Revised European Association for Palliative Care (EAPC) recommended framework on palliative sedation: An international Delphi study

BACKGROUND

The European Association for Palliative Care (EAPC) acknowledges palliative sedation as an important, broadly accepted intervention for patients with life-limiting disease experiencing refractory symptoms. The EAPC therefore developed 2009 a framework on palliative sedation. A revision was needed due to new evidence from literature, ongoing debate and criticism of methodology, terminology and applicability.

AIM

To provide evidence- and consensus-based guidance on palliative sedation for healthcare professionals involved in end-of-life care, for medical associations and health policy decision-makers.

DESIGN

Revision between June 2020 and September 2022 of the 2009 framework using a literature update and a Delphi procedure.

SETTING

European.

PARTICIPANTS

International experts on palliative sedation (identified through literature search and nomination by national palliative care associations) and a European patient organisation.

RESULTS

A framework with 42 statements for which high or very high level of consensus was reached. Terminology is defined more precisely with the terms suffering used to encompass distressing physical and psychological symptoms as well as existential suffering and refractory to describe the untreatable (healthcare professionals) and intolerable (patient) nature of the suffering. The principle of proportionality is introduced in the definition of palliative sedation. No specific period of remaining life expectancy is defined, based on the principles of refractoriness of suffering, proportionality and independent decision-making for hydration. Patient autonomy is emphasised. A stepwise pharmacological approach and a guidance on hydration decision-making are provided.

CONCLUSIONS

This is the first framework on palliative sedation using a strict consensus methodology. It should serve as comprehensive and soundly developed information for healthcare professionals.

[Concept-dependent and -independent care effects of site-specific care concepts using "pain" as an example]

BACKGROUND

Structures of palliative care, cross-sectoral transitions and care pathways of patients with palliative care needs were investigated at two sites. The systematic comparison of similarities and differences using the topic of 'pain' as an example is intended to provide information on the extent to which these are related to site-specific palliative care concepts (integrated and cooperative).

METHODS

The study follows a mixed-methods design. In addition to a document analysis of anonymised patient records (n = 774), expert interviews (n = 20), as well as interviews with patients, relatives (n = 60) and focus groups (n = 12), were conducted.

RESULTS

The systematic comparative analysis provides evidence for concept-independent commonalities (e.g. sociodemographic distribution, aggravated pain treatment) as well as concept-dependent differences (e.g. care pathways, facilitated continuous symptom control through integrated care structures) in the context of integrated or cooperative palliative care.

DISCUSSION

Commonalities and differences with regard to the topic of pain, as focused on here, and its organisational management become tangible as effects of the respective organisational structure (= concept-dependent) as well as concept-independent external influencing factors.

Development of Care Pathway for Assessment and Treatment of Fatigue in Palliative Care

Objectives

Fatigue is a frequent and burdensome symptom in patients with advanced disease in palliative care. However, it is under-assessed and undertreated in clinical practice, even though many treatment options have been identified in systematic reviews. Care pathways with defined and standardised steps have been recommended for effective management in the clinical setting. This paper describes a care pathway for managing fatigue in palliative care patients. This study aims to develop a care pathway with detailed guidance for screening, assessment, diagnosis, and treatment of fatigue in palliative care patients.

Material and methods

A collaborative effort of multidisciplinary clinicians participated in constructing the care pathway. The care pathway was developed using the following steps: (a) Developing an intervention; (b) piloting and feasibility; (c) evaluating the intervention; (d) reporting; and (e) implementation. This paper covers the first step, which includes the evidence base identification, theory identification/development, and process/outcomes modeling. A literature search was conducted to understand the extent of the fatigue problem in the palliative care setting and identify existing guidelines and strategies for managing fatigue. Consistent recommendations emanating from the included papers were then contributed to a care pathway. Patient representatives and palliative care professionals provided feedback on the draft.

Results

The care pathway address the following care processes: (1) Screening for the presence of fatigue; (2) assessment to evaluate the severity of fatigue; (3) diagnostic procedure, including history, physical examination, and laboratory finding; (4) therapeutic management pathway for clinical decision-making; and (5) valuation of treatment effect, using questionnaires, diaries and physical activity monitoring with body-worn sensors.

