Non-cancer patients in specialized palliative care in Germany: what are the problems?

To determine the role of non-cancer palliative care in inpatient services in Germany, data from the Hospice and Palliative Care Evaluation (HOPE) were analysed. Since 1999, a three-month census has been conducted annually in German palliative care units. Pooled data from 2002-2005 were tested for differences between non-cancer patients (NCs) and cancer patients (Cs). A total of 4182 patients (NC: 3.5%; C: 96.5%) were documented; functional status (using Eastern Cooperative Oncology Group (ECOG) measures) in NCs was lower compared to Cs (p?=?0.009). NCs suffered more often from dyspnoea (40%; C: 29%; p?=?0.004), weakness (92,3%; C: 84,5%; p?=?0.011) and tiredness (75.4%; C: 66.7%; p?=?0.03) and less from nausea (17.1%; C: 28.9%; p?=?0.002), vomiting (8.2%; C: 19.4%; p?=?0.001) or loss of appetite (55.5%; C: 67.9%; p?=?0.002). There were no differences in pain and constipation. Other problems (nursing, psychological) were more frequent for NCs, in particular the need for support in the activities of daily life (90.3%; C: 72.8%; p?相似文献   

The impact of palliative care on cancer deaths in Hong Kong: a retrospective study of 494 cancer deaths

OBJECTIVES: To study the utilization of public health care by advanced cancer patients in their last 6 months of life and their end-of-life process within the last 2 weeks of life. METHODS: This was a retrospective study on 494 cancer deaths from four public hospitals in 2005. This sample was selected from all in-patient cancer deaths by the ratio of one in four. Data were collected by review of charts and an electronic data base. RESULTS: A total of 494 cancer deaths were analysed. The mean age of all cancer patients (n = 494) was 72.6 years. Two-thirds of cancer patients received palliative care and half died in palliative care setting. Patients were categorized into three groups according to palliative care coverage and the place of death. The first group comprised of patients who received palliative care service and died in palliative care units (PCS-PCD group, n = 247); the second group of patients who received palliative care service within the last 6 months of life but died in non-palliative care wards (n = 86); and the third group of patients who never received palliative care and who died in non-palliative care wards (NPCS-NPCD group, n = 161). Differences among groups were tested by one way ANOVA. During the last 6 months of life, patients in the PCS-PCD group had less admission to acute care wards (P = 0.012), shorter duration of stay in acute care wards (P = 0.003), and less admission to an intensive care unit setting (P < 0.001). Within the last 2 weeks of life, the PCS-PCD group had fewer interventions initiated (P < 0.001); had higher number of symptoms documented in patient's record (P < 0.001); and were more likely to receive analgesics (P < 0.001), adjuvant analgesics (P < 0.001) and sedatives (P < 0.001). Patients in PCS-PCD group were more physically dependent in the last 2 weeks of life (P < 0.001), but mentally more alert at 72 hours before death (P < 0.001). Patients in the NPCS-NPCD group had fewer patients with a do not resuscitate order present (P < 0.001), and more patients with cardiopulmonary resuscitation performed (P < 0.001). CONCLUSION: Our results suggest that palliative care service has played a role in improving end-of-life cancer care in Hong Kong.     

The Impact of Combined Use of Opioids,Antipsychotics, and Anxiolytics on Survival in the Hospice Setting

Context

Opioids and sedatives are the cornerstone of symptom management in the end-of-life patients, but undertreatment is a common problem. Although several studies explored the individual effect of opioids, anxiolytics, and antipsychotics on survival, not much is known regarding their combined use. As these drugs share similar and potentially fatal side effects, primarily respiratory depression which occurs more often during night-hours, it is crucial to explore whether their interaction poses a danger for fragile hospice patients.

