Eine gesetzliche Regulierung des Umgangs mit Opiaten und Sedativa bei medizinischen Entscheidungen am Lebensende?

Zusammenfassung: Der ärztliche Umgang mit Opiaten und Sedativa bei Patienten am Lebensende kann ethische Fragen aufwerfen. Entsprechende Entscheidungen blieben bisher in aller Regel der ärztlichen Berufskunst und -pflicht überantwortet. Heute aber gerät dieser Bereich zunehmend auch in den Blickwinkel des Rechts. Ausdruck davon sind Bestrebungen, die indirekte Sterbehilfe, allenfalls auch die terminale Sedierung gesetzlich zu regeln. Ausgehend von einer Ist-Analyse der ärztlichen Praxis sowie von bereits bestehenden Regulierungen untersucht diese Arbeit die Konsequenzen derartiger Bestrebungen. Es zeigt sich, dass der Versuch, die Thematik der indirekten Sterbehilfe für sich allein, also unter Vermeidung einer Regelung der direkt aktiven Sterbehilfe, zu behandeln, zu großen Schwierigkeiten führen würde. Ernüchternd sind aber auch die Erfahrungen aus den Niederlanden, derartige Fragen im Rahmen eines umfassenden Sterbehilfegesetzes anzugehen. Insgesamt ist somit zu befürchten, dass der Versuch einer detaillierten gesetzlichen Regelung dieses Bereiches mehr neue Grauzonen und Unsicherheiten schafft, als er zu beseitigen verma

Content of health status reports of people seeking assisted suicide: a qualitative analysis

Two right-to-die organisations offer assisted suicide in Switzerland. The specific legal situation allows assistance to Swiss and foreign citizens. Both organisations require a report of the person's health status before considering assistance. This qualitative study explored these reports filed to legal authorities after the deaths of individuals in the area of Zurich. Health status reports in the legal medical dossiers of the deceased were analysed using content analysis and Grounded Theory. From 421 cases of assisted suicide (2001-2004), 350 reports on health status were filed. Many cases contained diagnosis lists only. Other reports had more elaborate reports revealing that some physicians were aware about the patient's death wish and the intention to solicit assisted suicide. Physicians' attitudes ranged from neutral to rather depreciative. Few physicians openly referred the patient to the organisations and supported the patient's request by highlighting a history of suffering as well as reporting understanding and agreement with the patient's wish to hasten death. In the health status reports five categories could be identified. Some files revealed that physicians were aware of the death wish. The knowledge and recognition of the patient's death wish varied from no apparent awareness to strongly supportive. This variety might be due to difficulties to discuss the death wish with patients, but might also reflect the challenge to avoid legal prosecution in the country of origin. To require comparable health status reports as requirements for the right-to-die organisations might be difficult to pursu

Prophylaxis of Heterotopic Ossification in Patients Sedated after Polytrauma: Medical and Ethical Considerations

Background and Purpose:: Heterotopic ossification (HO) often follows acetabular fractures after multitrauma. Irradiation is a mean for prophylaxis. We established a standard procedure in our hospital for patients under sedation, when obtaining informed consent for HO prophylaxis is impossible. Patients and Methods:: We reviewed current scientific evidence, calculated the risks of radiation and presented the ethical and legal framework. The subject was scrutinised by an interdisciplinary panel. Results:: Irradiation is the most effective means for prophylaxis and has few adverse effects in adult patients with fractures of the acetabulum. The lifetime risk of radiation-induced cancer or infertility are insignificant. Conclusions:: Informed consent for irradiation should be obtained before operation whenever possible. When this cannot be done prophylaxis can be postponed for a maximum of 3 days in order to obtain consent. If the patient is not able to communicate within this period, prophylactic irradiation should be given after consulting the relatives. The patient must be informed as soon as possibl

Chemotherapy near the end of life: a retrospective single-centre analysis of patients' charts

BACKGROUND: Chemotherapy near the end of life is an issue frequently discussed nowadays. The concern is that chemotherapy could cause more harm than good in a palliative situation; this is even truer as the patient nears death. The objective of our study is to evaluate the aggressiveness of patient care near the end of life by determining how many cancer patients receive chemotherapy during their final weeks. METHODS: In a retrospective analysis of patient charts, we investigated whether cancer patients had been treated with chemotherapy during the last four or two weeks of life. If they had, we looked at whether treatment was ongoing or newly initiated. RESULTS: Out of the 119 cancer patients who died in our hospital over two years, 14 (11.7%) received chemotherapy during the last four weeks of life, nine of whom (7.6%) in the last two weeks of life. Treatment had been ongoing in six (5%) and newly initiated for eight (6.7%) within four weeks of death. Corresponding figures for the last two weeks of life were seven patients (5.9%) who continued previously prescribed treatment and two (1.7%) who were started on chemotherapy. Patients given chemotherapy during the last four weeks of life were significantly younger than those who were not (p = 0.003). CONCLUSIONS: Cancer patient care in our hospital is not considered overly aggressive as only 7.6% of these patients receive chemotherapy within the last two weeks of life. To determine how aggressive care near the end of life really is, however, we suggest evaluating newly started chemotherapy alongside ongoing treatment. As the line between the effects (beneficience) and side effects (nonmaleficience) of chemotherapy is often very narrow, doctors and patients have to work together to find the best way of treading this fine line

