Oncology and palliative care

Oncology developed as a discipline over the last decades. Treatment is concentrated on cure or palliation of the illness with the help of chemotherapy, radiotherapy or surgery. Palliative care has its origin in the hospice movement that started around 1960 in the UK. Centre of care is the patient and his family. Focus of care has moved from quantity to quality of life. Symptom control, communication, rehabilitation and care for the dying are main areas of palliative care. Palliative care and palliative medicine have only developed over the last 10 years in Germany. It is still seen as care for the dying after completion of oncological treatment. The integration of palliative care in earlier stages of the disease is essential to offer a continuity of care for the patient and his family. Principles of palliative care need also be part of medical and post-graduate training

Adrenal insufficiency caused by bilateral adrenal metastases - a rare treatable cause for recurrent nausea and vomiting in metastatic breast cancer

Background: Nausea and vomiting are common symptoms in patients with malignant disease. Several, sometimes rare causes have to be considered to decide the right treatment. Case Report: We report of a patient suffering from advanced breast cancer and complaining of severe nausea and vomiting over several weeks without any successful treatment. Later on, she developed marked hyperpigmentation of the skin and hypo-osmolar dehydration. Adrenal enlargement was noted in an abdominal scan. The suspected diagnosis of primary adrenocortical insufficiency due to metastases was confirmed by laboratory tests. After replacement therapy with hydrocortisone and fludrocortisone, the general condition of the patient improved dramatically and the symptoms of nausea and vomiting disappeared completely. Conclusion: If a patient with advanced cancer presents with unexplained and protracted nausea, vomiting and weakness, particularly if accompanied by hyponatremia and normal potassium levels, adrenal insufficiency due to adrenal metastases should be considered

Nurses'decision-making in ethically relevant clinical situations using the example of breathlessness: study protocol of a reflexive grounded theory integrating Goffman's framework analysis

Introduction: Decision-making (DM) in healthcare can be understood as an interactive process addressing decision makers' reasoning as well as their visible behaviour after the decision is made. Other key elements of DM are ethical aspects and the role as well as the treatment options of the examined professions. Nurses' DM to choose interventions in situations of severe breathlessness is such interactions. They are also ethically relevant regarding the vulnerability of affected patients and possible restrictions or treatment options. The study aims to explore which factors influence nurses' DM to use nursing interventions in situations where patients suffer from severe breathlessness. Methods and analysis: Qualitative study including nurses in German hospital wards and hospices. A triangulation of different methods of data collection-participant observation and qualitative expert interviews -and analysis merge in a reflexive grounded theory approach which integrates Goffman's framework analysis. It allows an analysis of nurses' self-statements about DM, their behaviour in relevant clinical situations and its influences. Data collection and analysis will be examined simultaneously. Ethics and dissemination: Informed consent will be gained from all participants and the institutional stakeholders. Ongoing consent has to be ensured since observations will take place in healthcare institutions and many patients will be highly vulnerable. The study has been evaluated and approved by the Witten/ Herdecke University Ethics Committee, Witten, Germany. Results of the study will be published at congresses and in journal papers

Physical compared to mental diseases as reasons for committing suicide: a retrospective study

Background: Several studies investigated the relationship between mental disorders and suicidal ideation. However, little is known about physical illnesses being the major trigger for committed suicides. It is necessary to understand these risk factors to be able to meet the needs of patients in a palliative care setting. Methods: Suicide, medical and police notes were retrospectively analysed from all autopsies conducted in 2009-11 at the University of Munich, Germany. Documented reasons for suicide were classified into a "physical disease" (PD) or "mental disease" (MD) group and compared with respect to their sociodemographic characteristics and autopsy outcomes. Results: Of all 1069 cases, 18.9 % gave a PD as reason for committing suicide (MD, 32.7 %). Those indicating PD were older than MD (68.8 vs. 48.7 years;p < 0.001) with more men being in this group (72.8 % vs. 59.1 %;p=0.002). In PD, 30.7 % suffered from cancer, 28.7 % from chronic pain and 12.4 % from lung disease. 38.8 % of MD and 12.4 % of PD had previous suicide attempts. Conclusions: In palliative care, it is necessary to screen patients on a regular basis for suicidal ideation, especially those with previous suicide attempts

Physical compared to mental diseases as reasons for committing suicide: a retrospective study

Background: Several studies investigated the relationship between mental disorders and suicidal ideation. However, little is known about physical illnesses being the major trigger for committed suicides. It is necessary to understand these risk factors to be able to meet the needs of patients in a palliative care setting. Methods: Suicide, medical and police notes were retrospectively analysed from all autopsies conducted in 2009-11 at the University of Munich, Germany. Documented reasons for suicide were classified into a "physical disease" (PD) or "mental disease" (MD) group and compared with respect to their sociodemographic characteristics and autopsy outcomes. Results: Of all 1069 cases, 18.9 % gave a PD as reason for committing suicide (MD, 32.7 %). Those indicating PD were older than MD (68.8 vs. 48.7 years;p < 0.001) with more men being in this group (72.8 % vs. 59.1 %;p=0.002). In PD, 30.7 % suffered from cancer, 28.7 % from chronic pain and 12.4 % from lung disease. 38.8 % of MD and 12.4 % of PD had previous suicide attempts. Conclusions: In palliative care, it is necessary to screen patients on a regular basis for suicidal ideation, especially those with previous suicide attempts

