Ethik in der Onkologie

Medical ethics are concerned with moral values in health care. The challenge of new developments in medicine and handling of limited resources in health care are leading to enormous differentiation in medical ethics. Thus, even the field of ethics in oncology requires a special reevaluation of the situation and adjustment. The close cooperation between patients and physicians plays a central role and the essential bioethical values, such as autonomy, beneficence, justice, non-maleficence and dignity should be considered.     

癌痛的治疗

流行病学 据美国东部肿瘤协作组(ECOG)的调查,所有门诊癌症病人中有疼痛者达67%,其中42%没有得到合适的止痛治疗.此外,在肿瘤终末期前疼痛常常早已出现.     

Ethik-Konsil in der Onkologie

Background

Ethical dilemmas that arise during the treatment of patients in oncology are self-evident to any clinician or lay person who has cared for individuals battling cancer. Issues related to autonomy, advance directives, surrogate decision making, communication barriers, goals of care, treatment decisions, end of life decisions and admission to the intensive care unit of advanced cancer patients are emotionally laden and complex; therefore, circumstances can arise in which moral dilemmas or conflicting values are not so easily resolved. Clinical ethics consultation is a structured approach to assist in mitigating ethical questions and conflicts through careful deliberation and guidance among the parties involved, particularly in a setting of standardized team or family conferences.

Method

Research and analysis of the current literature.

Objective and conclusion

The resolution process involves a reasoned approach to the ethical or moral dilemma or conflict in which multiple perspectives and points of view are integrated into an ethically justifiable and workable solution that is driven by a shared decision-making process. In respect to emergency conflict interventions by an ethics consultation it is hoped that advance care planning will be able to minimize requested ethics consultations.

     

Supportivtherapie in der Onkologie

Die Supportivtherapie beinhaltet ein interdisziplin?res Spektrum von Ma?nahmen, die Voraussetzung für die Durchführbarkeit moderner onkologischer Therapiekonzepte sind. Daher müssen ad?quate supportive Strategien bereits vor Beginn der Therapie in die Planung des Behandlungskonzeptes einbezogen werden. Die Pr?vention und das Management von unerwünschten Wirkungen einer Tumorerkrankung und der onkologischen Therapie über den gesamten Zeitraum der Erkrankung hinweg erleichtert die Rehabilitation und verbessert Lebensqualit?t und überleben. Inzwischen gibt es etablierte Leitlinien für eine Reihe von supportiven Ma?nahmen, weitere sind in der Entstehung. Der Beitrag gibt einen überblick zu den aktuellen Empfehlungen und Behandlungsma?nahmen.     

Zertifizierungsverfahren in der Onkologie

Introducing quality management in health care takes a long time. Insufficient transparency in the presentation of treatment results will lead to an increasing use of routine data and the directing of patients to centres with special structure and process requirements. The medical societies give doctors support to establish a nationwide guideline-oriented cancer treatment which is free of third party interest. Models thus developed for the presentation and recognition of achievements also pursue the aim of transparency and centralization. Several certificates are available depending on the cancerous organ and the federal state in which the patient resides. This diversity has a right to exist on the way to a unified and understandable system of quality levels. The patients concerned have a right to insist on the shortest process possible.     

Infektionen in der Onkologie

Die h?ufigste Komplikation bei Patienten mit Tumorerkrankungen ist eine Infektion. Trotz hoher therapieassoziierter Mortalit?tsraten führen eine verbesserte Diagnostik und Therapie infekti?ser Komplikationen heute zu einem verbesserten überleben. Für die klinische Betreuung immunsupprimierter Patienten ist es wichtig, die für die jeweilige Art der Immunsuppression charakteristischen Infektionserreger zu kennen. Der Beitrag gibt einen überblick zu aktuellen Behandlungsoptionen bei Infektionen in der Onkologie – von der Therapie mit Purinanaloga und monoklonalen Antik?rpern über therapeutische Ma?nahmen nach autologer und allogener Stammzelltransplantation bis zum Therapiemanagement bei neutropenischen Patienten. Aspekte der antimikrobiellen Prophylaxe und Impfung werden berücksichtigt. Infektionen sind bei Patienten mit H?moblastosen und soliden Tumoren eine wesentliche Ursache für Morbidit?t und Mortalit?t. Medikament?se prophylaktische Ma?nahmen werden risikostratifiziert eingesetzt und sollten das Risiko von Nebenwirkungen, Resistenzentwicklung und hohen Therapiekosten berücksichtigen. Eine leitliniengerechte Impfprophylaxe sollte in Zukunft konsequenter umgesetzt werden. Bei neutropenischen febrilen Komplikationen besteht umgehender Handlungsbedarf. Die empirische Therapie erfolgt risikoadaptiert und muss von engmaschiger anamnestischer, klinischer, laborchemischer und ggf. bildgebender Beobachtung flankiert werden. ie Diagnostik, Prophylaxe und Therapie viraler Infektionen werden beim onkologischen Patienten nach dem jeweiligen Risikoprofil gesteuert. Für viele Patienten wird eine erfolgreiche, auch ambulant durchzuführende Behandlung der infekti?sen Komplikation m?glich sein.     

