Was beeinflusst Entscheidungen am Lebensende?

Meaning in life of terminally ill parents with minor children compared to palliative care patients - a quantitative analysis using SMiLE

Background

Caring for terminally ill patients with minor children can be very stressful. The perceived quality of life is significantly influenced by the Meaning in Life (MiL). No studies were found that focus on the prioritized special needs of this patient group.

Objectives

The aim is to compare and contrast terminally ill parents with minor children and palliative care patients in Germany, in order to provide appropriate support beyond medical, nursing or therapeutic interventions.

Methods

Terminally ill parents diagnosed were surveyed using a validated instrument 'Schedule for Meaning in Life Evaluation (SMiLE)'. The study listed various areas that contribute to the MiL, followed by an evaluation of their importance and satisfaction levels. The researchers then compared these findings with data collected from palliative care patients.

Results

In Germany, 54 patients, mostly female and with a mean age of 43, were included in this study between February 2017 and September 2020. The median age of the 96 children during the survey phase was 7 years. The comparison group consists of 100 palliative care patients in Germany; mostly aged 50 years and older. For terminally ill patients most important areas were in decreasing order family (100%), social relations (80%), leisure time (61%), nature/animals (39%) and home/garden (30%). Although the overall indices are close between both groups, there are significant and highly correlated differences between them. Parents felt limited by their illness in being a mother or father, as they wanted to be.

Conclusion

The involvement with SMiLE led patients to consider their coping resources. The areas relevant to terminally ill parents differed from those relevant to palliative care patients. All participants identified family as the most important factor for MiL. The results suggest that evaluating MiL can serve as a coping strategy and help terminally ill parents with minor children.

[Knowledge and misconceptions on advance directives-results of a citizen survey]

BACKGROUND

Advance directives (ADs) such as living wills or healthcare powers of attorney are important tools to anticipate medical treatment decisions when decision-making capacity is lost in the future. Although a rising number of citizens in Germany are creating such documents, little is known about their knowledge of the purpose, types, and use of ADs. After more than 10 years since legislation on ADs came into force, this study intends to measure the objective knowledge of citizens and detect deficits in knowledge.

METHODS

We conducted a cross-sectional quantitative survey of citizens aged 18+ in the city and county of Wuerzburg. The questionnaire included, among other things, possession, experience, and knowledge of ADs. Sampling was conducted via advertising and local networking.

RESULTS

Of the 282 participants who took part in the survey (Mage = 50 years, 2/3 female), 43.4% reported having created a minimum of one document. In the knowledge test, an average of 22/34 points was achieved. While questions about the specific application of ADs based on a case study were often answered correctly, we found deficits about the single document types. The results in the knowledge test and the variables on the subjective level of knowledge correlate positively.

DISCUSSION

The relatively high rate of ADs in this sample indicates their rapid dissemination during the past few years in Germany. Overall, the level of knowledge ADs appears to be low, revealing misconceptions about the creator's and involved people's rights and obligations. The measured knowledge level contradicts with the frequently expressed desire of citizens to preserve their autonomy by creating ADs for themselves.

Outpatient palliative care during the COVID-19 pandemic: a retrospective single centre analysis in Germany

Background

The coronavirus disease 2019 (COVID-19) pandemic has challenged health care systems worldwide. In Germany, patients in a palliative care setting have the opportunity to receive treatment by a specialised mobile outpatient palliative care team (OPC). The given retrospective single centre analysis describes the use of OPC structures for terminally ill COVID-19 patients during the height of the pandemic in Germany and aims to characterise this exceptional OPC patient collective.

Methods

First, death certificates were analysed in order to collect data about the place of death of all deceased COVID-19 patients (n = 471) within our local governance district. Second, we investigated whether advance care planning structures were established in local nursing homes (n = 30) during the height of the COVID-19 pandemic in 2020. Third, we examined patient characteristics of COVID-19 negative (n = 1579) and COVID-19 positive (n = 28) patients treated by our tertiary care centre guided OPC service.

