U. Bartels

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< 0.01).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.

„No-flow-time“-Reduzierung durch Einsatz des Larynxtubus

OBJECTIVE In 2005 the European Resuscitation Council (ERC) published the new guidelines for Advanced Life Support (ALS). One of the aims was to reduce the no flow time (NFT), without chest compression in the first period of cardiac arrest. Furthermore the guidelines recommend that endotracheal intubation should only be carried out by personnel experienced in this procedure. METHODS An attempt was made to evaluate whether the use of the laryngeal tube suction (LTS-D) for emergency airway management could contribute to reduce NFT compared to bag-mask ventilation (BMV). In a randomised prospective study 50 participants were asked to perform standardised simulated cardiac arrest management on a full-scale simulator following a one-day cardiac arrest training. Each participant was randomised into the LTS-D and the BMV group for airway management. At the end of each scenario an evaluation of the use of each ventilation procedure by the participants was made by means of a questionnaire. RESULTS During the manikin scenario (430 s for LTS-D and 420 s for BMV) there was a significant difference in the overall NFT comparing the use of the LTS-D vs. BMV (105.8 s, range 94-124 s vs. 150.7 s, range 124-179 s; p<0.01). This corresponded during the whole scenario to a proportion of 24.6% (LTS-D) or 35.9% (BMV). Using the LTS-D all participants were able to ventilate the manikin successfully (tidal volume 500-600 ml). In a subjective evaluation of the different airway management procedures by the participants more than 90% expressed a positive opinion about the LTS-D with respect to ease of insertion and safety of ventilation. CONCLUSION The use of the LTS-D on a manikin by emergency physicians after standardised cardiac arrest training significantly reduces the NFT in comparison to BMV. Therefore the LTS-D seems to be a good alternative to BMV during a simulated cardiac arrest scenario.

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.

Der finale Tumorpatient in der notfallmedizinischen Versorgung

We report about an emergency case of a female patient with terminal carcinoma of the ovary. On the basis of this case it becomes evident that palliative care questions are also important in emergency medicine. In this situation cooperation of the medical disciplines involved appears urgently necessary. This may allow the possibility for terminally ill patients to stay at home in the last days of life.ZusammenfassungBerichtet wird über die notärztliche Versorgung einer Patientin mit einem multipel metastasierten Ovarialkarzinom im finalen Krankheitsstadium. Anhand dieses Einsatzes soll verdeutlicht werden, dass palliativmedizinische Fragestellungen auch in der Notfallmedizin relevant sind. Eine strukturierte Kooperation der in dieser Situation involvierten medizinischen Fachgebiete erscheint dringend geboten.AbstractWe report about an emergency case of a female patient with terminal carcinoma of the ovary. On the basis of this case it becomes evident that palliative care questions are also important in emergency medicine. In this situation cooperation of the medical disciplines involved appears urgently necessary. This may allow the possibility for terminally ill patients to stay at home in the last days of life.

[Reduction in no flow time using a laryngeal tube: comparison to bag-mask ventilation].

OBJECTIVE In 2005 the European Resuscitation Council (ERC) published the new guidelines for Advanced Life Support (ALS). One of the aims was to reduce the no flow time (NFT), without chest compression in the first period of cardiac arrest. Furthermore the guidelines recommend that endotracheal intubation should only be carried out by personnel experienced in this procedure. METHODS An attempt was made to evaluate whether the use of the laryngeal tube suction (LTS-D) for emergency airway management could contribute to reduce NFT compared to bag-mask ventilation (BMV). In a randomised prospective study 50 participants were asked to perform standardised simulated cardiac arrest management on a full-scale simulator following a one-day cardiac arrest training. Each participant was randomised into the LTS-D and the BMV group for airway management. At the end of each scenario an evaluation of the use of each ventilation procedure by the participants was made by means of a questionnaire. RESULTS During the manikin scenario (430 s for LTS-D and 420 s for BMV) there was a significant difference in the overall NFT comparing the use of the LTS-D vs. BMV (105.8 s, range 94-124 s vs. 150.7 s, range 124-179 s; p<0.01). This corresponded during the whole scenario to a proportion of 24.6% (LTS-D) or 35.9% (BMV). Using the LTS-D all participants were able to ventilate the manikin successfully (tidal volume 500-600 ml). In a subjective evaluation of the different airway management procedures by the participants more than 90% expressed a positive opinion about the LTS-D with respect to ease of insertion and safety of ventilation. CONCLUSION The use of the LTS-D on a manikin by emergency physicians after standardised cardiac arrest training significantly reduces the NFT in comparison to BMV. Therefore the LTS-D seems to be a good alternative to BMV during a simulated cardiac arrest scenario.

