Serial murder in medical clinics and care homes. / Serientötungen in Kliniken und Heimen.

BACKGROUND: Serial murder in clinics and care homes have gained attention more than once in recent years. The strong yet quickly fading public outrage has not yet led to well-founded professional and health-political engagement with the topic. With few systematic studies conducted, knowledge about perpetrator-related and environment-related risk factors in the day-to-day context of healthcare is sparse. METHODS: Court cases of serial murder in clinics and care homes in Germany, Austria, and Switzerland that were concluded with a final verdict by February 2022 were investigated. Research materials consisted of court documents and observations made during the trials. The cases were evaluated with regard to the victims, crime scenes, methods of killing, perpetrators, and perpetrator motives. 12 serial murders involving 17 perpetrators were included in this study. RESULTS: Perpetrator-specific early warning signs included a pronounced insecurity in combination with a striving for prestige and power, which were accompanied by a loss of empathy. Reactions of the colleagues and supervisors of the perpetrators in the immediate professional environment included misjudgement, concern about one's own disadvantages, feared damage to the reputation of the institution, and insufficient willingness to clarify the situation. As a result, many initial murders went unsuspected and unreported so that the frequency of the criminal activity and the number of victims increased over time. CONCLUSION: More information about serial murder in clinics and care homes is necessary. Research efforts are needed to better assess the prevalence of such crimes and to develop appropriate preventive measures. Circumstances that enable such acts, risk factors, perpetrator profiles, and early-stage countermeasures must be comprehensively addressed in the context of education, training and further education.

[Practice of euthanasia among physicians and nurses in German hospitals]. / Praxis der Sterbehilfe durch Ärzte und Pflegekräfte in deutschen Krankenhäusern.

BACKGROUND: Active euthanasia and physician-assisted suicide are controversially discussed in Germany. Empirical studies are missing to estimate their respective incidence, including passive and indirect euthanasia in German hospitals. Physicians and nurses in German hospitals were surveyed regarding their practice of euthanasia and possible influence factors. METHOD: Information on euthanasia practice was obtained using descriptive terms and related definitions in an anonymous online survey. Participants' objective and subjective occupational situations and support of euthanasia were recorded. The final samples comprised N = 2507 physicians and N = 2683 nurses. RESULT: The practice of passive and indirect euthanasia was reported by a large number of physicians and nurses during the last 24 months, active euthanasia and assisted suicide was reported by substantially less participants. Variance among the practice of active euthanasia could be explained by occupational factors and the respective advocacy of euthanasia amongst other variables, but not by subjective burden. DISCUSSION: Euthanasia is practiced by physicians and nurses in German hospitals. The Incidence of different types of euthanasia and relevant influence factors are discussed considering methodical limitations.

[Open doors, open mind : Plea for an open treatment psychiatry]. / Open doors, open mind : Plädoyer für eine offene Versorgungspsychiatrie.

Patients who are committed against their natural will are regularly accommodated in closed wards in Germany. Only a few clinics treat patients who have been involuntarily committed on open wards. On the basis of own clinical experience and relevant study results, closed and open wards are compared with respect to the extent of aggression and coercive measures, the risks of absconding and suicide. Compared to open wards, closed wards are unlikely to reduce the risk of absconding, do not result in a decreased suicide rate and do not result in a reduction of aggressive behavior. In contrast, coercive measures seem to be practiced more frequently in closed wards. Therefore, the regular practice of accommodation in closed wards should be revised.

Aggression and violence in psychiatric hospitals with and without open door policies: A 15-year naturalistic observational study.

Aggressive behavior and violence in psychiatric patients have often been quoted to justify more restrictive settings in psychiatric facilities. However, the effects of open vs. locked door policies on aggressive incidents remain unclear. This study had a naturalistic observational design and analyzed the occurrence of aggressive behavior as well as the use of seclusion or restraint in 21 German hospitals. The analysis included data from 1998 to 2012 and contained a total of n = 314,330 cases, either treated in one of 17 hospitals with (n = 68,135) or in one of 4 hospitals without an open door policy (n = 246,195). We also analyzed the data according to participants' stay on open, partially open, or locked wards. To compare hospital and ward types, we used generalized linear mixed-effects models on a propensity score matched subset (n = 126,268) and on the total dataset. The effect of open vs. locked door policy was non-significant in all analyses of aggressive behavior during treatment. Restraint or seclusion during treatment was less likely in hospitals with an open door policy. On open wards, any aggressive behavior and restraint or seclusion were less likely, whereas bodily harm was more likely than on closed wards. Hospitals with open door policies did not differ from hospitals with locked wards regarding different forms of aggression. Other restrictive interventions used to control aggression were significantly reduced in open settings. Open wards seem to have a positive effect on reducing aggression. Future research should focus on mental health care policies targeted at empowering treatment approaches, respecting the patient's autonomy and promoting reductions of institutional coercion.

