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

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

Using a laryngeal tube suction-device (LTS-D) reduces the "no flow time" in a single rescuer manikin study.

BACKGROUND: In 2005, the European Resuscitation Council and the American Heart Association published new guidelines for Advanced Life Support. One of the points was to reduce the time without chest compressions in the first phase of cardiac arrest. OBJECTIVE: We evaluated in a manikin model whether using the single-use laryngeal tube with suction option (LTS-D) instead of endotracheal intubation (ET) and bag-mask-valve ventilation (BMV) for emergency airway management could reduce the "no-flow time" (NFT). The NFT is defined as the time during resuscitation when no chest compressions take place. METHODS: A randomized, prospective study was undertaken with 150 volunteers who performed management of a standardized simulated cardiac arrest in a manikin. Every participant was randomized to one of three different airway management groups (LTS-D vs. ET vs. BMV). RESULTS: The LTS-D was inserted significantly faster than the ET tube (15 s vs. 44 s, respectively, p < 0.01). During the cardiac arrest simulation, establishing and performing ventilation took an average of 57 s with the LTS-D compared to 116 s with ET and 111 s with the BMV. Using the LTS-D significantly reduced NFT compared to ET and the BMV (125 s vs. 207 s vs. 160 s; p < 0.01). CONCLUSIONS: In our manikin study, NFT was reduced significantly when the LTS-D was used when compared to ET and BMV. The results of our manikin study suggest that for personnel not experienced in tracheal intubation, the LTS-D offers a good alternative to ET and BMV to manage the airway during resuscitation, and to avoid the failure to achieve tracheal intubation with the ET, and the failure to achieve adequate ventilation with the BMV.

Prehospital emergency treatment of palliative care patients with cardiac arrest: a retrolective investigation.

BACKGROUND: Today, prehospital emergency medical teams (EMTs) are confronted with emergent situations of cardiac arrest in palliative care patients. However, little is known about the out-of-hospital approach in this situation and the long-term survival rate of this specific patient type. The aim of the present investigation was to provide information about the strategic and therapeutic approach employed by EMTs in outpatient palliative care patients in cardiac arrest. METHODS: During a period of 2 years, we retrolectively analysed emergency medical calls with regard to palliative care emergency situations dealing with cardiac arrest. We evaluated the numbers of patients who were resuscitated, the prevalence of an advance directive or other end-of-life protocol, the first responder on cardiac arrest, the return of spontaneous circulation (ROSC) and the survival rate. RESULTS: Eighty-eight palliative care patients in cardiac arrest were analysed. In 19 patients (22%), no resuscitation was started. Paramedics and prehospital emergency physicians began resuscitation in 61 cases (69%) and in 8 cases (9%), respectively. A total of 10 patients (11%) showed a ROSC; none survived after 48 h. Advance directives were available in 43% of cases. The start of resuscitation was independent of the presence of an advance directive or other end-of-life protocol. CONCLUSIONS: Strategic and therapeutic approaches in outpatient palliative care patients with cardiac arrest differ depending on medical qualification. Although many of these patients do not wish to be resuscitated, resuscitation was started independent of the presence of advance directive. To reduce legal insecurity and to avoid resuscitation and a possible lengthening of the dying process, advance directives and/or "Do not attempt resuscitation" orders should be more readily available and should be adhered to more closely.

Quality of out-of-hospital palliative emergency care depends on the expertise of the emergency medical team--a prospective multi-centre analysis.

