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Medau I, Jox RJ, Reiter-Theil S. How psychotherapists handle treatment errors -- an ethical analysis. BMC Med Ethics 2013; 14:50. [PMID: 24321503 PMCID: PMC4029351 DOI: 10.1186/1472-6939-14-50] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 11/27/2013] [Indexed: 11/21/2022] Open
Abstract
Background Dealing with errors in psychotherapy is challenging, both ethically and practically. There is almost no empirical research on this topic. We aimed (1) to explore psychotherapists’ self-reported ways of dealing with an error made by themselves or by colleagues, and (2) to reconstruct their reasoning according to the two principle-based ethical approaches that are dominant in the ethics discourse of psychotherapy, Beauchamp & Childress (B&C) and Lindsay et al. (L). Methods We conducted 30 semi-structured interviews with 30 psychotherapists (physicians and non-physicians) and analysed the transcripts using qualitative content analysis. Answers were deductively categorized according to the two principle-based ethical approaches. Results Most psychotherapists reported that they preferred to an disclose error to the patient. They justified this by spontaneous intuitions and common values in psychotherapy, rarely using explicit ethical reasoning. The answers were attributed to the following categories with descending frequency: 1. Respect for patient autonomy (B&C; L), 2. Non-maleficence (B&C) and Responsibility (L), 3. Integrity (L), 4. Competence (L) and Beneficence (B&C). Conclusions Psychotherapists need specific ethical and communication training to complement and articulate their moral intuitions as a support when disclosing their errors to the patients. Principle-based ethical approaches seem to be useful for clarifying the reasons for disclosure. Further research should help to identify the most effective and acceptable ways of error disclosure in psychotherapy.
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Jox RJ, Schöne-Seifert B, Brukamp K. [Current controversies in neuroethics]. DER NERVENARZT 2013; 84:1163-1164. [PMID: 24081274 DOI: 10.1007/s00115-013-3731-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Stutzki R, Weber M, Reiter-Theil S, Simmen U, Borasio GD, Jox RJ. Attitudes towards hastened death in ALS: A prospective study of patients and family caregivers. Amyotroph Lateral Scler Frontotemporal Degener 2013; 15:68-76. [DOI: 10.3109/21678421.2013.837928] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Lotz JD, Jox RJ, Borasio GD, Führer M. ADVANCE CARE PLANNING IN PAEDIATRICS: THE CARE PROVIDERS' PERSPECTIVE. BMJ Support Palliat Care 2013. [DOI: 10.1136/bmjspcare-2013-000491.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
BACKGROUND AND OBJECTIVES Advance care planning (ACP) is increasingly regarded as the gold standard in the care of patients with life-limiting illnesses. Research has focused on adults, but ACP is also being practiced in pediatrics. We conducted a systematic review on empirical literature on pediatric ACP (pACP) to assess current practices, effects, and perspectives of pACP. METHODS We searched PubMed, BELIT, and PSYCinfo for empirical literature on pACP, published January 1991 through January 2012. Titles, abstracts, and full texts were screened by 3 independent reviewers for studies that met the predefined criteria. The evidence level of the studies was assessed. Relevant study outcomes were retrieved according to predefined questions. RESULTS We included 5 qualitative and 8 quantitative studies. Only 3 pACP programs were identified, all from the United States. Two of them were informed by adult programs. Major pACP features are discussions between families and care providers, as well as advance directives. A chaplain and other providers may be involved if required. Programs vary in how well they are evaluated; only 1 was studied by using a randomized controlled trial. Preliminary data suggest that pACP can successfully be implemented and is perceived as helpful. It may be emotionally relieving and facilitate communication and decision-making. Major challenges are negative reactions from emergency services, schools, and the community. CONCLUSIONS There are few systematic pACP programs worldwide and none in Europe. Future research should investigate the needs of all stakeholders. In particular, the perspective of professionals has so far been neglected.