Results

The analysis of death certificates in our local district revealed that only 2.1% of all deceased COVID-19 patients had succumbed at their home address (n = 10/471). In contrast, 34.0% of COVID-19 patients died in nursing homes (n = 160/471), whereas 63.5% died in an inpatient hospital setting (n = 299/471). A large proportion of these hospitalised patients died on non-intensive care unit wards (38.8%). Approximately 33.0% of surveyed nursing homes had a palliative care council service and 40.0% of them offered advance care planning (ACP) structures for their nursing home residents. In our two OPC collectives we observed significant differences concerning clinical characteristics such as the Index of Eastern Cooperative Oncology Group [ECOG] (p = 0.014), oncologic comorbidity (p = 0.004), as well as referrer and primary patient location (p = 0.001, p = 0.033).

Conclusions

Most COVID-19 patients in our governance district died in an inpatient setting. However, the highest number of COVID-19 patients in our governance district who died in an outpatient setting passed away in nursing homes where palliative care structures should be further expanded. COVID-19 patients who died under the care of our OPC service had considerably fewer oncologic comorbidities. Finally, to relieve conventional health care structures, we propose the expansion of established OPC structures for treating terminally ill COVID-19 patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01035-x.

End-of-Life Decision-Making in Intensive Care Ten Years after a Law on Advance Directives in Germany

Background and Objectives: Mortality on Intensive Care Units (ICUs) is high and death frequently occurs after decisions to limit life-sustaining therapies. An advance directive is a tool meant to preserve patient autonomy by guiding anticipated future treatment decisions once decision-making capacity is lost. Since September 2009, advance directives are legally binding for the caregiver team and the patients' surrogate decision-maker in Germany. The change in frequencies of end-of-life decisions (EOLDs) and completed advance directives among deceased ICU patients ten years after the enactment of a law on advance directives in Germany is unknown. Materials and Methods: Retrospective analysis on all deceased patients of surgical ICUs of a German university medical center from 08/2008 to 09/2009 and from 01/2019 to 09/2019. Frequency of EOLDs and advance directives and the process of EOLDs were compared between patients admitted before and after the change in legislation. (No. of ethical approval EA2/308/20) Results: Significantly more EOLDs occurred in the 2019 cohort compared to the 2009 cohort (85.8% vs. 70.7% of deceased patients, p = 0.006). The number of patients possessing an advance directive to express a living or therapeutic will was higher in the 2019 cohort compared to the 2009 cohort (26.4% vs. 8.9%; difference: 17.5%, p < 0.001). Participation of the patients' family in the EOLD process (74.7% vs. 60.9%; difference: 13.8%, p = 0.048) and the frequency of documentation of EOLD-relevant information (50.0% vs. 18.7%; difference: 31.3%, p < 0.001) increased from 2009 to 2019. Discussion: During a ten-year period from 2009 to 2019, the frequency of EOLDs and the completion rate of advance directives have increased considerably. In addition, EOLD-associated communication and documentation have further improved.

Preferences for end-of-life care settings among the healthy population in Israel—Related socio-demographic variables

Objective

Preferences for end-of-life (EoL) care settings is of considerable interest for developing public health policy and EoL care strategies. Culture, the cause of illness, and background characteristics may impact preferences. The present study aimed to explore preferences for EoL care settings: homes, hospitals, and inpatient hospice units among the general healthy population in Israel. Possible associations between the setting preferences and socio-demographic characteristics were also examined.

Method

A cross-sectional survey was conducted among 311 healthy adults who were recruited through a representative internet panel of the Israeli population using the Israeli census sampling method. The sex ratio was almost 1:1 with 158 women (50.8%) and 153 men (49.2%). All participants completed self-report measures using an online survey system. The questionnaires assessed sociodemographics and preferences for EoL care settings.

Results

This survey revealed that 52.1% of the participants expressed preference for being cared for at home rather than in an inpatient hospice unit, 40.8% expressed being cared for at home rather than in a hospital, while 36.7% had no preference regarding being cared for in hospital or in a hospice unit. Among the socio-demographic variables, only age and gender were found to be significantly associated with preferences for EoL care settings.

