Palliative Experts Research Articles

Geriatric surgical service interventions in older emergency general surgery patients: Preliminary results.

Older adults comprise an increasing proportion of emergency general surgery (EGS) admissions and face high morbidity and mortality. We created a geriatric surgical service with geriatric and palliative expertise to mitigate risks of hospitalization most hazardous to older patients. We sought to identify geriatric surgical service interventions most relevant to EGS patients. We prospectively identified patients ≥75 years admitted to the EGS service at an urban tertiary care hospital from January 2020-March 2021 who screened positive for frailty (FRAIL score ≥3 [scale 0-5, higher being worse]) or with cognitive impairment. A pilot geriatric surgical service, led by a dually-board certified geriatric and palliative care specialist, conducted a comprehensive geriatric assessment and modified Rockwood Frailty Index calculation for each eligible patient. Patient, hospital admission, and geriatric consultation characteristics were collected via chart review. Fifty consecutive patients (median age 82 years [IQR 78-90], 56% female) received geriatric consultation (median time 3 days [IQR 1-6] from admission). The most common admission diagnosis was bowel obstruction (32%). Sixty-four percent of patients underwent ≥1 surgical procedure. Using the Frailty Index, 64% were moderately or severely frail. Interventions most frequently performed by the geriatric team included delirium prevention and management (66%), consideration of swallowing function (52%), individualized pain management (50%), and facilitation of serious illness conversations (58%). Geriatric service involvement addresses a high burden of both geriatric and palliative care needs in older EGS patients. Geriatric recommendations may direct interventions for surgical education in fundamental geriatric and palliative care knowledge to maximize geriatric resources for the most high-risk patients.

Aotearoa New Zealand emergency medicine specialists on the provision of care at or near the end of life: A survey.

The ED is an increasingly important venue for the initiation of palliative care. We sought to characterise the opinions, experience, training and education of ED staff in Aotearoa/New Zealand (NZ) with regard to specific aspects of palliative care in the NZ ED setting. All NZ FACEMs were personally emailed a simple unstructured 16-part survey asking questions about initiating palliative care, goals of care, initiation and availability of advance care plans, frailty screening, availability of palliative expertise, training and education, cultural safety and pastoral care of staff. All EDs were contacted and a link provided for non-FACEM ED staff who wished to participate. Free-text comments were analysed for dominant themes. All NZ EDs had at least one participant. There was a high level of senior medical staff engagement with 60% of NZ FACEMs participating. More than 300 free-text comments from this group were available for theme analysis. A total of 93% of NZ FACEM respondents agree that palliative care should be able to be initiated in the ED. Only 25% of this group knew of training in serious illness conversations in the ED while only 34% felt culturally competent when providing end-of-life care for Māori and their whanau (family). Pastoral care for ED staff appears to be ad hoc. Time and privacy limitations were common themes. There is significant opportunity for quality improvement in the initiation and provision of palliative care from the ED. Attention to how departments provide pastoral care to their staff is needed.

Palliative Wound Care: Case Studies.

Patients with advanced illness may present to palliative care or hospice with unmanaged symptoms that may be exacerbated by the presence of a wound. The wound can be a constant reminder to the patient and caregiver of the underlying illness. Distressing symptoms such as wound pain, odor, bleeding, and/or excessive exudate may impede the patients' ability to spend quality time with loved ones when they need them the most. Although patients may present with wounds of varying etiologies, the most common wounds seen in this patient population are pressure-related injuries. However, there is a shortage of both wound and palliative specialized clinicians. Telehealth and the use of other technology can be a way to address this shortage. This will grant access to a broader number of patients to ensure appropriate wound care plans are in place to meet the goals of care. Although wound healing may not always be possible in this patient population, having access to specialized wound and palliative experts can improve the quality of life for patients and their caregivers.