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Jox RJ, Bernat JL, Laureys S, Racine E. Disorders of consciousness: are we ready for a paradigm shift? – Authors' reply. Lancet Neurol 2013; 12:132. [DOI: 10.1016/s1474-4422(12)70286-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Jox RJ, Horn RJ, Huxtable R. European perspectives on ethics and law in end-of-life care. ETHICAL AND LEGAL ISSUES IN NEUROLOGY 2013; 118:155-65. [DOI: 10.1016/b978-0-444-53501-6.00013-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Jox RJ, Bernat JL, Laureys S, Racine E. Disorders of consciousness: responding to requests for novel diagnostic and therapeutic interventions. Lancet Neurol 2012; 11:732-8. [PMID: 22814543 DOI: 10.1016/s1474-4422(12)70154-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Severe brain injury can leave patients with chronic disorders of consciousness. Because of impaired responsiveness, many of these patients have traditionally been regarded as unaware. However, findings from recent clinical studies herald a potential paradigm shift: functional imaging and neurophysiological studies have identified ways to assess awareness and have revealed astounding cases of awareness despite clinical unresponsiveness. Hence, diagnostic classifications have been rewritten, prognostic knowledge is improving, and therapeutic studies have regained momentum, showing for the first time some therapeutic effects on responsiveness. Clinicians must increasingly respond to requests by patients' families and surrogate decision makers to use novel techniques for diagnosis, prognosis, and treatment, and in doing so several ethical and social issues need to be considered. Such requests provide an opportunity for clinicians to learn about patients' values and preferences and to maintain clinical acumen for changes in patient status with the patients' best interests in mind.
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Medau I, Jox RJ, Reiter-Theil S. Behandlungsfehler in der Psychotherapie: ein empirischer Beitrag zum Fehlerbegriff und seinen ethischen Aspekten. Ethik Med 2012. [DOI: 10.1007/s00481-012-0231-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Dietz I, Borasio GD, Molnar C, Müller-Busch C, Plog A, Schneider G, Jox RJ. Errors in palliative care: kinds, causes, and consequences: a pilot survey of experiences and attitudes of palliative care professionals. J Palliat Med 2012; 16:74-81. [PMID: 23140183 DOI: 10.1089/jpm.2012.0272] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Medical errors have recently been recognized as a relevant concern in public health, and increasing research efforts have been made to find ways of improving patient safety. In palliative care, however, studies on errors are scant. OBJECTIVE Our aim was to gather pilot data concerning experiences and attitudes of palliative care professionals on this topic. METHODS We developed a questionnaire, which consists of questions on relevance, estimated frequency, kinds and severity of errors, their causes and consequences, and the way palliative care professionals handle them. The questionnaire was sent to all specialist palliative care institutions in the region of Bavaria, Germany (n=168; inhabitants 12.5 million) reaching a response rate of 42% (n=70). RESULTS Errors in palliative care were regarded as a highly relevant problem (median 8 on a 10-point numeric rating scale). Most respondents experienced a moderate frequency of errors (1-10 per 100 patients). Errors in communication were estimated to be more common than those in symptom control. The causes most often mentioned were deficits in communication or organization. Moral and psychological problems for the person committing the error were seen as more frequent than consequences for the patient. Ninety percent of respondents declared that they disclose errors to the harmed patient. For 78% of the professionals, the issue was not a part of their professional training. CONCLUSION Professionals acknowledge errors-in particular errors in communication-to be a common and relevant problem in palliative care, one that has, however, been neglected in training and research.
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Medau I, Jox RJ, Dittmann V, Reiter-Theil S. [A pilot study for handling errors in psychotherapy - therapists report from practical experience]. PSYCHIATRISCHE PRAXIS 2012; 39:326-31. [PMID: 23044846 DOI: 10.1055/s-0032-1305192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To assess the views of psychotherapists regarding management of treatment errors by reviewing and analyzing interviews with therapists. METHODS A literature search was used to identify topics for the interview guide. Semi-structured interviews with 30 psychotherapists were conducted and analyzed according to qualitative content analysis, a framework approach. RESULTS Psychotherapists report an open approach to handling treatment errors: the majority claim that they would discuss errors with their patients. Experiences with error disclosure were on the whole rather positive. Errors of colleagues would be discussed in a supervisory way or, in more serious cases, be reported. CONCLUSION In psychotherapy, a constructive and open handling of errors seems to prevail. Therapists tend to be cautious when judging errors of colleagues.