Conclusion

The development of a care pathway will help to implement regular and structured assessment, diagnosis, and treatment of fatigue for healthcare professionals treating palliative care patients. Reviewing the pathway with a multidisciplinary expert group and field testing the pathway will be the next steps toward implementation.

[Who is afraid of Ockham's razor? : A discourse analysis on resilience in palliative care (2000-2021)]

BACKGROUND

The concept of resilience is becoming increasingly disseminated from material science into various fields of science. It is infiltrating medical fields predominantly via psychology and is also recommended for coping with the special burdens in pain management and palliative care. A precise definition of the term and its operationalization pose problems.

AIM

A critical stocktaking of the use of this term in the discourse of palliative care research.

METHOD

Analytical discourse analysis of a text corpus from palliative medical care publications in the time period from 2000 to 2021, obtained by means of a systematic literature search.

RESULTS

In the research discourse of palliative care, resilience is a topic primarily as a strategy for self-optimization of employees (e.g., burnout prophylaxis with the aim of preserving the workforce). Only rarely does the question of whether it offers potential for patients and their families take center stage, and then more as a catchword than as a concrete concept. The reason is that there is so far no adequate operationalization of the concept of resilience. Furthermore, there is a lack of sufficient justification for the relevance of the concept in patient care of palliative medicine.

CONCLUSION

There is a lack of qualified contributions of palliative research to the metadiscourse about resilience, especially in the context of affected patients. A successful operationalization of the term requires a highly complex multidimensionality of the palliative path of an interdisciplinary approach. There is a lack of ethical standards that prevent an affirmative instrumentalizing application of the term.

An analysis of the experiences of bereaved relatives and health care providers following palliative sedation: a study protocol for a qualitative international multicenter case study

BACKGROUND

Patients at the end-of-life may experience refractory symptoms of which pain, delirium, vomiting and dyspnea are the most frequent. Palliative sedation can be considered a last resort option to alleviate one or more refractory symptoms. There are only a limited number of (qualitative) studies exploring the experiences of relatives of sedated patients and their health care professionals (HCPs). The aims of this study protocol are: 1) to elicit the experiences of bereaved relatives and health care professionals of patients treated with palliative sedation and 2) to explore the understanding of the decision-making process to start palliative sedation across care settings in 5 European countries.

METHODS

This study protocol is part of the larger HORIZON 2020 Palliative Sedation project. Organisational case study methodology will be used to guide the study design. In total, 50 cases will be conducted in five European countries (10 per country). A case involves a semi-structured interview with a relative and an HCP closely involved in the care of a deceased patient who received some type of palliative sedation at the end-of-life. Relatives and health care professionals of deceased patients participating in a linked observational cohort study of sedated patients cared for in hospital wards, palliative care units and hospices will be recruited. The data will be analyzed using a framework analysis approach. The first full case will be analyzed by all researchers after being translated into English using a pre-prepared code book. Afterwards, bimonthly meetings will be organized to coordinate the data analysis.

DISCUSSION

The study aims to have a better understanding of the experiences of relatives and professional caregivers regarding palliative sedation and this within different settings and countries. Some limitations are: 1) the sensitivity of the topic may deter some relatives from participation, 2) since the data collection and analysis will be performed by at least 5 different researchers in 5 countries, some differences may occur which possibly makes it difficult to compare cases, but using a rigorous methodology will minimize this risk.

