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The article begins with a reflection on the intertwined nature of life and death; this reflection should also serve to sensitize us to the proactive and reactive expressions of a person's life at the end of life. It will be shown that attachment to life can also manifest itself in the case of depression, fear and exhaustion: One must not lose sight of their potential existence. The existing commitment to life allows us to better understand why the remaining time of life may be perceived as something precious; this may be in contrast to statements made in the living will. A distinction is made between subjectively, objectively and socially defined criteria for a good life in the borderline situation of a serious illness leading to death; their comparison is central to the end-of-life decision-making process. In addition to physical and neurocognitive illnesses, suicidality is at the centre of the article., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Advanced incurable diseases are often accompanied by numerous losses and burdens as the disease progresses, leading to a loss of autonomy, self-determination, and dignity for those affected, all of which can subsequently promote feelings of loneliness at the end of life. Declining health, increasing symptom burden, loss of social roles, and the fear of death and dying are among the key risk factors for loneliness towards the end of life. In this article, we provide an overview of the different dimensions of loneliness experienced at the end of life. We discuss existential loneliness alongside emotional and social loneliness, explore causes and health implications of loneliness at the end of life, suggest diagnostic tools for assessing loneliness, and finally provide recommendations for addressing emotional, social, and existential loneliness at the end of life. The loneliness of caregivers is also discussed. We suggest that addressing social and emotional loneliness early in the course of a terminal illness is crucial. Palliative, psychological, and spiritual support can strengthen interpersonal relationships, foster a sense of meaning and purpose, and alleviate the adverse effects of loneliness on mental and physical health as well as quality of life. In contrast, existential loneliness is considered an expression of profound emotional maturity and can offer opportunities for inner growth, contributing to a more refined sense of self while reinforcing identity, dignity, and transcendence at the end of life., (© 2024. The Author(s).)

Introduction: Fears and anxieties are a common cause of suffering for patients at the end of life. These are often either fears about dying - for example, fear of unbearable pain or fear of suffocation - or fear of death itself. If unrecognized and untreated, fears and anxieties can contribute to a considerable reduction in the quality of life in the last phase of life. Careful diagnosis of anxiety and fear is therefore crucial. Multimodal treatment, which includes psychotherapy and other non-pharmacological and - if necessary - pharmacological treatments, can provide significant relief., Competing Interests: Die Autoren haben keine Interessenkonflikte im Zusammenhang mit diesem Artikel deklariert., (© 2024 Aerzteverlag medinfo AG.)

Introduction: The topic of death and the dying is a crucial aspect of patient care, especially for individuals with terminal illnesses. However, discussions about death and dying are often avoided during patient interactions. In this article, our aim is to explore the reasons behind our fear of death and dying and to assess the importance of addressing these issues in shaping and cultivating relationships with our patients and in our personal lives. We argue that being open to impermanence is a valuable tool in our work with patients and their families and should be integrated into conversations with them. Furthermore, discussions about death and dying should play a central role in medical and nursing education as well as professional development., Competing Interests: Die Autorinnen und Autoren haben keine Interessenkonflikte im Zusammenhang mit diesem Artikel deklariert, (© 2024 Aerzteverlag medinfo AG.)