What is palliative care in Germany? Results from a representative survey

The recent development of palliative care inpatient units in Germany has been impressive. As a first step for quality assurance, a core documentation form was developed in 1996. The core documentation form consisted of 4 pages with 35 items documenting physical and psychosocial symptoms at the time of admission, diagnostic and therapeutic procedures before and during inpatient treatment, and outcome of physical and psychosocial dimensions. Checklists were used for most items and free text entries could be added. Of the 65 palliative inpatient units in Germany, 44 participated in the second phase of the evaluation of the core documentation in 2000. Eight units were affiliated with anesthesiology departments, 31 with internal medicine, two with radiotherapy, 1 with a surgical department, and 2 units were not affiliated with a department of the hospital. A total of 1087 patients were assessed in the 44 units during a period of up to 3 months. There was a high variability between units in all checklist items of the core documentation. Compared to units affiliated with internal medicine departments, units affiliated with anesthesiology departments performed less chemotherapy, but more immunotherapy; gave fewer infusions and blood transfusions but more skin and wound care, and more lymphatic drainage and massage; and documented psychosocial interventions more frequently for patients as well as for relatives. In one-third of the patients, a consent for omission of therapeutic options was documented. Inpatient treatment ended with the death of the patient in 45.3% of patients and with discharge in 51.6% (not documented 3.1%). The efficacy of inpatient treatment was rated very high by the staff. In conclusion, we found large variation in the documentation pertaining to palliative care patients at the time of admission, as well as for inpatient treatment, among palliative care units in Germany. This was related to the affiliation of the units at least to some degree, but also to differences in interests and documentation discipline. We suggest that training procedures for documentation should be included in crossectional surveys, as the results may not be comparable otherwise. However, common documentation instruments may be the first step towards an interdisciplinary discussion on aims and methods in palliative care.     

Treatment efficacy of neural blockade in specialized palliative care services in Japan: a multicenter audit survey

More than 85% of cancer-related pain is pharmacologically controllable, but some patients require interventional treatments. Although audit assessment of these interventions is of importance to clarify the types of patients likely to receive benefits, there have been no multicenter studies in Japan. The primary aims of this study were (1) to clarify the frequency of neural blockade in certified palliative care units and palliative care teams, (2) determine the efficacy of interventions, and (3) explore the predictors of successful or unsuccessful intervention. All patients who received neural blockade were consecutively recruited from seven certified palliative care units and five hospital palliative care teams in Japan. Primary responsible physicians reported pain intensity on the Support Team Assessment Schedule, performance status, communication levels on the Communication Capacity Scale, presence or absence of delirium, opioid consumption, and adverse effects before and one week after the procedure on the basis of retrospective chart review. A total of 162 interventions in 136 patients were obtained, comprising 3.8% of all patients receiving specialized palliative care services during the study period. Common procedures were epidural nerve block with local anesthetic and/or opioids (n = 84), neurolytic sympathetic plexus block (n = 24), and intrathecal nerve block with phenol (n = 21). There were significant differences in the frequency of neural blockade between palliative care units and palliative care teams (3.1% vs. 4.6%, respectively, P = 0.018), and between institutions whose leading physicians are anesthesiologists or have other specialties (4.8% vs. 1.5%, respectively, P < 0.001). Pain intensity measured on the Support Team Assessment Schedule (2.9 +/- 0.8 to 1.7 +/- 0.9, P < 0.001), performance status (2.7 +/- 1.0 to 2.4 +/- 1.0, P < 0.001), and opioid consumption (248 +/- 348 to 186 +/- 288 mg morphine equivalent/day, P < 0.001) were significantly improved after interventions. There was a tendency toward improvement in the communication level measured on the Communication Capacity Scale. There was no significant improvement in the prevalence of delirium, but six patients (32%) recovered from delirium after interventions. Adverse effects occurred in 9.2%, but all were predictable or transient. No fatal complications were reported. Pain intensity was significantly more improved in patients who survived 28 days or longer than others (P = 0.002). There were no significant correlations of changes in pain intensity with the performance status or previous opioid consumption. In conclusion, neural blockade was performed in 3.8% of cancer patients who received specialized palliative care services in Japan. Neural blockade could contribute to the improvement of pain intensity, performance service status, and opioid consumption without unpredictable serious side effects.     