"We don't want to sedate him" - A qualitative interview study on intentions when administering sedative drugs at the end of life in nursing homes and hospitals

BACKGROUND Previous data indicate major differences between countries and settings regarding the intention when administering sedative drugs at the end of life and the perception, which drugs are sedating. Therefore, we aimed to explore the concept of 'sedative drugs' and the intentions of German healthcare professionals in general palliative care when administering sedative drugs at the end of life. METHODS Semi-structured qualitative interviews with physicians and nurses (n = 49). Recruitment took place via contact persons in five hospital departments (haematology/oncology (n = 2), neurology, geriatrics, gynaecology) and five nursing homes. We thematically analysed the transcripts by the Framework approach, using MAXQDA version 2018.2. RESULTS Most interviewees referred to benzodiazepines, opioids, and antipsychotics. Some subsumed all into sedative drugs, others differentiated between sedative drugs, anxiolytics, and analgesics. In explaining their intention, interviewees particularly emphasized what they want to avoid when administering sedative drugs. We identified three main themes regarding (excluded) intentions: (1) use of sedative drugs to relieve the patient's suffering with reduction of consciousness as side effect, (2) use of sedative drugs to relieve the situation for the team and/or the family, (3) distinction between intention and expectation regarding hastening death. Interviewees often equated the term 'sedation' with inducing a state of unconsciousness, which should be avoided. CONCLUSION German healthcare professionals in general palliative care seem to negatively connote the term 'sedation'. Moreover, they see themselves in a more passive role by accepting a side effect rather than performing an intentional act. Critical reflection of indications and intentions in accordance with respective guidelines is needed

“Palliative syringe driver”? A mixed-methods study in different hospital departments on continuous infusions of sedatives and/or opioids in end-of-life care

Continuous infusions of sedatives and/or opioids (continuous infusions) are frequently used in end-of-life care. Available data indicate challenges in nonspecialist palliative care settings. We aimed to assess the use of continuous infusions during the last week of life in different hospital departments. METHODS: In a sequential mixed-methods design, a retrospective cohort study was followed by consecutive qualitative interviews in 5 German hospital departments. Medical records of 517 patients who died from January 2015 to December 2017 were used, and 25 interviews with physicians and nurses were conducted. Recorded sedatives were those recommended in guidelines for “palliative sedation”: benzodiazepines, levomepromazine, haloperidol (≥5 mg/d), and propofol. Exploratory statistical analysis (R 3.6.1.) and framework analysis of interviews (MAXQDA 2018.2) were performed. RESULTS: During the last week of life, 359 of 517 deceased patients (69%) received continuous infusions. Some interviewees reported that continuous infusions are a kind of standard procedure for “palliative” patients. According to our interviewees’ views, equating palliative care with continuous infusion therapy, insufficient experience regarding symptom control, and fewer care needs may contribute to this approach. In addition, interviewees reported that continuous infusions may be seen as an “overall-concept” for multiple symptoms. Medical record review demonstrated lack of a documented indication for 80 of 359 patients (22%). Some nurses experienced concerns or hesitations among physicians regarding the prescription of continuous infusions. CONCLUSIONS: Continuous infusions seem to be common practice. Lack of documented indications and concerns regarding the handling and perception of a “standard procedure” in these highly individual care situations emphasize the need for further exploration and support to ensure high quality of care

The feasibility and acceptability of short-term, individual existential behavioural therapy for informal caregivers of patients recruited in a specialist palliative care unit

Background: Existential behavioural therapy ( EBT) is a recently developed intervention to support informal caregivers of patients in a specialist palliative care unit and was initially established as a six-session group programme. This pilot study aimed to test the feasibility and acceptability of an adapted short-term, individual approach of EBT in preparation for a randomized controlled trial ( RCT). Methods: The study was conducted in a prospective, mixed methods design including four quantitiative assessments with embedded qualitative interviews at one assessment. The intervention offered two one-hour therapeutic sessions focusing on ( 1) mindfulness and ( 2) existential meaning-in-life as a source of strength provided by a trained psychotherapist. To test the feasibility of the intervention, doubling of the participation rate, compared to the previous group study ( 13,6 %) as well as an attrition rate of less than 30 % were set as thresholds. To test the acceptability of the intervention, self-rated usefulness of individual aspects of the intervention and the frequency of implementing therapeutic elements by the carers were set as criteria. Acceptability testing also included the number of participants who completed both sessions, where we expected more than 75 % as a criterion for acceptability. Return rates of quantitative questionnaires were set as criteria for the feasibility of data collection (<33 % loss expected within the study period). Qualitative interviews were used to collect additional data on feasibililty and acceptability and to explore potential harms and benefits of the intervention. Results: 44/102 ( 43,1 %) of eligible informal caregivers agreed to participate in the study. Due to attrition of 13 caregivers ( attrition rate: 29,5 %), 31 caregivers were included in the trial. Self-rated usefulness showed sufficiant results for all but one individual aspect. Frequency of implementing therapeutic elements showed wide inter-item as well as inter-participant ranges and decreased over the study period. All participants completed both sessions. Return rates of the questionnaires were within the expected range. According to the interviews, the intervention was associated with several participant-identified benefits. No severe adverse effects were observed. Conclusions: Findings suggest that the short-term, individual EBT proved feasible and mostly acceptable