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Dietrich CG, Schoppmeyer K. [Opportunities and risks of advance directives : An appraisal of the practice in Germany after legal regulation in 2009]. Schmerz 2024:10.1007/s00482-023-00771-0. [PMID: 38165491 DOI: 10.1007/s00482-023-00771-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Living wills/advance directives (AD) are an important tool for specifying patient wishes regarding medical care in the case of future inability to consent. Since 2009, German legislation defines framework conditions for the creation and validity of such directives in § 1901a BGB. METHODS An extensive literature search in an international and a German-language database was conducted to identify, analyze, and evaluate scientific articles on opportunities, risks, and problems in the creation and implementation of living wills. RESULTS Between 10 and 40% of patients have an AD. Among the stipulations in the AD, the demand for sufficient pain therapy is very important. However, numerous problems in the preparation and implementation of ADs reduce their value in everyday clinical practice. In particular, unclear conditions of validity, unspecific instructions for action, and lack of availability of the directives prevent practitioners from determining the patient's will. Other fundamental problems include frequent patient ambivalence and clinical ethical dissent. In addition, the framework condition of unlimited coverage set by the law carries the risk that changes of opinion in the course of life or disease are not taken into account. CONCLUSION Preparing an AD requires a high level of information, consultation, and time, as well as regular review or adjustment of its content. These factors are often not considered, thus complicating implementation and reducing the value of living wills. Possible solutions to these problems or alternative concepts for different patient settings are discussed in this review.
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Affiliation(s)
- Christoph G Dietrich
- Gastro-Praxis Wiesbaden im Medicum, Langenbeckplatz 2, 65189, Wiesbaden, Deutschland.
| | - Konrad Schoppmeyer
- Klinik für Innere Medizin II, Euregio-Klinik GmbH, Nordhorn, Deutschland, Albert-Schweitzer-Str. 10, 48527
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Zimmer M, Özkaya S, Sahm S. [Preclinical patient transport at the end of life]. DIE ANAESTHESIOLOGIE 2023; 72:635-642. [PMID: 37369813 DOI: 10.1007/s00101-023-01308-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 05/16/2023] [Accepted: 06/04/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Although most people would like to die at home, many die in hospitals. The study shows physicians' and paramedics' experiences with prehospital care of patients at the end of life. METHOD Using an anonymous online questionnaire, primary care physicians and ambulance personnel in the Frankfurt am Main metropolitan area were surveyed about their experiences with end of life care. RESULTS A total of 63 primary care physicians (PCP) and 62 emergency medical service staff (EMS) answered the questionnaire (female 31.2%, male 68.8%). Of the respondents 65.8% reported that patients are often still transported to hospital at the end of life. Of the participants 17.9% felt confident in their assessment of a patient at the end of life, 33.3% of PCP and 8.5% of EMS felt confident about subsequent treatment and 91.9% of PCP and 96.2% of EMS reported that they always/often ask about an advance healthcare directive. Of the participants 98.3% felt that EMS rarely/never ask about advance care planning, 78.7% of all participants would rarely/never ask about it and 90.4% of EMS would like to have a legally secure emergency document to guide their actions. CONCLUSION Transporting patients at the end of life is part of everyday prehospital practice. There are uncertainties in the assessment and care of these patients. In the future, rescue service and medical training should include specific palliative care strategies. Advance healthcare directive and advance care planning must be more widely recognized by the medical community, so that in emergency situations the desired corridors of action in the best interests of the patient are quickly made known.
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Affiliation(s)
- Matthias Zimmer
- Medizinische Klinik 1, Ketteler Krankenhaus gGmbH, Lichtenplattenweg 85, 63071, Offenbach am Main, Deutschland.
