Komplement?rtherapie in der Palliativmedizin

Even in the palliative context complementary therapy has a high value for patients and their relatives. In contrast to the methods of conventional medicine naturopathy as a holistic system has positive meanings for patients and their family. Complementary medicine in the palliative setting can be used as a supportive therapy in carefully selected cases. Doctors and patients should be careful regarding effect and side effects and should make sure that supportive therapy is given adequately and in effective doses. Complementary therapy should not be used in order to avoid the question of life and death. An adequate approach to the topic is mandatory, which acknowledges the needs of patients but also looks for their safety. Patients following alternative therapies sometimes neglect helpful therapeutic options. Carefully providing information on these therapies is mandatory. Physicians should avoid losing patients?? confidence in their competence and attention in their final course of disease. Also in palliative medicine a sensitive approach to the topic of complementary medicine is mandatory, which accounts for the eligible wishes of patients and their relatives but puts the patients safety first.     

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.     

Complementary therapy in palliative medicine

Even in the palliative context complementary therapy has a high value for patients and their relatives. In contrast to the methods of conventional medicine naturopathy as a holistic system has positive meanings for patients and their family. Complementary medicine in the palliative setting can be used as a supportive therapy in carefully selected cases. Doctors and patients should be careful regarding effect and side effects and should make sure that supportive therapy is given adequately and in effective doses. Complementary therapy should not be used in order to avoid the question of life and death. An adequate approach to the topic is mandatory, which acknowledges the needs of patients but also looks for their safety. Patients following alternative therapies sometimes neglect helpful therapeutic options. Carefully providing information on these therapies is mandatory. Physicians should avoid losing patients' confidence in their competence and attention in their final course of disease. Also in palliative medicine a sensitive approach to the topic of complementary medicine is mandatory, which accounts for the eligible wishes of patients and their relatives but puts the patients safety first.     

Palliative medicine and advanced incurable illness

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.     

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.     

Renal supportive care and palliative care: revision and proposal in kidney replacement therapy

Patients with chronic kidney disease may receive sustained renal supportive care and renal palliative care (RPC) starting with the diagnosis of the disease, throughout the various stages of renal replacement therapy (RRT), the cessation of the RRT, and in the decision of whether to provide conservative treatment or non-initiation of RRT. This article reviews the literature on the development of renal palliative care and proposed RPC models. We describe the progression of disease in organ failure, which is very different from other areas of palliative care (PC). We describe important components of resident nephrology training in PC. We discuss the management of pain and symptom control, as well as communication skills and other psychological and ethical aspects in the renal patient. We conclude that in chronic renal patients, a palliative care approach can provide a positive impact on the quality of life of patients and their families, as well as optimizing the complex treatment of the renal patient.     

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.     

Interdisciplinary training: hospital dental general practice/emergency medicine

The interaction between the residency training program in hospital dental general practice and emergency medicine at The Medical College of Pennsylvania is discussed. The contribution by the emergency medicine resident to the training of the dental resident and the role of the dental resident in the education of the emergency medicine resident are described in detail. Methods for enhancing this unique relationship between two departments are presented.     

Housestaff team research in the ambulatory setting

Training in research has been recognized as an importat component of internal medicine training. To provide a n search experience for their residents, the authors established a team research project designed and implemented by pos graduate year-2 and -3 internal medicine trainees with guidance from general medicine faculty. A successful research project was conducted by trainees, which resulted in an award-winning poster presentation at a scientific meeting and publication in a peer-reviewed journal. The process of conducting a resident faculty team research project in the ambulating care setting is described in this report. The authors encourage other internal medicine programs to consider resident team research efforts to expose a large number of trainees to research experience.     