Geriatric Surgical Service Complements Care of Older Adult Emergency General Surgery Patients

Introduction: Older adults comprise an increasing proportion of emergency general surgery (EGS) admissions and face high morbidity and mortality. We created a geriatric surgical service with geriatric and palliative expertise to mitigate risks of hospitalization most hazardous to older patients. In this study, we identified geriatric surgical service interventions most relevant to EGS patients. Methods: We conducted a retrospective chart review of patients >75 years admitted to the EGS service at our urban tertiary care hospital with a score >3 by the FRAIL scale, a five-point frailty screening instrument, or history of dementia. The geriatric surgical service, led by a dually-board certified geriatric and palliative care specialist, consulted on these patients from January 2020-January 2021;a hiatus was taken for the COVID-19 pandemic. Consults included a comprehensive geriatric assessment and calculated a modified Rockwood Frailty Index. Hospital admission characteristics and consultation components were collected via chart review. Results: Forty patients were evaluated (median age 82 years (IQR 78-89), 55.0% female). The most common admission diagnosis was small bowel obstruction (32.5%). 62.5% of patients underwent >1 surgical procedure. Median time to geriatric consult from admission was 3 days (IQR 1.0-4.3). By Frailty Index, 58% were moderately or severely frail. Interventions included medication changes (97.5%), symptom management (82.5%), delirium prevention and management (65.0%), mobility and function recommendations (65.0%), serious illness conversations (55.0%), and code status change (17.5%). Conclusion: Geriatric service involvement identifies and addresses a high burden of both geriatric and palliative care needs in older adult EGS patients.

Development of the Dutch Structure for Integrated Children's Palliative Care.

Children’s palliative care (CPC) is gaining attention worldwide, facilitated by the exchange of knowledge during regular specialised congresses. This article describes the developments in the Netherlands over the past 15 years. The Foundation for Children’s Palliative Expertise (PAL) was established as a nationwide initiative committed to improving palliative care for children countrywide. This led to the development of the first hospital-based CPC team in 2012, which expanded to a total of seven teams adjacent to children’s university hospitals. Regional networks for CPC were developed in parallel to these teams from 2014 onwards. The networks are a collaboration of professionals from different disciplines and organisations, from hospital to homecare, and have covered the aspects of CPC nationally from 2019 onwards. They are connected through the Dutch Knowledge Centre for CPC. This centre was established in 2018 by the PAL Foundation in collaboration with the Dutch Association for Pediatrics. In 2013, the first evidence-based guideline, ‘palliative care for children’, provided access to knowledge for parents and healthcare providers, and in 2017, a format for an individual palliative care plan was established. Within the Knowledge Centre for CPC, a physician’s support centre for dilemma’s regarding the end of life of children was set up. The efforts to have children’s palliative care embedded in the regular Dutch health care insurance are ongoing.

Predicting Anxiety in Routine Palliative Care Using Bayesian-Inspired Association Rule Mining.

We propose a novel knowledge extraction method based on Bayesian-inspired association rule mining to classify anxiety in heterogeneous, routinely collected data from 9,924 palliative patients. The method extracts association rules mined using lift and local support as selection criteria. The extracted rules are used to assess the maximum evidence supporting and rejecting anxiety for each patient in the test set. We evaluated the predictive accuracy by calculating the area under the receiver operating characteristic curve (AUC). The evaluation produced an AUC of 0.89 and a set of 55 atomic rules with one item in the premise and the conclusion, respectively. The selected rules include variables like pain, nausea, and various medications. Our method outperforms the previous state of the art (AUC = 0.72). We analyzed the relevance and novelty of the mined rules. Palliative experts were asked about the correlation between variables in the data set and anxiety. By comparing expert answers with the retrieved rules, we grouped rules into expected and unexpected ones and found several rules for which experts' opinions and the data-backed rules differ, most notably with the patients' sex. The proposed method offers a novel way to predict anxiety in palliative settings using routinely collected data with an explainable and effective model based on Bayesian-inspired association rule mining. The extracted rules give further insight into potential knowledge gaps in the palliative care field.

Respiratory Distress in Hospitalized Non-Mechanically Ventilated COVID-19 Adults: A Retrospective Multicenter Cohort Study.