The evaluation of health-related quality of life (HRQL) has gained importance in recent years. Disease-specific questionnaires are available for respiratory insufficiency, which enable the assessment of HRQL. The Severe Respiratory Insufficiency (SRI) questionnaire, which was specially developed for patients with respiratory insufficiency, is ideal for quantifying the quality of life in patients receiving home mechanical ventilation (HMV). Studies using the SRI questionnaire demonstrated that the physical functioning of patients with chronic lung diseases of various etiologies is significantly impaired, but frequently without significant impairment of psychological well-being. Therefore, severity of the disease and HRQL do not necessarily correlate with each other.Both invasive and non-invasive mechanical ventilation can improve quality of life. Co-morbidity, and above all advanced age, have the highest negative predictive value with regard to in-hospital mortality and weaning failure. The number of patients older than 80 years who remain dependent on invasive HMV after prolonged weaning in Germany is increasing significantly. High dependence on invasive HMV is often associated with a loss of quality of life and autonomy. Thus, ethical issues of the continued treatment of ventilated patients at the end of life are discussed increasingly.After weaning failure, the indication for invasive HMV should be critically examined and should focus on potentially severely reduced quality of life and poor prognosis, as well as the patient's wishes. If previously agreed treatment goals can no longer be achieved during the course of invasive HMV, changing the therapy goals should be discussed within the clinical team, with the patient, their relatives and, if necessary, with legal representatives.In order to avoid overtreatment and unnecessary patient suffering during invasive HMV, advanced care planning should be started as early as possible and if necessary accompanied by palliative medical measures., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Currently, 49% of deaths in Austria occur in a hospital which makes in-patient quality of care as well as quality of death and dying a highly relevant topic. In this article, we compare the quality of care and death and dying in departments of internal medicine and palliative care in hospitals from the perspective of relatives., Methods: In a pilot study, 210 relatives of patients who died on 4 departments of internal medicine and 2 departments of palliative care in the state of Styria (Austria) were interviewed in 2015-2017 by means of a postal survey with regard to communication by hospital personnel, quality of care, and time of dying., Results: Compared to the departments of internal medicine, the 2 departments of palliative care were perceived to provide better quality of care and better service with regard to the time of death and dying, that is, timely communication of critical health deterioration of the patient, enabling relatives' attendance at the time of death, preparing relatives, and the quality of death of the patient., Conclusion: Against the background of the large proportion of individuals who die in hospitals in Austria, this exploratory study showed that relatives perceived both better quality of care and better quality of death and dying in the assessed departments of palliative care compared to the departments of internal medicine. Thus, a more comprehensive and systematic evaluation of the potential added value of palliative care teams in Austrian hospitals is recommended., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Pain or misery strike us - but it is up to us how to deal with them. Suffering is a verb; this underlines the active nature of suffering. The present paper develops a constructive concept of suffering by taking up approaches from existential philosophy and psychology. It suggests that suffering, if allowed and accepted, has the potential to facilitate transformation and, subsequently, to release from pain. The text ends with reflections on how a transformative understanding of suffering can be opened up in the accompaniment of suffering or dying., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: End-of-life care (EOLC) in the intensive care unit (ICU) is becoming increasingly more common but ethical standards are compromised by growing economic pressure. It was previously found that perception of non-beneficial treatment (NBT) was independently associated with the core burnout dimension of emotional exhaustion. It is unknown whether factors of the work environment also play a role in the context of EOLC., Objective: Is the working environment associated with perception of NBT or clinician burnout?, Material and Methods: Physicians and nursing personnel from 11 German ICUs who took part in an international, longitudinal prospective observational study on EOLC in 2015-2016 were surveyed using validated instruments. Risk factors were obtained by multivariate multilevel analysis., Results: The participation rate was 49.8% of personnel working in the ICU at the time of the survey. Overall, 325 nursing personnel, 91 residents and 26 consulting physicians participated. Nurses perceived NBT more frequently than physicians. Predictors for the perception of NBT were profession, collaboration in the EOLC context, excessively high workload (each p ≤ 0.001) and the numbers of weekend working days per month (p = 0.012). Protective factors against burnout included intensive care specialization (p = 0.001) and emotional support within the team (p ≤ 0.001), while emotional exhaustion through contact with relatives at the end of life and a high workload were both increased (each p ≤ 0.001)., Discussion: Using the example of EOLC, deficits in the work environment and stress factors were uncovered. Factors of the work environment are associated with perceived NBT. To reduce NBT and burnout, the quality of the work environment should be improved and intensive care specialization and emotional support within the team enhanced. Interprofessional decision-making among the ICU team and interprofessional collaboration should be improved by regular joint rounds and interprofessional case discussions. Mitigating stressful factors such as communication with relatives and high workload require allocation of respective resources.