BACKGROUND: The number of palliative care patients who live at home and have non-curable life-threatening diseases is increasing. This is largely a result of modern palliative care techniques (e.g. specialised out-of-hospital palliative medical care services), changes in healthcare policy and the availability of home care services. Accordingly, pre-hospital emergency physicians today are more likely to be involved in out-of-hospital emergency treatment of palliative care patients with advanced disease. METHODS: In a prospective multi-centre study, we analysed all palliative emergency care calls during a 24-month period across four emergency services in Germany. Participating pre-hospital emergency physicians were rated according to their expertise in emergency and palliative care as follows--group 1: pre-hospital emergency physicians with high experience in emergency and palliative medical care, group 2: pre-hospital emergency physicians with high experience in emergency medical care but less experience in palliative medical care and group 3: pre-hospital emergency physicians with low experience in palliative and emergency medical care. RESULTS: During the period of interest, the centres received 361 emergency calls requiring a response to palliative care patients (2.8% of all 12,996 emergency calls). Ten percent of all patients were treated by group 1; 42% were treated by group 2 and 47% were treated by group 3. There was a statistically significant difference in the treatment of palliative care patients (e.g. transfer to hospital, symptom control, end-of-life decision) as a result of the level of expertise of the investigated pre-hospital emergency physicians (p< 0.01). CONCLUSIONS: In Germany, out-of-hospital emergency medical treatment of palliative care patients depends on the expertise in palliative medical care of the pre-hospital emergency physicians who respond to the call. In our investigation, best out-of-hospital palliative medical care was given by pre-hospital emergency physicians who had significant expertise in palliative and emergency medical care. Our results suggest that it may be necessary to take the core principles of palliative care into consideration when conducting out-of-hospital emergency medical treatment of palliative care patients.

[Expectations of relatives concerning palliative home care]. / Erwartungen Angehöriger an die spezialisierte arnbulante Palliativversorgung.

BACKGROUND: Palliative home care gains in importance in Germany. In addition to administering pain and symptom control for patients a "Palliative Care Team" (PCT) tries to address the patients' psychosocial and spiritual needs. METHODS: Retrospective analysis of caregiving relatives' expectations of the support by a PCT. RESULTS: Most relatives expected a sufficient pain therapy and support of the PCT. Additionally they wished for further outreach afterthe death of the patient. CONCLUSION: Palliative homecare is perceived as a helpful supporting factor by the care-giving relatives of palliative patients.

Successful transtracheal lung ventilation using a manual respiration valve: an in vitro and in vivo study.

BACKGROUND: Lung ventilation through a thin transtracheal cannula may be attempted in patients with laryngeal stenosis or "cannot intubate, cannot ventilate" situations. It may be impossible to achieve sufficient ventilation if the lungs are spontaneously emptying only through the thin transtracheal cannula, which imposes high resistance to airflow, resulting in dangerous hyperinflation. Therefore, the authors describe the use of a manual respiration valve that serves as a bidirectional pump providing not only inflation but also active deflation of the lungs in case of emergency transtracheal lung ventilation. METHODS: The effectiveness of such a valve was tested in vitro using mechanical lungs in combination with two different cannula sizes and various gas flows. The valve was then tested in five pigs using a transtracheal 16-gauge cannula with three different combinations of inspiratory/expiratory times and gas flows and an occluded upper airway. RESULTS: In the mechanical lungs, the valve permitted higher minute volumes compared with spontaneous lung emptying. In vivo, the arterial oxygen and carbon dioxide partial pressures increased initially and then remained stable over 1 h (arterial oxygen tension, 470.8 +/- 86.8; arterial carbon dioxide tension, 63.0 +/- 7.2 mmHg). The inspiratory pressures measured in the trachea remained below 10 cm H2O and did not substantially influence central venous and pulmonary artery pressures. Mean arterial pressure and cardiac output were unaffected by the ventilation maneuvers. CONCLUSIONS: This study demonstrated in vitro and in vivo in adult pigs that satisfactory lung ventilation can be assured with transtracheal ventilation through a 16-gauge cannula for a prolonged period of time if combined with a bidirectional manual respiration valve.

Using a laryngeal tube during cardiac arrest reduces "no flow time" in a manikin study: a comparison between laryngeal tube and endotracheal tube.

