Physician assisted suicide: knowledge and views of fifth-year medical students in Germany

Suicide and assisted suicide are not criminal acts in Germany. However, attempting suicide may create a legal duty for physicians to try to save a patient's life. This study presents data on medical students' legal knowledge and ethical views regarding physician assisted suicide (PAS). The majority of 85 respondents held PAS to be illegal. More than a third of the students viewed PAS in certain situations to be ethically acceptable whereas a smaller proportion thought that it should be legal. Compared with German physicians the medical students taking part in this study were less opposed to PAS. The majority perceived the undergraduate training concerning ethical aspect of assisted death as deficient.

Discussing living wills. A qualitative study of a German sample of neurologists and ALS patients

Patients suffering from amyotrophic lateral sclerosis (ALS) eventually lose their ability to communicate their treatment preferences in later stages of the disease. A living will enables ALS patients to specify their choices concerning life-sustaining treatment in advance. Our premise was that completion of a living will should be preceded by a discussion between patient and physician. We conducted a qualitative study of a sample of 15 neurologists and 15 ALS patients from two neurology centers in Germany. Our aim was to explore how discussions about living wills are undertaken. Data analysis followed grounded theory techniques. Our findings showed that both the patients and the physicians considered living wills to be closely connected to forthcoming death. Physicians waited for respiratory failure to occur before they informed ALS patients about living wills, an information strategy that we called the "wait-and-see-policy". The patients completed their living will when they had accepted the hopelessness of their disease. They mostly used living will forms and did not see the necessity to set down disease-specific preferences. They intended to wait for symptoms to emerge before they made the decision about whether or not to accept life-sustaining treatment. The patients as well as the physicians pursued a wait-and-see policy towards end-of-life care, thus weakening the purpose of living wills. Our results point to the necessity and importance of an open and honest patient-physician communication which is a prerequisite for the discussion of living wills.

Informed consent in clinical practice: pre-registration house officers' knowledge, difficulties and the need for postgraduate training

In clinical practice consent is often obtained by junior doctors. This study investigates the involvement of pre-registration house officers (PRHOs) in the process of obtaining consent, the supervision they receive and their knowledge on the subject. Some 74% of the PRHOs in post completed the questionnaire; 68% had often or sometimes obtained consent during their year as PRHO; 18% stated that on the occasions when they had obtained consent they were always the only person eliciting consent; 62% of the doctors perceived some lack of knowledge with regard to the nature of the procedure as a difficulty. Despite a comprehensive undergraduate programme in ethics, law and communication there is a need for applied education regarding the clinical procedures for which PRHOs are obtaining consent.

The cognitive based approach of capacity assessment in psychiatry: a philosophical critique of the MacCAT-T

This article gives a brief introduction to the MacArthur Competence Assessment Tool-Treatment (MacCAT-T) and critically examines its theoretical presuppositions. On the basis of empirical, methodological and ethical critique it is emphasised that the cognitive bias that underlies the MacCAT-T assessment needs to be modified. On the one hand it has to be admitted that the operationalisation of competence in terms of value-free categories, e.g. rational decision abilities, guarantees objectivity to a great extent; but on the other hand it bears severe problems. Firstly, the cognitive focus is in itself a normative convention in the process of anthropological value-attribution. Secondly, it misses the complexity of the decision process in real life. It is therefore suggested that values, emotions and other biographic and context specific aspects should be considered when interpreting the cognitive standards according to the MacArthur model. To fill the gap between cognitive and non-cognitive approaches the phenomenological theory of personal constructs is briefly introduced. In conclusion some main demands for further research to develop a multi-step model of competence assessment are outlined.

Breaking bad news: experiences, views and difficulties of pre-registration house officers

OBJECTIVES

To obtain information regarding the involvement of pre-registration house officers (PRHOs) in the discussions on bad news, and the competency and difficulties they perceive in clinical practice.

DESIGN

Structured telephone interviews.

PARTICIPANTS

104 PRHOs.

MAIN OUTCOME MEASURES

Information about frequency and quality of involvement of PRHOs in discussions on bad news with patients and relatives, perceived competency and difficulties related to this task as well as ethical views concerning the disclosure of bad news.