Review of European Guidelines on Palliative Sedation: A Foundation for the Updating of the European Association for Palliative Care Framework

In 2009, the European Association for Palliative Care (EAPC) developed a framework on palliative sedation, acknowledging this practice as an important and ethically acceptable intervention of last resort for terminally ill patients experiencing refractory symptoms. Before and after that, other guidelines on palliative sedation have been developed in Europe with variations in terminology and concepts. As part of the Palliative Sedation project (Horizon 2020 Funding No. 825700), a revision of the EAPC framework is planned. The aim of this article is to analyze the most frequently used palliative sedation guidelines as reported by experts from eight European countries to inform the discussion of the new framework. The three most reported documents per country were identified through an online survey among 124 clinical experts in December 2019. Those meeting guideline criteria were selected. Their content was assessed against the EAPC framework on palliative sedation. The quality of their methodology was evaluated with the Appraisal Guideline Research and Evaluation (AGREE) II instrument. Nine guidelines were included. All recognize palliative sedation as a last-resort treatment for refractory symptoms, but the criterion of refractoriness remains a matter of debate. Most guidelines recognize psychological or existential distress as (part of) an indication and some make specific recommendations for such cases. All agree that the assessment should be multiprofessional, but they diverge on the expertise required by the attending physician/team. Regarding decisions on hydration and nutrition, it is proposed that these should be independent of those for palliative sedation, but there is no clear consensus on the decision-making process. Several weaknesses were highlighted, particularly in areas of rigor of development and applicability. The identified points of debate and methodological weaknesses should be considered in any update or revision of the guidelines analyzed to improve the quality of their content and the applicability of their recommendations.

Schnittstellen in der Versorgung am Lebensende

Zusammenfassung. Schnittstellen stehen oft im Zusammenhang mit einer hohen Symptomlast, einem stetig wachsenden Versorgungsnetz und / oder einem häufigen Wechsel zwischen ambulanter und stationärer Versorgung. Schnittstellenproblematiken treten auf der Organisations-, Kommunikations-, Informations- und Wissensebene sowie beim Vernetzen von Institutionen auf. Hinweise auf Versorgungsdefizite am Lebensende und inwiefern eine nicht gelingende Symptomlinderung oder ein häufiger ambulanter und stationärer Versorgungswechsel abgefedert werden kann, wird anhand von Studienergebnissen erörtert. Am Lebensende sind offene empathische Gespräche, Symptomlinderung, psychosoziale Unterstützung und gegebenenfalls die Adressierung spiritueller Fragen bei bedarfsgerechter Anbindung an Einrichtungen und Dienste wichtige Grundpfeiler für Sterbende und Hinterbliebene. Ein Einblick in die unterschiedlichen hospizlichen und palliativen Versorgungsangebote im ambulanten und stationären Bereich, die mit ihren Angeboten auch Hinterbliebene mit einbeziehen, rundet diesen Beitrag ab.

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.

[Integration of palliative care into acute care medicine]

Palliativmedizin richtet sich an Patienten mit inkurablen onkologischen und nichtonkologischen Erkrankungen sowie deren Angehörige mit dem Ziel, die Lebensqualität zu erhalten oder zu verbessern. Zur Integration der Palliativmedizin in die Akutmedizin wird die Palliative-Care-Fort- bzw. Weiterbildungen einiger ärztlicher und pflegerischer Mitarbeiter empfohlen. Für die Ermittlung und Umsetzung des bisher unzureichend erhobenen palliativmedizinischen Behandlungsbedarfs in Notfallsituationen sollten geeignete Screeningtools und „standard operating procedures“ implementiert werden. Für die Palliativversorgung können die zur Verfügung stehenden spezialisierten palliativmedizinischen Dienste zur Beratung und/oder Mitbehandlung hinzugezogen werden. Symptomkontrolle, Versorgung maligner Wunden, schwierige ethische Entscheidungsfindungen und Kommunikationsschwierigkeiten mit Patienten, deren rechtlichen Stellvertretern oder Angehörigen sind Aufgabenbereiche palliativmedizinischer Experten.

"Never at ease" - family carers within integrated palliative care: a multinational, mixed method study

BACKGROUND

Family carers manage a wide range of responsibilities in the lives and care of patients receiving palliative care. They fulfil multiple roles and perform activities within different settings. This has immediate consequences on family carers' every-day lives. According to literature, family carers in palliative care are both part of the formal and informal care network, but also persons in need of support. This article aims to investigate 1) burdens and rewards associated with family caregiving and 2) what family carers find helpful in their contact with professionals from integrated palliative care initiatives (IPC-i) and other services.