| | - Senol Özkaya
- Medizinische Klinik 2, Ketteler Krankenhaus gGmbH, Offenbach am Main, Deutschland
- Dr. Senkenberg Institut für Geschichte und Ethik in der Medizin, Goethe-Universität Frankfurt am Main, Frankfurt am Main, Deutschland
| | - Stephan Sahm
- Medizinische Klinik 1, Ketteler Krankenhaus gGmbH, Lichtenplattenweg 85, 63071, Offenbach am Main, Deutschland
- Dr. Senkenberg Institut für Geschichte und Ethik in der Medizin, Goethe-Universität Frankfurt am Main, Frankfurt am Main, Deutschland
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Petri S, Zwißler B, In der Schmitten J, Feddersen B. [Advance Care Planning-further development of the patient advance directive : What the specialist in internal medicine must know]. Internist (Berl) 2022; 63:533-544. [PMID: 35441880 PMCID: PMC9020146 DOI: 10.1007/s00108-022-01333-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite the availability of the instruments of advance directives, power of attorney and healthcare proxy, the patient's preferences for life-sustaining medical treatment in a specific situation often remain unknown. The aim of the systemically designed German Advance Care Planning (ACP) program is the reflection, documentation and implementation of patients' preferences regarding future medical treatment in case they are incapable of legally binding decision-making. A specially trained ACP facilitator initially supports the verbalization of the attitudes towards life, severe illness and death on an individual level. Based on these principal views, concrete preferences on how to be treated under defined medical circumstances can be discussed and documented in an advance directive. This includes the three scenarios medical emergency, inpatient hospital treatment in situations with decisional incapability of unknown duration and the situation of permanent cognitive impairment. Through cautious, nondirective conversational techniques in the sense of shared decision-making, the person is enabled to reflect and decide well-informed according to the informed consent standard. All persons participating in decisions regarding future medical treatment, especially future surrogate decision makers, are involved in the process as early as possible. A systematic institutional and regional implementation of the concept is necessary to ensure that the carefully assessed and documented preferences of the patients will be known and honored. The new German § 132g of the Social Code Book V (SGB V) enables institutions for long-term care and for the care of disabled persons, to offer facilitated ACP to all residents at the expense of the statutory health insurance funds. An increased dissemination of this concept is to be expected.
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Affiliation(s)
- S Petri
- Caritasverband der Erzdiözese München und Freising e. V., München, Deutschland
| | - B Zwißler
- Klinik für Anästhesiologie, Klinikum der Universität München, LMU München, München, Deutschland
| | - J In der Schmitten
- Institut für Allgemeinmedizin, Universitätsklinik Essen, Essen, Deutschland
| | - B Feddersen
- Klinik und Poliklinik für Palliativmedizin, SAPV, Klinikum der Universität München, LMU München, Schillerstr. 40/III, 80336, München, Deutschland.
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Klemmt M, Neuderth S, van Oorschot B, Henking T. [Living wills of residents in nursing homes - which treatment situations and treatment measures are decreed?]. Dtsch Med Wochenschr 2021; 146:e81-e87. [PMID: 34544195 PMCID: PMC8514265 DOI: 10.1055/a-1576-6894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Einleitung
Die Möglichkeit, mittels Patientenverfügung Einfluss auf die spätere Behandlung im Falle der Einwilligungsunfähigkeit zu nehmen, gilt heutzutage als wichtiges Element zur Wahrung der Patientenautonomie am Lebensende. Behandlungsmaßnahmen bereits im Vorfeld einer Behandlung abzulehnen oder in diese einzuwilligen, ist für Bewohnende stationärer Pflegeeinrichtungen nicht nur vor dem Hintergrund der COVID-19-Pandemie von besonderer Bedeutung.
Methoden
Es wurde eine Vollerhebung aller Vorsorgedokumente von Bewohnenden in 13 stationären Pflegeeinrichtungen unterschiedlicher Größe und Trägerschaft in der Stadt und dem Landkreis Würzburg durchgeführt. Die Analyse der Dokumente erfolgte nach deduktiv-induktivem Vorgehen mittels kategorialer Zusammenfassungen und deskriptiver Häufigkeitsauszählungen.
Ergebnisse
In 265 erfassten Patientenverfügungen konnten 2072 Behandlungssituationen und 1673 medizinische Behandlungsmaßnahmen identifiziert werden. Bewohnende stimmen symptomlindernden und pflegerischen Maßnahmen größtenteils zu und lehnen lebensverlängernde bzw. -erhaltende Behandlungsmaßnahmen häufig ab, wobei letztgenannte zumeist auf bestimmte, festgelegte Behandlungssituationen beschränkt werden. Die Bezugnahme auf bestimmte Behandlungssituationen konnte beim Reanimationsversuch, sowohl in Form der Ablehnung wie der Einwilligung, in 88,6 % der Patientenverfügungen festgestellt werden. 62 % der Patientenverfügungen konnten einer Formularvorlage zugeordnet werden.
Diskussion
Die Untersuchung liefert Erkenntnisse über den Inhalt von Patientenverfügungen bei Bewohnenden stationärer Pflegeeinrichtungen. Sie gibt damit Hinweise auf medizinische Behandlungswünsche dieser Personengruppe im Falle der Einwilligungsunfähigkeit und zeigt auf, dass Behandlungsmaßnahmen (auch Reanimation) häufig in Bezug zu spezifischen Behandlungssituationen gesetzt werden.