Intentionally hastening death by withholding or withdrawing treatment

Zusammenfassung: ZWECK: Diese Arbeit soll empirische Daten zur Absicht des Arztes beim Behandlungsverzicht und -abbruch liefern und deren mögliche Bedeutung für die ethische Debatte diskutieren. METHODIK: Die präsentierten Daten basieren auf EURELD, einem breit angelegten Forschungsprojekt zur Erfassung medizinischer Entscheidungen am Lebensende in sechs europäischen Ländern. Ausgehend von einer fortlaufenden Zufallsstichprobe von Todesfallformularen war der zuständige Arzt anonym schriftlich zu den am Lebensende des Verstorbenen getroffenen Entscheidungen befragt worden. ERGEBNISSE: In allen sechs Ländern zusammengenommen gaben die befragten Ärzte in 45% aller Fälle von Behandlungsverzicht oder -abbruch am Lebensende eine ausdrückliche Absicht zur Beschleunigung des Todeseintrittes an. Höher als der Durchschnitt war dieser Prozentsatz in der Schweiz und in Schweden (52% resp. 51%), tiefer in Dänemark und Belgien (36% resp. 38%), im Mittelfeld lagen Italien und Holland (42% resp. 45%). Insgesamt war der Entscheid zum Verzicht oder Abbruch einer Dialyse oder einer Beatmung besonders häufig mit einer ausdrücklichen Absicht zur Beschleunigung des Todeseintrittes verbunden (57% resp. 54%), der Verzicht oder Abbruch von Krebstherapien besonders selten (34%). SCHLUSSFOLGERUNGEN: Ärztliche Entscheidungen zum Behandlungsverzicht oder -abbruch am Lebensende erfolgen in fast der Hälfte der Fälle mit der ausdrücklichen Absicht einer Beschleunigung des Todeseintrittes. Es findet sich keine klare Assoziation zwischen der ausdrücklichen Absicht zur Beschleunigung des Todeseintrittes und objektiven Merkmalen des jeweiligen Behandlungsabbruches oder -verzichtes wie der Wahrscheinlichkeit resp. dem Ausmaß eines lebensverkürzenden Effekts, der Unmittelbarkeit des Todeseintritts oder der zu erwartenden Belastung durch die mögliche lebenserhaltende Maßnahme. Diese Resultate wecken Zweifel an der Brauchbarkeit des Kriteriums der ärztlichen Absicht bei der moralischen Beurteilung von Entscheidungen zum Behandlungsverzicht und -abbruc

Pain Intervention for people with Dementia in nursing homes (PID) : study protocol for a quasi-experimental nurse intervention

Background: It is estimated that 19 to 83% of people with dementia suffer from pain that is inadequately treated in the last months of life. A large number of healthcare workers who care for these people in nursing homes lack appropriate expertise and may therefore not always recognise, assess and treat pain in those with dementia who have complex problems on time, properly and efficiently. The aim of this intervention trial is to identify care needs of people with dementia suffering from pain living in a nursing home. Methods: A quasi-experimental nurse-led intervention trial based on a convenience sample of four nursing homes in the Swiss Canton of Zurich examines the effects on dementia patients (n = 411), the healthcare institution and the qualification level of the healthcare workers compared to historical controls, using an event analysis and a multilevel analysis. Healthcare workers will be individually trained how to assess, intervene and evaluate acute and chronic pain. There are three data-monitoring cycles (T0, T1, T2) and two intervention cycles (I1, I2) with a total study duration of 425 days. There is also a process evaluation based on Dobbins analyses that analyze in particular the potentials for change in clinical practice of change agents. Discussion: The aim of the intervention trial is to improve pain management strategies in older people with dementia in nursing homes. Clinically significant findings will be expected that will help reduce suffering in the sense of “total pain” for people with dementia. The joint intra- and interdisciplinary collaboration between practice and supply-oriented (nursing) research will have both a lasting effect on the efficiency measurement and provide scientifically sound results. Nursing homes can integrate the findings from the intervention trial into their internal quality control process. The potential for improvements can be directly influenced by the nursing home itself

Content of health status reports of people seeking assisted suicide: a qualitative analysis

