National strategy for palliative care of severely ill and dying people and their relatives in pandemics (PallPan) in Germany - study protocol of a mixed-methods project

Background

In the SARS-CoV-2 pandemic, general and specialist Palliative Care (PC) plays an essential role in health care, contributing to symptom control, psycho-social support, and providing support in complex decision making. Numbers of COVID-19 related deaths have recently increased demanding more palliative care input. Also, the pandemic impacts on palliative care for non-COVID-19 patients. Strategies on the care for seriously ill and dying people in pandemic times are lacking. Therefore, the program ‘Palliative care in Pandemics’ (PallPan) aims to develop and consent a national pandemic plan for the care of seriously ill and dying adults and their informal carers in pandemics including (a) guidance for generalist and specialist palliative care of patients with and without SARS-CoV-2 infections on the micro, meso and macro level, (b) collection and development of information material for an online platform, and (c) identification of variables and research questions on palliative care in pandemics for the national pandemic cohort network (NAPKON).

Methods

Mixed-methods project including ten work packages conducting (online) surveys and qualitative interviews to explore and describe i) experiences and burden of patients (with/without SARS-CoV-2 infection) and their relatives, ii) experiences, challenges and potential solutions of health care professionals, stakeholders and decision makers during the SARS-CoV-2 pandemic. The work package results inform the development of a consensus-based guidance. In addition, best practice examples and relevant literature will be collected and variables for data collection identified.

Discussion

For a future “pandemic preparedness” national and international recommendations and concepts for the care of severely ill and dying people are necessary considering both generalist and specialist palliative care in the home care and inpatient setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00898-w.

[Cooperation between intensive care and palliative care : The status quo in German Comprehensive Cancer Centers]

Hintergrund

Die interdisziplinäre Zusammenarbeit zwischen Intensivmedizin und Palliativmedizin kann die Versorgungsqualität verbessern. Das Ausmaß dieser Zusammenarbeit ist aber bisher kaum untersucht.

Ziel der Arbeit

Es sollten die angebotenen und in Anspruch genommenen palliativmedizinischen Unterstützungsangebote auf den Intensivstationen deutscher onkologischer Spitzenzentren erfasst werden.

Material und Methoden

Durchgeführt wurde eine quantitativ-qualitative, deskriptive Umfrage an den 16 von der Stiftung Deutsche Krebshilfe geförderten Zentren. Die im quantitativen Teil erfragten Häufigkeiten werden als Mittelwert und Median mit den jeweiligen Streumaßen dargestellt, während die im qualitativen Teil erhobenen Triggerfaktoren mit einer Inhaltsanalyse nach Mayring ausgewertet wurden.

Ergebnisse

Von Juli bis August 2017 konnten Angaben aus 15 von 16 onkologischen Spitzenzentren (94 %) erfasst werden. Im Jahr 2016 wurden im Median 33 Intensivpatienten (Min. 0, Max. 100) palliativmedizinisch vorgestellt und 9 Patienten (Min. 1, Max. 30) auf eine Palliativstation verlegt. Regelmäßige intensivmedizinisch-palliativmedizinische Visiten sowie ein Screening-Tool zur Einbindung der spezialisierten Palliativmedizin sind an zwei onkologischen Spitzenzentren implementiert. Anhand von 23 genannten Triggern, die auf der Intensivstation eine palliativmedizinische Mitbehandlung ausgelöst haben, lassen sich nach qualitativer Analyse die drei Kategorien „Entscheidung und Einstellung des Teams“, „Zustand des Patienten“ und „Wunsch von Patienten und Angehörigen“ ableiten.

Diskussion

Trotz eines verfügbaren Angebots werden palliativmedizinische Ressourcen in den intensivmedizinischen Abteilungen der onkologischen Spitzenzentren immer noch selten genutzt. In die tägliche Routine integrierte Angebote wie Screening-Tools oder gemeinsame Visiten könnten die Ausnutzung der angebotenen palliativmedizinischen Ressourcen erhöhen und die Versorgungsqualität verbessern.

Unpredictable episodic breathlessness in patients with advanced chronic obstructive pulmonary disease and lung cancer: a qualitative study

PURPOSE

The internationally consented definition and categorization describe two categories of episodic breathlessness: predictable (with known triggers) and unpredictable. The link of known triggers only to predictable episodes can be read that unpredictable episodes have none known trigger. Our aim was to illuminate patients' experiences with episodes of unpredictable breathlessness, to collect descriptions of the episodes' impact on the patients' lives, and, in turn, the patients' individual coping strategies in this connection.

DESIGN

Qualitative study using semi-structured in-depth interviews with patients suffering from unpredictable episodes of breathlessness and chronic obstructive pulmonary disease (COPD; Global Initiative for Obstructive Lung Disease III and IV) or lung cancer (all stages). Interviews were audio-recorded, transcribed verbatim, and analyzed using Framework Analysis.