Background:COVID-19 typically presents with respiratory symptoms which may progress with severe disease. There are standard guidelines for managing respiratory distress (e.g. opioids, anxiolytics) and palliative care teams are well versed in managing these symptoms.Aim:Determine the extent to which hospitalized COVID-19 patients with moderate respiratory distress received medications or palliative consultation for symptom management and if these interventions had any association with outcomes.Design:Retrospective chart review for hospitalized COVID-19+ patients from March 2-April 30, 2020.Setting:Large integrated health system in the New York Metropolitan area.Patients:312 adult patients hospitalized with COVID-19 with an order for a non-rebreather mask and meeting criteria for moderate respiratory distress on the Respiratory Distress Observation Scale: concurrent respiratory rate ≥30 and heart rate ≥110 at any point during hospitalization. Patients receiving mechanical ventilation or intensive care were excluded.Results:Most COVID-19 patients experiencing moderate respiratory distress did not receive medications or palliative consultation for symptom management. Patients who received medications were predominantly white, older, and had a Do-Not-Resuscitate order. Patients who received a palliative consultation were more likely to be older, female, and white, with a Do-Not-Resuscitate order. Mortality was similar between those receiving medication and those who did not.Conclusion:Medications and palliative expertise for symptom management were underused for patients with moderate respiratory distress due to COVID-19. Education and triggers may help providers to identify moderate respiratory distress and consider symptomatic treatment and palliative consultation when appropriate.

IMPROVING SURVIVAL IS NOT THE ONLY RELEVANT OUTCOME FOR PATIENTS SUFFERING FROM MALIGNANT PLEURAL MESOTHELIOMA AND THEIR CAREGIVERS: AN EXPLORATIVE STUDY (POINTINME_EXPLOR)

Background: The study was aimed at exploring the patients’ and caregivers’ expectations on treatment outcomes, the understanding of the information delivered by the oncologists during the first and reevaluation visits and the role of the general practitioners (GP) in the management of patients suffering from advanced Malignant Pleural Mesothelioma (MPM) in the area of Casale Monferrato, in the North West of Italy, where the incidence of mesothelioma is more than 30 times higher than the median incidence in Europe. A multiprofessional mesothelioma unit involving specialists and also GPs has been created since 2012 to globally assist patients in each step of the diagnostic and therapeutic process. This study was conducted to better understand the need of MPM patients in our area and their satisfaction about the care provided within the unit. Methods: Patients and caregivers were asked to fill in a multiple-choice questionnaire after the first visit or the re-evaluation visits (the ones in which a new treatment program was communicated) asking what is most important as the result of treatment, how much the oncologist was clear in communicating the diagnosis, the therapeutic options, the side effects, the role of the GP in supporting the care process and the trust-relationship with both the referral oncologist and the GP. Patients were also asked about the importance of having a referral caregiver. Results: From March to August 2019, 31 consecutive patients, 18 males and 13 females, median age 71 (IQR 66-75) and 29 caregivers, 7 males and 22 females, median age 63 (IQR 49-67) were enrolled in the study. Improving survival was the most relevant expected outcome in 48% and 69% of patients and caregivers, respectively followed by maintenance of the quality of life (38% and 17%), having the minimal number of accesses in the hospital as possible (8% vs 4%) and improving symptoms (6% and 10%). Seventy-seven% of patients and 72% of caregivers stated that the communication of the diagnosis was very clear, 74% of patients and 72% of caregivers stated that explanations about treatments were very clear, 90% of both patients and caregivers stated that the communication of side effects was sufficiently clear. Ninety% of patients and 86% of caregivers are completely satisfied about the relationship with the referral oncologist whereas 58% of patients and 55% of caregivers are completely satisfied with the support given by the GP. Ninety-three% of patients think that having a referral caregiver is of utmost importance and 80% of patients appreciate the presence of a palliative expert in the patient-care team whereas 52% of patients think to require a psychological support. Conclusions: This study highlights that in the high incidence area of MPM of Casale Monferrato, only half of advanced MPM patients and less that 2/3 of caregivers think that improving survival is the most relevant treatment outcome. The majority of patients and caregivers state to have clear information about diagnosis, treatment and related side effects and feel satisfied about the relationship with the specialists of the mesothelioma unit.