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Affiliation(s)
- Malte Klemmt
- Institut für Angewandte Sozialwissenschaften (IFAS), Hochschule für angewandte Wissenschaften Würzburg-Schweinfurt
| | - Silke Neuderth
- Institut für Angewandte Sozialwissenschaften (IFAS), Hochschule für angewandte Wissenschaften Würzburg-Schweinfurt
| | | | - Tanja Henking
- Institut für Angewandte Sozialwissenschaften (IFAS), Hochschule für angewandte Wissenschaften Würzburg-Schweinfurt
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Köstenberger M, Diegelmann S, Terlutter R, Bidmon S, Neuwersch S, Likar R. Advance directives in Austrian intensive care units: An analysis of prevalence and barriers. Resusc Plus 2020; 3:100014. [PMID: 34223298 PMCID: PMC8244481 DOI: 10.1016/j.resplu.2020.100014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/20/2020] [Accepted: 06/16/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To investigate the prevalence of advance directives, healthcare proxies, and legal representatives in Austrian intensive care units (ICUs), and to explore barriers faced by adults engaged in the contemplation and documentation phase of the advance care planning process. Methods Two studies were conducted: (1) A 4-week multicenter study covering seven Austrian ICUs. A retrospective chart review of 475 patients who presented to the ICUs between 1 January 2019 and 31 January 2019 was conducted. (2) An interview and focus group study with 12 semi-structured expert interviews and three focus groups with 21 adults was performed to gain insights into potential barriers faced by Austrian adults planning medical decisions in advance. Results Of the 475 ICU patients, 3 (0.6%) had an advance directive, 4 (0.8%) had a healthcare proxy, and 7 (1.5%) had a legal guardian. Despite the low prevalence rates, patients and relatives reacted positively to the question of whether they had an advance directive. Patients older than 55 years and patients with children reacted significantly more positively than younger patients and patients without children. The interviews and focus groups revealed important barriers that prevent adults in Austria from considering planning in advance for potentially critical health states. Conclusion The studies show low prevalence rates of healthcare documents in Austrian ICUs. However, when patients were asked about an advance directive, reactions indicated positive attitudes. The gap between positive attitudes and actual document completion can be explained by multiple barriers that exist for adults in Austria when it comes to planning for potential future incapacity.
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Affiliation(s)
- Markus Köstenberger
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum Klagenfurt am Wörthersee, Feschnigstraße 11, 9020, Klagenfurt am Wörthersee, Austria.,Medical University of Graz, Austria
| | - Svenja Diegelmann
- Department of Marketing and International Management, Alpen-Adria-Universität Klagenfurt, Universitätsstraße 65-67, 9020, Klagenfurt am Wörthersee, Austria
| | - Ralf Terlutter
- Department of Marketing and International Management, Alpen-Adria-Universität Klagenfurt, Universitätsstraße 65-67, 9020, Klagenfurt am Wörthersee, Austria
| | - Sonja Bidmon
- Department of Marketing and International Management, Alpen-Adria-Universität Klagenfurt, Universitätsstraße 65-67, 9020, Klagenfurt am Wörthersee, Austria
| | - Stefan Neuwersch
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum Klagenfurt am Wörthersee, Feschnigstraße 11, 9020, Klagenfurt am Wörthersee, Austria
| | - Rudolf Likar
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum Klagenfurt am Wörthersee, Feschnigstraße 11, 9020, Klagenfurt am Wörthersee, Austria
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Petri S, Zwißler B, in der Schmitten J, Feddersen B. Behandlung im Voraus Planen – Weiterentwicklung der Patientenverfügung. Anaesthesist 2019; 69:78-88. [DOI: 10.1007/s00101-019-00697-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Glennon CA, Thomas W, Black K, Herrig M, Ishikawa J, Reedy I. Educating Healthcare Employees about Advance Care Planning. Asia Pac J Oncol Nurs 2019; 6:343-348. [PMID: 31572753 PMCID: PMC6696800 DOI: 10.4103/apjon.apjon_27_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/16/2019] [Indexed: 11/04/2022] Open
Abstract
The objective of this descriptive article is to provide a background of current research and data on advance care planning. Additionally, a proposed and detailed education initiative for increasing completion and understanding of advance care planning documents is presented.
