Palliativmedizin und fortgeschrittene, nicht heilbare Erkrankungen

Advanced incurable and life-threatening diseases of internal organs such as chronic obstructive pulmonary disease (COPD), heart failure, and terminal kidney failure are associated with considerable burden for the patients caused by pronounced symptoms (e.g., dyspnea, anxiety, depression) and unmet psychosocial needs. Nevertheless, in Germany addressing palliative medicine in the context of these disorders and co-treatment of these patients by cross-sector partnership with specialized palliative care physicians are not very developed. Against the background of an international perspective and current guidelines, general aspects of palliative care needs (symptom control, communication, advance care planning, etc.) are discussed together with the resultant implications for potential cooperation between internal medicine and palliative care as well as special aspects of the individual diseases (e.g., prognosis or implications of certain treatment options such as ??automatic implantable cardioverter-defibrillator??, AICD). Timely involvement of the specific expertise of palliative care medicine can ensure that the workload of the primary providers (and their teams) is reduced and better cross-sector management (hospital and home) of the severely ill patients and their families is achieved.     

Schwieriger Atemweg in der Notfall- und Intensivmedizin

A secured airway is of utmost importance in emergency and intensive care medicine to ensure sufficient oxygenation. In emergency and intensive care medicine, patients are usually considered to be in a life-threatening condition, environmental aspects are far from optimal, and the personal experience of all participants is often limited; thus, any attempt to intubate such patients has to be considered a failure-prone intervention. Therefore, one of the major goals should be the complete avoidance of endotracheal intubation, e.g., via noninvasive ventilation. If intubation is inevitable, it is crucial to plan alternative strategies in case of difficulties or failure. Fiberoptic intubation in alert patients and videolaryngoscopy have proven their effectiveness to decrease the risk of airway difficulties in acute and critically ill patients. Since availability and utility of videolaryngoscopy is not restricted technically, we strongly recommend its use in emergency and intensive care medicine.     

A Modern Integration of Palliative Care Into the Management of Heart Failure

Heart failure (HF), a clinical syndrome with a variable trajectory has become more common. As people with HF experience functional decline during periods of deterioration in their HF status, or with aging, their needs for palliative care increase. In this review we consider the palliative aspects of evidence-based HF care, which benefit patients while also addressing the underlying etiology of the HF. We also identify symptoms common to patients with HF and management beyond evidence-based HF care. Prognostic models and tools to identify patients appropriately evaluated by HF specialty experts might help clinicians understand the patient’s status. Rather than trying to identify a point at which palliative care should be included in care for a patient with HF, we suggest that identifying specific needs of the patient and family is a better way to target palliative care interventions. We review available publications that have explored integration of palliative care into HF care, and propose an outpatient clinic model to assess needs and symptoms and direct HF specialist or palliative care on the basis of this assessment.     

Clinical rheumatology training of primary care physicians: the resident perspective

Because nonspecialized physicians provide care for the vast majority of patients with rheumatic disorders, we surveyed 327 internal medicine and family medicine residents with respect to the nature of their training in rheumatology. Although most internal medicine residents had access to rheumatologists for training and had taken formal rheumatology rotations, this was often not the case for family medicine residents. Deficiencies evident in both types of programs included limited access to rheumatology electives; insufficient exposure to certain major categories of rheumatic disease, e.g., the spondyloarthropathies and systemic autoimmune disorders; and lack of direct participatory experience in orthopedics, rehabilitation, and psychosocial aspects of rheumatology.     

Co-morbidity does not reflect complexity in internal medicine patients

Internal medicine patients are mostly elderly; they have multiple co-morbidities, which are usually chronic, rather than self-limiting or acute diseases. Neither administrative indicators nor co-morbidity indexes, though validated in elderly patients, are able to completely define these "complex" patients or to allow physicians to correctly "cope" with them. For the complex patients found in internal medicine wards, internists need not only to find the best diagnosis and treatment, but also to apply a complex intervention (i.e., a comprehensive assessment and both continuous and multi-disciplinary care) in order to maintain their health and ability to function and to prevent or delay disability, frailty, and displacement from home and community. The aim of this review is to underscore the differences between the concepts of co-morbidity and complexity, to discuss instruments for their measurement, and to highlight related implications, areas of uncertainty, and the responsibilities of internists in the assessment and management of inpatients of their wards. The conclusion we come to is that it is mandatory to shift from a finance/administrative-based management system to a clinical process model (clinical governance) driven by the quality of the medical outcome and the cost of achieving that outcome. From a "complexity theory" standpoint, patient-centered care and collaboration can be seen as simple rules that guide desirable behaviors in a complex system. By exploring the real complexity of our patients, we exercise the holistic, anthropologic medicine of the person that is internal medicine.     