Two right-to-die organisations offer assisted suicide in Switzerland. The specific legal situation allows assistance to Swiss and foreign citizens. Both organisations require a report of the person's health status before considering assistance. This qualitative study explored these reports filed to legal authorities after the deaths of individuals in the area of Zurich. Health status reports in the legal medical dossiers of the deceased were analysed using content analysis and Grounded Theory. From 421 cases of assisted suicide (2001-2004), 350 reports on health status were filed. Many cases contained diagnosis lists only. Other reports had more elaborate reports revealing that some physicians were aware about the patient's death wish and the intention to solicit assisted suicide. Physicians' attitudes ranged from neutral to rather depreciative. Few physicians openly referred the patient to the organisations and supported the patient's request by highlighting a history of suffering as well as reporting understanding and agreement with the patient's wish to hasten death. In the health status reports five categories could be identified. Some files revealed that physicians were aware of the death wish. The knowledge and recognition of the patient's death wish varied from no apparent awareness to strongly supportive. This variety might be due to difficulties to discuss the death wish with patients, but might also reflect the challenge to avoid legal prosecution in the country of origin. To require comparable health status reports as requirements for the right-to-die organisations might be difficult to pursu

Responders and non-responders in a study on medical end-of-life decisions in Denmark, the Netherlands, Sweden and Switzerland

Summary.: Objectives: To determine the direction and magnitude of participation bias in end-of-life research. Methods: Within the framework of a European survey on medical end-of-life decisions, a non-response study was conducted among physicians in Denmark, the Netherlands, Sweden and Switzerland. People were asked about their attitudes and experiences in the area of medial end-of-life decision. The response rates ranged from 12.8% (Netherlands) to 39.4% (Switzerland). The responders (n = 5 403) and the non-responders (n = 866) were compared regarding socio-demographic characteristics, experiences with terminal patients and agreement with attitudes towards "end-of-life decisions”. The reasons for non-participation to the study were analyzed. Results: Non-response did not cause socio-demographic distortion, but non-responders had statistically significantly fewer terminal patients than responders. Agreement rates were statistically significantly higher among responders than among non-responders for euthanasia, non-treatment decision and life-preserving statements. Neutral answers were statistically significantly more frequent among non-responders than among responders for life-preserving and euthanasia statements. The most commonly mentioned reason for non-participation was "lack of time”. Conclusion: Non-participation does cause an overestimation of proponents of life-shortening, as well as of life-preserving end-of-life decisions. Non-responders more often have ambiguous attitudes towards end-of-life decisions than responder

Pain Interventions for people with dementia: a quasi-experimental study

Abstract Background Due to the complexity of the provision of care for people with dementia, pain assessment and management is still considered to be lacking. An optimal way to support frontline staff in providing pain assessment and management for people with dementia living in nursing homes has not yet been identified. The success of supporting interventions seems dependent on contextual factors in the nursing homes. This study, therefore, analyzes the feasibility of a nurse-led training intervention, using repeated on-site case studies, in modifying pain intensity and frequency in people with dementia. Methods Using a quasi-experimental design, we undertook a multi-center study of nurse-led training in pain management, with subsequent on-site case studies. Healthcare workers from 3 nursing homes assessed pain in 164 residents with dementia over 147 days. We used mixed-effect growth curve models with spline regression to analyze the data. Results We found that on-site case studies support frontline staff with pain management and assessment. Repeated reflection in case studies led to significantly longer pain free intervals (from 4.7 at baseline to 37.1 days at second follow-up) and decreased frequency of pain events (OR 0.54 at first follow-up and 0.43 at second follow-up). However no trends regarding pain intensity could be found. Therefore, on-site case studies may be valuable for improving pain frequency and pain-free intervals over time. Conclusion This feasibility study shows the potential of on-site support for frontline nursing home staff. On-site case studies may also affect health outcomes in people with dementia. However, the complexity of dementia care necessitates the management of a broader range of needs. Trial registration The study was retrospectively registered on the tenth of January 2017 with the German registry of clinical trials (DRKS00009726)

S1 Guideline onychomycosis

Onychomycosis is a fungal infection of the fingernails and toenails. In Europe, tinea unguium is mainly caused by dermatophytes. The diagnostic workup comprises microscopic examination, culture and/or molecular testing (nail scrapings). Local treatment with antifungal nail polish is recommended for mild or moderate nail infections. In case of moderate to severe onychomycosis, oral treatment is recommended (in the absence of contraindications). Treatment should consist of topical and systemic agents. The aim of this update of the German S1 guideline is to simplify the selection and implementation of appropriate diagnostics and treatment. The guideline was based on current international guidelines and the results of a literature review conducted by the experts of the guideline committee. This multidisciplinary committee consisted of representatives from the German Society of Dermatology (DDG), the German‐Speaking Mycological Society (DMykG), the Association of German Dermatologists (BVDD), the German Society for Hygiene and Microbiology (DGHM), the German Society of Pediatric and Adolescent Medicine (DGKJ), the Working Group for Pediatric Dermatology (APD) and the German Society for Pediatric Infectious Diseases (DGPI). The Division of Evidence‐based Medicine (dEBM) provided methodological assistance. The guideline was approved by the participating medical societies following a comprehensive internal and external review