Palliative Emergency Research Articles

Attitudes of German GP trainees regarding add-on training programs differ if in office or hospital training phase

BackgroundMany residents are exposed to negative attitudes towards primary care during hospital training. Attractive add-on training programs exist, but it is unclear whether these need to be tailored to the location of training (hospital vs. office). We report differences in learner attitudes from a large German add-on training program.MethodsBetween 2017 and 2020, a regional network offered 31 quarterly seminars to primary care residents. The seminars addressed medical content, practice management and mentoring. We elicited participants’ satisfaction, perceived topic relevance, preferences for future seminars, work situation and employer support for participation. A proportionate odds model was used to assess predictors of ratings; results were stratified by training location (hospital vs. office).ResultsMost respondents were female (380/575 = 70.0%), aged between 26 and 40 (80.8%), and had on average 3.54 ± 1.64 years of residency training. The majority (83.8%) was working in an office and full-time (63.0%). Overall evaluations were positive (very satisfactory 72.1%). Comparing residents in the hospital phase vs. the office phase, overall seminar ratings of the perceived impact on the motivation for primary care did not differ (p = 0.73 vs. 0.18, respectively). Hospital-based residents were less likely to rate the topics as relevant (39.4% vs. 55.7%, p = 0.02) and had different preferences for future seminar topics (top 3: palliative care, emergencies and chronic care vs. billing, disease management and practice finances for hospital and office phase, respectively).ConclusionsKeeping primary care residents motivated may require education tailored to training location. Our findings may be of interest to teachers, administrators and policymakers.

Palliative radiotherapy indications during the COVID-19 pandemic and in future complex logistic settings: the NORMALITY model

IntroductionThe COVID-19 pandemic has challenged healthcare systems worldwide over the last few months, and it continues to do so. Although some restrictions are being removed, it is not certain when the pandemic is going to be definitively over. Pandemics can be seen as a highly complex logistic scenario. From this perspective, some of the indications provided for palliative radiotherapy (PRT) during the COVID-19 pandemic could be maintained in the future in settings that limit the possibility of patients achieving symptom relief by radiotherapy.This paper has two aims: (1) to provide a summary of the indications for PRT during the COVID-19 pandemic; since some indications can differ slightly, and to avoid any possible contradictions, an expert panel composed of the Italian Association of Radiotherapy and Clinical Oncology (AIRO) and the Palliative Care and Supportive Therapies Working Group (AIRO-palliative) voted by consensus on the summary; (2) to introduce a clinical care model for PRT [endorsed by AIRO and by a spontaneous Italian collaborative network for PRT named “La Rete del Sollievo” (“The Net of Relief”)]. The proposed model, denoted “No cOmpRoMise on quality of life by pALliative radiotherapy” (NORMALITY), is based on an AIRO-palliative consensus-based list of clinical indications for PRT and on practical suggestions regarding the management of patients potentially suitable for PRT but dealing with highly complex logistics scenarios (similar to the ongoing logistics limits due to COVID-19).Material and MethodsFirst, a summary of the available literature guidelines for PRT published during the COVID-19 pandemic was prepared. A systematic literature search based on the PRISMA approach was performed to retrieve the available literature reporting guideline indications fully or partially focused on PRT. Tables reporting each addressed clinical presentation and respective literature indications were prepared and distributed into two main groups: palliative emergencies and palliative non-emergencies. These summaries were voted in by consensus by selected members of the AIRO and AIRO-palliative panels. Second, based on the summary for palliative indications during the COVID-19 pandemic, a clinical care model to facilitate recruitment and delivery of PRT to patients in complex logistic scenarios was proposed. The summary tables were critically integrated and shuffled according to clinical presentations and then voted on in a second consensus round. Along with the adapted guideline indications, some methods of performing the first triage of patients and facilitating a teleconsultation preliminary to the first in-person visit were developed.ResultsAfter the revision of 161 documents, 13 papers were selected for analysis. From the papers, 19 clinical presentation items were collected; in total, 61 question items were extracted and voted on (i.e., for each presentation, more than one indication was provided from the literature). Two tables summarizing the PRT indications during the COVID-19 pandemic available from the literature (PRT COVID-19 summary tables) were developed: palliative emergencies and palliative non-emergencies. The consensus of the vote by the AIRO panel for the PRT COVID-19 summary was reached. The PRT COVID-19 summary tables for palliative emergencies and palliative non-emergencies were adapted for clinical presentations possibly associated with patients in complex clinical scenarios other than the COVID-19 pandemic. The two new indication tables (i.e., “Normality model of PRT indications”) for both palliative emergencies and palliative non-emergencies were voted on in a second consensus round. The consensus rate was reached and strong. Written forms facilitating two levels of teleconsultation (triage and remote visits) were also developed, both in English and in Italian, to evaluate the patients for possible indications for PRT before scheduling clinical visits.ConclusionWe provide a comprehensive summary of the literature guideline indications for PRT during COVID-19 pandemic. We also propose a clinical care model including clinical indications and written forms facilitating two levels of teleconsultation (triage and remote visits) to evaluate the patients for indications of PRT before scheduling clinical visits. The normality model could facilitate the provision of PRT to patients in future complex logistic scenarios.