What are the problems in palliative care? Results from a representative survey

The development of a standardised core documentation for palliative care was initiated in Germany in 1996. Results from previous evaluations have shown the wide variability of the documentation in participating units. A different documentation form was used in 2001 using free text entries to find out what problems palliative care specialists perceive in their patients. Fifty-five of the 83 palliative inpatient units in Germany (66% of the units) as well as one unit each from Austria and Switzerland, documented 1304 patients in the core documentation in 2001. Inpatient care was continued until death for 531 patients, 604 patients were discharged home and 169 patients were transferred to other places of care. Palliative care treatment effectively reduced mean physical symptom intensity. Mean intensities of psychological and social problems also were reduced although not as much as physical symptom load. Nursing problems were reduced for those patients discharged but not for those who died in the unit. Anxiety and depression were the most frequent psychological problems. Nursing problems were focussed on impairment of mobility and other activities of daily living such as washing, nutrition and drinking. Excessive distress on caregivers and the organisation of home care were the predominant social problems. In conclusion, this representative prospective survey with the majority of palliative care units in Germany showed the high effectiveness of symptom relief. Using the categories identified in this study, checklists were constructed and included in the documentation forms that are currently used for the core documentation project.     

Knowledge and beliefs about end-of-life care and the effects of specialized palliative care: a population-based survey in Japan

To clarify the knowledge and beliefs of the Japanese general population related to legal options, pain medications, communication with physicians, and hydration/nutrition in end-of-life care, and to explore the associations between end-of-life care they had experienced and these beliefs, a questionnaire survey was conducted on two target populations: 5000 general population subjects and 866 bereaved family members of cancer patents who died in 12 palliative care units in Japan. The respondents were requested to report the legal knowledge about end-of-life options, pain-related beliefs, communication-related beliefs, and hydration/nutrition-related beliefs, and their experiences with end-of-life care. A total of 3061 responses were analyzed (effective response rate, 54%). The respondents were classified into six groups: no bereavement experience (n = 949), those who had lost family members within the past 10 years from noncancer diseases at institutions (n = 673), those who lost family members from noncancer disease at home (n = 264), those who lost family members from cancer at institutions other than palliative care units (n = 525), those who lost family members from cancer at home (n = 86), and those who lost family members from cancer at palliative care units (n = 548). Across groups, 32-45% and 50-63% of the respondents stated that treatment withdrawal and double effect act were legal, respectively. Between 34% and 44% believed that cancer pain is not sufficiently relieved, 27-38% believed that opioids shorten life, and 24-33% believed that opioids cause addiction. Communication-related beliefs potentially resulting in barriers to satisfactory end-of-life discussion were identified in 31-40% ("physicians are generally poor at communicating bad news") and in 14-25% ("physicians are not comfortable discussing death"). The bereaved family members of the patients who died in palliative care units were significantly more likely than the other groups to believe that cancer pain is sufficiently relieved, and significantly less likely to believe that opioids shorten life, that opioids cause addiction, that physicians are generally poor at communicating bad news, and that physicians are uncomfortable discussing death. Between 33% and 50% of the respondents, including families from palliative care units, believed "artificial hydration should be continued as the minimum standard until death," while 15-31% agreed that "artificial hydration relieves patient symptoms." A significant proportion of the Japanese general population has beliefs about legal options, pain medications, and communication with physicians that potentially result in barriers to quality end-of-life care. As their experiences in specialized palliative care significantly influenced their belief, systematic efforts to spread quality palliative care activity are of value to lessen these barriers and achieve quality end-of-life care.     