Significance of results

The present study highlights the need to be cautious when regarding home as the preferred EoL care setting, as some individuals declared that they would prefer EoL hospice/hospital care. Age and gender should be considered when discussing and tailoring strategies regarding EoL preferences.

[Heidelberg Milestones Communication (HeiMeKOM) - Experiences, Best Practice Examples and Recommendations from the Final Symposium on January 30 and 31 in 2020]

The National Cancer Plan emphasises the importance of medical communication and calls for its integration into medical education and training. In this context, the Milestone Communication Approach meets the communicative challenges in dealing with lung cancer patients. Interprofessional tandems, consisting of doctors and nurses, conduct structured conversations at defined moments with patients and their relatives. The concept aims at shared decision making, continuity in the care of lung cancer patients and the early integration of palliative care. During the symposium on the Heidelberg Milestone Communication in January 2020, recommendations on the care situation of lung cancer patients in advanced stages were developed. In addition, the further adaptability of HeiMeKOM to other settings and hospitals and to other diseases was discussed as well as the possibility of implementing such a concept in standard care. This article presents the experiences, best practice examples and recommendations discussed during the symposium in order to enable their extrapolation to other similarly oriented projects. The long-term goal is to transfer the milestone concept to other hospital, primarily certified lung cancer centers, and to ensure permanent funding. For further dissemination of the concept and, above all, to have it established in standard care, health policy awareness and support are required in addition to the integration of the concept in competence catalogues of continuing medical and nursing education.

Let us talk about death: gender effects in cancer patients' preferences for end-of-life discussions

Purpose

Patients with advanced cancer often receive suboptimal end-of-life (EOL) care. Particularly males with advanced cancer are more likely to receive EOL care that is more aggressive, even if death is imminent. Critical factors determining EOL care are EOL conversations or advance care planning. However, information about gender-related factors influencing EOL conversations is lacking. Therefore, the current study investigates gender differences concerning the content, the desired time point, and the mode of initiation of EOL conversations in cancer patients.

Methods

In a cross-sectional study, 186 female and male cancer patients were asked about their preferences for EOL discussions using a semi-structured interview, focusing on (a) the importance of six different topics (medical and nursing care, organizational, emotional, social, and spiritual/religious aspects), (b) the desired time point, and (c) the mode of discussion initiation.

Results

The importance of EOL topics differs significantly regarding issue (p = 0.002, η² = 0.02) and gender (p < 0.001, η² = 0.11). Males wish to avoid the engagement in discussions about death and dying particularly if they are anxious about their end-of-life period. They wish to be addressed regarding the “hard facts” nursing and medical care only. In contrast, females prefer to speak more about “soft facts” and to be addressed about each EOL topic. Independent of gender, the majority of patients prefer to talk rather late: when the disease is getting worse (58%), at the end of their therapy, or when loosing self-sufficiency (27.5%).

Conclusion

The tendency of patients to talk late about EOL issues increases the risk of delayed or missed EOL conversations, which may be due to a knowledge gap regarding the possibility of disease-associated incapability. Furthermore, there are significant gender differences influencing the access to EOL conversations. Therefore, for daily clinical routine, we suggest an early two-step, gender-sensitive approach to end-of-life conversations.

[Advance Care Planning (ACP). A Systematic Review of ACP Behavior by Women and Men in Germany]

BACKGROUND

The desire to retain control over one's life until the end has become highly important in our society. Women and men of different ages and of diverse social, cultural, and educational backgrounds increasingly decide in advance about prospective medical treatment (Advance Care Planning, ACP).

OBJECTIVES

Identification and analysis of literature on advance care planning behavior of men and women in Germany. The focus is on gender-specific differences.

MATERIALS AND METHODS

Systematic review of empirical studies with gender-specific data on advance care planning behavior in Germany. In-depth analysis of 21 of the 479 retrieved articles.