RESULTS

One hundred one patients were screened in a large university hospital; ten participants fulfilled the inclusion criteria and provided consent. The experienced episodes were evaluated as unpleasant and with higher intensity compared to predictable episodes. Non-pharmacological interventions were identified as useful coping strategies. Interestingly, although patients experienced the episodes in an unpredictable manner, a trigger could be detected retrospectively for the majority of cases (mostly emotions (especially panic) and, occasionally, physical exertion). Unpredictable episodes are less frequent than previously assumed.

CONCLUSION

The unpredictability of unpredictable breathless episodes refers to the patients' experience that these episodes occur "out-of-the-blue." However, a known trigger can be identified for the majority of unpredictable breathless episodes. These are therefore triggered as well. Further research needs to describe more possible triggers, to inquire the prevalence of unpredictable episodic breathlessness, and to develop effective management strategies.

[Characteristics of patients with breathlessness - results of the german hospice and palliative care evaluation]

BACKGROUND

Breathlessness is a common and distressing symptom in patients with advanced life-limiting disease. The aim of this study was to describe demographical and clinical characteristics of patients with breathlessness in Germany.

METHODS

We conducted a secondary analysis of hospice and palliative care inpatient data from 2006 to 2008. The Hospice and Palliative Care Evaluation (HOPE) is an annual prospective German survey, that includes a validated 16-item symptom-and-problem checklist (severity score 0-3). Characteristics of patients with or without breathlessness were compared in a pure descriptive manner. Interpretation of given p-values takes the error inflation due to multiple testing into account.

RESULTS

Breathlessness was recorded in 2860/5320 (53.8 %) patients (mean age 67.2 years (SD 12.4), 51.4 % female, 93.6 % malignant disease (female / male lung cancer 15.7/29.5 %, breast cancer 20.3/0.3 %, colon 10.3/8.7 %)). Breathless patients compared with those without breathless ness had a significantly worse functional status (ECOG 3-4: 78.4 % vs. 70.8 %, p < 0.001), suffered from a larger number (11.1 vs. 9.5, p < 0.001) of symptoms and the symptoms were of higher intensity (except confusion). Breathless patients had a higher risk to die during inpatient stay (43.5 % vs. 32.4 %, p < 0.001).

CONCLUSION

Based on this large sample of hospice and palliative care inpatients, breathlessness is associated with a high symptom burden and shortened survival. Breathless patients need more attention in health care.

[State of integration of palliative care at Comprehensive Cancer Centers funded by German Cancer Aid]

BACKGROUND

Similarities and differences of integration of palliative care in clinical care, research and education structures at German Comprehensive Cancer Centers (CCC) are not known in detail.

OBJECTIVE

Provide an overview of availability and the way of integration of specialized palliative care at CCCs funded by the German Cancer Aid (Deutsche Krebshilfe, DKH).

METHOD

We conducted structured interviews from May to August 2014 with heads of palliative care departments (personally or by telephone). The interviews included a quantitative and a qualitative part. Other stakeholders of CCCs were asked the questions of the qualitative part. We evaluated the qualitative data using the content analysis by Mayring and MAXQDA 11.0. SPSS 21.0 was used for quantitative analysis.

RESULTS

26 interviews were realized in 13 CCCs with 14 sites, which received funding, by DKH till August 2014 (one CCC had two university hospitals). Of these, 12 sites had a palliative care unit (86%), 11 sites had palliative care consulting services available (79%). Participation of palliative care specialists in tumor boards is not provided in 3 institutions (21%) and is often not feasible on regular basis in the other institutions, due to staffing shortage. In 7 sites (50%) defined criteria to integrate palliative care into CCCs were available. In the last 5 years specialized palliative care of 4 sites received an invitation for a research project by another department within the CCC (29%). 10 sites (71%) had started own palliative care research projects. Chairs in palliative care were available in 4 CCCs (29%).

CONCLUSION

The extent and depth of palliative care integration in the 14 CCC sites is heterogeneous.

[Episodic breathlessness: translation and consenting of the international definition using the Delphi method]

BACKGROUND

Similar to pain, refractory breathlessness can occur episodically. Episodic Breathlessness is a distressing symptom in patients with advanced life-limiting disease. The lack of a universal definition impedes symptom understanding in clinical practice and effective management, respectively. The aim of the study was to formally consent a German translation of the English definition and terminology of episodic breathlessness.

METHODS

A web-based Delphi survey was conducted with German breathlessness experts (breathlessness working group of Germany's National Guideline (S3) for Palliative Care). Drafts of German-language definitions und terminology were assessed using structured questionnaires by binary rating or rankings, respectively. Optional comments were analysed by content analysis. Consensus was defined by ≥ 70% agreement among participants.

RESULTS

In two resulting Delphi-rounds 8/16 (50%) und 11/16 (69%) experts, 30-59 years of age, 50%/55% female, participated. After the second round, consensus was reached for the symptom's description "Atemnotattacke" (73%) and a German-language definition (90%). The terms "vorhersehbar" vs. "unvorhersehbar" were directly consented for the categorization (88%).