Effect of a 1-week clinical rotation in palliative medicine on medical school graduates' knowledge of and preparedness in caring for seriously ill patients

OBJECTIVES: To assess the effect of a required 1‐week clinical rotation in palliative medicine during a 12‐week internal medicine–geriatrics clerkship on graduating medical students' knowledge and self‐assessed preparedness in caring for seriously ill patients. DESIGN: Historical control trial. SETTING: Mount Sinai School of Medicine (MSSM), New York, New York. PARTICIPANTS: Students from the MSSM classes of 2007 (MS07) and 2008 (MS08). INTERVENTION: MS08 was the first class to complete the required clinical rotation in palliative medicine. MS07 served as a historical control, having received only didactics in palliative care but no clinical rotation. MEASUREMENTS: Both classes were invited to complete an anonymous online survey designed to assess experiences and preparedness in caring for seriously ill patients and a 30‐question multiple choice knowledge examination. RESULTS: Fifty‐eight (55%) students from MS07 and 59 (51%) students from MS08 completed the survey. Students from MS08 rated their skill level in several areas of pain management and communication more favorably than did students from MS07. Mean scores on the knowledge portion of the survey were not significantly different between the two classes. CONCLUSION: Graduating medical students who had a 1‐week clinical rotation in palliative medicine had higher self‐assessed skills in pain management and communication than students who received no clinical exposure. A brief clinical experience in palliative care should be considered for integration into the curriculum at all medical schools.     

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.     

Report of the Geriatrics-Hospice and Palliative Medicine Work Group: American Geriatrics Society and American Academy of Hospice and Palliative Medicine leadership collaboration

Although the fields of hospice and palliative medicine and geriatrics have developed from separate origins, they share much in common. They share concerns for optimizing care of older adults with advanced illness. They both seek to address the common problem of care fragmentation for those with chronic illness. Both subspecialties see the patient and their loved ones as a unit requiring thoughtful, integrated care, rather than seeing the patient as a cluster of organ systems and conditions. The fields also share many core principles, including an emphasis on interdisciplinary care and care coordination. As increasing emphasis is placed on the medical home, chronic and advanced illness care, and systems changes to decrease care fragmentation, geriatrics and hospice and palliative medicine stand to benefit by blending efforts and common interests to improve care for patients and their loved ones. In 2009, a collaborative effort was begun involving the leadership of the American Geriatrics Society, the American Academy of Hospice and Palliative Medicine, and the John A. Hartford Foundation. The goal of the collaboration was to convene leaders in geriatrics and hospice and palliative medicine to identify areas of potential synergy between the two subspecialties and to design a plan for exploring and developing these areas of common interest. This article describes the progress of the collaborative effort to date.     

中西医结合治疗肝癌的思考

中医和西医在肿瘤治疗方面各有优势,西医注重消灭肿瘤,而中医则注重调变肿瘤和机体。肝癌治疗方面,中医适合于不能耐受手术/介入疗法患者,作为姑息性治疗,以改善生活质量,延长带瘤生存;作为其他疗法的辅助治疗,达到促进治疗后的恢复,减少复发转移、延长生存期。实验研究发现,5味中药的“松友饮”可通过抑制血管生成、降低肿瘤侵袭,可减少化疗和姑息性切除后的转移,并延长荷瘤鼠生存期,提示这方面中西医结合的可能性。临床实践中需要重视中医理论,而     

A brief history and lessons learned from twin efforts to transform medicine

In this article, we consider the intersection between the fields of geriatrics and palliative medicine in the United States. Although geriatrics and palliative medicine have sometimes used different strategies to address the same challenges, they have created opportunities where both fields can learn from the experiences of the other. One specialty may be able to learn from issues already dealt with by the other. Because the fields of geriatrics and palliative medicine have so much in common, including health professionals who bridge the two fields, it is the authors' goal to foster greater understanding and collaboration between the specialties and thus strengthen both.     

Analysis of selection criteria for medical residents: Differences between primary care and traditional pathway committees

A self-administered questionnaire was given to faculty members of resident selection committees for traditional and primary care medical residencies at one institution. Results from both committees revealed that applicant performance in medicine clerkships and communication from the applicant's department of medicine faculty, especially the chairman, were key criteria in evaluating the strength of each applicant. Negative personal characteristics were important in determining undesirable resident candidates. Primary care program selectors put more emphasis on the applicant's personal goals, skills, and interests, especially career plans in general internal medicine, than did their traditional program counterparts. Other differences included the tendency of traditional program committee members to value collegial communications and the perceived quality of the applicant's medical school more than the primary care members did.     