RESULTS

The analysis reveals that Advance Care Planning behavior is influenced by interacting factors such as gender, age, cultural and ethnic background, religion, and education. Gender alone does not explain the prevalence of ACP behavior. This prima facie negative result is partly due to the study designs. Heterogeneous data and a lack of gender sensitivity leave the question concerning the relationships between ACP behavior and gender mostly unanswered.

CONCLUSIONS

The analyzed studies reduce gender to a dualistic classification system, dismiss individual role models and positions and also neglect geographic and cultural contexts. There is a need for studies sensitive to gender and culture.

¿La sedación paliativa acorta la vida de los pacientes?

El respeto por la vida humana es central en el acto médico. En pacientes terminales, los síntomas refractarios son nicho de sedación paliativa. Este artículo identifica, a partir de evidencia científica, la sobrevida en pacientes con sedación paliativa en comparación con aquellos que no la recibieron. Se realizó́ búsqueda de revisiones sistemáticas de 2000 a 2016, se analizaron metodológicamente y se compararon los resultados. Por razones metodológicas no se pudo realizar meta-análisis. Se concluye que la sedación paliativa terminal no acorta la vida de los pacientes. Se reformula la aplicación del principio de doble efecto relacionado con el posible acortamiento de la vida; el mal no deseado es la pérdida de la conciencia.

Survey on German Palliative Care Specialists' Experiences with Advance Directives

Introduction

Advance directives (AD) play a central role in end-of-life treatments, intensive care, and palliative care. However, little is known about the experiences of healthcare professionals with ADs. This study reports on palliative care professionals’ views on advance directives (AD).

Methods

A questionnaire was handed out to attendants of a palliative care symposium.

Results

Complete answers were obtained from 126 physicians and 276 nurses. Almost all physicians and nurses had treated patients with an AD, and the majority more than 10 patients. The most frequent refusal by the patients was resuscitation (87.8%) followed by intensive care (79.1%), artificial ventilation, and nutrition. The most frequent wish was pain therapy (92.3%) followed by allowing the natural course of the illness (64.4%). The wish for hospice treatment (44.8%) or spiritual care (39.3%) was less frequent.

Discussion

The results hint at fears and deficits in the care of patients at the end of life. Often the quality of life and not the quantity of days remaining is in the center of a patient’s will and points to the growing importance of palliative care.

Conclusion

ADs are well established among palliative care professionals and regarded as helpful for patients at the end of life.

[Four years of specialized outpatient palliative care in a rural area : Cooperation and acceptability from general practitioners' view]

BACKGROUND

In 2011, a specialized palliative home care was introduced in the counties of Landshut and Dingolfing.

OBJECTIVES

The aim of the current survey was to evaluate the cooperation, acceptance and need of palliative measures for patients particulary from the general practitioner's perspective.

METHODS

From January to March 2015, 198 general practitioners from the counties of Landshut and Dingolfing were contacted with questionnaires. The questionnaires consisted of 16 questions covering five different issues, and drew upon the practical experiences of the authors and earlier surveys from the literature. The questionnaires were sent by post containing a self-addressed and postpaid envelope.

RESULTS

Completed questionnaires from 40 out of 198 contacted general practitioners (33 % female and 53 % male). Of these 85 % had cooperated with a SAPV team, 23 % had taken part in training for palliative medicine, 10 % intended to acquire a qualification and 10 % could imagine working in a SAPV team. In addition, 75 % stated that hospitalizations were avoided through the use of SAPV while 73 % felt that time and costs were saved for their own practices. The majority of general practitioners were satisfied with the work provided by the SAPV and the cooperation. Regarding additional palliative care for geriatric patients, 60 % believed that this was sensible. One main critique was that the information about including a patient in the SAPV program was transferred to the general practitioner too late.

CONCLUSION

The current data show that general practitioners recognize the need for palliative medicine skills and predominately welcome the work of a specialized palliative care team in treating their patients. However, close cooperation and communication is necessary for a successful network between generalists and specialists in palliative care.