Forging a New Frontier: Providing Palliative Care to People With Cancer in Rural and Remote Areas.

Mounting evidence supports oncology organizations' recommendations of early palliative care as a cancer care best practice for patients with advanced cancer and/or high symptom burden. However, few trials on which these best practices are based have included rural and remote community-based oncology care. Therefore, little is known about whether early palliative care models are applicable in these low-resource areas. This literature synthesis identifies some of the challenges of integrating palliative care in rural and remote cancer care. Prominent themes include being mindful of rural culture; adapting traditional geographically based specialty care delivery models to under-resourced rural practices; and using novel palliative care education delivery methods to increase community-based health professional, layperson, and family palliative expertise to account for limited local specialty palliative care resources. Although there are many limitations, many rural and remote communities also have strengths in their capacity to provide high-quality care by capitalizing on close-knit, committed community practitioners, especially if there are receptive local palliative and hospice care champions. Hence, adapting palliative care models, using culturally appropriate novel delivery methods, and providing remote education and support to existing community providers are promising advances to aid rural people to manage serious illness and to die in place. Reformulating health policy and nurturing academic-community partnerships that support best practices are critical components of providing early palliative care for everyone everywhere.

What palliative care can learn from geriatric medicine.

Most people die when they are old, with multiple pathologies, and while living with frailty or dementia. These circumstances need the specialist skills of geriatric medicine. Death may not be unexpected, but survival and restoration of function are usually uncertain, influencing the approach to medical intervention. Assessment considers medical, functional, mental, social and environmental domains. Care requires a mix of acute, rehabilitation, mental health and palliative expertise, and evolves with changing circumstances. Relief of suffering and maintenance of function are key goals, but not the only ones. Mental distress is as common as physical; investigation- and treatment-burden are important; drug treatments are prone to adverse effects. A focus on person-centredness rather than the end-of-life is needed. This prioritizes respect for individual diversity in needs, assets and priorities, and rigorous decision making, to achieve what is the right intervention for that person at that time.

The Opioid Epidemic and Opioid Prescribing Regulations: A Survey Exploring Potential Barriers to Adequate Pain Management in Adults with Cancer (FR440B)

•Identify current opioid prescribing regulations and describe their perceived impact on adult cancer patients in an outpatient palliative care clinic.•Identify factors that impact adult cancer patients’ experience of pain and pain management in the current climate of the “opioid crisis.”•Identify future areas of needed research to lessen the adverse impact of the “opioid crisis” and prescribing regulations on palliative care patients. In the United States, there has been an increase in opioid misuse leading to increased monitoring. Although many guidelines exclude treatment of palliative patients, it remains important to evaluate all patients receiving opioids for substance misuse to ensure safety. The primary objective was to determine if current opioid prescribing regulations are perceived by adult cancer patients as a barrier to adequate pain management. Following a review of the literature and discussion with palliative experts, we identified potential concerns for patients with prescribing guidelines and developed a 21-item survey. We used a convenience sample of patients receiving opioids in the University of Virginia Palliative Care clinic during the period from February to April 2018. We used chi-square and t-tests to evaluate the correlation between patient perceptions that regulations made pain management difficult and demographic variables, pain and physical function scores, and the opioid risk tool (ORT). Ninety patients completed the survey. The majority (88.9%) were aware of opioid prescribing laws and 83.2% agreed that opioid abuse is a problem. One-third reported increased regulations made it difficult to manage pain (37.1%) or that insurance issues were a barrier to getting pain medications (32.6%). 38.9% of patients reported their doctor is less likely to prescribe strong pain medications due to the opioid crisis and 24% stated family or friends have told them not to take opiates. In univariate analyses, patients with higher ORT scores (p=0.025) and those with higher pain scores (p=0.0058) were more likely to report difficulty obtaining pain medications due to prescribing regulations. This initial survey suggests many palliative care patients feel the increase in opioid prescribing regulations is a barrier to adequate pain management.

Palliative and end-of-life care for heart failure patients in an aging society.

