Effects of a communication training for oncologists on early addressing palliative and end-of-life care in advanced cancer care (PALLI-COM): a randomized, controlled trial.

INTRODUCTION: In advanced cancer care, early communication about palliative care (PC) and end-of-life (EoL)-related issues is recommended, but is often impeded by physicians' communication insecurities. We investigated the effect of a newly developed compact communication skills training 'PALLI-COM' on oncologists' competencies to early address PC/EoL-related issues. MATERIALS AND METHODS: We conducted a randomized, controlled trial (RCT) with an intervention group (IG; 2 × 90 min training) and a wait list control group (CG) at five sites. At two assessment points, participating oncologists led videotaped medical consultations with simulated patients (SPs) via a privacy compliant video conference platform. SPs were represented by trained actors. The taped conversations were rated for primary outcome (communication skills assessed by adapted COM-ON-checklist and COM-ON-coaching rating scales) by raters blinded for study group. Secondary outcomes included oncologists' self-reported communication skills (Self-Efficacy in Palliative Care Scale, Thanatophobia-Scale, Communication about End of Life Survey, study-specific items) as well as external rating of the SPs. Univariate analyses of covariance with baseline adjustment were used to analyze intervention effects. RESULTS: A total of 141 oncologists [age: mean (standard deviation) = 32.7 (6.3) years, 60% female (nIG = 73, nCG = 68)] participated. Following intervention, the IG showed significantly more improvement in four out of five assessed communication skills: 'reacting to emotions and showing empathy', 'pointing out opportunities and giving hope', 'addressing the EoL' and 'explaining the concept of PC'. IG participants also improved more than CG participants in almost all secondary outcomes assessed by participants and SPs: oncologists' self-efficacy, attitudes towards caring for terminally ill patients, communication strategies and confidence in dealing with PC/EoL-related issues as well as communication quality from the SPs' perspective. CONCLUSION: Findings indicate that the compact communication skills training PALLI-COM increases oncologists' competencies in early addressing PC/EoL-related issues from different perspectives. Implementation in routine oncology residency might improve advanced cancer care by strengthening these communication skills.

[Virtual palliative care : Pilot study of an electronic tool to test cognitive, psychomotor and affective palliative medical and pain therapeutic learning contents during medical training]. / Virtuelle Palliativversorgung : Pilotierung eines elektronischen Tools zur Prüfung kognitiver, psychomotorischer und affektiver palliativmedizinischer und schmerztherapeutischer Lerninhalte während der ärztlichen Ausbildung.

BACKGROUND: This article describes a first use of an electronic case-based assessment tool in undergraduate palliative care education. It describes the development of the tool presenting strengths and shortcomings in order to contribute to an innovative design of assessment tools in medical education. DESIGN AND METHOD: An electronic (virtual) case-based assessment tool (the virtual palliative patient, vPp) was developed. Palliative care levels of knowledge, skills and attitude of students were tested at a computer workplace as a voluntary and non-performance-relevant pilot project at four faculties. RESULTS: On average the students achieved 80% of the points using the vPp tool, which is below the average score of 91% achieved in the regular examination. In particular, the free text task on reflection of dealing with the patient's death wish caused uncertainty, while multiple choice questions and an interactive conversation sequence were perceived as relatively easy. Technical problems were also identified in the evaluation but overall the concept was evaluated positively and establishment as a regular examination or e­learning tool was desired. CONCLUSION: The implementation of an innovative assessment tool in medical education is technically challenging. A coordination with contents of the individual faculties is necessary in order that students do not have a feeling of a lack of preparation. The development of the vPp describes an innovative assessment format. In the long term, all interested faculties could receive a form of toolbox containing the technical framework of the assessment tool, which can then be fed with new contents.

[Anticancer therapy for symptom relief? : A systematic review of clinical trials in oncology]. / Symptomlinderung durch Tumortherapie? : Eine systematische Übersicht über onkologische Therapiestudien.