Zertifizierungsverfahren in der Onkologie

In the German health care system, a large number of different certification processes are available. It has to be assumed that the motivation for all of these processes is not only quality oriented, but that other elements, such as having defining power or participating in the certification market, may also have an impact. The more certificates on the market, the harder it is for policyholders to maintain an overview, and the higher the costs for the health care units involved. These again have to be financed by the policyholders. In addition to the four internationally accepted general certificates – from the EFQM and the ISO, the group of certificates developed by the medical profession and peer review – an increasing number of specific certificates for oncology departments are available in Germany. The main objective of a health care unit is to create confidence in its health care quality by showing a certificate to patients and policyholders. However, this objective can only be achieved when the certificate is trustworthy. Consequently, and in agreement with the International Society for Quality in Health Care, certification processes must have their own quality management and must make their quality transparent to the public.     

Futility-Debatte in der Onkologie

Limiting therapy and discontinuing therapy because of the futility of the treatment entail a complex ethical dilemma in which a mixture of brute facts and institutional facts play a role since the subjective assessment of the physician represents part of the situation. To subject futility decisions to even stricter rules of objectivity would exact the (overly) high moral price that the cost effectiveness of the treatment would have to be determined on an interindividual basis. While recent court decisions concerning discontinuance of therapy stress the priority of the patient’s will, the majority of Germans make hardly any precautionary arrangements to actually confirm their autonomy, e.g., with a signed disposition. In the routine clinical situation, decisions on withdrawing treatment are usually made by the physicians based on minimal reflection of subjective moral theory according to which the patient should rather die from the disease than from (withheld) medical intervention. Principles and guidelines proffered by professional organizations cannot supplant the ethically difficult decision in individual cases. In all probability, many patients will not die completely autonomously with self-determination as currently called for in certain precepts of medical law and ethics that are to some extent illusionary.     

Obduktionen in der Onkologie

In oncology as well as in other fields of medicine autopsies play an important role as an instrument of quality management. There are numerous situations in which autopsies may disclose unknown antemortem findings in cancer patients. Autopsies of patients who have died in different phases of the cancer disease may bring valuable information about the individual cancer cases. The spectrum of autopsy indications varies from the confirmation of a clinically suspected cancer to the recognition of the final tumor stage or findings of therapy-related side effects or secondary diseases, such as unexpected infections. Several examples are provided to show unexpected results from the autopsies of cancer patients. In a 10-year analysis of 1,301 autopsy cases revealing malignant diseases 74.5% were clinically known and 20.2% (263 cases) were clinically unknown.     

G-DRG-System in der Onkologie

The German prospective payment system has been recently adapted and recalculated. Many areas, including oncological treatments, which have been criticised, are now profoundly revised. Using the Australian AR-DRG in 2003, Germany has now thoroughly adapted the G-DRG system to meet German needs. Relevant improvements can be seen for oncological drugs und blood products. New parameters for DRG subdivisions have been defined e.g. sepsis or neutropenia and a considerable number of new DRG definitions has been designed. Problems noted by the German Cancer Society and the Society for Haematology and Oncology were analysed in a recent study. Most of the conclusions drawn from that analysis have now been implemented in the financing system for 2005. Nevertheless, unsolved problems remain: readmittance, payments for innovative treatments or financing highly specialised institutions. Further adjustments of the hospital financing systems are required to ensure adequate funding of oncological inpatient treatment.     

Bedeutung der Positronenemissionstomographie in der Onkologie

Die Positronenemissionstomographie (PET) mit ¹⁸F-2-Fluoro-2-Deoxy-D-Glukose (FDG) wird in Deutschland seit Anfang der 90er Jahre zunehmend zum pr?therapeutischen Staging sowie zur Therapiekontrolle und Rezidiverkennung von malignen Tumoren eingesetzt. Die diagnostische Treffsicherheit dieser Methode ist in der Regel h?her als die morphologischer Schnittbildverfahren wie der Computertomographie (CT) oder der Kernspintomographie (MRT). Dies liegt an den besonderen Eigenschaften des 18F-markierten Glukose-Analogons FDG, das von den meisten malignen Zellen vermehrt aufgenommen wird und vorübergehend in der Zelle gefangen bleibt. Mit modernen PET-Ger?ten lassen sich auch kleine Tumoren oder Metastasen unter 1 cm Durchmesser differenzieren. In Deutschland werden seit 1995 in 2–3-j?hrigen Abst?nden Konsensuskonferenzen abgehalten, die dazu dienen, die Indikationen zur klinischen Anwendung der PET in der Onkologie laufend zu aktualisieren. Diese auf Expertenmeinung basierenden Analysen beurteilten im Jahr 2000 den klinischen Nutzen der ¹⁸F-FDG-PET bei 24 Indikationen aus 8 verschiedenen Tumorentit?ten als erwiesen oder zumindest wahrscheinlich. Die vorliegende übersicht gibt zun?chst einen methodischen Einblick in die ¹⁸ FFDG-PET, beschreibt danach die wichtigsten Indikationen für ihren Einsatz in der Onkologie und gibt abschlie?end einen Ausblick auf die prognostische Bedeutung dieser Untersuchung. Priv.-Doz.M. J. Reinhardt Klinik und Poliklinik für Nuklearmedizin, Universit?tsklinikum Bonn, Sigmund-Freud-Stra?e 25, 53127 Bonn, E-Mail: michael.reinhardt@ukb.uni-bonn.de