Post-COVID Prospects for the EMU: The Pandemic Core-Periphery Divide, Palliative Measures and the Stakes of the Conference on the Future of Europe

The policy brief draws from previous and ongoing research on the heterogeneities of the impact of the - in principle - symmetric shock of the pandemic within the EU. Considering the pre-existing gaps within the core and periphery, further worsened by the Covid-19 outbreak, the analysis presents the economic and social prospects in 2020 and in the years to come across the Member States. In doing so the work identifies the key challenges in line with the legacy of the Eurozone crisis and well-established limits of EMU governance assessing palliative emergency instruments such as Next Generation EU against the benchmark of the scale of the core-periphery divide. In doing so the contribution puts forward policy recommendation for ambitious reform of economic governance of the Eurozone, against the backdrop of an unprecedented window of opportunity for transnational solidarity opened by the pandemic crisis in parallel with the onset of the Conference of the Future of Europe.

Scoring Systems May be Effective in Predicting Mortality Associated with Palliative Emergency Gastrointestinal Surgery: A Retrospective Observational Study

BackgroundPalliative emergency gastrointestinal surgery is associated with significant morbidity and mortality and weighing up the benefits and harms during the decision-making may be challenging. There are very few studies on surgery in palliative patient population. The aim of this retrospective study was to evaluate morbidity and mortality after palliative emergency gastrointestinal surgery and the usability of scoring systems in predicting the outcome.MethodsConsecutive adult patients undergoing palliative emergency surgery at a tertiary hospital during the period 2015 to 2016 were included. Pre- and post-operative functional status, morbidity and mortality of patients were assessed. The predictive value of the American Society of Anesthesiologists (ASA) classification, the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (ACS NSQIP SRC) and Palliative index (PI) in estimating morbidity and mortality were determined.ResultsA total of 93 patients (age 69 [28–92] years, 51% female) were included. Typical indications for surgery were bowel obstruction (52%) and securing food intake (30%). Pre-operatively two patients (2.2%) were totally dependent in daily activities, while post-operatively the respective share was 34% at discharge from hospital. The incidence of post-operative complications was 37% and 14% died during the hospital stay. One-, three-month and one-year mortality rates were 41%, 63% and 87%, respectively. While ASA score, PI score and ACS NSQIP did not predict post-operative morbidity, both ASA score and ACS NSQIP SRC predicted post-operative mortality.ConclusionsPalliative emergency laparotomy is associated with significant post-operative mortality and morbidity. Scorings, such as ASA score and ACS NSQIP SRC predict mortality in this patient population.

Developing a paramedic approach to palliative emergencies

Emergency health services (EHS) have experienced a steady increase in demand from palliative patients accessing 9-1-1 during times of acute crisis, although the majority of these patients do not wish for conveyance to hospital following paramedic treatment. To address this demand, and to provide patients with the right care, the first time, the British Columbia Emergency Health Service (BCEHS) introduced the province’s first Assess, See, Treat and Refer (ASTaR) Clinical Pathway. This alternative model of care is intended to improve patient-oriented care by providing care for patients in their own home and reducing the requirement for conveyance to the emergency department, thus reducing the requirement for hospitalization. Launched in June 2019, the ASTaR Pathway includes the early recognition of patients with palliative needs accessing 9-1-1, the use of secondary triage services and the automatic notification and referral of non-conveyed patients to primary healthcare teams for patient follow-up. The following commentary outlines the early integration of the ASTaR Palliative Clinical Pathway into the BCEHS paramedic approach to palliative patient care.