Role of the influence of cultural and religious beliefs on medical end-of-life decision-making Abstract. Decision-making at the end of life must encompass medical indication, therapeutic offer, patient autonomy and consent. Furthermore, physicians must reflect on whether their own cultural and religious beliefs have an influence on their decision-making process. Basic knowledge in palliative care or integration of experts in palliative care may be useful when dealing with patients at the end of life, particularly when shifting treatment goals to palliative or comfort care measures is considered or necessary. Expertise in palliative care may also be useful in the care for patients well before the end of life, for example in symptom management, wound care, communication with family or psycho-social care. Ideally, goals of care should be discussed with the patient. Decision-making includes judging, respecting individual values, caring and taking on responsibility - including responsibility for potentially wrong choices. It is imperative that respect for patient autonomy and increasingly strengthened patient competence must be reflected in physicians' reasoning about medical and ethical end-of-life decisions, as well as about empirical and normative aspects of medical indication.

Palliative Sedation: Comments on a controversial topic Abstract. Palliative sedation (PS) is an accepted medical practice for terminally ill patients. It intends the alleviation of unbearable suffering by intentionally lowering the level of consciousness. In contrast to physician assisted suicide and euthanasia, palliative sedation aims to relieve burdensome symptoms with no intention of hastening death. PC can be applied as "intermittent palliative sedation" or "continuous (deep) sedation until death". Most ethical controversies are related to the latter form of PS: 1: Is existential or psychosocial suffering a possible indication for PS? 2: What is the earliest possible time point to start PS? 3: The withdrawal or withholding of artificial nutrition and hydration during PS. A critical reflection of these ethical controversial aspects within the treatment team is highly desirable. However, the patient's well-being and the respect for the patient's decisions that are based on experiences which are made only by him or her, must remain the guiding principle for medical actions.

Caring for patients at the end of life: Experiences and needs of physicians Abstract. In the context of death and dying, physicians are challenged in many different ways, not only professionally but also personally. Physicians are described as having a hard time accepting the finality of life. Medical practitioners find difficulties balancing their emotional involvement and their anxiety in facing death. Many specialists focus their treatment on pressing physiological problems at the time of acute crises, and have difficulty accepting that the limits of treatment effectiveness have been reached. This manuscript provides an overview of the aspects that characterise physicians' attitudes, experiences and needs when dealing with dying patients, with a view to provide information on useful approaches to communication at the end of life, as well as to encourage the development of strategies to better integrate end of life conversations and self-care practices into everyday practice. Medical training has favoured overtime a detached approach to emotions and death and dying as an isolating experience. While some patient deaths may be more confronting than others, and some conversations more difficult to start than others, turning the view to oneself can help to not only understand where the discomfort comes from, but also to improve communication patterns, stay healthy, and derive job satisfaction. By sharing perspectives and learning how other colleagues deal with similar issues, there is an opportunity for medical practitioners to develop a well-rounded approach to dealing with death and dying, which may enhance personal and professional relationships and may ultimately influence future generations of medical practitioners, as well as societal expectations.

The quality of life can be severely impaired in patients with COPD. In addition to physical restraints, they often suffer from psychological comorbidities (e. g. anxiety, depression). Psychological comorbidities are often associated with dysfunctional beliefs about the illness and its treatment. Such dysfunctional beliefs, in turn, are likely to negatively affect patients' quality of life as well as their communication with physicians and their illness behavior in general. It is therefore important for physicians to adapt their communication to account for patients' dysfunctional beliefs. This paper will review the role of dysfunctional beliefs and psychological comorbidities in COPD. It will also elaborate on potential ways to adjust communication between physicians and patients accordingly., Competing Interests: Interessenkonflikt: Dieses Manuskript basiert auf einem Vortrag bei der Expertentagung „Luftschlösser“ zum Thema „Exazerbation der COPD“ am 17. Februar 2017 in Wiesbaden (Sponsor: Boehringer Ingelheim). Von Seiten des Sponsors erfolgte keine Einflussnahme auf den Inhalt dieses Manuskriptes., (© Georg Thieme Verlag KG Stuttgart · New York.)

