Involvement of an anaesthetic department in terminal therapy

[Palliative care oriented therapy for all patients : recommendations of an expert circle]

BACKGROUND

Since 2011 palliative care has been a compulsory part of the German medical study course (so-called Q13 palliative and pain medicine). Palliative care content does not, however, as often taught, have to focus only on patients in the so-called palliative stages of disease. The aim of this investigation was to encourage a discussion concerning the integration of palliative care aspects into general medical treatment.

METHODS

For data collection an open discussion of the main topics by experts in palliative medical care was used. The main outcome measures and recommendations included responses regarding current practices related to expert opinions, national and international literature and one case report. The literature search was performed using the databases "PubMed", "Medline" and "Google" (1990-2011).

RESULTS

As an important consensus, the following recommendations for optimization of inpatient and outpatient care were: (1) integration of aspects of palliative care into medical curricula of all disciplines, (2) palliative care content should be extended to the general optimization of therapy for all patients, (3) palliative medicine should be part of the everyday medical practice in all disciplines and (4) palliative medicine should not be isolated as "death medicine" or medicine of the dying patient.

CONCLUSIONS

Palliative care treatment is increasingly becoming integrated into medical education and into medical curricula of all disciplines. Palliative ideas and goals are focussed on patients in the so-called palliative stages of disease. Furthermore, palliative medicine is often described as the medicine of dying patients. As a result of this study it seems to make sense to extend palliative care aspects to all patients and to all patient care. The extent to which such opportunities exist and such health care is economically feasible remains to be the subject of further clinical studies.

[Anesthesiology and palliative medicine. Structured results of a prospective questionnaire-based survey in German hospitals]

BACKGROUND

Anesthesiology departments were often integrated into the primary formation of palliative activities in Germany. The aim of this study was to present the current integration of anesthesiology departments into palliative care activities in Germany.

METHODS

The objective was to determine current activities of anesthesiology departments in in-hospital palliative care. A quantitative study was carried out based on a self-administered structured questionnaire used during telephone interviews.

RESULTS

A total of 168 out of 244 hospitals consented to participate in the study and the response rate was 69%. In-hospital palliative care activities were reported for most of the surveyed hospitals. Only two hospitals in the maximum level of care reported no activities. Participation in these activities by anesthesiology departments was described in up to 92%. Historically, most activities are due to the commitment of individuals, whereas the development of palliative care of cancer pain services and hospital support teams took place in the university hospitals by 2005.

CONCLUSIONS

Until 2005 many university palliative care activities had their origins in cancer pain services. These were often integrated into anesthesiology departments. Currently, anesthesiology departments work as an integrative part of palliative medicine. However, it appears from the present results that there is a domination of internal medicine (especially hematology and oncology) in palliative activities in German hospitals. This allows the focus of palliative activities to be formed by subjective specialist interests. Such a state seems to be reduced by the integration of anesthesiology departments because of their neutrality with respect to faculty-specific medical interests. Advantages or disadvantages of these circumstances are not considered by the present investigation.

Palliative care and involvement of anaesthesiology: current discussions

PURPOSE OF REVIEW

To summarize various developments related to palliative care, especially related to ethical issues. To emphasize the involvement of anaesthesiology in palliative care.

RECENT FINDINGS

Euthanasia has been legalized in Belgium, the Netherlands and Luxemburg (BENELUX countries). A group from Belgium has now proposed using euthanasia in patients in whom palliative care has been deemed 'futile'. This practice of so-called 'integral palliative care' is strongly rejected in a study from Germany. Palliative sedation is an ethically different approach with no intention to kill the patient. The European Association of Palliative Care has proposed a framework for individual guidelines for palliative sedation. The important role of anaesthesiology in palliative care teams is emphasized.

SUMMARY

Palliative care is a powerful approach to patient care during terminal illness, emphasizing quality of life even if it may shorten the length of life. Traditionally, palliative care has been contrasted with active euthanasia, but a group from Belgium has challenged this concept recently, advocating the use of euthanasia in circumstances in which palliative care has become 'futile'. This new approach led to strong reactions by a group from Germany, stressing that killing on demand in palliative care should under no circumstances be justified. In contrast, palliative sedation is a common method in special cases to reduce intractable symptoms. A new framework for palliative sedation produced by the European Association of Palliative Care may encourage institutions to set up their own palliative sedation guidelines. Worldwide, anaesthesiologists have a significant role in palliative care due to their unique complex expertise mainly in pain therapy and including transient sedation of patients.

[Palliative medicine. Fifth pillar of anaesthesia departments]

Palliative medicine has progressed during recent years to an independent medical faculty within the German health system. Despite this development palliative care systems for out-of-hospital and in-hospital palliative care are still insufficient in Germany so that the development of necessary resources must be considered as not yet completed. To support the further national development palliative medicine can be temporarily or permanently coupled to existing departments, which can be advantageous for all concerned and last but not least be profitable to patients and their relatives. Possibilities for participation of anaesthesiologists in this area of medical care are discussed in the study reported here. Anaesthesiologists have always historically been represented in palliative medical departments, e.g. as pain specialists. In the following investigation the special possibilities of anaesthesia departments for supporting the education and development of in-hospital and out-of hospital palliative medical care departments are reported. Previous experience of co-operation between these two departments is well established. Departments of palliative medicine depend on a well working interdisciplinary co-operation between different medical disciplines (e.g. anaesthesiology, radiotherapy, surgery and oncology) and several medical professions (e.g. physicians, nurses, psychologists). The aim of palliative care therapy is to be responsible for the best possible therapy for cancer patients and to give support to their care-giving relatives. Due to the increasing establishment of palliative care procedures in Germany, departments of anaesthesiology should actively take part in the further development. Part of the responsibility of most anaesthesia departments is to practice pain management and critical care medicine, which are reasons why anaesthesiologists are predestined to be part of the system for palliative care patients and their relatives. Anaesthesia departments can be responsible for the organization of in-hospital and out-of-hospital palliative medicine and palliative care. The integration of anaesthesiological expertise into palliative medicine departments and vice versa can be a great opportunity for both medical departments and therefore represents a worthwhile engagement.