RESUMEN
Especially in the last 15 years Palliative Care and Palliative Medicine in Germany have increasingly attracted professional and public attention and made remarkable progress. One of the characteristics of Palliative Care in Germany is the differentiation of palliative care from hospice care. Under different viewpoints structure, target groups and aims of Palliative Care have been under discussion in the last 30 years, which made an impact on different forms in the provision of care. Palliative therapy should be distinguished from supportive care and palliative medicine. The revised WHO-definition of Palliative Care broadened the aspects of care in a comprehensive and more holistic understanding of the social, emotional and spiritual needs of patients and their families, including bereavement; and, finally, interdisciplinary and team working issues. It is important to differentiate the palliative care approach from general and specialized palliative care provision for patients with incurable progressive illness and in old age. In Germany 10-12% of all dying patients per year are in need of a specialized palliative care service. The growth in the group of the "very old" will be an important challenge for palliative care in the near future.
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Enfermedad Crónica/terapia , Cuidados Paliativos/clasificación , Cuidados Paliativos/tendencias , Cuidado Terminal/clasificación , Cuidado Terminal/tendencias , Terminología como Asunto , Alemania , HumanosRESUMEN
The German Society for the Study of Pain has formed an interdisciplinary committee to answer urgent ethical questions on the diagnosis and treatment of pain and to give an ethical orientation on the care of pain and palliative patients. The treatment of pain is a fundamental objective of medicine. Competent and adequate relief of pain in all stages of life is a basic characteristic of a humane medicine oriented to the quality and meaning of life for people. However, there are substantial deficits in all areas, especially in the knowledge of physicians and patients, in training and further education, diagnosis and therapy. Freedom from pain is a substantial element of quality of life. A central duty of all physicians is an adequate diagnosis and treatment of acute pain and thereby the prophylaxis of chronic pain. If pain persists over a longer period of time, it loses the warning function and becomes taken for granted. Alterations, disabilities and limitations of the physical, psychic and social levels are the consequences. For these patients an interdisciplinary approach is necessary by which various medical disciplines, psychologists and physiotherapists are involved and all collaborate on the diagnosis and therapy of pain. All patients have the right to sufficient and individually tailored treatment of pain. Special attention must be paid to vulnerable patient groups, such as newborns, children and adolescents, as well as aged and mentally retarded patients. For cancer patients pain relief of their tumor pain is totally in the forefront. Indications of "unbearable pain" must not lead to resignation or even be seen as an argument for legalization of "death on request". The nursing of terminally ill patients necessitates a special measure not only of clinical, but also ethical competence, communication and multiprofessional collaboration. The modern options for palliative care are real alternatives to demands for legalization of "death on request". Physician-assisted suicide does not belong to the scope of functions of palliative medicine. The basic constitutional law makes an appropriate treatment of pain obligatory. Neglect of pain treatment fulfils the elements of criminal bodily harm. As a consequence, there is a legal right to a comprehensive pain diagnosis and a pain treatment corresponding to the appropriate standard. The state is obliged to provide the legal, social and financial prerequisites for an adequate treatment of pain. Continuous efforts in research are necessary to fill the existing gaps in our knowledge. The transfer between basic research and clinical application of pain therapy must be urgently improved. Of central importance for the German Pain Society are therefore: Improvement of training and further education in pain therapy. Chronic pain must be accepted and coded as an autonomous sickness. Graded structures for care of pain patients must be realized. Interdisciplinary structures of care must be made available to patients with chronic pain. Palliative medical care is a basic right of all terminally ill patients. Politics and health care providers must establish prerequisites for adequate pain diagnosis, pain therapy and palliative medicine.
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Códigos de Ética , Ética Médica , Dolor , Sociedades Médicas/ética , Alemania , Humanos , Cuidados Paliativos/ética , Cuidado Terminal/éticaRESUMEN
OBJECTIVES: To analyse legislation and medical professional positions concerning the doctor's role in assisted dying in western Europe, and to discuss their implications for doctors. METHOD: This paper is based on country-specific reports by experts from European countries where assisted dying is legalised (Belgium, The Netherlands), or openly practiced (Switzerland), or where it is illegal (Germany, Norway, UK). RESULTS: Laws on assisted dying in The Netherlands and Belgium are restricted to doctors. In principle, assisted suicide (but not euthanasia) is not illegal in either Germany or Switzerland, but a doctor's participation in Germany would violate the code of professional medical conduct and might contravene of a doctor's legal duty to save life. The Assisted Dying for the Terminally Ill Bill proposed in the UK in 2005 focused on doctors, whereas the Proposal on Assisted Dying of the Norwegian Penal Code Commission minority in 2002 did not. Professional medical organisations in all these countries except The Netherlands maintain the position that medical assistance in dying conflicts with the basic role of doctors. However, in Belgium and Switzerland, and for a time in the UK, these organisations dropped their opposition to new legislation. Today, they regard the issue as primarily a matter for society and politics. This "neutral" stance differs from the official position of the Royal Dutch Medical Association which has played a key role in developing the Dutch practice of euthanasia as a "medical end-of-life decision" since the 1970s. CONCLUSION: A society moving towards an open approach to assisted dying should carefully identify tasks to assign exclusively to medical doctors, and distinguish those possibly better performed by other professions.
