[Patients as partners. Tumor patients and their participation in medical decisions]

[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.

Living with and dying from advanced heart failure: understanding the needs of older patients at the end of life

Background

Heart failure (HF) is a life-limiting illness and patients with advanced heart failure often suffer from severe physical and psychosocial symptoms. Particularly in older patients, HF often occurs in conjunction with other chronic diseases, resulting in complex co-morbidity. This study aims to understand how old and very old patients with advanced HF perceive their disease and to identify their medical, psychosocial and information needs, focusing on the last phase of life.

Methods

Qualitative longitudinal interview study with old and very old patients (≥70 years) with severe HF (NYHA III-IV). Interviews were conducted at three-month intervals over a period of up to 18 months and were analysed using qualitative methods in relation to Grounded Theory.

Results

A total of 95 qualitative interviews with 25 patients were conducted and analysed. The following key categories were developed: (1a) dealing with advanced heart failure and ageing, (1b) dealing with end of life; (2a) perceptions regarding care, and (2b) interpersonal relations. Overall, our data show that older patients do not experience HF as a life-limiting disease. Functional restrictions and changed conditions leading to problems in daily life activities were often their prime concerns. The needs and priorities of older HF patients vary depending on their disease status and individual preferences. Pain resulting in reduced quality of life is an example of a major symptom requiring treatment. Many older HF patients lack sufficient knowledge about their condition and its prognosis, particularly concerning emergency situations and end of life issues, and many expressed a wish for open discussions. From the patients’ perspective, there is a need for improvement in interaction with health care professionals, and limits in treatment and medical care are not openly discussed.

Conclusion

Old and very old patients with advanced HF often do not acknowledge the seriousness and severity of the disease. Their communication with physicians predominantly focuses on curative treatment. Therefore, aspects such as self-management of the disease, dealing with emergency situations and end-of-life issues should be addressed more prominently. An advanced care planning (ACP) programme for heart disease in older people could be an option to improve patient-centred care.

Advance directives and end-of-life decisions in Switzerland: role of patients, relatives and health professionals

Background

Little is known in Europe about end-of-life (EOL) decisions and advance directives (AD), particularly in patients with severe advanced disease. Switzerland is a multicultural and multilingual federal country and has the particularity of being divided into four linguistic and cultural regions

Objective

To understand better in different regions of Switzerland which specific patient's characteristics could have an impact on their decision to complete AD or not.

Design/setting/participants

Prospective study conducted in four palliative care units. Patients with an advanced oncological disease, fluent in French, German or Italian and with a Mini-Mental State Examination >20 were included. Demographic data, symptom burden (Edmonton Symptom Assessment System, ESAS; Hospital Anxiety and Depression Scale, HADS) and spiritual well-being (Functional Assessment of Chronic Illness Therapy-Spiritual well-being, FACIT-sp) have been assessed. A structured questionnaire has been completed by patients, their relatives and health professionals.

Results

143 patients were included (mean age 68.3 years; 62 male). 41 completed ADs. No particular features were associated with the completion of ADs. Most patients were satisfied with the medical information received. A third of them were not worrying about their future, especially those living in the German-speaking part. Should they become unable to communicate, 87 expected their relative to transmit their own wishes, but only 38 had spoken recently with them about what they wanted. 23 of the 69 included relatives would like to play a more active role in decision-making.

Conclusions

These results illustrate the fact that terminally ill patients wish to be active in decision-making, but only seldom transmit their wishes to their relative or complete a written document. The discussion about ACP should be defined according to the particularity of each region and the role of healthcare professionals’ attitudes towards ADs, but we should also be creative and find other ways to promote shared decision-making.

Cancer patients and advance directives: a survey of patients in a hematology and oncology outpatient clinic

BACKGROUND

In 2009, Germany enacted a new law supporting advance directives that led to heated discussions in the media and the public. 3 years after the law passed, we surveyed patients with malignant diseases with regards to their views on advance directives.