The populations of Asian countries are expected to age rapidly in the near future, with a dramatic increase in the number of heart failure (HF) patients also anticipated. The need for palliative and end-of-life care for elderly patients with advanced HF is currently recognized in aging societies. However, palliative care and active treatment for HF are not mutually exclusive, and palliative care should be provided to reduce suffering occurring at any stage of symptomatic HF after the point of diagnosis. HF patients are at high risk of sudden cardiac death from the early stages of the disease onwards. The decision of whether to perform cardiopulmonary resuscitation in the event of an emergency is challenging, especially in elderly HF patients, because of the difficulty in accurately predicting the prognosis of the condition. Furthermore, advanced HF patients are often fitted with a device, and device deactivation at the end of life is a complicated process. Treatment strategies should thus be discussed by multi-disciplinary teams, including palliative experts, and should consider patient directives to address the problems discussed above. Open communication with the HF patient regarding the expected prognosis, course, and treatment options will serve to support the patient and aid in future planning.

The (Palliative) care of Huntington’s disease

Palliative care services are increasingly becoming involved in the care of neurodegenerative disorders. Huntington’s disease is a rare, familial disorder. Care from diagnosis is palliative. Though other specialist disciplines need to be involved in the care, palliative expertise and oversight is valuable and appreciated. Based upon a review of literature and three decades of clinical experience with over a hundred patients and their families this article provides an overview of the palliative care issues confronted when attending these patients and their families.

Improving Palliative Care for Patients with Heart Failure and Family Caregivers: Results from a National Working Group Examining Clinical and Research Priorities for Heart Failure and Palliative Care (TH309)

•Review results from the June 2015 Clinical & Research Priorities for Heart Failure and Palliative Care National Symposium of cardiology and palliative experts (funded by the John A. Hartford Foundation, American Federation for Aging Research, National Palliative Care Research Center, University of Alabama-Birmingham, and Icahn School of Medicine at Mount Sinai), which focused on the barriers to and opportunities for improving palliative care integration among patients with advanced cardiac disease.•Discuss opportunities and strategies for collaboration of palliative care and heart failure within the domains of research, clinical care, and policy change.•Identify two specific implementation projects to improve care for patients with advanced heart failure within each area of research, clinical programs, and policy. Hospital readmission rates, mortality rates, and Medicare costs for patients with heart failure (HF) are high. Patients with HF are burdened by multiple symptoms that increase as the disease progresses. Because HF carries a substantial burden, it is critical to understand how palliative care can contribute to improving the quality of care for this population. Yet, the evidence base demonstrating the benefits of palliative care on outcomes and quality of care in patients with HF is still lacking. Change can only happen with an interdisciplinary, explicit strategic change approach. We conducted a series of telephonic nominal groups followed by a 2-day in-person symposium, which pulled together a group of interdisciplinary, nationally-recognized clinicians, investigators, and policy experts representing HF, geriatrics, and palliative care to address the following 3 questions: 1) What are the greatest challenges and barriers faced in HF regarding the integration of palliative care? 2) What are the state of the science and gaps in knowledge regarding patients with advanced HF and their family caregivers? 3) What are the most successful care models or strategies that are currently making a difference in HF care? The purpose of this concurrent session is to 1) describe the methods we used to develop consensus of strategies for each of these domains and 2) detail symposium results and achievements. The overall goal is to build support for a national agenda to advance the field of palliative care for patients with HF and their family caregivers. Specifically, we will review proposed research, clinical demonstration projects, national guidelines, and policy to develop priorities for implementation and endorsement. We will also describe and solicit additional input to create sustainable working groups that can formulate research, policy, and practice priorities and potential opportunities for collaboration and funding in order to develop a sustainable model for future collaboration.

Characteristics of a palliative care consultation service with a focus on pain in a German university hospital.

