End-of-life practices in 11 German intensive care units : Results from the ETHICUS-2 study

BACKGROUND

End-of-life care is common in German intensive care units (ICUs) but little is known about daily practice.

OBJECTIVES

To study the practice of end-of-life care.

METHODS

Prospectively planned, secondary analysis comprising the German subset of the worldwide Ethicus‑2 Study (2015-2016) including consecutive ICU patients with limitation of life-sustaining therapy or who died.

RESULTS

Among 1092 (13.7%) of 7966 patients from 11 multidisciplinary ICUs, 967 (88.6%) had treatment limitations, 92 (8.4%) died with failed CPR, and 33 (3%) with brain death. Among patients with treatment limitations, 22.3% (216/967) patients were discharged alive from the ICU. More patients had treatments withdrawn than withheld (556 [57.5%] vs. 411 [42.5%], p < 0.001). Patients with treatment limitations were older (median 73 years [interquartile range (IQR) 61-80] vs. 68 years [IQR 54-77]) and more had mental decision-making capacity (12.9 vs. 0.8%), advance directives (28.6 vs. 11.2%), and information about treatment wishes (82.7 vs 33.3%, all p < 0.001). Physicians reported discussing treatment limitations with patients with mental decision-making capacity and families (91.3 and 82.6%, respectively). Patient wishes were unknown in 41.3% of patients. The major reason for decision-making was unresponsiveness to maximal therapy (34.6%).

CONCLUSIONS

Treatment limitations are common, based on information about patients' wishes and discussion between stakeholders, patients and families. However, our findings suggest that treatment preferences of nearly half the patients remain unknown which affects guidance for treatment decisions.

[Practice of regional anesthesia for chronic pain patients in specialized pain services : A nationwide survey in Germany]

BACKGROUND

The prevalence of chronic pain has been estimated to be 19% in the European population and criteria for disabling chronic pain were found in approximately 7% of the German population. Clinical care for these patients is provided in ambulant and hospital-associated facilities. In this context, invasive interventions are part of the diagnosis and treatment of several specific diseases. Current data on the structure of clinical care based regional anesthesia for chronic pain patients in Germany are not available.

OBJECTIVE

This study focused on the application and practice of interventional procedures in the context of pain management.

MATERIAL AND METHODS

An internet-based survey addressing pain facilities and pain specialists in Germany was carried out. The response rate achieved 54%.

RESULTS

Overall 79% of the pain therapists who responded included regional anesthesia techniques in the therapeutic spectrum in up to 25% of patients. The leading indications for invasive procedures were back pain and neuropathic pain. Two thirds of the therapists reported performing a series of blocks. A reduction of pain intensity of 30-50% was often reported as a sufficient criterion for the success of regional anesthesia interventions. Typically, approximately 40% of the chronic pain patients undergoing a series of blocks achieved sufficient pain relief which lasted most commonly for 12 weeks up to 6 months.

CONCLUSION

This survey describes the current structures of specialized pain facilities for regional anesthesia in Germany including responses from predominantly anesthesiologists in a hospital-associated setting. In light of the limited evidence in the literature there is no consensus on the interventional therapeutic management of chronic pain. Especially the application of a series of blocks and the frequency as well as criteria to support continuing or terminating a series of regional anesthesia interventions are not sufficiently evaluated. This survey also gives an incentive for a possible revision of the existing practice in regional anesthesia in the context of multimodal therapy and currently existing guidelines in future clinical studies.

Effect of sensory discrimination training on cortical reorganisation and phantom limb pain

Phantom limb pain is a frequent consequence of the amputation of a body part. Based on the finding that phantom limb pain is closely associated with plastic changes in the primary somatosensory cortex and animal data showing that behaviourally relevant training alters the cortical map, we devised a sensory discrimination training programme for patients with intractable phantom limb pain. Compared with a control group of medically treated patients, the training group had significant reductions in phantom limb pain (p=0.002) and cortical reorganisation (p=0.05) that were positively associated with improved sensory discrimination ability.

The relationship of perceptual phenomena and cortical reorganization in upper extremity amputees

In this study 16 unilateral upper extremity amputees participated in a comprehensive psychophysiological examination that included the assessment of painful and non-painful phantom and stump sensations, thermal and electric perception as well as two-point discrimination thresholds, the detailed analysis of referred sensation and the measurement of reorganizational changes in primary somatosensory cortex using neuroelectric source imaging. Reorganization of the primary somatosensory cortex was associated with increased habitual phantom limb pain, telescoping, non-painful stump sensations and painful referred sensation induced by painful stimulation. It was unrelated to non-painful phantom sensations, non-painful referred sensation elicited by painful or non-painful stimulation, painful referred sensation elicited by non-painful stimulation, perception thresholds and stump pain. These data substantiate the hypothesis that painful and non-painful phantom phenomena are mediated by different neural substrates.

A neural substrate for nonpainful phantom limb phenomena

Activity in the cerebral cortex associated with non-painful phantom limb sensation was studied in 14 upper extremity amputees. In four subjects, repetitive tactile stimulation of the digits or the lower corner of the mouth elicited non-painful phantom sensation in the amputated limb, in the remaining 10 patients no sensation could be evoked. Neuroelectric source imaging revealed significantly elevated activity in SI and posterior parietal cortex, and significantly decreased activity in ipsilateral SII cortex when referred sensations were present. However, nonpainful referred phantom sensations were not associated with a shift of the cortical representation of the mouth into the hand region, as previously suggested. Nonpainful phantom limb experiences seem to have widely distributed neural networks in multiple cortical regions.

[Drug-induced headache--pathomechanisms of addiction]

The pathogenesis of drug abuse in patients suffering from drug-induced headache is not known in detail. It is unclear whether drug abuse in chronic daily headache should be classified as a form of drug dependence. Current findings concerning the neurobiological correlates of addictive behavior and affective disorders point to the importance of monoaminergic dysregulation, especially a dysfunction of central serotonergic neurotransmission. We reviewed the literature on drug-induced headache and examined hypothetical pathomechanisms of addiction. Drugs causing drug-induced headache such as paracetamol, coffein and ergotamine interfere with behavior patterns or neurotransmitter systems that are also affected by drugs of abuse. Several drugs that ameliorate acute headache interact with central serotonergic neurotransmission and may affect anxiety and depression in patients with chronic daily headache. Non human primate and human studies revealed mechanisms of serotonergic dysfunction in drug dependence, which may also be relevant for drug-abuse in medication-induced headache. Medication-induced dysfunction of monoaminergic, especially serotonergic neurotransmission, may affect drug dependence by exacerbating mood disorders. Further studies are necessary to assess serotonergic neurotransmission in patients with drug-induced headache and abuse of medication.