UNLABELLED: In 2005 the European Resuscitation Council published new guidelines for advanced life support. One of the issues was to reduce the "no flow time", which is defined as the time without chest compression in the first period of cardiac arrest. In a manikin study, we evaluated whether using the laryngeal tube instead of endotracheal intubation for airway management during cardiac arrest could reduce the "no flow time". METHODS: The study was prospective and included 50 volunteers who performed standardized management of simulated cardiac arrest in a manikin. All participants had completed an obligatory course in emergency medicine but had not been specifically trained in endotracheal intubation; they were therefore designated as unfamiliar in using the endotracheal tube to secure the airway, in accordance with the definition of the European Resuscitation Council. We defined two groups for the study: the LT group, who used the laryngeal tube to secure the airway; and the ET group, who used the endotracheal tube and bag-mask ventilation to ventilate the manikin. The participants were initially randomly assigned to one of the groups and thereafter completed the other scenario. Study endpoints were the total "no flow time" and adherence to guidelines of the European Resuscitation Council. RESULTS: Use of the laryngeal tube during cardiac arrest in the manikin significantly reduced the "no flow time" when compared with endotracheal intubation (109.3 s vs. 190.4 s; P < 0.01). The laryngeal tube was inserted significantly faster than the endotracheal tube (13 s vs. 52 s; P < 0.01) and was correctly positioned by 98% of the participants at the first attempt, compared with 72% using the endotracheal tube. CONCLUSION: With regard to the guidelines of the European Resuscitation Council, we are convinced that during cardiac arrest supraglottic airway devices should be used by emergency personnel unfamiliar with endotracheal intubation.

Influence of airway management strategy on "no-flow-time" during an "advanced life support course" for intensive care nurses - a single rescuer resuscitation manikin study.

BACKGROUND: In 1999, the laryngeal tube (VBM Medizintechnik, Sulz, Germany) was introduced as a new supraglottic airway. It was designed to allow either spontaneous breathing or controlled ventilation during anaesthesia; additionally it may serve as an alternative to endotracheal intubation, or bag-mask ventilation during resuscitation. Several variations of this supraglottic airway exist. In our study, we compared ventilation with the laryngeal tube suction for single use (LTS-D) and a bag-mask device. One of the main points of the revised ERC 2005 guidelines is a low no-flow-time (NFT). The NFT is defined as the time during which no chest compression occurs. Traditionally during the first few minutes of resuscitation NFT is very high. We evaluated the hypothesis that utilization of the LTS-D could reduce the NFT compared to bag-mask ventilation (BMV) during simulated cardiac arrest in a single rescuer manikin study. METHODS: Participants were studied during a one day advanced life support (ALS) course. Two scenarios of arrhythmias requiring defibrillation were simulated in a manikin. One scenario required subjects to establish the airway with a LTS-D; alternatively, the second scenario required them to use BMV. The scenario duration was 430 seconds for the LTS-D scenario, and 420 seconds for the BMV scenario, respectively. Experienced ICU nurses were recruited as study subjects. Participants were randomly assigned to one of the two groups first (LTS-D and BMV) to establish the airway. Endpoints were the total NFT during the scenario, the successful airway management using the respective device, and participants' preference of one of the two strategies for airway management. RESULTS: Utilization of the LTS-D reduced NFT significantly (p < 0.01). Adherence to the time frame of ERC guidelines was 96% in the LTS-D group versus 30% in the BMV group. Two participants in the LTS-D group required more than one attempt to establish the LTS-D correctly. Once established, ventilation was effective in 100%. In a subjective evaluation all participants preferred the LTS-D over BMV to provide ventilation in a cardiac arrest scenario. CONCLUSION: In our manikin study, NFT was reduced significantly when using LTS-D compared to BMV. During cardiac arrest, the LTS-D might be a good alternative to BMV for providing and maintaining a patent airway. For personnel not experienced in endotracheal intubation it seems to be a safe airway device in a manikin use.