RESULTS

82 PRHOs (78.9%) had initiated the breaking of bad news to a patient at least once, whilst patients themselves had initiated discussions of bad news by asking the doctors questions (92.3%). Almost all (96.2%), indicated that they had broken bad news to relatives of a patient. The majority of the junior doctors participating in our study felt fairly or very confident (90.4%) to break bad news. 'Often' quoted difficulties for over a fifth of the sample included 'Thinking I was not the appropriate person to discuss the bad news', 'Having all the relevant information available', 'Dealing with emotions of patient/relative', 'Lack of privacy' and 'Patients/relatives do not speak English'. Although 99 PRHOs (95.2%) believed that patients should be informed about a serious life threatening illness, 30.8% of the participants stated that doctors need to judge whether or not to tell a patient bad news. Factors most frequently selected by the PRHOs from a given list of possible factors contributing to a gap between theory and practice included problems with the organization of clinics (73.1%), insufficient postgraduate training (63.5%) and lack of staff (54.8%).

CONCLUSIONS

The results indicate that PRHOs are frequently involved in the breaking of bad news. Whilst no claims can be made for their,actual performance in practice, their perceptions of competency would indicate that the extensive and compulsory undergraduate teaching they had received on this subject has served to prepare them for this difficult task. Organizational and structural aspects need to be taken into account as factors assisting or undermining doctors in their efforts to put into practice ethically sound and skilled communication when disclosing bad news.

["Truth at the bedside"--continuing medical education and breaking bad news]

INTRODUCTION

Discussions with seriously-ill patients are part of the physicians' tasks. These discussions demand good communication skills. In this paper we present the concept of a postgraduate course for physicians on ethics and breaking bad news, as well as the results of the course evaluation.

METHODS

Questionnaire distributed before and immediately after the course using closed-ended questions and Likert scales.

RESULTS

37 physicians (response rate: 84.1%) from seven specialties completed the questionnaires. Twenty-eight respondents (75.6%) had been involved in breaking bad news more than 5 times per month. Approximately half of the respondents (N = 18; 48.6%) rated the discussions on the limits of curative treatment as particularly difficult communication situations. With one exception, all physicians denied the existence of guidelines on breaking bad news in their institutions. Compared with the beginning of the course, the respondents rated their communication skills to be improved at the end of the course. Positive evaluations were obtained for practice relevance, teaching methods, and organisation of the course.

CONCLUSION

The interest in this optional postgraduate course and the feedback of the participants indicate the necessity of professional training on difficult communication situations. The self-rating of improved communication skills may be interpreted as a positive effect of the course. Observational studies are required to confirm the effects of the training.

Ethische Entscheidungen am Lebensende - Kenntnisstand und Einstellungen Medizinstudierender

BACKGROUND AND OBJECTIVE

Physicians are often confronted with ethical and legal questions at the end of life. In this study we asked medical students at the universities of Mainz and Berlin (Charité) about the "Guidelines on Physicians' Aid to the Dying" issued by the German Medical Association: their moral attitude and legal knowledge regarding the limitation of medical procedures at the end of life and their judgement about the quality of medical education on these topics.

METHODS

569 medical students in their 1. and 4. clinical semester as well as the final year of their studies in Mainz and students in their 5. year of studies in Berlin received a questionnaire containing 14 items relating to ethical and legal questions at the end of life.

RESULTS

308 (54.1%) completed the questionnaire. 7.8% knew the contents of the "Guidelines on Physicians' Aid to the Dying". Between 10% (use of catecholamines) and 62% (parenteral feeding) viewed withholding or withdrawing life-sustaining measures from dying patients as illegal. 39-72% held the view that measures of nutrition and hydration were part of the indispensable basic medical care for every patient. 12-26% were unsure with respect to their moral views about withholding and withdrawal of therapy. 82% felt insufficiently prepared for dealing with ethical questions at the end of life.

CONCLUSION

Only a minority of medical students was informed about ethical principles and legal regulations regarding end-of-life decisions. Teaching of ethical and legal knowledge and integration of these issues into clinical problem solving should be mandatory.

Klinische Ethikkomitees an deutschen Universitätskliniken

OBJECTIVE

Health Care Ethics Committees (HEC) are new ways of implementing clinical ethics in hospitals and nursing homes. In the US all health care institutions must provide some structure to handle ethical conflicts in everyday patients' care. However, in Germany only a minority of hospitals, often members of the Protestant or Catholic Hospital Associations, have founded HEC. No studies exist in regard to the situation at German university hospitals.