PATIENTS AND METHODS

Between September 2011 and July 2012 an anonymous survey on advance directives was conducted among 617 patients at the hematology and oncology outpatient department of the University Hospital Mannheim, using a standardized questionnaire developed for this investigation.

RESULTS

Of the 503 patients who returned the questionnaire, 31% (n = 157) indicated having an advance directive. Of these 157, 54% (n = 85) completed the advance directive after 2009. 56% (282 out of 503) desired more information on advance directives. Of these, 71% (201 out of 282) wanted their general physician and 45% (128 out of 282) their specialist, to provide more information about this issue. Of the 339 patients without an advance directive, 47% (n = 158) stated that they had 'not worried about that yet'.

CONCLUSION

Although the percentage of patients with advance directives has increased since the legislative amendment, more information is still required by patients. It is recommended that physicians should discuss advance directives more frequently with their patients.

A critical review of advance directives in Germany: attitudes, use and healthcare professionals' compliance

OBJECTIVE

Recent legal changes in Germany make non-compliance with advance directives (ADs) a criminal offence. This article assesses the evidence on attitudes towards, use of, and physician compliance with ADs in Germany.

METHODS

Critical review: studies on ADs, identified from a systematic review of culture and end-of-life care in Germany (11 electronic databases, 3 journals, reference lists, and grey literature), were included. An interpretative synthesis of findings revealed cross-cutting themes.

RESULTS

Thirty-two studies (1996-2009) were identified. Key themes were: awareness; utilization; compliance; and bindingness of ADs. There was a positive trend between awareness of ADs and study publication date. Use varied between patient groups (0.3-62%) and was low amongst the general population (2.5-10%). Fears about ADs' purpose and possible abuse were identified. Physician discomfort in discussing ADs and non-compliance were reported. Physicians preferred legally binding ADs, though conflicting results were reported for patients' desired level of bindingness.

CONCLUSION

Although there is increasing awareness of ADs in Germany, there remains low use, poor communication, fears of abuse, some non-compliance and contradictory evidence regarding desired bindingness.

PRACTICAL IMPLICATIONS

Although legal changes will hopefully improve compliance, low awareness, communication difficulties and uncertainties surrounding ADs must be addressed if use is to increase.

[Where do people die?: On the question of dying in institutions]

There is a great discrepancy in society between the number of people that prefer to die within their home and the number of cases where this wish actually becomes reality. The most frequent place of dying in Western societies is not the home but an institution, such as a hospital or nursing home. But what is the actual distribution of places of dying? Can we identify social patterns of dying related to the various places of dying? The article provides a theoretical and empirical overview of place of dying as a social phenomenon. Contemporary discourse on the institutionalization of dying is subjected to critical scrutiny in light of the state of the art of research.

Preference for place of death in Germany

BACKGROUND

Dying in the preferred place is considered a key requirement for a "good death." The aims of our study were to explore preferred places of death of deceased people and their bereaved relatives in Rhineland-Palatinate (Germany). We further wanted to assess the congruence between preferred and actual place of death.

METHODS

The cross-sectional study was based on a random sample of 5000 inhabitants of Rhineland-Palatinate (Germany) who died between May 25 and August 24, 2008. Relatives of these deceased persons were interviewed by a written survey.

RESULTS

After removing duplicates, 4967 questionnaires were sent out, 3832 delivered, and 1378 completed, yielding a response rate of 36.0%. Regarding the deceased, 93.8% wanted to die at home, 0.7% in a hospital, 2.8% in palliative care, 2.4% in a nursing home, and 0.3% elsewhere. The figures for the relatives were 80.7%, 4.3%, 7.5%, 7.1%, and 0.5%, respectively. Of the deceased 58.9% and of the relatives 59.1% had their wish fulfilled. Logistic regression analysis revealed that living in a rural municipality (adjusted odds ratio [aOR]: 1.88; 95% confidence interval [CI]: 1.02-3.43), rural town (aOR: 2.30; 95% CI: 1.17-4.49) or small town (aOR: 1.95; 95% CI: 1.04-3.68), having a nonworking relative (aOR: 1.79; 95% CI: 1.16-2.76), and living together with a relative (aOR: 2.28; 95% CI:1.57-3.32) increases the probability to die in the preferred place.