Palliative Emergency mediastinal tracheostomy in carcinoma thyroid

Palliative Emergency mediastinal tracheostomy in carcinoma thyroid

Unexpected result of competency-based medical education: 9-year application trends to enhanced skills programs by family medicine residents at a single institution in Canada

ABSTRACTIn Canada, family physicians may pursue extended training for added competence in areas such as Palliative Care or Emergency Medicine by applying to Enhanced Skills (ES) programmes. Despite the increasing popularity of ES programmes, there are no studies that examine trends in applications to ES programmes before and after the introduction of family medicine focused competency-based curricula at individual universities. Additionally, there is a scarcity of research examining factors common among applicants to ES programmes.We undertook a retrospective observational study using secondary data analysis of archived resident files from a large Canadian family medicine residency programme. The proportion of applicants to ES programmes decreased since implementation of a competency-based curriculum in the subject programme. Older, male, and Canadian medical graduates (CMGs) applied to ES programmes more often than their respective counterparts. Residents in a family medicine competency-based curriculum may be less inclined to extend their training by applying to ES programmes. This is remarkable considering that the Canadian residency programme is the shortest among high-income countries. Further studies are needed to investigate the role of competency-based medical education programmes in enabling shortening residency training around the world.

Coordination of Care Within a Mobile Palliative Care Team and Organization of a Continuing Education Program for Health Professionals in Palliative Care

Background: In DR Congo (DRC), many cancer patients in the terminal phase of their condition have minimal access to palliative care. There is a combined effect of poverty, the deterioration of the health system and the absence of a well-defined national policy on palliative care. Patients are for the most part abandoned to the care of inexperienced family members. Founded in 2009, Palliafamilli aims to improve the quality of life of patients requiring palliative care in the DRC by providing visits and care for patients, by striving to increase access to palliative care in the region and by informing, raising awareness and mobilizing key national stakeholders. In September 2018, Palliafamilli will launch a mobile palliative care team (MPCT) in partnership with the general hospital of Ndjili in Kinshasa. The MPCT is an interdisciplinary team consisting of physicians, nurses, a psychologist and a project manager; all experienced in accompaniment, symptom management and palliative emergency. It has a consultancy role for professionals, patients and their caregivers. Aim: Through a African Cancer Fellowship award, I will visit a mobile team of palliative care from CHRU Besançon, France, for one month in May 2018 to gain experience in designing and implementing best practices for a mobile palliative care team. Methods: I will work closely with the mobile palliative care team of the Besançon Regional Hospital Center to gain experience regarding the coordination and care administration of palliative care within a mobile team. I will also learn about the different programs of continuing education for health professionals, make comparisons and adapt the programs to the reality of DR Congo. Results: With a view to promoting access to palliative care patients, I intend to learn from the host organization the best practices that they apply to overcome communication difficulties with the patient and their relatives which can constitute delays to access to adequate care. This delay is more marked for patients suffering from cancer because the evolution of their pathology is unpredictable. The main barriers are the insufficient knowledge of patients' needs and the opportunities offered by palliative care. Upon my return, I will adapt the best practices learned in France to the DRC context during the launch of the new mobile palliative care team. Conclusion: In Congo, a cross-cutting approach is required to provide patients with palliative care and pain relief, as resources are limited, many people are in need of care, and there are few nurses and doctors empowered to provide care. An effective approach is to involve community or volunteer caregivers supervised by health professionals, and Palliafamilli is successful due in its multidisciplinary and multisectoral approach, with adaptation to cultural, social and economic specificities and its integration with existing health systems, focusing on primary health care and community and home care.

