Vorsorgedokumente in der präklinischen Notfallmedizin

Background

The handling of advance directives (AD) in prehospital emergency treatment in Germany is characterized by instability. In the project “Advance directives in preclinical emergency medical aid” (“Patientenverfügungen in der präklinischen Notfallmedizin”) the frequency and quality of ADs in emergency situations was investigated.

Aim

The aim of this study was to fill the gaps in research and to collate data on how consideration of the self-determination of patients in emergency situations can be optimized.

Material and methods

Over a period of 12 months from December 2007 to December 2008 a questionnaire was included in the emergency documentation of the medical emergency service in Aachen. Emergency patients were asked by emergency physicians to provide an AD and the quantitative as well as qualitative features of these ADs were examined. Furthermore, the study recorded what kinds of problems occurred with ADs in emergency situations and what measures were needed to correct this deficiency. The reactions of patients were documented on a numeral rating scale with a score of 1 reflecting a negative and 10 reflecting a positive reaction. In the 12-month period emergency doctors recorded 1,321 missions and after application of the exclusion criteria (e.g. missing signature, incomplete documentation and late delivery) 1,047 documented questionnaires were available for the analysis.

Results

A total of 127 out of 1,047 emergency patients provided an AD, 44 had a durable power of attorney and 27 had appointed a legal representative for healthcare. Of the emergency patients 20 had a legal attendant and 43 out of the 127 ADs could be presented to the emergency team during the emergency mission. The emergency team often encountered difficulties regarding the handling of the ADs due to the time factor and unclear wording. The latter included the following problems: misleading formulation (19.1?%), difficulty with the complexity (14.9?%) and contradicting information (4?%). Only 29 (61.7?%) of the durable powers of attorney were signed and legally binding. From the view of the emergency physicians the following information was lacking but would be helpful in emergency situations: emergency plan, hierarchy of those given power of attorney, knowledge of risks regarding ADs and medication requirements.

Conclusion

The results show that for an AD to apply in an emergency situation certain standards are necessary that assure the practicability, especially if a patient does not wish to be resuscitated. Most difficulties with ADs occurred with imprecise formulation, text length and inconsistency of statements. The following instructions were usually missing: hierarchy of those given power of attorney and specification on medication, information about the scope of the ADs, statement about resuscitation, extent and limitations of the desired treatment, especially with patients certified as terminally ill and instructions on who should decide about medical treatment in a conflict situation. A so-called emergency instruction which gives on a single page the patient’s statement on resuscitation would have been very helpful in individual cases. The results suggest that patients may need more information and education about AD to guarantee patients rights and self-determination.     

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Characterization Methods along the Process Chain of Electrical Steel Sheet—From Best Practices to Advanced Characterization

Non-oriented (NO) electrical steel sheets find their application in rotating electrical machines, ranging from generators for wind turbines to motors for the transportation sector and small motors for kitchen appliances. With the current trend of moving away from fossil fuel-based energy conversion towards an electricity-based one, these machines become more and more important and, as a consequence, the leverage effect in saving energy by improving efficiency is huge. It is already well established that different applications of an electrical machine have individual requirements for the properties of the NO electrical steel sheets, which in turn result from the microstructures and textures thereof. However, designing and producing tailor-made NO electrical steel sheet is still challenging, because the complex interdependence between processing steps, the different phenomena taking place and the resulting material properties are still not sufficiently understood. This work shows how established, as well as advanced and newly developed characterization methods, can be used to unfold these intricate connections. In this context, the respective characterization methods are explained and applied to NO electrical steel as well as to the typical processing steps. In addition, several experimental results are reviewed to show the strengths of the different methods, as well as their (dis)advantages, typical applications and obtainable data.     

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