Residency recruitment: postmatch survey says..

BACKGROUND: Information is limited regarding the most effective methods of recruitment in internal medicine residency programs. To address this deficiency, we conducted a 4-year survey of students who interviewed at our program addressing aspects of the application and interview process to maximize recruitment. METHODS: A 25-item questionnaire was mailed after the match to all students who interviewed but did not match with our program from 1994 to 1997. RESULTS: The response rate varied from 35% in 1994 to 70% in 1997. Variables that showed significant improvement after intervention included brochure mailings, resident greeting, resident luncheon, and perceived resident satisfaction. There was a 50% increase in program applications and the percent of applicants rating our program in their first 3 choices rose from 21% in 1995 to 51% in 1997. CONCLUSIONS: The major factors influencing our applicant's decisions regarding our program included resident involvement and brochure development/mailings. We have focused our efforts on those components to make the greatest impact on increasing the attractiveness of our program for internal medicine training.     

Gastroenterological palliative care

On consideration of current medical and socio-economical factors, palliative care is becoming an increasingly important aspect of modern medicine in Germany. The German Society for Digestive and Metabolic Disorders (DGVS) has taken this into account by founding the working group "Palliative Gastroenterology". Patients with gastrointestinal malignancies or advanced non-malignant liver disease represent an important group that benefits from palliative care. Approximately 80 % of all palliative care patients suffer from gastrointestinal symptoms and endoscopic procedures performed by gastroenterologists play an important role in relieving symptoms such as obstruction. It is the object of this paper to evaluate the role of gastroenterologists in palliative medicine. It will give a brief definition, a historical review and the current legal background for palliative care in Germany and examine special aspects of ethics, decision making and research. Considering the current evidence on palliative endoscopic procedures this paper wants to establish the role of the gastroenterologist in palliative care far beyond the mere practicalities of endoscopy. The gastroenterologist is a crucial element of the interdisciplinary palliative care team and a partner to the patient in the process of decision-making. Finally, it is demonstrated how palliative care structures can be implemented in the setting of a university acute-care hospital.     

Palliativmedizin

Emergency physicians and intensivists are increasingly faced with situations requiring them to care for patients for whom no curative treatment options are available. This is due to the epidemiologic evolution as well as the trend to delegate end-of-life decisions to emergency services and intensive care units. Difficult decisions under time pressure in emergency medicine frequently induce a response to use the full potential of feasible actions but without consideration of palliative treatment options. In intensive care the issue of palliative care might arise during decisions about admission of a patient as well as limiting treatment in the intensive care unit. In fact palliative care can be seen as a constant part of intensive care medicine. Palliative treatment concepts should be recognized as an expansion of the spectrum of emergency medicine and an essential goal in intensive care medicine. This is a task for daily practice and the further development of both medical specialities.     

A comparison of humanistic qualities among medical students, residents, and faculty physicians in internal medicine

Humanistic qualities of integrity, respect and compassion are important components of medical education. Studies, however, suggest that students may not perceive their faculty physicians as humanistic. Knowing how the perception of humanistic qualities varies by training level may offer insight on how we teach humanism. In this study, the authors compared humanistic quality scores of fourth-year medical students, internal medicine residents, and attending physicians on a general medicine ward of a teaching hospital. A validated nursing survey to assess humanistic qualities among physicians was distributed to randomly selected nurses on the medicine wards. The survey measured physician relationships with other medical staff, the patient, and family members. Each item was scored on a 5-point Likert scale. Composite scores for physician to staff relationships and physician to patient/family relationships, as well as an overall evaluation score, were compared across levels of physician training. A t test was done to determine statistical significance across training levels. No statistically significant differences were found between internal medicine residents and attending physicians. Subinterns appear to have better perceived qualities of humanism compared with resident and attending physicians. Because resident and attending physicians play an important role in medical education, efforts should be made to improve the perceived humanistic qualities of both resident and attending physicians.