Martina Pestinger

Criteria for successful multiprofessional cooperation in palliative care teams

Introduction : Team work is considered a central component of palliative care. Within this comparatively young field of medicine, the emergence of new institutions (eg, palliative care units) highlights the challenge of establishing a completely new team. Methods : This study focuses on the factors, which enhance both the success and outcome criteria of good team work from the perception of team members in a palliative care unit. The palliative care team at the University Hospital of Aachen (n = 19) was interviewed 1 year after the units startup by the means of semistructured interviews. Interview texts were analysed using qualitative content analysis. Results : Factors crucial to cooperation in the team members views were close communication, team philosophy, good interpersonal relationships, high team commitment, autonomy and the ability to deal with death and dying. Moreover, close communication was by far the most frequently mentioned criteria for cooperation. Team performance, good coordination of workflow and mutual trust underpin the evaluation of efficient team work. Inefficient team work is associated with the absence of clear goals, tasks and role delegation, as well as a lack of team commitment. Conclusion : In a new team, close communication is particularly important for staff as they reorientate themselves to the dynamics of a new peer group. The results confirm the overwhelming importance of clarity, commitment and close, positive exchange among team members for succesful team work. Pallative Medicine 2007; 21: 347—354

Outcome indicators in palliative care—how to assess quality and success. Focus group and nominal group technique in Germany

PurposeThe call for clinically relevant outcome criteria has been raised, as assessment of adequate quality of service providers is essential with increasing momentum in the development of palliative care in most European countries. The aim of this study is to investigate important dimensions and indicators for assessment and evaluation of palliative care from the perspective of multi-disciplinary German experts working over years in the field of palliative care.MethodsA focus group, using the structured consensus method of the improved nominal group technique (INGT), with nine experts from different disciplines was conducted in Germany.ResultsAn abundance of topics (16) were identified, pointing at the complexity of the issue. Main topics were: quality of life, needs assessments of patients and relatives, resource assessment, surveillance of decision-making processes, as well as spiritual well-being. The following properties were claimed as essential for outcome criteria sensitivity, without additional burden on patients, easy applicability, scientific validity, and helpful for communication within the team, ethical discussions as well as for quality management.ConclusionsThe study identified topics considered important by experts in clinical practise. The discussions exposed the diversity of demands on outcome assessment put up by different stakeholder groups. This and the high number of relevant items show the complexity for the agreement on a unique set of outcome criteria. Further research considering other perspectives is needed.

Barriers and needs in paediatric palliative home care in Germany: a qualitative interview study with professional experts

BackgroundIn North-Rhine Westphalia (Germany) a pilot project for an extensive service provision of palliative care for children and adolescents has been implemented. Accompanying research was undertaken with the aim to assess the status quo of service delivery at the outset of the project and to evaluate the effects of the pilot project. As part of the research, barriers and needs with respect to paediatric palliative home care in the target region were explored.MethodsSemi-structured interviews with 24 experts in the field of paediatrics, palliative and hospice care have been conducted and were analysed by qualitative content analysis.ResultsFour main categories emerged from the interviews: (1) specific challenges and demands in palliative care for children and adolescents, (2) lack of clear legal and financial regulations, (3) gaps in the existing care delivery, and (4) access to services. Generally the interviews reflected the observation that the whole field is currently expanding and that certain deficits are temporary barriers that will be resolvable in the medium-term perspective.ConclusionsPredominant barriers were seen in the lack of clear legal and financial regulations which take into account the specific challenges of palliative care in children and adolescents, as well as in a shortcoming of specialist services for a local based care provision throughout the federal country.

Antibiotics in palliative medicine—results from a prospective epidemiological investigation from the HOPE survey