METHODS

Family carers looking after patients with cancer, chronic obstructive pulmonary disease or chronic heart failure were purposefully recruited at 22 IPC-i in Belgium, Germany, Hungary, the Netherlands and the United Kingdom in the course of the project "Patient-centred palliative care pathways in advanced cancer and chronic disease" (InSup-C). Semi-structured interviews (n = 156) and 87 quantitative questionnaires (CRA, POS, CANHELP Lite) were conducted with family carers. Interviews were analysed with transnationally agreed thematic codes (MAXQDA or NVivo). Statistical tests (SPSS) were carried out in accordance with the characteristic value of the items and distributions.

RESULTS

On average, quantitative data showed moderate burden, but the qualitative findings indicated that this burden might be underrated. There is some evidence that IPC-i with well-developed professional care networks and communication systems relieved family carers' burden by direct and indirect interventions; e.g. provision of night shift nurses or psychological support. Needs of family carers were similar in all participating countries. However, in all countries IPC-i mostly offered one-off events for family carers, lacking systematic or institutionalised support structures.

CONCLUSIONS

Data suggest that, most IPC-i did not pay enough attention to the needs of most family carers, and did not offer proactive care and access to supportive resources to them (e.g. training, respite care, access to resources). We recommend recognizing family carers as part of the 'unit of care' and partner in caregiving, to improve their knowledge about, and access to, and the support available.

Identification of the palliative phase in people with dementia: a variety of opinions between healthcare professionals

BACKGROUND

People with dementia can benefit from a palliative care approach. Recommendations, such as those of the EAPC have been proposed to strengthen the provision of palliative care for this group of patients. Yet, it remains challenging for professionals to identify when a person with dementia is in need of palliative care. The objective of this study therefore was to explore when professionals in long-term care settings consider a person with dementia in need of palliative care.

METHODS

Teams with in total 84 professionals working in 13 long-term care settings from 6 countries (France, Germany, Italy, Norway, Poland and the Netherlands) received a case-vignette concerning a person with dementia recently admitted to a nursing home. Teams were asked to discuss when they considered people with dementia eligible for palliative care. The constant comparative method was used to analyse their answers.

RESULTS

Three different time points in the disease trajectory when people with dementia were considered to be eligible for palliative care were extracted: (1) early in the disease trajectory; (2) when signs and symptoms of advanced dementia are present; and (3) from the time point that curative treatment of co-morbidities is futile. Yet, none of these time points was uniformly considered by the professional teams across Europe. In some cases, professionals working in the same nursing home didn't even reach consensus when considering persons with dementia eligible for palliative care.

CONCLUSION

The results of the study identified that professionals across Europe have different opinions regarding the time point when to consider a person with dementia in need of palliative care.

Testing feasibility and reliability of a set of quality indicators to evaluate the organization of palliative care across Europe: a pilot study in 25 countries

BACKGROUND

A well-organized palliative care service is a prerequisite for offering good palliative care. Reliable and feasible quality indicators are needed to monitor the quality of their organization.

AIM

To test feasibility and reliability of a previously developed set of quality indicators in settings and services that provide palliative care across Europe.

METHODS

A total of 38 quality indicators, applicable in all types of settings, rated in a RAND Delphi process, and operationalized into 38 yes/no questions, were used. Descriptives statistics, factor and reliability analyses, analysis of variance, and chi-square analyses were used.

DESIGN

Cross-sectional online survey.

SETTING/PARTICIPANTS

Questionnaires were sent to representatives of 217 palliative care settings in 25 countries. Included settings were hospices, inpatient dedicated palliative care beds, palliative care outpatient clinics, palliative care units, day care centers for palliative care, palliative care home support teams, inpatient palliative care support teams, care homes, and nursing homes.

RESULTS

All invited 25 European Association of Palliative Care countries took part. In total, 107 out of 217 participants responded (57%). The quality indicators were reduced to four coherent sub-scales, being "equipment and continuity of care," "structured documentation of essential palliative care elements in the medical record," "training and appraisal of personnel," and "availability of controlled drugs." No significant differences in quality criteria between the different types of settings and services were identified.