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Affiliation(s)
| | - Wendy Thomas
- The University of Kansas Cancer Center, Westwood, KS, USA
| | - Katherine Black
- University of Kansas Medical Center, Department of Occupational Therapy Education, Kansas City, KS, USA
| | - Madison Herrig
- University of Kansas Medical Center, Department of Occupational Therapy Education, Kansas City, KS, USA
| | - Jane Ishikawa
- University of Kansas Medical Center, Department of Occupational Therapy Education, Kansas City, KS, USA
| | - Isabel Reedy
- University of Kansas Medical Center, Department of Occupational Therapy Education, Kansas City, KS, USA
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Meyer-Zehnder B, Bucher E, Vogt DR, Pargger H. [Existential questions prior to elective surgery. Survey in a preoperative anesthesia consultation service]. Anaesthesist 2016; 65:258-66. [PMID: 27033115 DOI: 10.1007/s00101-016-0153-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 02/18/2016] [Accepted: 02/19/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Existential questions concerning the limitation of treatment must be answered when a major complication occurs after an elective operation. In these situations, the patient himself/herself cannot be asked about his/her will. Therefore, medical professionals must attempt to determine the patient's presumed will either through an existing advance directive (AD) or by consulting with the patient's relatives. Only one-fifth of all patients create an AD in advance, and the relatives cannot always reliably reproduce the patient's presumed will. Thus, it is important to talk about issues such as do-not-resuscitate before a patient undergoes elective major surgery. However, such discussions may unsettle and frighten the patient. This study aimed to determine if patients are willing to talk about difficult questions such as resuscitation before major surgery. How many patients create an AD? Who should decide when patients themselves are no longer capable? OBJECTIVES Between March 1 and October 30, 2014, patients who attended the preoperative anaesthesia consultation service received a one-page questionnaire. In addition to a few personal questions (e.g. sex, age, surgery, health status), the questionnaire included four questions that could be answered according to a four-point Likert scale, with a yes or no response, or a with a selection of answers. RESULTS 272 men (45.5%) and 321 women (53.7%) with a mean age of 52.9 years (standard deviation: 17.8 years) completed a questionnaire. 312 patients (52.2%) claimed to be healthy, while 116 patients (19.4%) observed a minimal health restriction. 125 patients (19.4%) suffered from a chronic illness that markedly (n = 108) or strongly (n = 17) limited daily life. More than three-fourths of the respondents were very ready (377/63.0%) or ready (79 patients/13.2%) to talk about the treatment of severe complications after an elective operation. 12.7% of the patients would rather not to talk about this topic (n = 47) or refused (n = 37). 58 patients (9.7%) checked the box "I do not know" or gave no answer. There was no significant difference between men and women (p = 0.58). The patient's state of health did not significantly affect the patient's willingness to talk (p = 0.61). 110 patients (18.4%) had already completed an AD. The probability of having an AD is highly dependent on the age and state of health. The likelihood of having one increases by 4% for each year of life, and in health-impaired patients it is 73% higher than in healthy ones. If the patient could no longer decide for himself/herself, the following options were selected from multiple possible answers: a relative decides (n = 272), discussing this with a physician prior to surgery (n = 212), previously created AD (n = 198), the treatment team decides (n = 28), I do not know/not (n = 48). CONCLUSIONS Although the majority of the respondents were willing to talk about difficult issues before an operation, it remains unclear to what extent these results can be generalized. However, the results justify efforts to carefully inquire about and document the will of sick patients prior to major surgery. Both the treatment team and the relatives are relieved if the patient's will is known when difficult decisions have to be made.
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Affiliation(s)
- B Meyer-Zehnder
- Departement für Anästhesie, Operative Intensivbehandlung, präklinische Notfallmedizin und Schmerztherapie, Universitätsspital Basel, Spitalstraße 21, 4031, Basel, Schweiz.