Entwicklung und Stand der stationären palliativmedizinischen Einrichtungen in Deutschland

In April 1999 altogether 114 inpatient units providing palliative care (50 palliative care units, 64 inpatient-hospices) offered a total of 989 beds. Compared to 1993 this has been an increase of 256%, compared to 1997 of 60%. The number of available beds, compared to 1997, increased markedly (58%), with a availability of 12 beds per one million residents. However, there are still major deficits: the distribution of the units is very irregular and the number of available beds is still to low, compared to the estimated need of 50 inpatient beds per one million residents. The quality of palliative care shows significant deficits (e. g. the availability of nursing staff, cooperation with pain clinics, standardised documentation, education). Differences between palliative care wards and hospices were huge. According to the definition of the German Society for Palliative Care, a palliative care ward should provide a ratio of at least 1.4 nursing staff per bed, however, only 18% of the palliative care units fulfil this definition. Only few hospices and half of the palliative care units worked in close cooperation with pain clinics. Despite a significant increase in units and inpatient beds providing palliative care, there still is a major deficit in the overall number of beds and the quality of palliative care.     

Sedation for delirium and other symptoms in terminally ill patients in Edmonton

The use of sedation and the management of delirium and other difficult symptoms in terminally ill patients in Edmonton has been reported previously. The focus of this study was to assess the prevalence in the Edmonton region of difficult symptoms requiring sedation at the end of life. Data were collected for 50 consecutive patients at each of (a) the tertiary palliative care unit, (b) the consulting palliative care program at the Royal Alexandra Hospital (acute care), and (c) three hospice inpatient units in the city. Patients on the tertiary palliative care unit were significantly younger. Assessments confirmed the more problematic physical and psychosocial issues of patients in the tertiary palliative care unit. These patients had more difficult pain syndromes and required significantly higher doses of daily opioids. Approximately 80% of patients in all three settings developed delirium prior to death. Pharmacological management of this problem was needed by 40% in the acute care setting, and by 80% in the tertiary palliative care unit. The patients sedated varied from 4% in the hospice setting to 10% in the tertiary palliative care unit. Of the 150 patients, nine were sedated for delirium, one for dyspnea. The prevalence of delirium and other symptoms requiring sedation in our area is relatively low compared to others reported in the literature. Demographic variability between the three Edmonton settings highlights the need for caution in comparing results of different palliative care groups. It is possible that some variability in the use of sedation internationally is due to cultural differences. The infrequent deliberate use of sedation in Edmonton suggests that improved management has resulted in fewer distressing symptoms at the end of life. This is of benefit to patients and to family members who are with them during this time.     

A multicentre international study of sedation for uncontrolled symptoms in terminally ill patients

The issue of symptom management at the end of life and the need to use sedation has become a controversial topic. This debate has been intensified by the suggestion that sedation may correlate with 'slow euthanasia'. The need to have more facts and less anecdote was a motivating factor in this multicentre study. Four palliative care programmes in Israel, South Africa, and Spain agreed to participate. The target population was palliative care patients in an inpatient setting. Information was collected on demographics, major symptom distress, and intent and need to use sedatives in the last week of life. Further data on level of consciousness, adequacy of symptom control, and opioids and psychotropic agents used during the final week of life was recorded. As the final week of life can be difficult to predict, treating physicians were asked to complete the data at the time of death. The data available for analysis included 100 patients each from Israel and Madrid, 94 patients from Durban, and 93 patients from Cape Town. More than 90% of patients required medical management for pain, dyspnoea, delirium and/or nausea in the final week of life. The intent to sedate varied from 15% to 36%, with delirium being the most common problem requiring sedation. There were variations in the need to sedate patients for dyspnoea, and existential and family distress. Midazolam was the most common medication prescribed to achieve sedation. The diversity in symptom distress, intent to sedate and use of sedatives, provides further knowledge in characterizing and describing the use of deliberate pharmacological sedation for problematic symptoms at the end of life. The international nature of the patient population studied enhances our understanding of potential differences in definition of symptom issues, variation of clinical practice, and cultural and psychosocial influences.     