CONCLUSION

The set of quality indicators appeared to measure four reliable domains that assess the organization of different palliative care settings. It can be used as a starting point for quality improvement activities.

To what extent are the wishes of a signatory reflected in their advance directive: a qualitative analysis

Background

Advance directives (ADs) are assumed to reflect the patients’ preferences, even if these are not clearly expressed. Research into whether this assumption is correct has been lacking. This study explores to what extent ADs reflect the true wishes of the signatories.

Methods

Semi-structured interviews (INT), pretest. Transcribed INT and the contents of ADs were inductively categorised (Mayring) and triangulated. Software: MAXQDA 2007. Participants: Patients receiving palliative care (PPC), healthy (H) and chronically ill (CI) individuals with an AD completed ≥3 months prior to recruitment.

Results

Between 08/2008 and 07/2009, 53 individuals (20 H, 17 CI, 16 PPC) were interviewed (mean age 63.2 years (55–70 years)), 34% male). Most important (in)consistencies between preferences as expressed in INT compared to ADs included preconditions for termination/rejection of life-sustaining measures, refusal of/demand for medical interventions and the nomination of proxies. Standardized AD forms were rarely tailored to the individual. We found a high tendency to use set phrases, such as want to die with dignity or do not want to suffer/vegetate. Likely events in the course of an existing progressive disease were not covered, even in ADs of PPC close to death.

Conclusions

Only some of the incongruities between verbally expressed preferences and the contents of the AD can be put down to use of standardized forms or lack of medical knowledge. Nevertheless, the non-involvement of a doctor in the process of making an AD must be seen as potentially problematic and seeking medical advice should be promoted by politics and physicians. Standardised forms should encourage amendments and present space for free text entries for all aspects covered. Set phrases need to be defined by the individual to enable them to be translated into a specific course of action.

Quality palliative care for cancer and dementia in five European countries: some common challenges

OBJECTIVES

There is a growing consensus worldwide that palliative care needs to be both more inclusive of conditions other than cancer and to improve. This paper explores some common challenges currently faced by professionals providing palliative care for patients with either cancer or dementia across five countries.

METHOD

One focus group (n=7) and 67 interviews were conducted in 2012 across five countries: England, Germany, Italy, the Netherlands and Norway, with professionals from dementia, cancer and palliative care settings.

RESULTS

The interviews revealed five common challenges faced across the five countries: communication difficulties (between services; and between professionals, and patients and their families); the variable extent of structural/functional integration of services; the difficulties in funding of palliative care services; problematic processes of care (boundaries, definitions, knowledge, skills and inclusiveness) and, finally, time constraints.

CONCLUSION

These are not problems distinct to palliative care, but they may have different origins and explanations compared to other areas of health care. This paper explored deeper themes hidden behind a discourse about barriers and facilitators to improving care.

Validation of quality indicators for the organization of palliative care: a modified RAND Delphi study in seven European countries (the Europall project)

BACKGROUND

Validated quality indicators can help health-care professionals to evaluate their medical practices in a comparative manner to deliver optimal clinical care. No international set of quality indicators to measure the organizational aspects of palliative care settings exists.

AIM

To develop and validate a set of structure and process indicators for palliative care settings in Europe.

DESIGN

A two-round modified RAND Delphi process was conducted to rate clarity and usefulness of a previously developed set of 110 quality indicators.

SETTING/PARTICIPANTS

In total, 20 multi-professional palliative care teams of centers of excellence from seven European countries.

RESULTS

In total, 56 quality indicators were rated as useful. These valid quality indicators concerned the following domains: the definition of a palliative care service (2 quality indicators), accessibility to palliative care (16 quality indicators), specific infrastructure to deliver palliative care (8 quality indicators), symptom assessment tools (1 quality indicator), specific personnel in palliative care services (9 quality indicators), documentation methodology of clinical data (14 quality indicators), evaluation of quality and safety procedures (1 quality indicator), reporting of clinical activities (1 quality indicator), and education in palliative care (4 quality indicator).