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Jox RJ, Denke E, Hamann J, Mendel R, Förstl H, Borasio GD. Surrogate decision making for patients with end-stage dementia. Int J Geriatr Psychiatry 2012; 27:1045-52. [PMID: 22139621 DOI: 10.1002/gps.2820] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Accepted: 10/20/2011] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We aim to explore how health surrogates of patients with dementia proceed in decision making, which considerations are decisive, and whether family surrogates and professional guardians decide differently. METHODS We conducted an experimental vignette study using think aloud protocol analysis. Thirty-two family surrogates and professional guardians were asked to decide on two hypothetical case vignettes, concerning a feeding tube placement and a cardiac pacemaker implantation in patients with end-stage dementia. They had to verbalize their thoughts while deciding. Verbalizations were audio-recorded, transcribed, and analyzed according to content analysis. By experimentally changing variables in the vignettes, the impact of these variables on the outcome of decision making was calculated. RESULTS Although only 25% and 31% of the relatives gave their consent to the feeding tube and pacemaker placement, respectively, 56% and 81% of the professional guardians consented to these life-sustaining measures. Relatives decided intuitively, referred to their own preferences, and focused on the patient's age, state of wellbeing, and suffering. Professional guardians showed a deliberative approach, relied on medical and legal authorities, and emphasized patient autonomy. Situational variables such as the patient's current behavior and the views of health care professionals and family members had higher impacts on decisions than the patient's prior statements or life attitudes. CONCLUSIONS Both the process and outcome of surrogate decision making depend heavily on whether the surrogate is a relative or not. These findings have implications for the physician-surrogate relationship and legal frameworks regarding surrogacy.
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Jox RJ, Schaider A, Marckmann G, Borasio GD. Medical futility at the end of life: the perspectives of intensive care and palliative care clinicians. JOURNAL OF MEDICAL ETHICS 2012; 38:540-545. [PMID: 22562948 DOI: 10.1136/medethics-2011-100479] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVES Medical futility at the end of life is a growing challenge to medicine. The goals of the authors were to elucidate how clinicians define futility, when they perceive life-sustaining treatment (LST) to be futile, how they communicate this situation and why LST is sometimes continued despite being recognised as futile. METHODS The authors reviewed ethics case consultation protocols and conducted semi-structured interviews with 18 physicians and 11 nurses from adult intensive and palliative care units at a tertiary hospital in Germany. The transcripts were subjected to qualitative content analysis. RESULTS Futility was identified in the majority of case consultations. Interviewees associated futility with the failure to achieve goals of care that offer a benefit to the patient's quality of life and are proportionate to the risks, harms and costs. Prototypic examples mentioned are situations of irreversible dependence on LST, advanced metastatic malignancies and extensive brain injury. Participants agreed that futility should be assessed by physicians after consultation with the care team. Intensivists favoured an indirect and stepwise disclosure of the prognosis. Palliative care clinicians focused on a candid and empathetic information strategy. The reasons for continuing futile LST are primarily emotional, such as guilt, grief, fear of legal consequences and concerns about the family's reaction. Other obstacles are organisational routines, insufficient legal and palliative knowledge and treatment requests by patients or families. CONCLUSION Managing futility could be improved by communication training, knowledge transfer, organisational improvements and emotional and ethical support systems. The authors propose an algorithm for end-of-life decision making focusing on goals of treatment.
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Jox RJ. Ralf J Jox. Lancet Neurol 2012; 11:666. [PMID: 22993762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Kuehlmeyer K, Borasio GD, Jox RJ. How family caregivers' medical and moral assumptions influence decision making for patients in the vegetative state: a qualitative interview study. JOURNAL OF MEDICAL ETHICS 2012; 38:332-7. [PMID: 22375077 PMCID: PMC3359521 DOI: 10.1136/medethics-2011-100373] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 01/11/2012] [Accepted: 01/16/2012] [Indexed: 05/31/2023]
Abstract
BACKGROUND Decisions on limiting life-sustaining treatment for patients in the vegetative state (VS) are emotionally and morally challenging. In Germany, doctors have to discuss, together with the legal surrogate (often a family member), whether the proposed treatment is in accordance with the patient's will. However, it is unknown whether family members of the patient in the VS actually base their decisions on the patient's wishes. OBJECTIVE To examine the role of advance directives, orally expressed wishes, or the presumed will of patients in a VS for family caregivers' decisions on life-sustaining treatment. METHODS AND SAMPLE A qualitative interview study with 14 next of kin of patients in a VS in a long-term care setting was conducted; 13 participants were the patient's legal surrogates. Interviews were analysed according to qualitative content analysis. RESULTS The majority of family caregivers said that they were aware of aforementioned wishes of the patient that could be applied to the VS condition, but did not base their decisions primarily on these wishes. They gave three reasons for this: (a) the expectation of clinical improvement, (b) the caregivers' definition of life-sustaining treatments and (c) the moral obligation not to harm the patient. If the patient's wishes were not known or not revealed, the caregivers interpreted a will to live into the patient's survival and non-verbal behaviour. CONCLUSIONS Whether or not prior treatment wishes of patients in a VS are respected depends on their applicability, and also on the medical assumptions and moral attitudes of the surrogates. We recommend repeated communication, support for the caregivers and advance care planning.