Outpatient palliative medicine : Attitudes in the care of palliative emergencies. Prospective questionnaire-based investigation

The right to adequate outpatient palliative care has existed for several years in Germany. In recent years outpatient palliative care has developed very positively. Nevertheless, in emergency situations paramedics and emergency physicians were often included in the care of palliative care of patients. The aim of our study was to investigate the cooperation between outpatient palliative care teams and the emergency medical services. Another aim was to identify structural realities and based on these to discuss the possibilities in the optimization of outpatient palliative medical emergency situations. Astandardized self-designed questionnaire was distributed to specialized outpatient palliative care teams (SPCS) in Germany. For this purpose, closed and open questions (mixed methods) were used. The evaluation was carried out according to the questionnaire categories in quantitative and qualitative forms. The questionnaire was subdivided into general information and specific questions. The survey response rate was 79% from a total of 81SPCS in 2011. The following standards in palliative emergency care were recommended: (1)early integration of outpatient palliative care services and basic outpatient palliative care systems, (2)end-of-life discussions, (3)defined emergency medical documents, emergency drug boxes, do not attempt resuscitation orders and (4)emergency medical training (physicians and paramedics). Outpatient palliative care in Germany has developed very positively during the last years; however, there are still deficits in terms of optimal patient care, one of which refers to the treatment of palliative care emergencies. In this context, optimization in the cooperation between outpatient palliative care services and emergency medical services should be discussed.

Long-term Postprocedural Outcomes of Palliative Emergency Stenting vs Stoma in Malignant Large-Bowel Obstruction

Colonic stenting was introduced for palliation of malignant large-bowel obstruction (MLBO) more than 20 years ago but remains controversial. To compare outcomes after palliative stenting vs stoma creation in patients with MLBO requiring emergency management. This observational cohort study assessed 345 patients from New York State with an urgent or emergency admission to the hospital for obstruction secondary to colorectal cancer and who underwent stenting or stoma creation from October 1, 2009, through December 31, 2013. Patients were excluded if they underwent resection within 1 year of the index admission. Palliative stenting vs stoma creation. Primary outcomes included subsequent operation and readmission within 90-day and 1-year follow-up. Secondary outcomes were in-hospital death, major medical and surgical complications, length of stay, total charges, and discharge dispositions. Multivariable hierarchical analyses and propensity score matching were used to compare outcomes between the exposure groups. The cohort included 345 patients (mean [SD] age, 69.9 [14.4] years in the stoma group and 70.9 [16.8] years in the stent group; 87 men [50.3%] in the stoma group and 90 [52.3%] in the stent group; and 114 non-Hispanic white patients [65.9%] in the stoma group and 90 [52.3%] in the stent group). Most patients undergoing stenting were treated at high-volume (104 [60.5%]) vs medium-volume (42 [24.4%]) or low-volume (26 [15.1%]) hospitals (P < .001). Patients undergoing stenting were significantly less likely to experience prolonged length of stay (odds ratio [OR], 0.50; 95% CI, 0.26-0.97; P = .04), more likely to be discharged to their usual residence (OR, 0.14; 95% CI, 0.07-0.28; P < .001), and tended to have similar or fewer complications (major events: OR, 0.81; 95% CI, 0.30-2.18; P = .68; procedural complications: OR, 0.57; 95% CI, 0.11-1.22; P = .10). There was no significant difference between the groups in terms of 90-day and 1-year readmission to the hospitals (90 days: OR, 0.93; 95% CI, 0.49-1.78; P = .83; 1 year: OR, 0.72; 95% CI, 0.38-1.37; P = .30). Subsequent operation at 90 days was also not different between the groups (OR, 1.34; 95% CI, 0.26-6.89; P = .72), but there was a higher chance of subsequent operation at 1 year after the stenting procedure (OR, 2.93; 95% CI, 1.12-7.68; P = .03), with most subsequent operations being restenting. In patients with MLBO and if resection is not part of the treatment plan, stenting is safe and improves the efficiency of care with obvious quality-of-life benefits. It should be offered at experienced centers, and patients should be counseled regarding increased risk of subsequent stenting within 1 year.

Palliative emergencies in geriatric patients

Der Notfall bzw. die Akutsituation bei einem Palliativpatienten verursacht aufgrund der verschiedenen moglichen Ursachen (z. B. somatisch, psychisch, sozial und ethisch) bei Notfallmedizinern oftmals Unsicherheiten im therapeutischen Vorgehen. Die hier vorliegende Arbeit hat zum Ziel, den palliativen Notfall zu definieren, seine Besonderheiten darzustellen und therapeutische Ideen im Umgang mit palliativen Notfallen zu geben.

