for implementing open wards in psychiatric hospitals.MethodsSemi-structured interviews were conducted with 15 psychiatrists, 15 psychiatric nurses and 15 patients, and were analyzed using qualitative content analysis.ResultsThe interviewees identified conceptual, personnel and spatial requirements necessary for an open door policy. Observation and door watch concepts are judged to be essential for open wards, and patients appreciate the therapeutic value they hold. However, nurses find the door watch problematic. All groups suggest seclusion or small locked divisions as a possible way of handling agitated patients. All stakeholders agree that such concepts can only succeed if sufficient, qualified staff is available. They also agree that freedom of movement is a key element in the management of acutely ill patients, which can be achieved with an open door policy. Finally, the interviewees suggested removing the door from direct view to prevent absconding.ConclusionsFor psychiatric institutions seeking to implement (partially) open wards, the present results may have high practical relevance. The stakeholders’ suggestions also illustrate that fundamental clinical changes depend on resource investments which – at least at a certain point – might not be feasible for individual psychiatric institutions but presumably require initiatives on the level of mental health care providers or policy makers.

„Etwas Menschliches ist verloren gegangen“ Erfahrungen leitender Ärzte in Bezug auf das DRG-System – eine qualitativ-normative Analyse

Only a few years after the implementation of the G-DRG (German Diagnosis Related Group) system physicians already began to complain of its negative effects on the quality of inpatient healthcare. The present study examines the recent experiences senior physicians have made with regard to the impact of the G-DRG system on the quality of healthcare and medical professionalism. Nine qualitative guided expert interviews were conducted focusing on the experiences of physicians in leading positions dealing with the G-DRG system in their everyday work. The interviewees report an intensification of work attributable to an increasing number of inpatient cases, a more lenient definition of medical indications and a reduction in patient retention time. The physicians interviewed have felt increasingly constrained by economic conditions. Additionally, they stated that the G-DRG systems incentive structure encourages the discrimination of older, care-dependent and multimorbid patients. Possible countermeasures include a political revision of incentive regulation as well as a strengthening of up-to-date professional ethical education and teaching.

Treatment recommendations within the leeway of clinical guidelines: A qualitative interview study on oncologists’ clinical deliberation

BackgroundRecommending the optimal treatment for an individual patient requires a well-balanced consideration of various medical, social and ethical factors. The interplay of these factors, interpretation of the patient’s situation and understanding of the existing clinical guidelines can lead to divergent therapy recommendations, depending on the attending physician. Gaining a better understanding of the individual process of medical decision-making and the differences occurring will support the delivery of optimal individualized care within the clinical setting.MethodsA case vignette of a 64-year-old patient with locally advanced pancreatic adenocarcinoma was discussed with oncologists in 14 qualitative, semi-structured interviews at two academic institutions. Relevant factors that emerged were ranked by the participants using the Q card sorting method. Qualitative data analysis and descriptive statistics were performed.ResultsOncologists recommend different therapeutic approaches within the leeway of the relevant clinical guidelines. One group of participants endorses a rather aggressive and potentially curative approach with a combination chemotherapy following the FOLFIRINOX protocol to provide the patient with the best chances of resectability. The second group suggests a milder chemotherapy approach with gemcitabine, highlighting the palliative approach and the patient’s quality of life. Clinical guidelines are generally seen as an important point of reference, but are complicated to apply in highly individual cases.ConclusionThe physician’s individual assessment of factors, such as biological age, general condition or prognosis, plays a decisive role in treatment recommendations, particularly in those cases which are not fully covered by guidelines. Judgment and discretion remain crucial in clinical decision-making and cannot and should not be fully ruled out by evidence-based guidelines. Therefore, a more comprehensive reflection on the interaction between evidence-based medicine and the physician’s estimation of each individual case is desirable. Knowledge of existing barriers can enhance the implementation of guidelines, for example, through medical education.