BackgroundA minority of patients with incurable and advanced disease receive specialised palliative care. Specialised palliative care services that complement the care of difficult and complex cases ought to be integrated with services that deliver general care for most patients. A typical setting in which this integrative concept takes place is the hospital setting, where patients suffering from incurable and advanced disease are treated in many different departments.The aim of the study is to investigate the profile and spectrum of a palliative care consultation service (PCCS) at a German university hospital with special reference to pain therapy.MethodsWe retrospectively analysed the PCCS documentation of three years.ResultsMost patients were referred from non-surgical departments, 72% were inpatients, and 28% were outpatients. 98% of the patients suffered from cancer. Counselling in pain therapy was one of the key aspects of the consultation: For 76% of all consulted patients, modifications of the analgesic regimen were recommended, which involved opioids in 96%. Recommendations on breakthrough-pain medication were made for 70% of the patients; this was an opioid in most cases (68%). The most commonly used opioid was morphine. For 17% of the patients, additional diagnostic procedures were recommended. Besides pain management palliative care consultation implied a wide range of recommendations and services: In addition to organising home care infrastructure, palliative care services supported patients and their families in understanding the life-limiting diseases. They also coordinated physical therapy and social and legal advice.ConclusionThis survey clearly shows that for a consultation service to support patients with incurable or advanced disease, a multi-disciplinary approach is necessary to meet the complex requirements of a needs-adapted palliative care in inpatient or outpatient settings. Timely integration of palliative expertise may support symptom control and may give the required advice to patients, their carers, and their families.

Protection against perceptions of powerlessness and helplessness during palliative care: The family members' perspective

Resilience in relation to coping with stress, loss, and bereavement has recently received increased attention. The aim of the current study was to describe aspects that are experienced as a protection against powerlessness and/or helplessness during advanced palliative home care (APHC) or as a help when coping with such perceptions. Both family members during ongoing APHC and family members 3-9 months after the patient's death responded (in total, N = 233; response rate 72%) to a postal questionnaire with mainly open-ended questions. The text responses were analyzed using Manifest Content Analysis. Protection against powerlessness and helplessness had been facilitated by a stable patient condition, the patient coping well, a trusting relationship with the patient, practical and emotional support from family and friends, access to palliative expertise, and staff support that was both individually-focused and cooperative. Other aspects that had helped or protected family members against powerlessness and helplessness were a belief that they had their own reliable knowledge to manage the difficult situation, talking to someone, doing good for the patient, distracting activities, acceptance, meaning and hope, and an inner feeling of security. The findings are discussed in relation to existential psychology, the dual process model of coping with bereavement, and repressive coping. Clinical implications are suggested.

Self-Perceived Burden in Terminally Ill Cancer Patients: A Categorization of Care Strategies Based on Bereaved Family Members' Perspectives

Terminally ill cancer patients often experience a self-perceived burden that affects their quality of life; however, no standard care strategy for coping with this form of suffering has ever been established. The objectives of this present study were 1) to investigate the prevalence of self-perceived burden among terminally ill cancer patients based on a survey of family members, 2) to assess the level of family perceived usefulness of expert-recommended care strategies, and 3) to categorize the care strategies. The subjects were bereaved family members of patients who had died in certified palliative care units throughout Japan. The Good Death Inventory was used to evaluate patients' self-perceived burden based on the proxy ratings of family members. The perceived usefulness of care was assessed using a 27-item questionnaire developed by a focus group of palliative experts and a systematic review. A total of 429 responses (64%) received from a member of each of 666 bereaved families was analyzed. In their responses, 25% of the bereaved family members reported that the patient had experienced a mild self-perceived burden, whereas 25% reported that the patient had experienced a moderate to severe self-perceived burden. The family members recommended the following as particularly effective care strategies: "Eliminate pain and other symptoms that restrict patient activity (53%);" "Quickly dispose of urine and stools so that they are out of sight (52%);" and "Support patients' efforts to care for themselves (45%)." A factor analysis showed that the expert-recommended care strategies could be categorized into seven different components. Many terminally ill cancer patients suffer from a self-perceived burden. Family members recommended a variety of care strategies to alleviate patient-perceived burden. Palliative care specialists should have adequate knowledge of promising care strategies for alleviating patient-perceived burden.