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Eutanasia/ética , Rol del Médico , Relaciones Médico-Paciente/ética , Europa (Continente) , Eutanasia/legislación & jurisprudencia , Humanos , Pautas de la Práctica en MedicinaRESUMEN
Availability of different WHO-step 3 opioids has encouraged the discussion on their value and led to the concepts of opioid rotation. Rotation is suggested, when other measures fail to achieve optimal analgesia and tolerability in cancer pain treatment. Opioid use was assessed in a prospective cohort study of 412 palliative care patients from 14 inpatient and outpatient palliative care facilities in Germany. The most frequently used opioids at baseline were morphine and fentanyl. The most frequent changes in medication (N=106) occurred from oral to parenteral morphine. Only in 49 cases true switches to other long acting opioids were recorded. This is far less than expected from other reports. True switches and adverse side effects were found to occur more frequently in inpatients, while efficacy problems were more frequently recorded in outpatients. There was no correlation between the opioid used at baseline and switch frequency, but numbers of cases receiving other opioids than fentanyl or morphine were low. Reasons for and frequencies of changes in medication were found to be largely shaped by the setting reflecting patients' needs and clinical necessities. Recommendation of first line therapy and availability of opioid formulations define the frequency of opioid use. This impedes evaluation of specific differences between the opioids.
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Instituciones de Atención Ambulatoria , Analgésicos Opioides/administración & dosificación , Revisión de la Utilización de Medicamentos , Hospitales , Dolor/tratamiento farmacológico , Cuidados Paliativos/métodos , Anciano , Instituciones de Atención Ambulatoria/normas , Analgésicos Opioides/efectos adversos , Analgésicos Opioides/provisión & distribución , Buprenorfina/administración & dosificación , Buprenorfina/efectos adversos , Estudios de Cohortes , Relación Dosis-Respuesta a Droga , Vías de Administración de Medicamentos , Esquema de Medicación , Quimioterapia Combinada , Femenino , Fentanilo/administración & dosificación , Fentanilo/efectos adversos , Hospitales/normas , Humanos , Hidromorfona/administración & dosificación , Hidromorfona/efectos adversos , Masculino , Persona de Mediana Edad , Morfina/administración & dosificación , Morfina/efectos adversos , Oxicodona/administración & dosificación , Oxicodona/efectos adversos , Dolor/fisiopatología , Dolor/prevención & control , Cuidados Paliativos/tendencias , Estudios Prospectivos , Resultado del TratamientoRESUMEN
Sedation in the final stages of life plays an increasing role to control refractory physical and psychological symptoms and to diminish distress and anxiety in palliative care. In the debate on euthanasia and self determination also in Germany the issue of "terminal sedation" has evoked ethical concerns and is discussed controversially. With respect for personal needs the intentions, aims and indications for medical sedation should be carefully reflected under ethical aspects to clarify its position in end-of-life care
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Ética Médica , Hipnóticos y Sedantes/administración & dosificación , Cuidado Terminal/ética , Actitud Frente a la Muerte , Humanos , Dolor/prevención & controlRESUMEN
BACKGROUND: Due to recent legislations on euthanasia and its current practice in the Netherlands and Belgium, issues of end-of-life medicine have become very vital in many European countries. In 2002, the Ethics Working Group of the German Association for Palliative Medicine (DGP) has conducted a survey among its physician members in order to evaluate their attitudes towards different end-of-life medical practices, such as euthanasia (EUT), physician-assisted suicide (PAS), and terminal sedation (TS). METHODS: An anonymous questionnaire was sent to the 411 DGP physicians, consisting of 14 multiple choice questions on positions that might be adopted in different hypothetical scenarios on situations of "intolerable suffering" in end-of-life care. For the sake of clarification, several definitions and legal judgements of different terms used in the German debate on premature termination of life were included. For statistical analysis t-tests and Pearson-correlations were used. RESULTS: The response rate was 61% (n = 251). The proportions of the respondents who were opposed to legalizing different forms of premature termination of life were: 90% opposed to EUT, 75% to PAS, 94% to PAS for psychiatric patients. Terminal sedation was accepted by 94% of the members. The main decisional bases drawn on for the answers were personal ethical values, professional experience with palliative care, knowledge of alternative approaches, knowledge of ethical guidelines and of the national legal frame. CONCLUSIONS: In sharp contrast to similar surveys conducted in other countries, only a minority of 9.6% of the DGP physicians supported the legalization of EUT. The misuse of medical knowledge for inhumane killing in the Nazi period did not play a relevant role for the respondents' negative attitude towards EUT. Palliative care needs to be stronger established and promoted within the German health care system in order to improve the quality of end-of-life situations which subsequently is expected to lead to decreasing requests for EUT by terminally ill patients.