Treatment with an implantable cardioverter-defibrillator (ICD) represents a prognostic but not symptomatic therapy. It should therefore be restricted to patients where an improvement of prognosis is possible and reasonable. ICD implantation should only be performed in patients with a life expectancy of at least 1 year at reasonable quality of life. The decision in which patient improvement of prognosis is no longer a desirable target is problematic, both medically and ethically. It is not entirely clear in which elderly patient an ICD therapy can convey prognostic benefit despite comorbidity and competitive life-threatening diseases, as it is unclear how old age should be defined. In primary prophylaxis of sudden cardiac death, data on a prognostic benefit of the ICD in elderly patients are less clear than in secondary prophylaxis since short-term mortality due to other causes is higher in the elderly. However, elderly ICD patients have a similar rate of appropriate ICD therapy as younger patients. Complications at ICD implantation or long-term lead failure do not occur more frequently in elderly patients and therefore do not represent a reason to withhold ICD implantation in elderly patients or to set an age limit above which ICD implantation should no longer be performed. The ICD indication in elderly patients should be individualized depending on remaining life expectancy, comorbidity, "biological age" and patient preferences which play a particularly important role in elderly patients. Aspects of a potential improvement in quality of life by the ICD which may also serve as a system for antibradycardiac or resynchronization treatment should be included into considerations. Deactivation of at least shock therapy should be discussed in elderly patients fitted with an ICD if the subject is brought up by the patient or if clinical deterioration suggests the need to talk about a "do not resuscitate" order. This talk should be performed before death is imminent and before an electrical storm in terminal illness leads to multiple shocks by the active device.

Volunteering in the hospice movement has had a profound impact on generating awareness of hospice work and palliative care in the context of supporting dying persons and their relatives as well as on integrating respective services in the existing health care system. This paper focuses on two specific questions: First, it asks how society is changing with respect to dealing with dying and death, and more precisely with dying persons, which is recognizable by the integration of hospice work and palliative care in the healthcare system and related to the relevance of volunteering in the sense of a citizens' movement. Second, this paper asks what the specific roles of volunteers are as well as the possibilities and limits of voluntary practice in end-of-life care and accompaniment. To answer these questions, the pivotal objectives of the hospice movement - the transformation of the social awareness regarding dying and death, as well as the reorganization of "institutions of dying" - will first be outlined by reference to the concept of "good dying", a specific hospice attitude together with hospice culture and palliative competence. In a second step, the relevance of volunteering and the specific role of volunteers in the actual practice of hospice work and palliative care will be outlined alongside current indicators and recognizable alteration tendencies, before concluding with a discussion of the perspectives of hospices as a citizens' movement.

Whereas changes to the existing legal situation regarding assisted suicide have been a topic of controversial debate in Germany for the last few years, this issue has long been of interest for international film-makers. Since the mid-1980s, the theme of assisted suicide has repeatedly been taken up by cinema, predominantly as central to a relationship drama. A sick person asks somebody close to them for help. Often this somebody is a physician or a nurse, ultimately an obvious way of solving the practical problem of how the assistant is to gain access to a lethal substance. At the same time, this constellation enables a physician or nurse to be forced into a dramatic conflict between professional ethics and a personal obligation towards a loved one.Alongside more classic clinical pictures such as terminal cancer, recent films about assisted suicide have featured neurodegenerative diseases and physical disabilities. Another new development is that elderly patients are no longer alone in requesting assistance; films also and increasingly portray young adults. Besides a fear of unbearable pain, more recent films have also increasingly addressed the worry that permanent nursing might be required, as well as the subjectively experienced loss of dignity. The possibilities offered by palliative care hardly play a role in feature films. However, we should not forget, that movies are fictional and orchestrated, or, in other words, they are neither educational nor documental. They neither need nor want to portray reality, although they do wish to draw upon real experiences. They exploit highly emotional and ethically controversial themes to create tensions and stir up emotions in the audience, but ultimately they seek to entertain. Movies about death and dying are always "die-tainment".