BACKGROUND: When patients suffer from incurable cancer, drug-based, systemic anticancer therapy is usually used with the aim of longer survival, while minimizing toxicity and ensuring a tolerable quality of life. It is unclear to what extent and with what degree of success systemic tumor therapy can be used to specifically improve pre-existing pain and an already compromised quality of life (QoL). METHODS: Therefore, a systematic review of oncological therapy studies (PubMed) was conducted. Only studies that identified the pain-relieving and QoL-enhancing effects of systemic anticancer therapy as the primary endpoint were selected and evaluated descriptively. RESULTS: Of the 2229 abstracts identified using a piloted search string, only 13 studies met the inclusion criteria. Of these, 10 studies showed an improvement in QoL-parameters through the use of systemic tumor therapies. DISCUSSION: Only a few studies focused primarily on the improvement of parameters related to quality of life-although this is the primary therapeutic goal for many patients suffering from incurable and advanced cancer. The study results encourage regular inclusion of symptom- and QoL-related data in clinical studies and to more explicitly address the potential of systemic anticancer therapy in relieving pain and other symptoms, thereby supporting the goals of palliative care.

Palliative home care for patients with advanced haematological malignancies-a multicenter survey.

Patients with advanced haematological malignancies in non-curative settings suffer from complex physical symptoms and psychosocial distress, comparable to patients with solid tumour entities. Nevertheless, numerous problems at the interface between haematology and palliative home care have been described. From January 2011 until October 2014, we performed a retrospective, multicenter analysis of all patients with haematological malignancies (ICD 10: C81-C95) being treated by the respective specialized palliative home care (SAPV) team. Three SAPV teams were surveyed. Disease entity, physical symptoms, psychosocial distress, number of hospital admissions, therapeutic interventions and other items were analysed descriptively. Of 3,955 SAPV patients, 1.8% (n = 73) suffered from haematological malignancies. Main problems were deterioration of general condition, pain or psychological problems. Thirty-seven percent developed new symptoms during SAPV, mainly pain, psychological distress or deterioration of general status. In 33%, patients were referred to hospital, mainly due to deterioration of general condition or pain. Seventy percent died within 3 months after beginning SAPV care; 83% died at home or in a nursing home. Patients suffering from advanced haematological malignancies were statistically underrepresented in SAPV, and SAPV was installed rather at the very last days of life. By far, more patients were able to die outside a hospital as compared to reference cohorts of haematological patients not being treated in SAPV. The spectrum of documented problems is comparable to other patient cohorts being treated in SAPV; therefore, the options and benefits of palliative home care should be incorporated in palliative haematological treatment concepts more vigorously and consequently.

[Choosing wisely at the end of life : Recommendations of the German Society for Palliative Medicine (DGP)]. / Klug entscheiden am Lebensende : Empfehlungen der Deutschen Gesellschaft für Palliativmedizin (DGP).

In addition to an overuse of unnecessary or no longer indicated diagnostic or therapeutic procedures at the end of life in the sense of overtreatment, there is often also a lack of therapeutic awareness in terms of a healthcare deficit, for example concerning the recognition and treatment of symptoms and complex burden of the disease. Sticking closely to the methodology of the German S3 "Palliative Medicine" guideline, the Choosing wisely recommendations of the German Society for Palliative Medicine address various examples of over- and underuse of healthcare services and treatment at the end of life, and thus also mirror basic principles of palliative medical care.

[Characteristics of Patients with Breathlessness]. / Charakteristika von Palliativpatienten mit Atemnot.

Background Breathlessness is a common and distressing symptom in patients with advanced life-limiting disease. The aim of this study was to describe demographical and clinical characteristics of patients with breathlessness in Germany. Methods We conducted a secondary analysis of hospice and palliative care inpatient data from 2006 to 2008. The Hospice and Palliative Care Evaluation (HOPE) is an annual prospective German survey, that includes a validated 16-item symptom-and-problem checklist (severity score 0 - 3). Characteristics of patients with or without breathlessness were compared in a pure descriptive manner. Interpretation of given p-values takes the error inflation due to multiple testing into account. Results Breathlessness was recorded in 2860/5320 (53.8 %) patients (mean age 67.2 years (SD 12.4), 51.4 % female, 93.6 % malignant disease (female/male lung cancer 15.7/29.5 %, breast cancer 20.3/0.3 %, colon 10.3/8.7 %). Breathless patients compared with those without breathless ness had a significantly worse functional status (ECOG 3 - 4: 78.4 % vs. 70.8 %, p < 0.001), suffered from a larger number (11.1 vs. 9.5, p < 0.001) of symptoms and the symptoms were of higher intensity (except confusion). Breathless patients had a higher risk to die during inpatient stay (43.5 % vs. 32.4 %, p < 0.001). Conclusion Based on this large sample of hospice and palliative care inpatients, breathlessness is associated with a high symptom burden and shortened survival. Breathless patients need more attention in health care.