Transferring palliative care knowledge, evaluating the use of a telephone advice line

Accessing specialist palliative expertise, particularly out of hours, is an important, but often problematic aspect of meeting directives to provide comprehensive around-the-clock care. A telephone advice line can be a successful route to transferring palliative care knowledge between specialists and generalists. In contrast to telephone expert systems, which demand standardization, this type of expert system emphasises the use of professional judgement. Based on a three-year evaluation, this article highlights that assessing and advising professionals about the use of a telephone as a communication mechanism demands specific communication skills and processes which need to be developed and nurtured. Another important feature to acknowledge is that the predominate aim of a telephone advice line may most appropriately be to transfer knowledge on a case-by-case basis to contribute to the resolution of a clinical need.

Palliative care nurses' views on euthanasia.

In debates on euthanasia legalization in Belgium, the voices of nurses were scarcely heard. Yet studies have shown that nurses are involved in the caring process surrounding euthanasia. Consequently, they are in a position to offer valuable ideas about this problem. For this reason, the views of these nurses are important because of their palliative expertise and their daily confrontation with dying patients. The aim of this paper is to report a study of the views of palliative care nurses about euthanasia. A grounded theory approach was chosen, and interviews were carried out with a convenience sample of 12 palliative care nurses in Flanders (Belgium). The data were collected between December 2001 and April 2002. The majority of the nurses were not a priori for or against euthanasia, and their views were largely dependent on the situation. What counted was the degree of suffering and available palliative options. Depending on the situation, we noted both resistance and acceptance towards euthanasia. The underlying arguments for resistance included respect for life and belief in the capabilities of palliative care; arguments underlying acceptance included the quality of life and respect for patient autonomy. The nurses commented that working in palliative care had a considerable influence on one's opinion about euthanasia. In light of the worldwide debate on euthanasia, it is essential to know how nurses, who are confronted with terminally ill patients every day, think about it. Knowledge of these views can also contribute to a realistic and qualified view on euthanasia itself. This can be enlightening to the personal views of caregivers working in a diverse range of care settings.

Improvement of palliative outpatient treatment of terminally ill cancer patients - SUPPORT as example - The ethically preferable alternative to euthanasia

Industrial countries are experiencing substantial increases in cancer prevalence. While advanced cancer therapies resulted in prolonged survival most neoplasms still are incurable. Especially advanced stages of cancer are often accompanied by severe pain and other disabling symptoms. Sufficient pain and symptom control is needed to maintain a decent quality of life for cancer patients. However, expert palliative care for patients suffering from cancer pain is still insufficient. These deficits have encouraged pro-euthanasia pressure groups demanding legitimation of physician-assisted-suicide in Germany. Acting under the guise of promoting patient's autonomy these groups are gaining additional momentum from similar legislation passed in the Netherlands. Hospice movement and specialists in palliative medicine reject euthanasia as unethical and instead push for the global development of palliative care services. To address these issues the project SUPPORT was established in the Southern part of Lower-Saxony in 1996 with approval by the local ethics committee and sponsored by the German Ministry of Health. A palliative-care-team (PCT) of nurses and physicians with expert knowledge in palliative medicine supports patients after discharge from hospital by providing state-of-the-art palliative care at home. The PCT is available as a 24/7 standby service and can be called on demand by general practitioners, members of outpatient nursing services as well as by patients and their relatives. By cooperating with the PCT these professional and lay caregivers improve their knowledge and skills regarding pain and symptom control for terminally ill patients. During almost 4 years of practical work more than 50 % of the patients enrolled in the project died at home compared to about 20 % under regular conditions. These data point out quite impressively that due to the PCT-interventions recurrent hospitalisations in a majority of cancer pain patients can be avoided when expert knowledge and help is available at home for patients, their relatives and caregivers whenever needed. When sufficiently supported at home by palliative experts the number of patients dying at home is reasonably higher than the rate observed under regular conditions. This would also comply with the wishes of most patients who prefer to die in the privacy of their own home. The project data suggest that the concept of SUPPORT should be capable to improve the current state of palliative medicine in other areas of Germany as well.