| | - E Bucher
- Departement für Anästhesie, Operative Intensivbehandlung, präklinische Notfallmedizin und Schmerztherapie, Universitätsspital Basel, Spitalstraße 21, 4031, Basel, Schweiz
| | - D R Vogt
- Clinical Trial Unit, Universitätsspital Basel, Basel, Schweiz
| | - H Pargger
- Departement für Anästhesie, Operative Intensivbehandlung, präklinische Notfallmedizin und Schmerztherapie, Universitätsspital Basel, Spitalstraße 21, 4031, Basel, Schweiz
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Schröder L, Hommel G, Sahm S. Intricate decision making: ambivalences and barriers when fulfilling an advance directive. Patient Prefer Adherence 2016; 10:1583-9. [PMID: 27574407 PMCID: PMC4993391 DOI: 10.2147/ppa.s109040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Despite a recent statutory ruling stating the binding nature of advance directives (ADs), only a minority of the population has signed one. Yet, a majority deem it of utmost importance to ensure their wishes are followed through in case they are no longer able to decide. The reasons for this discrepancy have not yet been investigated sufficiently. PATIENTS AND METHODS This article is based on a survey of patients using a well-established structured questionnaire. First, patients were asked about their attitudes with respect to six therapeutic options at the end of life: intravenous fluids, artificial feeding, antibiotics, analgesia, chemotherapy/dialysis, and artificial ventilation; and second, they were asked about the negative effects related to the idea of ADs surveying their apprehensions: coercion to fulfill an AD, dictatorial reading of what had been laid down, and abuse of ADs. RESULTS A total of 1,260 interviewees completed the questionnaires. A significant percentage of interviewees were indecisive with respect to therapeutic options, ranging from 25% (analgesia) to 45% (artificial feeding). There was no connection to health status. Apprehensions about unwanted effects of ADs were widespread, at 51%, 35%, and 43% for coercion, dictatorial reading, and abuse, respectively. CONCLUSION A significant percentage of interviewees were unable to anticipate decisions about treatment options at the end of life. Apprehensions about negative adverse effects of ADs are widespread.
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Affiliation(s)
- Lars Schröder
- Department of Gynecology and Obstetrics, Center of Integrated Oncology, University Hospital Bonn, Bonn
- Correspondence: Lars Schröder, Department of Gynecology and Obstetrics, Center of Integrated Oncology, University Hospital Bonn, Sigmund-Freud Street 25, 53127 Bonn, Germany, Tel +49 151 1968 9224, Email
| | - Gerhard Hommel
- Institute of Medical Biometry, Epidemiology and Informatics, Johannes Gutenberg University, Mainz
| | - Stephan Sahm
- Department of Gastroenterology and Oncology, Ketteler Hospital, Offenbach
- Institute for Ethics and History of Medicine, Johann Wolfgang Goethe University, Frankfurt, Germany
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Peters M, Kern BR, Buschmann C. [Medicolegal aspects in emergency medical care : Analysis of the frequency of advance health care directives and the influence on decision making in emergency medicine]. Med Klin Intensivmed Notfmed 2015; 112:136-144. [PMID: 26604092 DOI: 10.1007/s00063-015-0120-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 09/28/2015] [Accepted: 10/15/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Medical decisions in an emergency medical services (EMS) situation are always extremely time- critical and sensitive, potentially leading to medicolegal consequences. Advance health care directives (AHCDs) are crucial components in the patients' participative decision making. When a patient refuses resuscitation, and/or other life-extending treatments, emergency physicians face possible ethical, medical, and medicolegal conflicts. METHODS As part of the RIMANO II Study [Risk Management Präklinische (prehospital) Notfallmedizin (emergency medicine)], all 18 "emergency physician bases" of the Berlin Fire Department were polled regarding the influence of AHCDs in regard to emergency medical decision making. The assessment was based on anonymous questionnaires. Furthermore, emergency medical suggestions for improvement of AHCDs were gathered. Descriptive statistics and qualitative methods were used for evaluation. RESULTS A total of 112 responses from emergency physicians could be incorporated into the study. Anesthesiologists represented the largest group (n = 55, 49 %), followed by internists (n = 40, 36 %). The median length of experience in EMS was 7 years [interquartile range (IQR) 4-14 years]. Patients' "do not resuscitate" orders were obeyed in 78/112 cases (70 %, 95 % CI 69-78 %). In 49/112 cases (44 %, 95 % CI 34-53 %), the request to not be hospitalized was granted. The length of EMS experience, type of medical specialty, the number of EMS cases and ways in which AHCDs were handled were all contributing factors to the various emergency medical interventions. CONCLUSION AHCDs appear to have an influence in the emergency medical decision process. However, it is presently unclear as to what a standardized and universally comprehensible AHCD should look like, in order to provide a framework that is both acceptable and necessary in a prehospital emergency medicine environment, ensuring medicolegal certainty for the parties involved.
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Affiliation(s)
- Mike Peters
- Institut für Rechtsmedizin, Charité-Universitätsmedizin Berlin, Turmstraße 21, 10559, Berlin, Deutschland.
| | - B R Kern
- Juristenfakultät Universität Leipzig, Leipzig, Deutschland
| | - C Buschmann
- Institut für Rechtsmedizin, Charité-Universitätsmedizin Berlin, Turmstraße 21, 10559, Berlin, Deutschland
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