Background: The aim of palliative medicine is to adequately care for and attend to patients suffering from life-threatening and incurable medical conditions according to their needs. This implies that for these patients it is not a matter of dealing with diseases that can be treated separately but with their existence in the face of their approaching death., Objective: This article investigates which ethical questions are currently prioritized for discussion in palliative medicine., Method: Review of the current medical and ethical literature and own reflections with a relational ethics approach that puts patient wishes at the centre of attention., Results: Palliative medicine is not a "luxury medicine" but has to be considered as primary care to which every person is entitled. If there is a need for improvement of care, promoting it is an ethical obligation. In this respect the question of a "good death" is extremely complex. The term is connected to the ethics of a good life and includes the dimensions of happiness-suffering as well as meaning-futility; therefore, the best possible treatment of symptoms, most of all pain is just as important as recognizing subjective questions of meaning. Dealing with the wishes of patients, including possible wishes to die, are the starting point for elaborating palliative care measures. It is concerned with finding the right point in time for each patient individually, in their best interests and according to their wishes, at which dying should no longer be held back but for their own benefit the patient should be accompanied and supported during dying., Conclusion: In the current construction of palliative medicine, including its normative configuration within the law and medical ethics, the criteria which are essential for the quality of life up to death are being discussed.

Background: In the last year of life, persons with advanced cancer and their significant others are affected by several transitions. They perform psychological adjustment processes during transformation. This requires strategies for patients and their significant others. Research in German about this theme is missing. Aim: We explored the experiences with illness management during transitions in the last year of life of patients with advanced cancer and their significant others. Method: In this qualitative study, we conducted structured interviews with five dyads, consisting of persons with Karnofsky Index ≥ 60 % and life expectancy of six to twelve months as well as their significant others. To interpret the interviews, we used qualitative content analysis according to Mayring. Results: The main theme “Don't let the world become too small” expresses that limitations diminished the lifeworld and the participants struggled against this process. This is revealed in three categories: “Being shocked by diagnosis – realigning again”, “Bearing limitations and loss – finding new ways in daily life”, “Living in uncertainty – holding out together”. Conclusions: Patients and significant others live in changing lifeworlds caused by transitions. Health care professionals should be attentive and may gain deeper knowledge about transitions. Further research in German-speaking contexts will help to improve nursing care and psychooncological interventions.

Palliative care in the delivery room is a multiprofessional challenge directed to the dying newborn and the parents as well as to the care-givers. Clinical experience shows that many aspects regarding this unique palliative care situation are not well known and cause relevant emotional distress to the health care providers. In this article basic background information of palliative care of newborns in the delivery room are presented. Furthermore, recommendations are given focusing on 2 main aspects: 1. non-pharmacological and pharmacological ways of symptom control in palliative care of dying newborns and 2. meeting the individual psychological, emotional and spiritual needs of the parents., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Aim: Taking care of a person at the end of life at home is difficult and challenging. In a qualitative study, the burdens experienced by informal caregivers as well as their coping strategies to face these burdens were investigated., Material and Methods: Narrative interviews with 25 informal caregivers were conducted. Interviews were transcribed verbatim and analyzed using a constant comparative approach., Results: Informal caregivers feel tired and overburdened, alone and abandoned, experience grief and fear, feel helpless and experience a feeling of having lost control over their own life. To cope with these stressful emotions, they actively seek help and support, inform themselves and acquire skills and competencies, talk to others, allow themselves time off and emphasize the positive and meaningful aspects of caring for someone at home., Conclusion: The burdens experienced by informal caregivers are highly subjective and depend on the coping strategies and the available resources. A main resource is the help and support provided by the informal social network.

Background: Because of demographic changes of an aging society, palliative care is becoming increasingly important. It is therefore necessary to evaluate preferences at the end of life at an early stage to meet the needs and requests of future patients., Objectives: The aim of this study was to find out preferences in a theoretical scenario ("If you developed a serious medical condition such as cancer and you had less than a year to live…") regarding the desired involvement in decision-making at the end of life and the preferred place of death., Materials and Methods: As part of the international PRISMA project, a representative telephone survey was carried out in Germany., Results: A total of 1,363 Germans took part in the survey (response rate 29.0 %, 47.1 ± 15.7 years, 42 % male). 90.8 % wanted to make their own decisions with regard to end-of-life care, which was most important for people with higher education. 83.3 % wanted to predetermine decisions by means of an advance directive in case they are no longer able to make them at the time. This was again more important for individuals with higher education and for older subjects (≥ 65 years). The preferred place of death was their own home (63.3 %), and the least preferred place for death was in hospital in 48.2 %. In particular, women did not want to die in a hospital., Conclusion: These results should be considered when planning health care structures to meet the wishes of people at the end of their life, in particular to strengthen the importance of patient provision and the desire for their own home to be the preferred place to die.

