Medical errors and patient safety in palliative care: a review of current literature

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.

A new law on advance directives in Germany

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.

[End-of-life decisions, powers of attorney, and advance directives]

In modern medicine, decisions about the kind of treatment at life's end are often inevitable. According to German law, powers of attorney and advance directives can be of help in these decisions. When a patient in a state of competence has issued a lasting power of attorney, there is no need for courts to appoint a proxy, and physicians immediately have a legally empowered decision-maker they can address. According to current German law, advance directives are legally valid and binding expressions of a patient's will. They are, however, more powerful when issued after consultation with a physician. If treatment at life's end no longer complies with the patient's will or loses its medical indication, the goal of treatment should be redirected towards palliation. This implies that life-sustaining treatment may be withdrawn or withheld, which is best accomplished with sensitivity to the needs of patients, relatives, and health care professionals.

Substitute decision making in medicine: comparative analysis of the ethico-legal discourse in England and Germany

Health care decision making for patients without decisional capacity is ethically and legally challenging. Advance directives (living wills) have proved to be of limited usefulness in clinical practice. Therefore, academic attention should focus more on substitute decision making by the next of kin. In this article, we comparatively analyse the legal approaches to substitute medical decision making in England and Germany. Based on the current ethico-legal discourse in both countries, three aspects of substitute decision making will be highlighted: (1) Should there be a legally predefined order of relatives who serve as health care proxies? (2) What should be the respective roles and decisional powers of patient-appointed versus court-appointed substitute decision-makers? (3) Which criteria should be determined by law to guide substitute decision-makers?

Inappropriate sexual behaviour in a case of ALS and FTD: successful treatment with sertraline

In a subset of patients, ALS is associated with frontotemporal dysfunction (ALS-FTD). Clinically, ALS-FTD may present with a variable spectrum of cognitive and behavioural deficits. We report a 53-year-old ALS-FTD patient developing inappropriate sexual behaviour (ISB) manifesting as a vigorous sexual drive with exhausting demands for sexual intercourse and physical aggressions against his wife. This distressing symptom could be alleviated with the selective serotonin reuptake inhibitor sertraline. ISB is an embarrassing symptom for most patients and their caregivers and may therefore be under-reported. Since effective treatment is available, we suggest an open and proactive discussion of sexual issues in this patient group.