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Kuehlmeyer K, Racine E, Palmour N, Hoster E, Borasio GD, Jox RJ. Diagnostic and ethical challenges in disorders of consciousness and locked-in syndrome: a survey of German neurologists. J Neurol 2012; 259:2076-89. [PMID: 22407274 PMCID: PMC3464386 DOI: 10.1007/s00415-012-6459-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Revised: 02/14/2012] [Accepted: 02/15/2012] [Indexed: 11/03/2022]
Abstract
Diagnosis and decisions on life-sustaining treatment (LST) in disorders of consciousness, such as the vegetative state (VS) and the minimally conscious state (MCS), are challenging for neurologists. The locked-in syndrome (LiS) is sometimes confounded with these disorders by less experienced physicians. We aimed to investigate (1) the application of diagnostic knowledge, (2) attitudes concerning limitations of LST, and (3) further challenging aspects in the care of patients. A vignette-based online survey with a randomized presentation of a VS, MCS, or LiS case scenario was conducted among members of the German Society for Neurology. A sample of 503 neurologists participated (response rate 16.4%). An accurate diagnosis was given by 86% of the participants. The LiS case was diagnosed more accurately (94%) than the VS case (79%) and the MCS case (87%, p < 0.001). Limiting LST for the patient was considered by 92, 91, and 84% of the participants who accurately diagnosed the VS, LiS, and MCS case (p = 0.09). Overall, most participants agreed with limiting cardiopulmonary resuscitation; a minority considered limiting artificial nutrition and hydration. Neurologists regarded the estimation of the prognosis and determination of the patients’ wishes as most challenging. The majority of German neurologists accurately applied the diagnostic categories VS, MCS, and LiS to case vignettes. Their attitudes were mostly in favor of limiting life-sustaining treatment and slightly differed for MCS as compared to VS and LiS. Attitudes toward LST strongly differed according to circumstances (e.g., patient’s will opposed treatment) and treatment measures.
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Jox RJ, Winkler EC, Borasio GD. [Changing the treatment goal at the end of life: effects of a guideline at a hospital]. Dtsch Med Wochenschr 2012; 137:829-33. [PMID: 22278719 DOI: 10.1055/s-0031-1298890] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND AND OBJECTIVE Deciding about treatment goals at the end of life is a frequent and difficult challenge to medical staff. As more health care institutions issue ethico-legal guidelines to their staff the effects of such a guideline should be investigated in a pilot project. PARTICIPANTS AND METHODS Prospective evaluation study using the pre-post method. Physicians and nurses working in ten intensive care units of a university medical center in Germany answered a specially designed questionnaire before and one year after issuance of the guideline. RESULTS 197 analyzable answers were obtained from the first (pre-guideline) and 251 from the second (post-guideline) survey (54 % and 58 % response rate, respectively). Initially the clinicians expressed their need for guidelines, advice on ethical problems, and continuing education. One year after introduction of the guideline one third of the clinicians was familiar with the guideline's content and another third was aware of its existence. 90% of those who knew the document welcomed it. Explanation of the legal aspects was seen as its most useful element. The pre- and post-guideline comparison demonstrated that uncertainty in decision making and fear of legal consequences were reduced, while knowledge of legal aspects and the value given to advance directives increased. The residents had derived the greatest benefit. CONCLUSION By promoting the knowledge of legal aspects and ethical considerations, guidelines given to medical staff can lead to more certainty when making in end of life decision.
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Jox RJ, Kühlmeyer K, Borasio GD. [Vegetative state patient Rom Houben: certainly did not wake up]. MMW Fortschr Med 2011; 153:24. [PMID: 22053441 DOI: 10.1007/bf03368930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Jox RJ. [Best interests in the 'vegetative state']. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2011; 79:576-81. [PMID: 21989510 DOI: 10.1055/s-0031-1281736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Treatment decisions for patients in the vegetative state often have to be based on the patient's best interests, if the patient's will is not known. Physicians are, however, highly uncertain what kind of treatment is in such a difficult situation the patient's best interests. This article presents new insights from neuroscience and shows how treatment decision making should proceed to reach an ethically justified decision. Pivotal elements are a careful diagnosis using validated behavioural scales, an informed judgment about the existence of awareness and sentience, and an early prognostic assessment. As new imaging techniques and treatment options are not yet clinical standard due to low evidence, the best interests have to be judged in the context of uncertainty. The leading question should be whether the preferred treatment goal can be achieved with a realistic probability and a justifiable benefit-harm-ratio. This has to be judged for the individual patient, considering his personality and communicating with the family members. There cannot be a general answer to the question of best interests in the vegetative state, but only an individual answer in shared responsibility and based on the particular features of a special case.