The advances of modern medicine did not only result in prolongation of life expectancy, but also led to a shift from dying at home to dying in public institutions. In western countries most people die at advanced age in medical facilities. Hence, the question regarding the conditions, which should be provided by society and especially medicine, to allow terminally ill people to experience "good dying" is substantial. For this purpose, an examination of patients', family members' and health care providers' understanding of the term " good dying" is required. The present paper aims at shedding light on the term "good dying" and to summarize the current state of research. Therefore, the attributes of "good dying" will be described from the perspectives of patients, family members and health care providers, which are discussed and examined in current medical-sociological research. These attributes can be illustrated on three dimensions: Quality of life at the end of life (e. g. pain relief, mental well-being), quality of dying (e. g. avoiding prolonged dying, autonomy, presence of relatives) and quality of health care at the end of life (e. g. patient-oriented health care, positive communication between health care providers and patients, availability of guidelines). Although the attributes of "good dying" are described in detail in the existing literature, further studies have to clarify the relevance and impact of these attributes as predictors of "good dying"., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Older people living alone are a disadvantaged group of society with regard to preferences for care, especially in the last phases of life. Non-kin carers seem to play a vital role for these people; however, these carers tend to be neglected in research as well as policy compared to professional caregivers or family members., Aim: In order to investigate how non-kin carers support older people living alone, e.g. to fulfill their preference for dying at home, a scoping review was carried out., Material and Methods: The databases MEDLINE, CINAHL and GeroLit were searched and 12 studies were identified which form the basis of this review., Results: Non-kin care relationships are characterized by low key initial phases and often salient transition from support to permanent caring. Various motives for becoming involved can be found from the studies but a differentiation between relationships such as pure friendship, casual aquaintance and neighbors seem to be important. The needs of older people living alone are closely connected with their preference for staying at home., Conclusion: Non-kin carers face several challenges and have to deal with increasing needs for physical care towards the end of life. Palliative care services are most often involved at this phase. More research is needed to better understand the limits as well as ressources of non-kin carers and the interplay between them and professional carers.

Paediatric Palliative Care in Switzerland is still in its infancy. In comparison to palliative care in adults, the knowledge about palliative care in children is limited. To facilitate the decision of when to start palliative care, an instrument for health professionals has been developed. The instrument, called Paediatric Palliative Screening Scale (PaPaS Scale), builds on five domains shedding light on the child's illness: 1) trajectory of disease and impact on daily activities; 2) treatment options and burden of treatment; 3) symptoms, controllability, and problem burden; 4) preferences of patient or parents; and 5) life expectancy. The aims of a reasonably starting palliative care are quality of life and the ability to actively create the rest of life.

Palliative care and end of life at home remains a challenge for the general practitioner. The success is related to many factors, including the situation of the patient, his social and family environment, the presence of the various health professionals and the physician's engagement. Beyond the medical-technical skills, he plays a central coordinating role in an interdisciplinary team regularly adjusted according to the patient's evolution. The positive emotional impact on bereaved relatives after the end of life at home is often underestimated by the physician.

It is not uncommon for patients with an advanced disease to express a desire to their physician to hasten their death. Recent studies show that the motivation of such a desire is multifactorial and multidimensional, including depression, physical, psycho-social and spiritual suffering, fears about the process of dying and/or misunderstandings about the options for end-of-life care. The objective of this paper is to propose to the physician how to explore the dimensions of this request and some elements to answer it.

The recent development in optimising palliative care standards in thoracic oncology is associated with an increased demand in specialized communication skills. Standardised and integrated assessments of the palliative care need of the patient is met by limited health care resources. The model of communication described in this article emphasizes the need to structure palliative distress assessment of the patient. Communication pathways are shown as a platform to evaluate and support patient and caregivers. Standards to establish algorithms of communication in palliative care will improve the very important interaction between patient and caregivers., (© Georg Thieme Verlag KG Stuttgart · New York.)