Palliative cancer care in two health centres and one hospice in Finland

This study evaluates palliative treatment of inpatient cancer patients in two health centres and in one hospice in Finland. Apart from outpatient clinics, health centres in Finland also have inpatient wards where patients are treated by GPs. The hospice provides a home-like environment for terminal patients, who are cared for by a specialist in internal medicine. Our patient population comprised 36 health centre patients and 36 hospice patients enrolled in 1998. A structured questionnaire was used containing information on diagnosis, duration of the illness, current medication, daily activities, and socioeconomic background. The nurses assessed their patients' emotional needs. We found that the two groups of patients were similar in terms of gender, marital status and social situation. The hospice patients were significantly younger (P < 0.05) and better educated than the health centre patients (P = 0.001), and their disease had lasted longer (P < 0.05). Upon admission, 12 (33%) of the hospice patients were using opioids, as were 6 patients (17%) in the health centre group. During the treatment period in the hospice the nurses reported more anxiety and depression in their patients (P < 0.05); staff in the health centres were more often unable to report on their patients' feelings. Hospice patients (20/35) were significantly (P < 0.001) more concerned about the wellbeing of their relatives than patients in the health centres (2/35). In the hospice 18 patients (50%) showed significantly (P < 0.001) more spiritual needs than health centre patients (4/34). We conclude that more education is needed to improve the awareness of the multidimensional needs of terminally ill cancer patients in primary health care.     

Opioid switch in palliative care, opioid choice by clinical need and opioid availability.

Availability of different WHO-step 3 opioids has encouraged the discussion on their value and led to the concepts of opioid rotation. Rotation is suggested, when other measures fail to achieve optimal analgesia and tolerability in cancer pain treatment. Opioid use was assessed in a prospective cohort study of 412 palliative care patients from 14 inpatient and outpatient palliative care facilities in Germany. The most frequently used opioids at baseline were morphine and fentanyl. The most frequent changes in medication (N=106) occurred from oral to parenteral morphine. Only in 49 cases true switches to other long acting opioids were recorded. This is far less than expected from other reports. True switches and adverse side effects were found to occur more frequently in inpatients, while efficacy problems were more frequently recorded in outpatients. There was no correlation between the opioid used at baseline and switch frequency, but numbers of cases receiving other opioids than fentanyl or morphine were low. Reasons for and frequencies of changes in medication were found to be largely shaped by the setting reflecting patients' needs and clinical necessities. Recommendation of first line therapy and availability of opioid formulations define the frequency of opioid use. This impedes evaluation of specific differences between the opioids.     

When nothing helps: propofol as sedative and antiemetic in palliative cancer care

Benzodiazepines, neuroleptics, and barbiturates are commonly used for sedation to achieve symptom control in end-of-life care. Propofol has several advantages over traditional sedating agents that would indicate its use in treatment-refractory situations. We report on the use of propofol in 35 patients. In 22 patients, propofol was used for palliative sedation when treatment with benzodiazepines had failed. The mean dose range during treatment was between 0.90 and 2.13 mg/kg/h. The effect was assessed as good or very good in 91% of the patients. Thirteen patients were treated with propofol due to intractable nausea and vomiting. The mean dose range during the infusion period was 0.67–1.01 mg/kg/h. The effect was judged as good or very good in 69% of the patients. Based on our experience, we propose clinical guidelines on the safe use of propofol in specialized palliative inpatient units.     

Factors associated with the coping of parents with a child in psychiatric inpatient care

The purpose of this study was to establish the parental coping' factors associated with having a child in psychiatric inpatient care. The data were collected from 19 hospitals with child psychiatry units. At the time of data collection, all parents of children in psychiatric inpatient care in these hospitals were recruited. The method of data collection was a questionnaire (n = 79). The data were analysed with the Statistical Package for the Social Sciences (SPSS) for Windows statistical software. The connections between variables were studied with cross-tabulation, and the chi2 test was used to determine significance. Changes in internal and external family relationships and matters related to the upbringing of the child with mental problems statistically correlated significantly with parental coping (P < 0.001). Problem-oriented and emotionally-oriented coping strategies, skills and palliative strategies correlated significantly with parental coping (P < 0.001). Emotional support, support for the care and upbringing of the child in inpatient care, and love and acceptance also had statistically significant associations with parental coping (P < 0.001).