The palliative care in geriatrics: a retrospective study of 40 cases

INTRODUCTION: Owing to the very great age and the polypathology of the patients in geriatrics, we are often confronted to the palliative care decision. PURPOSE: The purposes of this retrospective study were both to define the criteria leading to palliative care and to analyse the evolution of patients. METHOD: We analysed 40 files of patients hospitalised in Geriatric internal medicine or Geriatric rehabilitation departments over 11 months. RESULTS: Mean age was 85.4 years and 62.5% of patients were females. Infections, heart failure, general weakness, orthopaedic affections, strokes and cancers were the main causes of hospitalisation. Patients had 3 medical or surgical histories of chronic or cured serious diseases and a MMSE average value of 17.7. The rate of malnutrition was 92% and 90% of patients were very dependent. Severe infections, cancers, heart failure and severe pressure ulcers were the main affections for decision of palliative care. The latter was always decided by the staff with patients or families taking part in 8 cases and being informed in other cases. The palliative care lasted 7 days on average. Morphine was used in 31 cases. No artificial nutrition was introduced. CONCLUSION: The decision of palliative care is very complex since great age, polypathology, great dependence and high prevalence of cognitive disorders are frequent in this population.     

Ethik und Palliativmedizin in Intensiv- und Beatmungsmedizin

Ethics and palliative care have a growing impact at the present time. This is true not only in oncology but also increasingly more for intensive care medicine and home mechanical ventilation. In particular, the large number of invasively ventilated patients with weaning failure has led to a clear focus on this both life-sustaining and possibly undesired life-prolonging treatment. In addition to what is technically feasible, the perspectives of patients and their families are coming more into focus. Palliative care skills are needed to elicit and adequately react to the patient’s wishes, even if that leads to therapy withdrawal or withholding treatment. Changing the aim of the treatment is becoming increasingly more important. In the non-clinical area of home mechanical ventilation the establishment of palliative care structures for chronically critically ill patients mainly suffering from dyspnea are crucially needed. Early intervention in and counseling of patients with chronic diseases is helpful in avoiding futile long-term invasive mechanical ventilation.     

Onkologie und Palliativmedizin

Approximately one half of patients who receive the diagnosis of cancer still die as the result of their disease. To be able to adequately meet the patients and their families needs, it is essential that oncologists and palliative care physicians cooperate closely. How the recommendations of international institutions are concerning the cooperation between the fields of oncology and palliative care medicine can be approached is exemplified by the concepts developed in the Center for Integrated Oncology (CIO Cologne/Bonn) at the University Hospital in Cologne and discussed critically.     

Oncology and palliative medicine

Approximately one half of patients who receive the diagnosis of cancer still die as the result of their disease. To be able to adequately meet the patients and their families needs, it is essential that oncologists and palliative care physicians cooperate closely. How the recommendations of international institutions are concerning the cooperation between the fields of oncology and palliative care medicine can be approached is exemplified by the concepts developed in the Center for Integrated Oncology (CIO Cologne/Bonn) at the University Hospital in Cologne and discussed critically.     

Palliative Access Through Care at Home: Experiences with an Urban, Geriatric Home Palliative Care Program

The aging of the U.S. population has resulted in a large number of persons with multiple, chronic illnesses and gradual functional decline. Many older adults with these conditions are homebound and have great difficulty accessing medical care. They are also more likely to suffer from unaddressed symptoms and end-of-life care needs. Certain groups, such as African-American patients and patients with dementia, are even less likely to access palliative care and hospice services. Although the informal caregivers attending to such persons may become overwhelmed without adequate support, palliative care, which covers a broad population, is an optimal way to address many of these needs. This article describes a unique, urban, home-based geriatrics palliative care program (Palliative Access Through Care at Home (PATCH)) designed to address some of these unmet needs. After 1 year of providing service, a mixed-methods study consisting of chart review, telephone interviews, and face-to-face interviews was conducted to assess caregiver expectations of and satisfaction with the program. Caregivers for the elderly, mostly African-American patients, more than half of whom had dementia, were overall very satisfied with their experience, despite the large amount of time necessary to provide the care that patients required. Themes extracted during qualitative analysis were the desire to remain at home, the need for easy access to a practitioner specializing in geriatrics and palliative medicine, and the challenges of transitions of care. PATCH was able to address many of these needs and provide high levels of caregiver satisfaction.     

Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology

Heart failure is a serious condition and equivalent to malignant disease in terms of symptom burden and mortality. At this moment only a comparatively small number of heart failure patients receive specialist palliative care. Heart failure patients may have generic palliative care needs, such as refractory multifaceted symptoms, communication and decision making issues and the requirement for family support. The Advanced Heart Failure Study Group of the Heart Failure Association of the European Society of Cardiology organized a workshop to address the issue of palliative care in heart failure to increase awareness of the need for palliative care. Additional objectives included improving the accessibility and quality of palliative care for heart failure patients and promoting the development of heart failure‐orientated palliative care services across Europe. This document represents a synthesis of the presentations and discussion during the workshop and describes recommendations in the area of delivery of quality care to patients and families, education, treatment coordination, research and policy.     

Definitions and goals in palliative medicine

Especially in the last 15 years Palliative Care and Palliative Medicine in Germany have increasingly attracted professional and public attention and made remarkable progress. One of the characteristics of Palliative Care in Germany is the differentiation of palliative care from hospice care. Under different viewpoints structure, target groups and aims of Palliative Care have been under discussion in the last 30 years, which made an impact on different forms in the provision of care. Palliative therapy should be distinguished from supportive care and palliative medicine. The revised WHO-definition of Palliative Care broadened the aspects of care in a comprehensive and more holistic understanding of the social, emotional and spiritual needs of patients and their families, including bereavement; and, finally, interdisciplinary and team working issues. It is important to differentiate the palliative care approach from general and specialized palliative care provision for patients with incurable progressive illness and in old age. In Germany 10-12% of all dying patients per year are in need of a specialized palliative care service. The growth in the group of the "very old" will be an important challenge for palliative care in the near future.     

Point of care ultrasound for rapid assessment and treatment of palliative care patients in acute medical settings

The combination of an ageing population with improving survival in malignant and non-malignant disease processes results in a growing cohort of patients with advanced or end-stage chronic diseases who require acute medical care. Emergency care has historically been stereotyped as the identification and treatment of acute life-threatening problems. Although palliative care may be considered to be new to the formal curriculum of emergency medicine, in many domains the ultrasound skillset of a physician in acute medical care can be efficaciously deployed the benefit of patients with both malignant and non-malignant disease processes that require palliative care in the full breadth of acute healthcare settings.In diagnostic domains (abdominal pain, urinary tract obstruction, dyspnoea, venous thromboembolism and musculoskeletal pain) and for specific intervention guidance (thoracentesis, paracentesis, venous access, regional anaesthesia and musculoskeletal interventions) we suggest that POCUS has the potential to streamline improve patient satisfaction, streamline diagnostic strategies, optimise patient length of stay, expedite timely symptomatic relief and reduce complications in this important patient population.POCUS is a mandatory competence in the European curriculum of internal medicine, and specific training programs which cover applications in the domains of palliative care in acute care settings are available. Supervision, quality assurance and appropriate documentation are required. We expect that as the availability of mobile units suitable for point of care applications increases, these applications should become standard of care in the acute management of patients who require palliative care.     

Importance des troubles cognitifs en médecine interne : physiopathologie, évaluation,prise en charge. L’exemple du lupus systémique

Systemic diseases, which are in France mainly monitored in internal medicine, affect multiple organs or tissues. While cutaneous or articular manifestations are the most common, neurological involvement is often associated with severity. Diagnosis of peripheral (e.g, neuropathies) or central (e.g, myelitis) nervous disorders is quite easy through clinical examination and dedicated complementary tests. However, neuropsychological manifestations that affect cognition, including memory, attention, executive functions or reasoning, are difficult to diagnose, sometimes trivialized by practitioners. Their causes are often numerous and interrelated. Nevertheless, these cognitive manifestations are closely related to patients’ quality of life, affecting their social life, family dynamics and professional integration but also the treatment adherence. The purpose of this review, focused on the example of systemic lupus erythematosus, is to raise awareness of cognitive dysfunction in systemic diseases including their management from diagnosis to treatments. The final aim is to go further into setting up research groups and care programs for patients with cognitive impairment followed in internal medicine.     

Definitionen und Ziele in der Palliativmedizin

Especially in the last 15?years Palliative Care and Palliative Medicine in Germany have increasingly attracted professional and public attention and made remarkable progress. One of the characteristics of Palliative Care in Germany is the differentiation of palliative care from hospice care. Under different viewpoints structure, target groups and aims of Palliative Care have been under discussion in the last 30?years, which made an impact on different forms in the provision of care. Palliative therapy should be distinguished from supportive care and palliative medicine. The revised WHO-definition of Palliative Care broadened the aspects of care in a comprehensive and more holistic understanding of the social, emotional and spiritual needs of patients and their families, including bereavement; and, finally, interdisciplinary and team working issues. It is important to differentiate the palliative care approach from general and specialized palliative care provision for patients with incurable progressive illness and in old age. In Germany 10?C12% of all dying patients per year are in need of a specialized palliative care service. The growth in the group of the ??very old?? will be an important challenge for palliative care in the near future.     