CONCLUSION

The formally consented German definition and terminology of episodic breathlessness enable clearer symptom understanding and provide a precise basis for education and research on the symptom and its management also in Germany. Effective management options are warranted to improve quality of life of suffering patients and their relatives.

Preferences for place of death if faced with advanced cancer: a population survey in England, Flanders, Germany, Italy, the Netherlands, Portugal and Spain

BACKGROUND

Cancer end-of-life care (EoLC) policies assume people want to die at home. We aimed to examine variations in preferences for place of death cross-nationally.

METHODS

A telephone survey of a random sample of individuals aged ≥16 in England, Flanders, Germany, Italy, the Netherlands, Portugal and Spain. We determined where people would prefer to die if they had a serious illness such as advanced cancer, facilitating circumstances, personal values and experiences of illness, death and dying.

RESULTS

Of 9344 participants, between 51% (95% CI: 48% to 54%) in Portugal and 84% (95% CI: 82% to 86%) in the Netherlands would prefer to die at home. Cross-national analysis found there to be an influence of circumstances and values but not of experiences of illness, death and dying. Four factors were associated with a preference for home death in more than one country: younger age up to 70+ (Germany, the Netherlands, Portugal, Spain), increased importance of dying in the preferred place (England, Germany, Portugal, Spain), prioritizing keeping a positive attitude (Germany, Spain) and wanting to involve family in decisions if incapable (Flanders, Portugal).

CONCLUSIONS

At least two-thirds of people prefer a home death in all but one country studied. The strong association with personal values suggests keeping home care at the heart of cancer EoLC.

Are we heading in the same direction? European and African doctors' and nurses' views and experiences regarding outcome measurement in palliative care

OBJECTIVE

To examine and compare doctors' and nurses' views and experiences regarding outcome measurement in palliative care, including patient-reported outcome measures (PROMs).

METHODS

A web-based survey developed through expert review and piloting was conducted in Europe and Africa with palliative care professionals working in clinical care, audit and research.

RESULTS

The overall participation rate was 42% (663/1592) and the overall completion rate was 59% (392/663). Of these respondents, 196 were doctors (51% male, mean 47 years) and 104 were nurses (84% female, mean 45 years). Doctors' most common reported reasons for not using tools were time constraints followed by lack of training. For nurses, it was lack of training followed by time constraints. Provision of information and guidance influenced willingness to use measures. For those that used tools, most reported favourable outcome measurement experiences. Both prioritized brief PROMs, and measures that included physical and psychological domains. For clinical purposes, the main advantage for doctors was assessment/screening, and clinical decision making for nurses. For research, doctors were most influenced by a measure's comparability with national/international literature followed by its validation in palliative care. For nurses, validation in palliative care was followed by tool access.

CONCLUSION

Overall these respondents shared similar views and experiences, and both were influenced by similar factors. Multidisciplinary outcome measurement education and training is feasible and required. Multidimensional and brief PROMs that include physical and psychological domains need to be prioritized, and access to freely available, validated and translated tools is needed to ensure cross-national comparisons and coordination of international research.

[Care of the dying in the hospital: initial experience with the Liverpool Care Pathway (LCP) in Germany]

BACKGROUND AND OBJECTIVE

In the last few years public interest in the care of severely ill and dying patients has been growing. The aim of palliative medicine is to improve the care of the dying. However, this is still not achieved in many general hospitals. The Liverpool Care Pathway (LCP) for the care of the dying intends to change this situation. The aim of this study was to explore the views of professionals using the LCP as a framework for ensuring good care of the dying.

METHODS

A qualitative study was conducted with an interdisciplinary focus group of ten professionals (nurses, physicians, spiritual adviser, social worker, physiotherapist and art therapist) to explore their views and experience after implementation of the LCP in a palliative care unit (PCU). The recorded discussion between them was transcribed verbatim and analysed using content analysis by three independent reviewers.

RESULTS

Seven nurses and three physicians with an average work experience of 16 years each took part in the focus group. Based on the experience of 24 patients, the LCP was evaluated as very positive by all participants. In particular, three aspects were emphasized as having high relevance for a good quality of care: improvement of self-confidence, better control of symptoms, and enhancement of the communication between professionals and with patients and their relatives. However, some weaknesses were also mentioned, e.g. inadequate effort of documenting the beginning of implementing the scheme.

CONCLUSION

The LCP was well received by professionals after the initial implementation of the LCP in a German PCU. The LCP was judged as an appropriate and helpful framework in the care of the dying.

Effect of four vehicles on the pH of calcium hydroxide and the release of calcium ion

Nonsetting calcium hydroxide pastes are commonly used in endodontic practice. The desired therapeutic effect of such a paste is in part dependent on the dissociation of calcium hydroxide into hydroxy ion and calcium ion. This in turn is influenced by the vehicle used to make the paste. This investigation attempts to quantitatively estimate the release of hydroxyl ion and calcium ion from pastes made by using distilled water, normal saline solution, camphorated monochlorophenol and also an experimental vehicle, propylene glycol. The results of this study indicate that propylene glycol induces the most favorable release characteristics of the two ionic species.