CONCLUSION

The modified RAND Delphi process resulted in 56 international face-validated quality indicators to measure and compare organizational aspects of palliative care. These quality indicators, aimed to assess and improve the organization of palliative care, will be pilot tested in palliative care settings all over Europe and be used in the EU FP7 funded IMPACT project.

Modelling the landscape of palliative care for people with dementia: a European mixed methods study

BACKGROUND

Palliative care for people with dementia is often sub-optimal. This is partly because of the challenging nature of dementia itself, and partly because of system failings that are particularly salient in primary care and community services. There is a need to systematize palliative care for people with dementia, to clarify where changes in practice could be made.To develop a model of palliative care for people with dementia that captures commonalities and differences across Europe, a technology development approach was adopted, using mixed methods including 1) critical synthesis of the research literature and policy documents, 2) interviews with national experts in policy, service organisation, service delivery, patient and carer interests, and research in palliative care, and 3) nominal groups of researchers tasked with synthesising data and modelling palliative care.

DISCUSSION

A generic model of palliative care, into which quality indicators can be embedded. The proposed model includes features deemed important for the systematisation of palliative care for people with dementia. These are: the division of labour amongst practitioners of different disciplines; the structure and function of care planning; the management of rising risk and increasing complexity; boundaries between disease-modifying treatment and palliative care and between palliative and end-of-life care; and the process of bereavement.

SUMMARY

The co-design approach to developing a generic model of palliative care for people with dementia has placed the person needing palliative care within a landscape of services and professional disciplines. This model will be explored further in the intervention phase of the IMPACT project.

Comparison of legislation, regulations and national health strategies for palliative care in seven European countries (Results from the Europall Research Group): a descriptive study

BACKGROUND

According to EU policy, anyone in need of palliative care should be able to have access to it. It is therefore important to investigate which palliative care topics are subject to legislation and regulations in Europe and how these are implemented in (national) health care plans. This paper aims to deliver a structured overview of the legislation, existing regulations and the different health care policies regarding palliative care in seven European countries.

METHODS

In 2008 an inventory of the organisation of palliative care was developed by the researchers of the Europall project. Included were two open questions about legislation, regulations, and health policy in palliative care. This questionnaire was completed using palliative care experts selected from Belgium, England, France, Germany, the Netherlands, Poland and Spain. Additionally, (grey) literature on palliative care health policy and regulations from the participating countries was collected to complete the inventory. Comparative analysis of country specific information was performed afterwards.

RESULTS

In all countries palliative care regulations and policies existed (either in laws, royal decrees, or national policies). An explicit right to palliative care was mentioned in the Belgium, French and German law. In addition, access to palliative care was mentioned by all countries, varying from explicit regulations to policy intentions in national plans. Also, all countries had a national policy on palliative care, although sometimes mainly related to national cancer plans. Differences existed in policy regarding palliative care leave, advance directives, national funding, palliative care training, research, opioids and the role of volunteers.

CONCLUSIONS

Although all included European countries have policies on palliative care, countries largely differ in the presence of legislation and regulations on palliative care as well as the included topics. European healthcare policy recommendations should support palliative care access across Europe.

The burden of non-acute dying on society: dying of cancer and chronic disease in the European Union

OBJECTIVES

Due to the ageing of the European population, the burden of non-acute dying on society is expected to increase. The aim of this study is to estimate the number of persons dying of cancer and chronic disease in Europe, including regional differences.

METHODS

Death certificates of deceased persons in the European Union (EU)-27 countries in 2007 (some countries 2006 or 2004) were analysed and primary death causes were listed. These data were prepared for the general population and for the population of 65 years and older. Crude death rates (CDRs) were calculated for both groups and for all included countries.

RESULTS

Of 480 million deceased European people, 202 million died of cancer and chronic disease in 2007 (42%). The CDR of the EU-27 countries was 409 (95% CI 370 to 451) for cancer and other chronic diseases per 100 000 inhabitants in 2007. For the 65+ population, the CDR for the EU-27 was 1783 (95% CI 1701 to 1868) for cancer and chronic disease. Large differences across countries appeared. An inverse relationship was shown for country-specific CDRs for cancer and chronic disease versus CDRs for other death causes (R=-0.41; p=0.04).