Palliative medicine. Fifth pillar of anaesthesia departments

Palliative medicine has progressed during recent years to an independent medical faculty within the German health system. Despite this development palliative care systems for out-of-hospital and in-hospital palliative care are still insufficient in Germany so that the development of necessary resources must be considered as not yet completed. To support the further national development palliative medicine can be temporarily or permanently coupled to existing departments, which can be advantageous for all concerned and last but not least be profitable to patients and their relatives. Possibilities for participation of anaesthesiologists in this area of medical care are discussed in the study reported here. Anaesthesiologists have always historically been represented in palliative medical departments, e.g. as pain specialists. In the following investigation the special possibilities of anaesthesia departments for supporting the education and development of in-hospital and out-of hospital palliative medical care departments are reported. Previous experience of co-operation between these two departments is well established. Departments of palliative medicine depend on a well working interdisciplinary co-operation between different medical disciplines (e.g. anaesthesiology, radiotherapy, surgery and oncology) and several medical professions (e.g. physicians, nurses, psychologists). The aim of palliative care therapy is to be responsible for the best possible therapy for cancer patients and to give support to their care-giving relatives. Due to the increasing establishment of palliative care procedures in Germany, departments of anaesthesiology should actively take part in the further development. Part of the responsibility of most anaesthesia departments is to practice pain management and critical care medicine, which are reasons why anaesthesiologists are predestined to be part of the system for palliative care patients and their relatives. Anaesthesia departments can be responsible for the organization of in-hospital and out-of-hospital palliative medicine and palliative care. The integration of anaesthesiological expertise into palliative medicine departments and vice versa can be a great opportunity for both medical departments and therefore represents a worthwhile engagement.

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.BACKGROUND 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.

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% (n = 92 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.

Kurs „Lebensrettende Sofortmaßnahmen“@@@Obligatory first aid courses: Überprüfung der theoretischen Kenntnisse von Teilnehmern@@@What can we expect?

ZusammenfassungHintergrundDie Laienhilfe hat einen entscheidenden Stellenwert in der Versorgung von Notfallpatienten. Sie bildet das vermeintlich schwächste Glied der Rettungskette und definiert mithin deren Gesamtstärke. Durch ihre Verbesserung kann es zu einer entscheidenden Verkürzung des therapiefreien Intervalls kommen.MethodikWir untersuchten Teilnehmer eines standardisiert durchgeführten Kurses „Lebensrettende Sofortmaßnahmen“ bezüglich ihrer theoretischen Kenntnisse nach Abschluss des Kurses. Für die Erhebung wurde ein selbst entwickelter Fragebogen verwendet.ErgebnisseEin direkt nach dem Kurs durchgeführter theoretischer Wissenstest wird von den meisten Teilnehmern bestanden. Es gibt keine signifikanten Unterschiede zwischen Teilnehmern, denen zu Beginn des Kurses bekannt ist, dass ein Test geschrieben wird, und Teilnehmern, denen dieses nicht bekannt ist. Teilnehmer mit wiederholten Teilnahmen an „Erste-Hilfe-Kursen“ erreichten signifikant bessere Ergebnisse.DiskussionEs bestanden keine signifikanten Unterschiede in den Testergebnissen zwischen Teilnehmern, denen bekannt war, dass am Ende des Kurses ein Test stattfindet, und Teilnehmern, denen dieses nicht bekannt war. Teilnehmer, die mehrere Kurse besucht und zusätzlich eigene Notfallerfahrungen hatten, erreichten in dem Test signifikant bessere Ergebnisse.AbstractBackground First aid administered by lay persons is an essential element in the care of emergency patients. So far, it has seemed to be the weakest link in the “chain of rescue”, meaning that this chain is no stronger than the first aid given. Better first aid would lead to decisively shorter times without treatment.MethodsAt the end of a standard “life-saving first aid” course for lay persons, which is required before candidates can proceed to the German driving test, we used a questionnaire we had developed ourselves to check the theoretical knowledge of the course members .ResultsMost of the participant passed the test of theoretical knowledge held directly after the course. We found no relevant differences between course members who knew about the test at the beginning of the course and those who were not informed about it until the end of the course. Significantly better test results were achieved by persons who had already taken the course several times in the past.DiscussionWe were able to show that repeating first aid courses can improve lay persons’ results in the test of theoretical knowledge at the end of a first aid course. Candidates who also had experience of applying first aid in an emergency also attained significantly better test results.

Palliativpatienten im weit fortgeschrittenen Krankheitsstadium

BACKGROUND Prehospital emergency teams will be confronted with the specific needs of resuscitation in palliative patients in whom a return of spontaneous circulation (ROSC) could be found significantly less frequently than in other emergency situations. The present investigation aims to show medical and judicial problems related to cardiopulmonary resuscitation (CPR), external examination of the corpse and death certification. METHODS Over a 12-month period all emergency cases involving physicians in an out-of-hospital resuscitation setting in cancer patients were retrospectively analysed for indications for emergency call, situation on-site and prehospital treatment by emergency physicians, external examination of the corpse and determination of death. RESULTS For the period mentioned 164 (2.7% of the total) emergency calls by cancer patients or their relatives were identified. In the following study 43 patients (26.2%) could be included. In 20 cases (46.5%) the emergency physicians attempted to resuscitate the patient by performing CPR. In the majority of cases (36; 83.7%) death certification and external examination of the corpse were necessary at the scene. CONCLUSIONS Due to a reduced rate of ROSC in palliative patients, death certification and external examination of the corpse are more often necessary than in other emergency situations. Therefore every emergency physician should be familiar with the ethics of resuscitation of patients in palliative care and with external examination of the corpse to do justice to patients and their caregivers.