BackgroundPatients with advanced cancer are highly susceptible to infections. The decision whether to treat an active or suspected infection or to withhold or withdraw an antibiotic treatment in end-of-life care may be difficult. In order to quantify the antimicrobial prescribing practices and decision-making processes in palliative care units in Germany, a survey was performed as part of the Hospice and Palliative Evaluation in 2006.MethodWith a specifically designed questionnaire, 448 patients for whom an active or suspected infection and antibiotic treatment was discussed were documented. Data on the use of and indication for antibiotic treatment and the decision-making on withdrawal or withholding of antibiotic therapy were collected.Results286 (63.8%) received an antibiotic therapy. In 88 cases, withdrawal of an ongoing treatment was documented. The most frequent reasons for withdrawal were: deterioration of general status (41.4%), inefficiency of therapy (25.7%), and explicit wish of patient (14.3%; multiple answers possible). Outcome of antimicrobial therapy was rated poor or very poor for a fifth of the cases and accordingly, antibiotics were more likely to be withdrawn if the clinical success was considered to be poor. The initiation of therapy was often decided by physicians solely, whereas withdrawing and withholding therapy demanded more often involvement of other team members in the decision-making process.ConclusionThe initiation of therapy seems to be easier than withdrawing and withholding, as involvement of other team members in the decision-making process was then sought more often. When antibiotics were given until death, the indication should be reconsidered because of a possibly undesirable prolongation of the dying process. Clinical practice may benefit from clear definitions of treatment goals and outcome criteria to better evaluate the necessity for and success of antimicrobial treatment.

The neurofunctional mechanisms of traumatic and non-traumatic memory in patients with acute PTSD following accident trauma

Neurofunctional alterations in acute posttraumatic stress disorder (PTSD) and changes thereof during the course of the disease are not well investigated. We used functional magnetic resonance imaging to assess the functional neuroanatomy of emotional memory in surgical patients with acute PTSD. Traumatic (relative to non-traumatic) memories increased neural activity in the amygdala, hippocampus, lateral temporal, retrosplenial, and anterior cingulate cortices. These regions are all implicated in memory and emotion. A comparison of findings with data on chronic PTSD suggests that brain circuits affected by the acute disorder are extended and unstable while chronic disease is characterized by circumscribed and stable neurofunctional abnormalities.

The use of Grounded theory in palliative care: methodological challenges and strategies

BACKGROUNDnThe need for research methods that are suited to evaluate important issues and phenomena in palliative care has established different qualitative research approaches during the last years. This article describes the use and adaptation of a qualitative research methodology in a palliative care setting.nnnRESEARCH PROCESSnThe wish for hastened death of terminally ill patients is an important end-of-life issue. Proponents of palliative care have argued that good palliative care would prevent the wish for hastened death. However, this wish is stated by a few patients receiving palliative care, raising a challenging dilemma for patients, relatives and caregivers involved. In order to investigate the motivations of the patients asking for hastened death, we conducted a qualitative study using Grounded theory (GT). This article aims to illustrate the use of a flexible, less burdening qualitative research method and the adaptation of the research process of GT in a palliative care research setting. This is based on experiences and illustrated by examples from the qualitative study on the wish for hastened death in patients receiving palliative care.nnnCONCLUSIONSnGT allowed a systematic understanding of patients experiences and attitudes and careful in-depth exploration of this vulnerable population. Conducting a GT study needs high staff resources, a great catchment area for participant recruitment and realistic inclusion and exclusion criteria to allow for theoretical sampling. The use of GT should be facilitated by an experienced researcher familiar with this method because of high methodological requirements and rather complex analysis procedures.

The desire to hasten death: Using Grounded Theory for a better understanding “When perception of time tends to be a slippery slope”

Background: Some patients with advanced and progressive diseases express a desire to hasten death. Aim: This study evaluated the motivations of patients expressing such a desire in a country with prohibitive legislation on euthanasia and physician-assisted suicide. Design: A modified form of Grounded Theory was used. Setting/participants: Patients from the departments of palliative medicine in three hospitals in Germany were recruited when they had made a statement or request to hasten death. Participants were interviewed face to face. Recruitment was stopped with 12 participants because of data saturation. Results: Thematic analysis revealed three main motivational themes: self-determination, agony, and time. Expectations toward health professionals, attitudes toward death, and secureness related to the end of life were additional main themes emerging from the analysis. Conclusions: The desire to hasten death may be used as an extreme coping strategy to maintain control against anticipated agony. Patients expected health professionals to listen to and respect their experiences. Emerging hypotheses included the following: (a) patients try to balance life time and anticipated agony, and the perception of time is distressing in this balancing act; (b) anticipated images of agony and suffering in the dying process occur frequently and are experienced by patients as intrusive; (c) patients expressing a desire to hasten death are in need of more information about the dying process; and (d) patients wanted their caregivers to listen to and respect their wish to hasten death, and they did not expect the caregivers to understand this as an order to actually hasten their death.