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Jox RJ, Kuehlmeyer K. Introduction: Reconsidering Disorders of Consciousness in Light of Neuroscientific Evidence. NEUROETHICS-NETH 2011; 6:1-3. [PMID: 23526139 PMCID: PMC3602640 DOI: 10.1007/s12152-011-9138-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Accepted: 09/07/2011] [Indexed: 11/30/2022]
Abstract
Disorders of consciousness pose a substantial ethical challenge to clinical decision making, especially regarding the use of life-sustaining medical treatment. For these decisions it is paramount to know whether the patient is aware or not. Recent brain research has been striving to assess awareness by using mainly functional magnetic resonance imaging. We review the neuroscientific evidence and summarize the potential and problems of the different approaches to prove awareness. Finally, we formulate the crucial ethical questions and outline the different articles in this special issue on disorders of consciousness.
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Führer M, Jox RJ, Borasio GD. [Treatment decisions for severely ill children and adolescents]. MMW Fortschr Med 2011; 153:35-38. [PMID: 21950186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Jox RJ, Kühlmeyer K, Borasio GD. [End-of-life decisions for patients with dementia and the vegetative state]. MMW Fortschr Med 2011; 153:31-34. [PMID: 21950185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Jox RJ. [Not Available]. MMW Fortschr Med 2011; 153:31-35. [PMID: 27371257 DOI: 10.1007/bf03368772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Dietz I, Borasio GD, Schneider G, Jox RJ. Medical errors and patient safety in palliative care: a review of current literature. J Palliat Med 2011; 13:1469-74. [PMID: 21155641 DOI: 10.1089/jpm.2010.0228] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Recently, the discussion about medical errors and patient safety has gained scientific as well as public attention. Errors in medicine have been proven to be frequent and to carry enormous financial costs and moral consequences. We aimed to review the research on medical errors in palliative care and to screen relevant literature to appreciate the relevance of safety studies to the field. METHODS We performed a literature search using the database PubMed that cross-matched terms for palliative care with the words "errors" and "patient safety." Publications were classified according to type of study and kind of error, and empiric research results were extracted and critically assessed. RESULTS We found 44 articles concerning medical errors in palliative care, most of which were case studies. Of these 44 articles, 16 deal with palliative care errors as a key issue, referring mostly to symptom control (n = 13). Other examples are errors in communication, prognostication, and advance care planning. There are very few empirical studies, which are mostly retrospective observational studies. DISCUSSION Although patients in palliative care are more vulnerable to errors and their consequences, there is little theoretical or empirical research on the subject. We propose a specific definition for errors in palliative care and analyze the challenges of delineating, identifying and preventing errors in such key areas as prognostication, advance care planning and end-of-life decision-making.
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Wiesing U, Jox RJ, Hessler HJ, Borasio GD. A new law on advance directives in Germany. JOURNAL OF MEDICAL ETHICS 2010; 36:779-783. [PMID: 21112938 DOI: 10.1136/jme.2010.036376] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
This article presents the new German law on advance directives from 1 September 2009. The history of the parliamentary process of this law is described, the present regulations are explained, their relevance for medical practice discussed and shortcomings are identified. Finally, the new law is compared with other regulations in the international context. Previously established legal practice in Germany has now become largely confirmed by the new law: An advanced directive must be respected in any decision concerning medical treatment, regardless of the stage of the illness. It can be informally revoked at any time, even with limited decision-making capacity. Nobody may be obliged to issue a directive in any way. Advance directives do not need notarisation or routine updating after certain time intervals. Provided that the patient, who is no longer mentally competent, has issued a lasting power of attorney (Bevollmächtiger), or provided that the patient has been appointed a healthcare proxy by the courts (Betreuer), this authorized surrogate must assert the patient's will. The role of the guardianship court is clarified: it only needs to be involved in cases of disagreement as to the patient's will. The new German law thus combines more legal certainty with a liberal emphasis on patient autonomy and flexible, adaptable regulations.
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