DISCUSSION

Because the availability of a relative was the most important factor to die in the preferred place, relatives of dying people should be supported in providing informal care. The introduction of palliative home care teams should allow more people to die in their preferred place by easing the burden of informal carers.

[Specialized outpatient palliative treatment by the Bochum Medical Service for Palliative Treatment]

Most people would like to spend the end of their life at home in their familiar surroundings. Is it possible to look after and care for people at home if the work of doctors, carers and hospices is coordinated and comprehensive?

MATERIAL AND METHODS

After receiving approval from the Ethics Committee of the Ruhr University Medical Faculty, the data of patients at the Bochum Medical Service for Palliative Treatment were anonymized and statistically evaluated.

RESULTS

Complete data from 104 patients were evaluated. On average, the patients were 69.8 years old, and 91% were suffering from malignancies. In 95% of the patients, the main symptom was fatigue, followed by pain (87%) of a mean score of NRS 5.5. Of those patients who were treated and looked after until the end of their lives, only 15.8% died in hospital and 73% of them on the palliative care ward.

CONCLUSION

Our results indicate that by introducing a specialized structure for outpatient palliative care, including a specialized 24-h palliative medical service, an improvement in total care for patients at the end of their lives can be achieved.

[Palliative care patients in an advanced state of disease. Cardiopulmonary resuscitation and determination of death]

BACKGROUND

Prehospital emergency teams will be confronted with the specific needs of resuscitation in palliative patients in whom a return of spontaneous circulation (ROSC) could be found significantly less frequently than in other emergency situations. The present investigation aims to show medical and judicial problems related to cardiopulmonary resuscitation (CPR), external examination of the corpse and death certification.

METHODS

Over a 12-month period all emergency cases involving physicians in an out-of-hospital resuscitation setting in cancer patients were retrospectively analysed for indications for emergency call, situation on-site and prehospital treatment by emergency physicians, external examination of the corpse and determination of death.

RESULTS

For the period mentioned 164 (2.7% of the total) emergency calls by cancer patients or their relatives were identified. In the following study 43 patients (26.2%) could be included. In 20 cases (46.5%) the emergency physicians attempted to resuscitate the patient by performing CPR. In the majority of cases (36; 83.7%) death certification and external examination of the corpse were necessary at the scene.

CONCLUSIONS

Due to a reduced rate of ROSC in palliative patients, death certification and external examination of the corpse are more often necessary than in other emergency situations. Therefore every emergency physician should be familiar with the ethics of resuscitation of patients in palliative care and with external examination of the corpse to do justice to patients and their caregivers.

Places of Death from Cancer in a Rural Location

BACKGROUND

Most people would like to die at home, however, this wish still cannot be realized to any satisfactory extent. Provision of qualified palliative care can increase the death rate at home. Distribution of places of death of cancer patients in rural locations and possible factors influencing this distribution are still unknown.

PATIENTS AND METHODS

We retrospectively evaluated the data relating to death certificates of cancer patients issued between 1997 and 2003 by the administrative district Sächsische Schweiz'.

RESULTS

In small-town and rural locations, the places of death from cancer were equally distributed among hospital and home. Patients living in a rural location and diagnosed as having breast cancer were more likely to die at home. Since 2001, the number of breast cancer patients dying at home has been increasing.

CONCLUSIONS

Rural locations provide favorable conditions for home deaths. High therapy costs and transfer of expensive therapies away from hospitals into the outpatient therapy sector appear to have an effect on the place where patients are finally cared for and where they eventually die. This circumstance meets the wishes of most patients and leads to a relevant cost saving for the healthcare system. An effective and rigorous health and economic policy is necessary in order to realize an extensive home care for terminally ill patients.