End-of-life decisions are frequently necessary in intensive care units. These decisions are made more difficult through rapidly changing disease dynamics, lack of continuity of care, differing expectations, as well as a lack of support. In these situations, structured communication concepts can help families and staff, e. g. through structured family conferences, the concept of family as the expert for the patient's preferences, and empathetic reactions to emotions. The article discusses concrete strategies how to communicate about end-of-life care., (© Georg Thieme Verlag Stuttgart · New York.)

Background: Ethical questions at the end of life are at the centre of scientific and public debates. Up to the present there is scarcity of empirical data regarding physicians' end-of-life practices in Germany., Methods: Cross-sectional study among a random sample of German physicians by means of the questionnaire of the EURELD Consortium with additional questions on experiences and attitudes regarding physician assisted suicide., Results: 734 physicians from five state chambers of physicians responded (response rate 36.9 %). 403 physicians reported about end-of-life practices regarding adult patients. Alleviation of symptoms took place in 86.7 % of cases and in 50.7 % medical treatment had been withheld. In three cases death was the consequence of a drug which was provided or administered by respondents. 20.7 % of respondents had been requested to perform physician-assisted suicide (PAS). 41.7 % of participants could not imagine participating in PAS, whereas 40.2 % could imagine this under certain circumstances. A prohibition of PAS by professional law war rejected by 33.7 %, 25.0 % support such a ban and 41.4 % were undecided., Conclusion: Physicians in Germany perform a broad spectrum of end-of-life practices. The empirical findings can serve as a starting point for the reflection about an appropriate normative framework for physicians' end-of-life practices., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Care for cancer patients is often provided by family caregivers. The terminal care period is usually associated with restricted mobility., Aim: The aim of this literature review is to analyse the needs of caregivers concerning mobility support and encouragement in everyday care of a cancer patient at the end of life., Methods: Relevant articles were identified via electronic database searches in Cochrane, PubMed, PsychINFO, ERIC, and CINAHL. Studies examining needs concerning mobility support and encouragement for terminal cancer care provided by family caregivers at home, published in English or German, have been included. The methodological quality of the included studies was assessed by two authors., Results: A total of eleven studies with various designs have been included. The results show a need for information, guidance and support regarding mobility in two areas: i) activities of daily living including personal hygiene and ii) usage of equipment including transport., Conclusion: The literature review indicates that practical needs of family caregivers concerning mobility support and encouragement have been assessed unsystematically and not yet adequately studied. This should be done in future studies, in order to implement well-defined interventions for teaching nursing skills subsequently.

Sedation in palliative care is generally considered as an important therapy in terminally ill patients with refractory symptoms. However the sedation of patients with intractable psycho-existential suffering is still under discussion. This paper discusses the case of a 56-year-old patient in the final phase of carcinoma of the ovaries, who required palliative sedation for refractory, mainly psycho-existential suffering. It describes the course on our ward and the difficult process of decision-making. We discuss our approach based on literature.

The aim of palliative care is to improve the quality of life (QOL) of patients with a limited life expectancy in a comprehensive multidisciplinary approach. It encompasses consideration of medical, physical, psychosocial and spiritual problems, including treatment and help from a team of various professionals. Palliative care often extents to the patient's families and may continue after the death of the patient. Half of all head and neck cancer patients will die of their malignancy within 5 years of diagnosis. The primary medical issues affecting QOL at the end of life are communication problems due to laryngectomy or tracheostomy, disturbed eating and drinking due to surgery and radiotherapy, edematous changes of the face and neck with resultant functional and cosmetic consequences, as well as strong-smelling ulcerated wounds, which often lead to social isolation. General symptoms occurring at the end of life include pain, anxiety, different types of dyspnea and acute bleeding. All therapeutic approaches applied during the last phase of life must be questioned regarding their real efficacy and side effects. Consideration of the patient's wishes is of the highest priority.

Suicidal thoughts are a common phenomenon in palliative care which can be seen in around 10% of the patients. There is very little knowledge about attempted and committed suicide. This article is a case report about a patient with lung cancer in a terminal state of illness who ingested drugs in a toxic dose while receiving palliative home care. This article deals with ethical issues in medical treatment and various ways of decision-making.