CONCLUSIONS

Dying of cancer and chronic diseases involves a considerable burden on the European society. Future research should relate this information to the prevalence of symptoms and the use of palliative care services. European policy makers should take into account regional variations in developing long- and short-term palliative care strategies.

[The physician's role in various clinical contexts. The physician's role in palliative care]

The palliative care physician accompanies patients and their families in times of great disstress and potentially difficult medico-ethical decision making. The main objective of palliative care is the alleviation of pain and distressing symptoms in patients with progressive, incurable illness. By addressing physical problems and psychosocial as well as spiritual needs, palliative care aims at improving the quality of life of patients in order to help them to spend their remaining lifetime with as much autonomy as possible and in dignity. The concept of accompaniment in palliative care involves a multiprofessional team. Important factors in this approach are time, trust, professional, ethical, communicative, social, and emotional competencies and the attitude of physicians and other professionals. The physician is given responsibility by the patient. In accepting the role as a respondent to another individual's request for help, the physician can avoid the pitfalls of the obsolete paternalistic relationship model, or of one that is either merely autonomy based or of a provider-customer nature.

Evaluation of the clinical effectiveness of physiotherapeutic management of lymphoedema in palliative care patients

OBJECTIVE

Lymphoedema is a common sequela of cancer or its treatment that affects lymph node drainage. The physiotherapist, as member of the multiprofessional team in palliative care, is one of the keys to successful rehabilitation and management of patients with cancer and non-malignant motoneuron disease such as amyotrophic lateral sclerosis and palliative care needs. The aim of the study was to evaluate the frequency and effect of manual lymphatic drainage in palliative care patients with lymphoedema in a far advanced stage of their disease.

METHODS

Retrospective study (reflexive control design) of data of the 208 patients admitted to our palliative care unit from January 2007 to December 2007. Demographic and disease-related data (diagnosis, symptoms, Karnofsky performance status and effect of manual lymphatic drainage interventions) were documented and compared.

STATISTICS

mean ± SD, median; Wilcoxon's test.

RESULTS

Of the 208 patients, 90 who reported symptom load due to lymphoedema were included; 67 (74.4%) had pain, 23 (25.6%) dyspnoea due to progredient trunk oedema. Mean age 65.5 ± 13.0 years; 33 (36.7%) male; Karnofsky index 50% (30-80%), mean length of stay 15.6 ± 8.0 days. The mean number of physiotherapeutic treatment interventions was 7.0 ± 5.8. Manual lymphatic drainage was well tolerated in 83 (92.2%) patients; 63 of 67 (94.0%) patients showed a clinically relevant improvement in pain, and 17 of 23 (73.9%) in dyspnoea.

CONCLUSIONS

The majority of the patients showed a clinical improvement in the intensity of symptoms after manual lymphatic drainage.

[How many patient deaths can a team cope with? : a nationwide survey of palliative care units in Germany]

BACKGROUND

How many patient deaths the teams at palliative care units can cope with, the supporting factors in coping and the future prospects of the teams have not yet been subject to research in Germany. The aim of the study was to assess burden factors, burden symptoms and protective factors, the critical number and distribution of patient deaths as well as the prospects of the teams.

SAMPLE AND METHODS

A total of 873 members of palliative care teams from 95 (60% of n=158) German palliative care units took part in this explorative evaluation. Basic factors could be identified using factor analysis. Differences between professional groups were checked with analysis of variance.

RESULTS

Results showed that not having reached the objectives of palliative care was the central burden factor. In the majority of cases a team reacted by being loquacious. The team itself was ranked as the most important protective factor. The mean critical number of deaths was 4.4 per week. Consecutive patient deaths were rated as being significantly more stressful than evenly spread deaths. Ratings for the future prospects of the team were significantly lower in teams where not meeting the objectives of palliative care was considered a high burden factor.

CONCLUSION

A clearer definition of the objectives of palliative care and support of team communication are desirable.