[Unreported Intentional Life-Ending Acts in Physicians and Nurses]. / Das Dunkelfeld intentional lebensbeendender Handlungen durch Ärzte und Pflegekräfte.

Introduction Intentional life-ending acts (LA) including euthanasia and termination of life without explicit request are illegal in Germany and have not been extensively studied. In a pilot study, unreported LA administered by physicians and nurses in German health care were explored. Methods All hospitals and nursing homes registered in 2015 (n = 13 393) were contacted via mail or e-mail and physician and nursing staff were asked to complete an anonymous online-survey or the identical attached paper-pencil questionnaire. 4629 participants, including physicians (n = 356), nurses (n = 3121) und geriatric nurses (n = 1152) from a predominant in-patient working area responded to questions about LA at their workplace, requests for euthanasia and performance of LA. Results 2.25 - 4.01 % (172 participants) of all physicians and nurses indicated to have heard of euthanasia at their workplace in the last 12 months and 1.42 - 3.39 % (77 participants) indicated to have performed LA themselves. LA was more frequently administered by male participants, physicians and on intensive care units. More than one third of all participants who had administered LA (38.10 - 41.67 %) were never asked for it. Discussion This pilot study indicates that beside legal forms of passive and indirect euthanasia, illegal intentional life-ending acts are administered by physicians and nurses in all health-care areas under investigation.

[Spurious pity--lethal consequences: how helpers turn into offenders]. / Falsches Mitleid - tödliche Konsequenzen: Wie aus Helfern Täter werden.

This study gives a general view of 40 cases of killing series by members of staff in health care professions in hospitals and homes. The main issue of the analyses are the nine killing series in the German language area. For the investigation legal documents concerning specific characteristics of victims, site of crime and offenders were evaluated. The respective fields of work were investigated concerning the working climate, the position of the offenders in their working group, conflicts in the work place and the handling of the first intern hints to suspective behaviour. It is derives from the case-by-case analyses if there are any preliminary warnings and if there are any commonalities with regard to the victims, the offenders and the respective fields of activity. Personal sensitivities, working conditions and permanent confrontation with human sufferings can be interlaced with each other in that way that the superficial motivation to help is abysmally reversed. In this repect a term of compassion, which confounds real sympathy and self-pity, is essential.

How therapists react to patient's suicide: findings and consequences for health care professionals' wellbeing.

OBJECTIVES: To test the robustness of the findings of previous studies in a large aggregated sample regarding (a) the impact of a patient's suicide on therapist's distress; (b) identify a potential subgroup of therapists needing special postvention; (c) and assess potential differences in overall distress between professional groups and at different levels of care. METHODS: A questionnaire, characterizing the therapists, their reactions and the patients, had been sent out to 201 psychiatric hospitals in Germany providing different levels of care. Aggregated data from previous studies have been used. RESULTS: In 39.6% of all cases, therapists suffer from severe distress after a patients' suicide. The global item "overall distress" can be used as an indicator to identify a subgroup of therapists that might need individualized postvention. No significant difference in overall distress experienced was observed between professional groups and at different levels of care. CONCLUSION: Our data suggest that identifying the severely distressed subgroup could be done using a visual analogue scale for overall distress. As a consequence, more specific, individualized and intensified help could be provided to these professionals, helping them to overcome distress and thereby ensuring delivery of high quality care to the patient.

The therapist's reaction to a patient's suicide: results of a survey and implicationsfor health care professionals'well-being.

BACKGROUND: A substantial proportion of therapists experience the loss of a patient to suicide at some point during their professional life. AIMS: To assess (1) the impact of a patient's suicide on therapists distress and well-being over time, (2) which factors contribute to the reaction, and (3) which subgroup might need special interventions in the aftermath of suicide. METHODS: A 63-item questionnaire was sent to all 185 Psychiatric Clinics at General Hospitals in Germany. The emotional reaction of therapists to patient's suicide was measured immediately, after 2 weeks, and after 6 months. RESULTS: Three out of ten therapists suffer from severe distress after a patients' suicide. The item "overall distress" immediately after the suicide predicts emotional reactions and changes in behavior. The emotional responses immediately after the suicide explained 43.5% of the variance of total distress in a regression analysis. LIMITATIONS: The retrospective nature of the study is its primary limitation. CONCLUSIONS: Our data suggest that identifying the severely distressed subgroup could be done using a visual analog scale for overall distress. As a consequence, more specific and intensified help could be provided to these professionals.