METHODS

In November 2002 we posted a questionnaire with 13 items to all medical directors (M) and directors of nursing (N) of the 36 German university hospitals.

RESULTS

The response rate was 82 %. Limitation of treatment, informed consent and the conflict between beneficience and autonomy are the most relevant ethical issues in everyday practice. N estimated the need for additional support of their staff in ethical issues higher than M. Improvement of interdisciplinary teamwork, further education in ethics and ethical guidelines have been identified in order to improve ethical professional performance. However, N mentioned the lack of time and the low priority of ethics more often than M as problems in implementing theses measures. Five German university hospitals are planning to establish a HEC and two hospitals want to employ a clinical ethicist.

CONCLUSION

Our data show a high need for information about HEC in German university hospitals. The tasks, working methods and chances for further development of HEC are neither known nor used in the majority of German university hospitals.

Determination of the material properties of microstructures by laser based ultrasound

In most applications of MEMS the mechanical properties of the used materials are key parameters for the perfect working of the microsystems. Measuring bulk acoustic waves excited in MEMS structures with ultra-short laser pulses is a powerful method for the accurate and non-destructive evaluation as well as for the characterization of material properties. The pump-probe laser-based acoustic method generates bulk acoustic waves in a thermo-elastic way by absorbing the pump laser pulses. The acoustic waves are partly reflected at any discontinuity of the acoustic impedance. At the surface of the specimen the reflected acoustic pulses cause changes of the optical reflection coefficient, which are measured with the probe laser pulses. Thin membranes are part of numerous microelectromechanical systems (MEMS) like sensors, activators and bulk acoustic wave (BAW) filters for example. The described non-destructive and non-contact method is the right approach for testing such thin and brittle structures like membranes. Results of measurements on freestanding aluminium-silicon nitride multi-layer membranes with total thicknesses in the order of several hundred nanometers are presented and compared with thermo-elastic models and with measurements of the supported case. The measured results are used for the determination of the moduli of the membranes.

Competence of mentally ill patients: a comparative empirical study

BACKGROUND

This study investigates the competence of patients with dementia, depression and schizophrenia to make treatment decisions. The outcome of an objective test instrument is presented and compared with clinical assessment of competence by the attending physician.

METHOD

The MacArthur Competence Assessment Tool-Treatment (MacCAT-T), a test instrument to assess abilities in different standards of competence, was administered to patients with diagnoses of dementia (N = 31), depression (N = 35) and schizophrenia (N = 43). Statistical significance of group differences in the MacCAT-T results were tested with the chi-square test. The concordance of the test and clinical assessment of competence by the attending physician were evaluated by Cohen's kappa coefficient.

RESULTS

Patients with dementia, as a group, showed significantly more often impaired performance than those with schizophrenia who were still more impaired than depressed patients. Patients were classified as impaired or not depending on the standards used. By combination of all standards substantially more patients were classified as impaired than by clinical assessment (67.7 v. 48.4% of patients with dementia, 20.0 v. 2.9% of patients with depression, 53.5 v. 18.4% of patients with schizophrenia).

CONCLUSIONS

Using different standards of competence the study showed substantial differences among patients with dementia, depression and schizophrenia. The high proportion of patients identified as incompetent raises several ethical questions, in particular, those referring to the selection of standards or the definition of cut-offs for incompetence. The discrepancy between clinical and formal evaluations points out the influence of the used procedure on competence judgements.

[Advance Directives: theoretical concept and practical significance in the USA]

The article examines on the basic of empirical data the discrepancy between the theoretical demand and the practical role of advance directives. Often advance directives have no influence on medical decision-making in clinical care of critically ill patients. The vague language of the widely used standard living wills and the lack of physician-patient communication in the process of delivering an advance directives are contributing factors. However, many physicians even disregard patients' preferences in concrete and meaningful living wills at the end of life. Besides the lack of information many even seriously ill patients do not deliver an advance because they misjudge their medical prognosis and life expectancy. Often the communication between patients and doctors are blocked because they expect from the each other the first step to talk about end of life decisions and advance directives. In this context physicians claim lack of time, training in communication skills and their discomfort in talking about death and dying with their patients.