Findings from a Clinical Learning Needs Survey at Ireland's first children's hospice.

Caring for children with life-limiting conditions places exceptional demands on health professionals. Staff require the optimal skills and expertise necessary to provide the highest quality of care and to achieve this it is essential to understand their learning requirements. The aim is to share the main findings from a Clinical Learning Needs Survey conducted at LauraLynn, currently Ireland's only children's hospice. To date no other Irish service has conducted a formal identification of professional learning and development needs specific to the Irish context. The findings from the study assist workforce planning by providing a glimpse into the immediate study needs of staff working in a children's palliative care setting. The study had two main aims: a) Assist clinical staff within one organisation to identify their own professional learning priorities in children's palliative care and b) Inform the design and delivery of a responsive suite of workshops, programmes and study sessions for children's palliative care. The study identified the key learning needs as end-of-life care, palliative emergencies, communication skill development and bereavement support. These findings are similar to those found internationally and demonstrate the commitment of a new organisation to ensure that specific employee learning requirements are met if the organisation and wider specialty of Irish children's palliative care is to continue its evolution.

Enquiry into Practice: Management of Terminal Catastrophic Intracranial Haemorrhage in Palliative Care

Abstract The management of terminal catastrophic haemorrhage is a rare clinical palliative emergency for which the management is based largely on anecdotal and experiential guidelines, with no high grade evidence but rather robust contention and controversy. Whilst often rapid and deadly, inevitably dramatic and devastating for the treating health professionals and family, the key management areas include risk identification, supportive practices, the use of sedative medication and the ethical issues faced in the management of terminal haemorrhage.

Primary Care for Older Persons with Mental Disorders at UK

With an increasingly elderly population, Primary Care physicians are involved in the complex care of the elderly patients with co-morbidity and often complex needs. Most people with advanced dementia in the UK live and die in care homes. In the later stages of dementia, people are profoundly physically and cognitively disabled. Especially this vulnerable group of patients benefits from a close collaboration between the primary care physician and the old age psychiatrist. Clear protocols for end of life palliative care and emergency care should be in place for all patients and discussed and agreed with clinicians, nursing staff, relatives and if possible with the patient.

Simulation as possible training for palliative emergencies: prospective initial data analysis of participants from two simulation training sessions

Palliative emergencies describe an acute situation in patients with a life-limiting illness. At present defined curricula for prehospital emergency physician training for palliative emergencies are limited. Simulation-based training (SBT) for such palliative emergency situations is an exception both nationally and internationally. This article presents the preparation of recommendations in the training and development of palliative care emergency situations. A selected literature search was performed using PubMed, EMBASE, Medline and the Cochrane database (1990-2013). Reference lists of included articles were checked by two reviewers. Data of the included articles were extracted, evaluated und summarized. In the second phase the participants of two simulated scenarios of palliative emergencies were asked to complete an anonymous 15-item questionnaire. The results of the literature search and the questionnaire-based investigation were compared and recommendations were formulated based on the results. Altogether 30 eligible national and international articles were included. Overall, training curricula in palliative emergencies are currently being developed nationally and internationally but are not yet widely integrated into emergency medical training and education. In the second part of the investigation, 25 participants (9 male, 16 female, 20 physicians and 5 nurses) were included in 4 multiprofessional emergency medical simulation training sessions. The most important interests of the participants were the problems for training and further education concerning palliative emergencies described in the national and international literature. The literature review and the expectations of the participants underlined that the development and characteristics of palliative emergencies will become increasingly more important in outpatient emergency medicine. All participants considered palliative care to be very important concerning the competency for end-of-life decisions in palliative patients. For this reason, special curricula and simulation for dealing with palliative care patients and special treatment decisions in emergency situations seem to be necessary.