老年内科危重症患者急性肾衰竭的临床分析

目的 了解老年内科危重症患者发生急性肾衰竭(ARF)的致病因素及转归.方法 对我院内科近10年老年(≥60岁)ARF患者的临床资料进行回顾分析,将老年患者分为院外获得性ARF(院外ARF)组和院内获得性ARF(院内ARF)组,并与同期内科非老年ARF患者进行比较.结果 (1)老年内科ARF患者381例,院外获得性ARF为218例(57.2%),医院获得性ARF为163例(42.8%),其中来自内科重症监护室153例(93.9%);(2)与院外ARF组比较,院内ARF组患者年龄较高.慢性基础疾病较多,伴发感染和/或心力衰竭的比率和病死率较高,ARF的程度较重;(3)院内ARF组的致病因素以感染及心力衰竭或心肌缺血为主;(4)院内ARF组死亡147例,死亡组伴慢性基础疾病、合并严重感染及心力衰竭、伴发老年多器官功能障碍综合征(MODS)者均多于存活组,危霞症程度(APACHEⅡ评分)更高,肾衰竭程度更重;(5)与非老年组比较,老年组院内ARF构成比、伴发MODS、APACHEⅡ评分及病死率均显著增高. 结论 老年危重症患者更易发生ARF,医院获得性ARF的主要诱因为感染,心力衰竭或严重心肌缺血,病死率较高.     

M?glichkeiten der Palliativmedizin beim Lungenkarzinom

The nature of palliative medicine or palliative care is the holistic approach to the individual patient encompassing social background, religious binding, education, intellectual capacity and other complex characteristics that make an individual unique. Therefore, it is unlikely to find high levels of evidence for complex answers in multimorbid patients at the end of their life. On the other hand high levels of evidence do exist for various ways and means of symptom control and the following article brings both aspects (individuality and evidence-based medicine) together as good as it may seem. Essentially, only bits and pieces in the whole range of palliative care remain evidence-based but these should be known and implemented for best practice in palliative medicine.     

Advanced heart failure: prognosis, uncertainty, and decision making

Heart failure is a serious clinical management challenge for both patients and primary care physicians. The authors studied the perceptions and practices of internal medicine residents and faculty at an academic medical center in the Southeast to guide design of strategies to improve heart failure care. Data were collected via a self-administered survey. Eighty-nine faculty and resident physicians in general internal medicine and geriatrics participated (74% response rate). Items measured perceived skills and barriers, adherence to guidelines, and physician understanding of patient prognosis. Case studies explored practice approaches. Clinical knowledge and related scales were generally good and comparable between physician groups. Palliative care and prognostic skills were self-rated with wide variance. Physicians rated patient noncompliance and low lifestyle change motivation as major barriers. Given the complexities of caring for elderly persons with heart failure and comorbid conditions, there are significant opportunities for improving physician skills in decision making, patient-centered counseling, and palliative care.     

Alumni perspectives comparing a general internal medicine program and a traditional medicine program

Objective:To evaluate a primary care internal medicine curriculum, the authors surveyed four years (1983–1986) of graduates of the primary care and traditional internal medicine residency programs at their institution concerning the graduates’ preparation. Design:Mailed survey of alumni of a residency training program. Setting:Teaching hospital alumni. Subjects/methods:Of 91 alumni of an internal medicine training program for whom addresses had been found, 82 (90%) of the residents (20 primary care and 62 traditional) rated on a five-point Likert scale 82 items for both adequacy of preparation for practice and importance of training. These items were divided into five groups: traditional medical disciplines (e.g., cardiology), allied disciplines (e.g., orthopedics), areas related to medical practice (e.g., patient education), basic skills and knowledge (e.g., history and physical), and technical procedures. Main results:Primary care residents were more likely to see themselves as primary care physicians versus subspecialists (84% versus 45%). The primary care graduates felt significantly better prepared in the allied disciplines and in areas related to medical practice (p<0.01). There was no significant difference overall in perceptions of preparation in the traditional medical disciplines, basic skills and knowledge, and procedures. The same results were obtained when the authors looked only at graduates from the two programs who spent more than 50% of their time as primary care physicians versus subspecialists. There was no significant difference between the two groups in the perceived importances of these areas to current practice. Conclusions:These results suggest that the primary care curriculum has prepared residents in areas particularly relevant to primary care practice. Additionally, these individuals feel as well prepared as do their colleagues in the traditional medical disciplines, basic skills and knowledge, and procedural skills. Received from the Division of General Internal Medicine, Brown University Program in Medicine, and the Rhode Island Hospital, Providence, Rhode Island. Dr. Kiel is a Henry J. Kaiser Family Foundation Faculty Scholar in general internal medicine. Address correspondence and reprint requests to General Internal Medicine, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903.