[Mental competence and neuropsychologic impairments in demented patients]

The study aim was to examine if neuropsychological tests and clinical dementia scales identify incompetent patients with dementia. Eighteen demented outpatients (ICD-10: F00-F03) underwent psychiatric examination, neuropsychological testing, and formal (MacArthur Competence Assessment Tool Treatment, Hopkins Competency Assessment Test) and clinical assessment of competence. Clinical dementia scales but not neuropsychological testing correlate with formal and clinical assessment of competence in patients with dementia. Our results do not support a neuropsychological model of competence assessment. However, in cases with poor results in clinical dementia scales, clinicians should assess the patients' competence in more detail. It remains open which is the best and ethically grounded methodology for competence assessment.

[Patients' perspective on the quality of informed consent into psychopharmacological treatment in schizophrenia and depression]

BACKGROUND

Respect for autonomy and the right to self-determination require informed consent of patients before any medical procedure. So far the majority of empirical studies on informed consent deal mainly with single aspects e. g. delivery and recall of information and legal questions from a physicians' perspective. In our study we examine the quality of informed consent to psychopharmacological treatment from the perspective of patients with schizophrenia and depression in a German university department of psychiatry.

METHODS

Face to face interviews using a structured questionnaire by a research psychiatrist. The participants taking part in this study were inpatients diagnosed with schizophrenia and depression. All patients received medication for their condition.

RESULTS

Half of the patients rated the information they received and the process of informed consent positive. Only a minority recalls information regarding the aim and the risks of the treatment. 20 % indicated that they have been informed about alternative treatment options. A quarter of the patients did not know that they had a right to refuse any treatment.

CONCLUSION

Compared with studies including patients with somatic illnesses the participants in our study judge the process of informed consent rather critical. The results need to be discussed in the light of the special aspects of psychopharmacological treatment and different cultural and institutional settings.

[Attitudes of psychiatrists toward physician-assisted suicide]

BACKGROUND

Physician-assisted suicide (PAS) is an important subject of the public debate. So far, legal regulations exist in the Netherlands, Belgium and in Oregon (USA). This review reports results of nine empirical studies from Japan, the Netherlands, the United Kingdom and the U. S. which examine attitudes of psychiatrists toward PAS.

RESULTS

The approval of PAS by psychiatrists varies between the four countries (40 - 69 %). Comparisons with the attitudes of other physicians show a greater agreement among the psychiatrists. A psychiatric examination in order to evaluate competence even in patients with severe somatic illness was advocated by the majority of psychiatrists.

CONCLUSION

Psychiatrists' attitudes toward PAS vary and are compared with other medical specialties, as well as in different legal and cultural contexts. Therefore, and because of missing empirical studies, results can not be transferred into the context of German speaking countries easily. So far, no acknowledged criteria for the assessment of competence exist. Further empirical research is needed on German psychiatrists' attitudes towards PAS and on competence assessment at the end of life. It remains an open question how legal changes and future developments of palliative care will influence attitudes toward PAS.

[Informed consent and patient competence in the psychically ill. A review of empirical studies]

In clinical practice, patients' self-determination has become more and more important. However, in psychiatry, the practice of informed consent encompasses several problems. In many cases the psychiatrist is faced with the issue of determining patients' competence. This paper gives an overview of empirical studies on competence assessment in psychiatry. In the course of some of these studies, test instruments were developed which allow objective and reliable assessment of different standards of competence. The applicability of these tests is discussed. We present empirical data on the relationship between competence and psychopathologic symptoms and cognitive factors. In recent empirical research, a shift from an initial skepticism of the applicability of informed consent in psychiatry towards a more differentiated approach and an interest in multidisciplinary research can be observed.

Ultrasonic wave propagation in focussing tips with arbitrary geometries

Pulsed laser acoustic experiments have the advantage of very high temporal resolution. However, the lateral resolution amounts to several wavelengths of light. To improve the lateral resolution a focussing tip in which the mechanical waves are focussed is introduced. The combination of high resolution in time and space domain leads to a new potential time resolved scanning probe method. Therefore several axi-symmetric structures are investigated numerically using a finite difference method. The ultrasonic wave propagation in different tips is discussed. By varying the geometry of the tip, the displacement at the sharp end is maximized. The numerically calculated results are verified experimentally on structures having macroscopic dimensions. Scaling effects are considered in order to translate the results into the microscopic scale where arbitrary geometries are much more challenging to implement.