Palliative emergencies in the pre-hospital setting

Objective: To provide a narrative on the most common palliative emergency situations that requires the attendance of a paramedic. This narrative looks specifically at pain, seizures and breathlessness, and critiques the underpinning evidence supporting their treatment and protocols. Discussion: Pain—the presence of pain in palliative care is highly prevalent with up to 70% of patients living in a permanent painful state. Clinician-led pain assessment has been shown to underestimate the patient's pain by as much as 60–68% and none of the assessment tools used are fully inclusive. Further research is needed to formulate an assessment tool that recognises palliative pain as a progressive disorder requiring constant assessment. Seizures—Seizures occur as either a result of disease progression or as a side effect of medications. Studies have shown that intramuscular midazolam is more effective than intravenous lorazepam, which is itself more effective than intravenous diazepam. The ease of administration of intramuscular and buccal midazolam for out-of-hospital use should make midazolam the first-line treatment for palliative care patients that suffer from seizures. The implication for future paramedic practice highlighted from these studies is the need for more research in the treatment of palliative patients with seizures. Breathlessness—Cold facial stimulation has been shown to be very effective as a non-pharmacological treatment for breathlessness. Opioids help to relax the patient which aid in regulating breathing patterns although a consensus on the route of administration which provides the best possible effect is yet to be reached. The evidence base for the use of anxiolytics is weak and some studies have shown no beneficial effect to their use. Although anxiolytics are effective in reducing anxiety their effectiveness in helping breathlessness in palliative patients is questionable. Home oxygen should be adopted as a first line treatment according to experts working in end-of-life care, and treatment of oxygen should not be delayed by waiting for results of other trials for other treatments.

International recommendations for outpatient palliative care and prehospital palliative emergencies – a prospective questionnaire-based investigation

BackgroundTo determine the international recommendations and current practices for the treatment and prevention of palliative emergencies. The primary goal of the study was to gather information from experts on their nationally practised concepts.MethodsOne hundred and fifty self-report surveys were distributed by email to selected leading experts (palliative and emergency medical care) in Europe, North and South America, Africa, Asia, and Australia. An expert in this context was defined as an author of an article that was ranked by three reviewers as relevant to outpatient palliative and emergency medical .ResultsThe total response rate was 61% (n = 92 experts). Survey responses were obtained from 35 different countries. The following standards in the treatment of palliative emergencies were recommended: (1) early integration of “Palliative Care Teams” (PCTs) and basic outpatient palliative care systems, (2) end-of-life discussions, (3) defined emergency medical documents, drug boxes, and “Do not attempt resuscitation” orders and (4) emergency medical training (physicians and paramedics).ConclusionsThis study detected structurally and nationally differences in outpatient palliative care regarding the treatment of palliative emergencies. Accordingly, these differences should be discussed and adapted to the respective specifications of individual single countries. A single established outpatient palliative emergency medical care concept may be the basis for an overall out-of-hospital palliative care system.

Paramedics' ‘end-of-life’ decision making in palliative emergencies

Background: Paramedics in Germany routinely treat palliative care patients at the end-of-life (EoL). For this, they play a legally significant role in EoL decision making in the outpatient emergency setting. This study was undertaken to determine paramedics’ understanding of their role in withholding or withdrawing resuscitation/EoL-treatment of palliative care patients when an advance directive is present. Methods: Using a self-administered survey, participants/paramedics were asked about (1) ‘their occupational experience’ (less/more than 10 years, (2) ‘emergency responses’ (less/more than 100/month), (3) ‘their experiences in palliative emergencies’ (less/more than 10 palliative emergencies/year), (4) ‘palliative emergency sheets concerning end-of-life decisions’, and (5) ‘their treatment options during resuscitation’. Participants were paramedics from two cities in Germany. Results: Overall, 728 questionnaires were returned (response rate: 81%). Seventy-three percent of respondents were older than 20 years, 98.5% were male. Most paramedics dealt with palliative emergencies and terminally ill patients during their work (71%). Work experience and training in palliative care shows statistically significant differences concerning our dependent variables. Conclusions: Our results underline the necessity for more training in EoL. Paramedics stated that improved guidelines regarding EoL decisions/advance directives and the possibility to withdrawing resuscitation for appropriative cases are necessary. The treatment of terminally ill patients by paramedics may present an ethical problem: if paramedics honour patients' wishes, they will violate juridical regulations. In future, a change concerning current regulations seems to be necessary as well.