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Actitud del Personal de Salud , Eutanasia , Cuidados Paliativos/ética , Médicos/estadística & datos numéricos , Suicidio Asistido , Eutanasia/legislación & jurisprudencia , Femenino , Alemania , Humanos , Masculino , Persona de Mediana Edad , Suicidio Asistido/legislación & jurisprudencia , Encuestas y CuestionariosRESUMEN
Over the last five decades the progress in intensive care has extended the limitations of controlling the process of dying and given doctors more influence in determining the time of death. More recently, palliative care has emerged as a new approach in response to the ethical dilemmas of modern medicine, which accepts that dying is a natural process that should not be hastened or delayed through medical interventions. While in Germany in 1999 more than 50 000 people have died in intensive care units, only a small number of 8000 patients have died in palliative care. In comparison to the highly-developed intensive care sector, palliative care is a much neglected area. The public debate following the legalisation of euthanasia in the Netherlands has highlighted concerns in Germany that intensive care has the potential of inappropriately prolonging life and raised expectations about the alternative therapies offered by palliative care. Doctors in intensive care and in palliative care face similar ethical dilemmas, though with a different weighting: the dilemma between professional judgement and patient autonomy, between traditional medical roles and patient self-determination and the dilemma of extending the span of life at the expense of quality of life. The approach of palliative care with its strong focus on alleviating the suffering of the terminally ill, has influenced the ethical debate of dying in intensive care. Although intensive care and palliative care have different aims and priorities, there are common problems of decision-making which could benefit from a shared orientation and interdisciplinary debate. Both the interpretation of a dying parent's will as well as withdrawing or withholding treatment in patients who are unable to decide for themselves should not merely be guided by the debate on active and passive euthanasia, but rather take into account the appropriateness or inappropriateness of medical actions in the specific situation.
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Cuidados Críticos/tendencias , Ética Médica , Cuidados Paliativos/tendencias , Cuidado Terminal/tendencias , Cuidados Críticos/economía , Humanos , Cuidados Paliativos/economía , Población , Cuidado Terminal/economíaRESUMEN
There are only few publications about the effect of music therapy on pain relief. The intention of this prospective study is to demonstrate the influence of the Nordoff/Robbins method of active music therapy in a group of 12 patients with fibromyalgia, myofascial pain syndromes and polyarthritis on pain reduction, life quality and coping. The clinical parameters of each patient were related to the observations in the audio- and video-documented music therapy settings and to the self-reported changes in pain intensity and pain behaviour. There was a significant reduction of pain intensity and pain-related disability in the music group compared to a control group, but no change in the depression and anxiety score. The influence of music therapy could be even better demonstrated in the systematic analysis of the single cases by individual profiles. Active music therapy affects especially the communicative and emotional dimension of chronic pain. Psychophysiological and psychodynamic models are presented to explain the effectiveness of music therapy on pain reduction. Clinical studies on music therapy as well as on other "art therapies" should relate the analysis of clinical parameters to the descriptive-phenomenological documentation of the therapeutic process to demonstrate systematically the influence of music and art in the individual case.
