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The European Association for Palliative Care (EAPC) considers sedation to be an important and necessary therapy option in the care of selected palliative care patients with otherwise refractory distress. Prudent application of this approach requires due caution and good clinical practice. Inattention to potential risks and problematic practices can lead to harmful and unethical practice which may undermine the credibility and reputation of the responsible clinicians and institutions as well as the discipline of palliative medicine more generally. Procedural guidelines are helpful to educate medical providers, set standards for best practice, promote optimal care and convey the important message to staff, patients and families that palliative sedation is an accepted, ethical practice when used in appropriate situations. EAPC aims to facilitate the development of such guidelines by presenting a 10-point framework that is based on the pre-existing guidelines and literature and extensive peer review.

Because of the gap between the high need for cornea tissue for transplantation and the current lower numbers of donors, there is high pressure to succeed in telephone calls to relatives of deceased for obtaining consent. Besides the attempt to increase the rate of donors, these telephone calls should be gentle for relatives and not overstrain professionals. This study assesses the need and expectations of physicians towards communication training in preparation for their task.In September-October 2009 a needs assessment for communication training among physicians who currently work or have worked for the eye bank took place. Personal data were recorded and their estimate of the perceived burden as well as needs and potential benefits from a specific communication training for obtaining consent for cornea donation by telephone were assessed using numeric rating scales between 1 (minimum) and 10 (maximum). Results were expressed as mean and range.The participants felt only moderately prepared for the task regarding information content, their emotions and personal convictions. They considered a specific training to be highly meaningful, necessary and helpful. Their highest burden during telephone calls previously experienced was documented as 8.4 and the average burden as 6.3. Accordingly, their willingness to continue working at an eye bank after their rotation was moderate.Physicians involved in obtaining consent for cornea donation by telephone feel highly stressed and only moderately prepared for fulfilling the task both for the information content and on the emotional level. Accordingly, specific communication training is perceived as highly meaningful, necessary and helpful. An educational program was developed to meet the needs and expectations of physicians.

"There's nothing more to do, so let's come to an end, Doc!" A request for euthanasia or physician-assisted suicide is a dramatic expression of patients' suffering and causes difficulties for staff members to react to these questions. Great efforts have been made in the last two centuries to gain a deeper understanding of the wish for hastened death of terminally ill patients and to develop conclusions for the management of these situations. This article presents differences in international legislation on euthanasia and summarises the ethical background. The current results from the literature according to motivations for the wish for hastened death, communicative functions of the request, attitudes and practices of physicians and their willingness to accompany the patient in euthanasia as well as practical implications for clinical practice are discussed.

Even when the guidelines for cancer pain management are followed, acute severe pain requiring immediate treatment will occur in some patients. Titration with intravenous morphine may provide fast and efficient pain relief and give an indication of the amount of opioid necessary for continuous treatment. In cooperation with a general practitioner we performed an intravenous morphine titration in a patient with severe cancer pain at home. Adequate analgesia was reached with 20 mg intravenous morphine. Blood pressure, cardiac frequency and oxygen saturation did not change. No side effects were reported during the titration, and the previous regimen with tramadol 150 mg per day was switched to slow release morphine 300 mg per day. This medication was prescribed by the general practitioner and provided good pain relief until the patient died two weeks later. We conclude that intravenous morphine titration may be performed even in cancer patients at home, adequate monitoring, however, should be available.

Problems and deficits in the transition between hospital-based and outpatient care of cancer patients were evaluated. The project was initiated by the Public Health Department of the City of Aachen and was carried out with cooperation from all hospitals in the urban areas.From September 2002 to April 2003 a total of 145 cancer patients fulfilling the inclusion criteria from 4 regional hospitals were documented at 4 time points within a period of 6-8 weeks by questionnaires, telephone and personal interviews. Aspects of interest were disease type, symptom burden, well-being, the homecare situation and medical aids required.Patients and their relatives reported on inadequate pain management, insufficient preparation of transition, problems in information flow, organisational problems, lack of attention and humaneness, deficiency of care, delay of diagnosis, inadequate access to services, insufficient prescription of drugs and adjuvants, financial problems and quarrels with the health insurance company on payment of aid devices. Coping strategies were mostly non-functional and not problem-orientated.Special attention should be paid to psychosocial and interpersonal needs of patients. Volunteers may have an important role in the care of patients and relatives. The introduction of case managers might lead to an advancement of care. Sensitisation of physicians, nurses and other caregivers for deficits in transition of patients is needed and should be covered in palliative care education and training.

Benzodiazepines are often used in palliative care for symptom control, for example in treatment of dyspnea or anxiety. They are also used for palliative sedation, if symptoms are not controlled (fast) enough and a reduction of consciousness is therefore necessary. Incidence of palliative sedation has been reported to vary between 5-52% of all patients in a palliative care setting in several studies.Information from the records of 160 patients treated in the palliative care unit from September 2003 to December 2004 was evaluated from an electronic database. Gender, age, diagnosis, symptoms and medication, especially benzodiazepine dosage and application were analyzed.Of the patients 70% were treated with benzodiazepines but only 3.1% received deep and continuous sedation. Benzodiazepines were applied as required in oral or sublingual form in 71.8% of all cases. Lorazepam was given most often because of anxiety and agitation, oxazepam to induce sleep and midazolam in five cases of terminal sedation. Only rarely were diazepam and clonazepam prescribed to prevent or resolve convulsions.The majority of patients had been treated with benzodiazepines whereas only very few had received deep and continuous sedation.