Psychosocial and spiritual problems of terminally ill patients in Kerala, India

AIMnTo investigate psychosocial and spiritual problems of terminally ill patients in Kerala, India.nnnMATERIALS & METHODSnSemi-structured qualitative interviews of terminally ill patients were carried out at the Trivandrum Institute of Palliative Sciences Palliative Care Clinic in Trivandrum, Kerala, India and in patients homes in the surrounding area.nnnRESULTSnInterviews with 37 terminally ill patients in Kerala showed several problems regarding their emotional state, faith, knowledge about the disease, family life and the major impact of financial issues.nnnCONCLUSIONnThis study shows that more effort should be focused on the reduction of the problems terminally ill patients have to face. While many of these problems are a result of financial troubles and could be eliminated if sufficient funds were available, others are a consequence of tradition and culture. Solutions for the improvement of patients situations in accord with tradition and culture have to be found.

Wunsch nach vorzeitigem Lebensende

Zusammenfassung„Herr Doktor, können Sie mir nicht eine Spritze geben, damit ich morgen nicht mehr aufwachen muss?“ Diese und ähnliche Bitten um ärztliche (Sterbe-)Hilfe drücken einerseits auf dramatische Art und Weise das Leid von Patienten aus und bringen Behandlerteams andererseits in eine schwierige Situation. Umfangreiche Forschungsbemühungen beschäftigen sich seit nun fast 2xa0Jahrzehnten mit den Fragen, was der Wunsch nach dem vorzeitigen Sterben von unheilbar erkrankten Patienten bedeuten und wie man adäquat darauf reagieren kann. Diese Übersichtsarbeit soll (inter)nationale ethisch-rechtliche Hintergründe beleuchten und den aktuellen Forschungsstand zum Sterbewunsch von unheilbar erkrankten Patienten zusammenfassen. Im Mittelpunkt stehen Gründe für den Sterbewunsch, kommunikative Funktionen der Bitte um Sterbehilfe, ärztliche Einstellungen und die Bereitschaft zur Sterbehilfe sowie Empfehlungen für den Umgang mit den betreffenden Patienten im klinischen Behandlungsalltag.Abstract“There’s nothing more to do, so let’s come to an end, Doc!” A request for euthanasia or physician-assisted suicide is a dramatic expression of patients’ suffering and causes difficulties for staff members to react to these questions. Great efforts have been made in the last two centuries to gain a deeper understanding of the wish for hastened death of terminally ill patients and to develop conclusions for the management of these situations. This article presents differences in international legislation on euthanasia and summarises the ethical background. The current results from the literature according to motivations for the wish for hastened death, communicative functions of the request, attitudes and practices of physicians and their willingness to accompany the patient in euthanasia as well as practical implications for clinical practice are discussed.Theres nothing more to do, so lets come to an end, Doc! A request for euthanasia or physician-assisted suicide is a dramatic expression of patients suffering and causes difficulties for staff members to react to these questions. Great efforts have been made in the last two centuries to gain a deeper understanding of the wish for hastened death of terminally ill patients and to develop conclusions for the management of these situations. This article presents differences in international legislation on euthanasia and summarises the ethical background. The current results from the literature according to motivations for the wish for hastened death, communicative functions of the request, attitudes and practices of physicians and their willingness to accompany the patient in euthanasia as well as practical implications for clinical practice are discussed.

Subjective Definitions of Problems and Symptoms in Palliative Care

Background Data from the core data set of the Hospice and Palliative Care Evaluation (HOPE) from 1999 to 2001 demonstrated considerable variance in the incidence of patients’ symptoms and problems between participating services. This paper aims to investigate these differences more closely. Methods During the evaluation period of HOPE in 2002 a telephone survey with a representative of each participating unit was performed. Telephone interviews assessed the professionals’ definitions of selected symptoms and estimates of problem and symptom incidences. Content analysis was used to evaluate qualitative answers. Results Staff members rated pain, weakness, nausea/emesis as the most frequent physical symptoms; anxiety, depression and amentia as most frequent psychological symptoms; wound treatment, mobilisation and weakness as nursing problems and organisation of care settings, loneliness, demands of relatives the most common social needs. Staff members used a wide range of definitions for cachexia, weakness and depression. Discussion Standard definitions of symptoms and problems were lacking in the articulation of subjective staff members’ perspectives. Meaningful evaluation of multicentre surveys would require training in symptom assessment and classification in order to produce a common basis for documentation. Even though definitions differed widely, underlying concepts seemed to be compatible.