[Emergency care management of patients with cancer at the final stage of disease--seven cases]. / Notärztliche Betreuung von Tumorpatienten--Sieben Fälle aus der finalen Krankheitsphase.

The care of patients with cancer disease in the final stage amounts to 2.5% of all emergency-medical applications. This corresponded to the number of pediatric emergency cases. For this every emergency physician can be involved in the care of those patients. Emergency physicians may allow adapted treatment in the will or supposed will of the patient always. Therefore it is necessary to know special legal bearings of the case. We analysed seven emergency cases with patients in the final stage of their cancer disease retrospectively. For this we present seven different emergency cases with different regulatory framework for each emergency physician. The cases have shown seven possible care concepts of patients in the final stage of a cancer disease. All patients could be categorised as palliative ones. Nevertheless, the emergency physicians were alarmed by the patients' relatives because of needing professional help at the moment. The differences of the cases appeared in the regulatory framework. The seven cases have shown that different legal meanings could be important in emergency therapy of palliative patients.

Post-mortal bereavement of family caregivers in Germany: a prospective interview-based investigation.

BACKGROUND: Care aspects of outpatient palliative-care teams involve the medical, psychological, and spiritual needs of patients and their caregivers. The objective of our study was to examine the post-mortal bereavement of family caregivers. METHODS: The investigation was based on interviews with 50 family caregivers of 50 palliative-care patients assessed by a palliative-care team. Each caregiver was interviewed using interview sheets (mixed method designs) in accordance with three groups of validated criteria for complicated grief: Prigerson, Horowitz, and ICD-10. RESULTS: Forty-six family caregivers of terminally ill patients participated in the study. Complicated grief existed in up to 30% of the caregivers, based on the three sets of criteria. There was no significant difference (P > 0.05) among the three groups and no significant differences were found (P > 0.05) in relation to age, sex, psychosocial distress, primary cancer disease, and duration of illness or quality of care. Overall, 97% of the care-giving relatives were satisfied with the help given by the palliative-care team. CONCLUSION: The results of the study suggest that care from a specialized palliative-care team providing psychological and social support may reduce the risk of complicated grief. Careful exploration of possible risk factors for complicated grief is important for optimal care. Our study shows that healthcare providers play an important role in helping family caregivers to manage the multiple burdens and the grieving reaction. Family-focused grief therapy may prevent complicated grieving reactions.

[Emergency outpatient palliative care in acute situations by paramedics]. / Betreuung von Palliativpatienten in Akutsituationen durch Rettungsassistenten.

BACKGROUND: In recent years outpatient palliative care, even for patients in an advanced state of their disease, has gained importance. Therefore, also paramedics are more often confronted with palliative emergencies, advance directives, and ethical end-of-life issues. Presently in emergency medicine there is undoubtedly a lack of education on palliative medicine and ethical questions for paramedics. METHODS: In a period of six months we questioned 250 paramedics from two German regions (Göttingen and Braunschweig) about their experiences in palliative medicine, palliative emergencies and about their knowledge of advance directives. For these key questions we drew up a specific questionnaire. RESULTS: The response rate in the set period of time amounted to 64.8% (n = 162). Most of the interviewed paramedics (91.4%, n = 148) had been confronted with palliative emergency situations on duty. 47.6% felt uncertain about the correct psychosocial care of the patients. 84% of the paramedics were insecure concerning their knowledge about advance directives. 72.8% had already taken care of patients with advance directives. These advance directives had influenced their therapy decision in 42.8%. CONCLUSION: The emergency treatment of palliative patients can present a particular challenge to paramedics. Most of the interviewed paramedics felt insecure both about the social care and the assessment of legal issues in dealing with advance directives and decisions at the end of life. Therefore emergency medical training apparently needs to be improved in these fields. Further information and training are necessary to guarantee adequate patient-oriented care of palliative patients und their relatives also in emergency situations.