Many patients accept sedation in the early phase or in the course of sort-term opioid treatment in exchange for adequate pain relief. Long-term pain treatment often alters the priorities of patients from pure pain relief to their ability to function in everyday life, which includes mobility and driving a car. Patients with malignant or other diseases often have numerous concomitant symptoms which may directly affect their driving ability. A significant percentage of patients will have an improvement in cognitive and physical abilities as a result of appropriate analgesic treatment with opioids and may thus be able to do what they had previously not been able to (e.g. driving). But the result of testing driving ability can also have great significance in other areas of life. In consequence we find that patients who have done poorly in driving tests will have difficulties also in other areas, just as the opposite may be true.

Einsatz von Antibiotika in der Palliativmedizin M Pestinger , A Muller , C Ostgathe , C Bausewein , I Strohscheer , W Etspuler , S Schulzeck , F Elsner , L Radbruch 1 1 Klinik fur Palliativmedizin, RWTH Aachen 2 Klinik und Poliklinik fur Palliativmedizin, Universitatsklinikum Koln 3 Interdisziplinares Zentrum fur Palliativmedizin, Klinikum Harlaching 4 Klinik fur Onkologie, Karl-Franzen Universitat, Graz, Osterreich 5 Vita Natura Klinik, Eppenbrunn 6 Klinik fur Anasthesiologie, Universitatsklinikum Kiel

Social developments and medical progress in the last decades have led to a significant change of values in medicine, which spans from the cornerstone of the patient's autonomy to the increasingly difficult decision-making process related to available medical treatments. This conflict exaggerates with end-of-life situations, where a purely palliative approach to the therapy is applied, or in cases of reduced ability for patient's consent. From a legal point of view, many uncertainties have been clarified in recent years. The patient's autonomy has been strengthened, however, the law requires the doctor to review and carefully balance the treatment options so that a new and modified patient-doctor relationship is often necessary in this difficult decision-making process. The doctor should no longer retreat into the classical role of a neutral advisor and leave the complete responsibility of medical decisions to the patient. Instead, in order for the patient to be able to make a balanced and individually tailored autonomous decision, the doctor needs to bring in his medical expertise along with his own personal experiences and personal opinions, as long as he clearly differentiates between personal and professional views. This way the patient will be empowered to make complex medical decisions, considering his personal situation and previous experiences as well as his own set of values. For complex situations medical practitioners can find support from reflection within the treatment team, or through an external ethical advisory panel. Algorithms can be helpful to illustrate the steps in a decision-making process and thus support medical staff in situations of difficult medical decisions.

Cancer pain treatment should follow the recommendations of the World Health Organisation. Treatment should be with oral application, regular application times and following the analgesic step-ladder. Non-opioids such as dipyrone or non-steroids are used for slight to moderate pain, step-2 opioids such as tramadol or tilidine/naloxone for moderate pain and step-3 opioids such as morphine, oxycodone or hydromorphone for severe pain. Transdermal application of fentanyl or buprenorphine offer a non-invasive parenteral alternative for patients with stable pain syndromes. Cannabinoids such as tetrahydrocannabinol offer a valuable add-on option for cancer patients with refractory pain, spasticity, nausea or appetite loss.

Einleitung: Ethische Entscheidungen spielen in der Palliativmedizin eine wichtige Rolle. Themen wie Vorausverfugung, terminale Sedierung, Sterbehilfe sowie Therapieentscheidungen werden kontrovers diskutiert. Ziel der vorliegenden Arbeit war es, den aktuellen Stand und das Vorgehen in ethisch schwierigen Situationen bei Palliativpatienten zu erheben. Methodik: Im Rahmen der Kerndokumentation 2004 sollten auf einem Bogen mit Checklisten und Freitextfeldern ethische Fragestellungen (Aufklarung, Patientenverfugung, Therapieverzicht, terminale Sedierung, Sterbehilfe und ethische Konflikte) patientenbezogen bei Aufnahme und im Verlauf dokumentiert werden. Ergebnisse: Bei 1211 von 2214 dokumentierten Patientenverlaufen wurden bei Aufnahme Angaben zu ethischen Problemfeldern gemacht. 86,8% waren in vollem Umfang uber die Diagnose, jedoch nur 64,4% uber die Prognose aufgeklart. Eine Patientenverfugung war bei 16,6% dokumentiert. Bei Therapieverzicht wurde am haufigsten Reanimation (57,1%), am seltensten Flussigkeitssubstitution (15,5%) genannt. Eine Sedierung wurde bei 13,1% (kontinuierlich 5,1%, intermittierend 8,0%) der Patienten dokumentiert. Die haufigsten in Freitext genannten Grunde hierfur waren Unruhe, Angst, Schmerz, Luftnot, Hilfe beim Sterben, Ersticken, Blutung, Leiden und Verwirrtheit. Eine ethische Beratung wurde bei 11,9% der Patienten durchgefuhrt. Bei 3,1% wurde der Wunsch nach aktiver Sterbehilfe dokumentiert. Schlussfolgerung: Bei palliativmedizinischen Patienten besteht ein groser Klarungsbedarf bei ethischen Problemen. Die kompetente ethische Beratung stellt einen wesentlichen Bereich des palliativmedizinischen Angebotes dar, auf die in Zukunft starker fokussiert werden muss.