Vorbeugendes Krisenmanagement in der allgemeinen ambulanten Palliativversorgung

General out-patient palliative care (GOPC) must be integrated into the care of patients with life-limiting diseases. Aim of the study was to evaluate experiences of general practitioners concerning advance directives and palliative emergency sheets. A self-provided survey was mailed to all general practitioners in Regensburg (cross-sectional study). Main outcome measures included responses regarding a palliative emergency sheet (PES) and a palliative emergency plan (PEP). The investigation period was four months. The analysis was performed using defined criteria (e. g. professional experience concerning palliative care patients, patients treated in nursing homes, patients with dementia). Sixty-nine questionnaires from 259 were analysed (response rate 27 %). 86 % of respondents named practical experience in the care of palliative patients, 46 % named theoretical knowledge in this field. 41 % and 40 % consider creating an advance directive for their practical work as important/very important (p = 0.004 concerning the treatment of more than five palliative care patients per three months). 52 % and 49 % regard a PES or a PEP to be relevant (PES median: 6.5, SD ± 2.7; PEP median: 6.5 SD ± 2.9; inter-group analysis p < 0.05). 94 % of respondents name the general practitioner to be suitable for creating an advance directive. In Germany, GOPC in end-of-life care is very important. This study shows that advance directives were declared as an important instrument for patients? autonomy. The sense of PES and PEP to ensure patients? autonomy, especially for acute emergency medical palliative care, must be better recognized. However, the increase in acceptance in the GOPC for such instruments must be disclosed. Further studies to investigate this problem are necessary.

A Framework for Providing Quality Pediatric Palliative Care

This Oxford Specialist Handbook is designed for inpatient or community pediatric teams, as well as other non-palliative care professionals, to “equip them to provide good palliative medicine to children in their care, despite lack of training.” It is authored by a pediatric palliative care specialist and a general practitioner. The first three chapters include the basics of pediatric palliative care—identifying which children need palliative care, balancing the burdens and benefits of every intervention, the range of life-limiting conditions seen in pediatric palliative care, disease trajectories, basic ethical principles, and withholding and withdrawal of treatment. There is a description of the different palliative care settings for children in the United Kingdom, from the children’s hospice to the inpatient adult palliative medicine service. All topics are presented concisely and in outline form. Five chapters are devoted to the topic of pain, which is the strength of the handbook. Diagnosis, assessment, and evaluation of pain are addressed. A helpful table of common errors in opioid prescribing for children is provided. A chapter on pain evaluation includes a list of self-report pain scales, objective and behavioral measures of pain, and their strengths and weaknesses. Three remaining chapters address opioids, adjuvants, and an analysis of each step in the World Health Organization analgesic ladder. The next seven chapters address common symptoms such as gastrointestinal, neurological and psychological symptoms, feeding and hydration, dyspnea, and skin symptoms. Pathophysiology, etiology, and management are discussed in practical terms, with helpful tables and management algorithms. The chapters on nausea/vomiting and dyspnea are remarkably practical; the former includes a flow chart outlining “a rational approach to antiemesis”. After the chapter on pediatric palliative emergencies, the next several chapters cover specific diseases commonly seen in pediatric palliative care. There is a general overview of malignant diseases, and more in-depth coverage of the most common pediatric malignancies, along with a general discussion on management of cancer-related symptoms. Specific nonmalignant diseases are outlined in more detail, including clinical features and management strategies. The concluding chapters provide a worthwhile practical overview of the clinical issues surrounding death, the major religious issues related to death, funeral practices, bereavement, coping and communication skills, education, and training. As with many pediatric books, a pediatric formulary is included, with recommended dose ranges based on the child’s weight, and notes pertinent to each drug. Each chapter is primarily presented in outline form, with several current references provided at the end. This makes the handbook easy to read and understand. On the other hand, the descriptions of palliative care services for children refer exclusively to services in the United Kingdom and could be less relevant to readers from other countries. In addition, the formulary includes several medications that are unavailable in the United States. As the authors point out in the preface of this book, most children with life-limiting conditions will be cared for not by pediatric palliative medicine specialists but by general pediatric or subspecialist teams. Hospice teams, medical students, pediatric residents, pediatricians, and oncology fellows will appreciate this practical introduction to pediatric palliative medicine. The handbook also will benefit adult palliative care fellows who are rotating through their pediatric palliative training. The authors have succeeded in producing a handbook that provides basic concepts and information for the professional without specialty training in pediatric palliative medicine. The handbook can serve as a framework for those professionals endeavoring to provide good palliative care for children. Katherine Leonard, MD, is an Attending Physician in the Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, NY, USA.