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In rheumatology, all of the more than 400 specified syndromes are associated with pain. In the conceptual discussion on the multidimensional influences postulated to explain the development of chronic pain, fibromyalgia has gained increasing interest. Fibromyalgia (fibrositis) is an unspecific soft-tissue disorder with chronic wide-spread musculoskeletal pain and palpable hypersensitivity at fibrositic tender points. Fibromyalgia is often associated with fatigue, nonrestorative sleep and other symptoms. The syndrome has a high prevalence in women, but in most cases it has a long course with unsatisfactory attempts at therapy before the diagnosis is made. Though diagnostic criteria have been defined to describe it as a distinct clinical syndrome, speculations on its aetiology and pathogenetic mechanisms are still controversial. Histochemical investigations on muscle biopsy and biochemical tests have revealed unspecific changes but no characteristic muscle abnormality. It is supposed that the clinical features may result from central neurohumoral dysfunction combining with peripheral mechanisms to result in hyperalgesia. An integrated therapeutic concept with a reassuring and positive doctor-patient relationship can be helpful in achieving satisfactory treatment results.
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The following pages contain summaries and short statements on chronic pain providing further material for reflection and debate, namely: a) synopses of recent findings on: the physiology and biochemistry of pain; the contribution of psychoneuroimmunology; b) some views on a sociology of pain; c) analysis of various concepts and approaches which consider pain as: a symptom of disease a form of behaviour a psychosomatic reaction and a social learning process a communication phenomenon a symptom of disintegrated life a disruption in the integrity of the system a signal of broken unity a breach in the wholeness of the individual; d) a holistic approach in pain therapy; e) some unanswered questions.
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Dolor , Enfermedad Crónica , Comunicación , Salud Holística , Humanos , Modelos Neurológicos , Modelos Psicológicos , Dolor/etiología , Dolor/psicología , Manejo del Dolor , Psiconeuroinmunología , Rehabilitación/métodos , Sociología MédicaAsunto(s)
Arte , Educación Médica/organización & administración , Salud Holística , Ciencia , Alemania , Humanos , Filosofía MédicaRESUMEN
In the therapy of chronic disease and functional disorders, art therapy is considered to be of increasing importance. The idea behind this type of therapy is that the stimulation of creative activities promotes the healing process and rehabilitation. Music therapy in particular has a long tradition in the treatment of pain and health disorders. In patients, whose perception of disease and treatment expectation is determinated by the idea that their pain results from physical causes alone, compliance in music therapy is usually better than direct psychotherapeutic approaches. In addition to music therapy, the creative arts, creative dance and movement-based creative therapy have also been used in the treatment of patients with chronic pain. A model of chronic pain as a changeable phenomenon of consciousness which depends on subjective perception, communication and coping is the basis for understanding art therapy. The conceptual framework of art therapy offers various explanations for the integration of these forms of therapy in complementary, supportive pain management programs: (1) enhancing the activity level and creative capacity as a healing source; (2) stimulation of positive emotional experience; (3) experiencing social communication and interaction; (4) facilitating projective coping; (5) stimulation of imaginative experience and awareness; (6) promotion of suggestive elements. Anecdotical experience indicates that there could be a broad field for the use of art therapy in pain management programs. The need to validate this form of therapeutic approach by appropriate methodological studies and well-documentated single case series is emphasized.
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Despite all of the progress that has been made in diagnostic procedures and the increasing number of treatment facilities available the number of people suffering from chronic pain conditions seems to be growing constantly in all industrialized countries, a fact which is demonstrated impressively by the epidemiology of low back pain. "Chronic" means "life-determining"-chronic pain, as all chronic illnesses represent a turning point in the life situation of the people concerned. They not only affect the patients, but also the members of their immediate social environment. Chronic pain becomes a destructive stigma when society reduces the afflicted persons to the status of the chronically ill. The conceptual framework for health promotion and chronic pain is based on the discussions on lifestyles that have been conducted at WHO/EURO since 1980 and the Ottawa Charter on Health Promotion adopted at the the First International Conference on Health Promotion held in November 1986. The introduction of the concept of the "healthy pain patient" has the goal of raising the competence of the individual and his/her social environment to improve the quality of life in spite of chronic pain. The educational aim is to enable patients with pain to be autonomous and to maximize their potential health. The therapeutic approach is demonstrated by individual case histories.
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Continuous recording of cerebral activity by the Cerebral Function Monitor is a useful supplementation to anaesthetic monitoring in cardiac surgery. It is a simple and reliable method for early detection of cerebral damage during heart surgery and in other situations with possible cerebral impairment. The operating principles of the Cerebral Function Monitor and the interpretation of the electrical activity tracings are presented. Therapeutic considerations to minimize or to prevent anoxic brain damage are offered.