[Characteristics of patients with breathlessness - results of the german hospice and palliative care evaluation]. / Charakteristika von Palliativpatienten mit Atemnot.

BACKGROUND: Breathlessness is a common and distressing symptom in patients with advanced life-limiting disease. The aim of this study was to describe demographical and clinical characteristics of patients with breathlessness in Germany. METHODS: We conducted a secondary analysis of hospice and palliative care inpatient data from 2006 to 2008. The Hospice and Palliative Care Evaluation (HOPE) is an annual prospective German survey, that includes a validated 16-item symptom-and-problem checklist (severity score 0-3). Characteristics of patients with or without breathlessness were compared in a pure descriptive manner. Interpretation of given p-values takes the error inflation due to multiple testing into account. RESULTS: Breathlessness was recorded in 2860/5320 (53.8 %) patients (mean age 67.2 years (SD 12.4), 51.4 % female, 93.6 % malignant disease (female / male lung cancer 15.7/29.5 %, breast cancer 20.3/0.3 %, colon 10.3/8.7 %)). Breathless patients compared with those without breathless ness had a significantly worse functional status (ECOG 3-4: 78.4 % vs. 70.8 %, p < 0.001), suffered from a larger number (11.1 vs. 9.5, p < 0.001) of symptoms and the symptoms were of higher intensity (except confusion). Breathless patients had a higher risk to die during inpatient stay (43.5 % vs. 32.4 %, p < 0.001). CONCLUSION: Based on this large sample of hospice and palliative care inpatients, breathlessness is associated with a high symptom burden and shortened survival. Breathless patients need more attention in health care.

[Student assessments in palliative medicine as the cross-disciplinary subject 13: Survey of 34 medical faculties in Germany]. / Prüfungen im Querschnittsbereich Palliativmedizin (QB 13) : Befragung an 34 medizinischen Fakultäten in Deutschland.

BACKGROUND: In 2009 palliative medicine was integrated into the undergraduate curriculum as cross-disciplinary subject 13 and is now part of mandatory education in German medical faculties (MF). Surveys across German MFs have shown an inhomogeneous development of this cross-disciplinary subject. The aim of this study was to assess the current state and the needs in terms of assessments in the cross-disciplinary subject 13 at German MFs. MATERIAL AND METHODS: Palliative care coordinators at German MFs were surveyed by using a standardized telephone interview. Closed-ended questions were analyzed by descriptive analysis and open-ended questions by content analysis. RESULTS: A total of 34 out of 36 MFs participated. Multiple choice tests were the major form of assessment (94.1%) and 9 MFs planned to implement another form of assessment, mainly an objective structured clinical examination (OSCE) station (55.5%). The majority of the MFs (91.2%) had no blueprint to develop assessments but conducted a review (78.8%) afterwards. A successful implementation of the assessment was mostly achieved when the concept of the assessment was felt to be suitable. The lack of human resources was found to be the most relevant obstacle for the implementation of a practical assessment format. CONCLUSION: The major form of assessment in palliative care is still a written examination, especially multiple choice tests. This format is considered to be of limited value for assessing communicative competencies and attitudes in palliative medical care. Further steps should include the development of a competence-based assessment that is also feasible for smaller MFs with limited resources.

[Knowledge and attitude of medical students in Germany towards palliative care : Does the final year of medical school make a difference?]. / Wissen und Selbsteinschätzung in Bezug auf palliativmedizinische Fragestellungen bei Medizinstudierenden : Macht das praktische Jahr einen Unterschied?

BACKGROUND: The practical year (PY) during the final year of medical education is intended to deepen and broaden knowledge, skills, and abilities that were acquired during previous years of their studies. Against this background, this study pursues the question of how the knowledge of future physicians and their confidence in terms of cancer pain therapy and other palliative care issues develops during the PY. MATERIALS AND METHODS: At the end of the PY, students from two university hospitals completed a 3-part online questionnaire (self-assessment of the confidence, questions about palliative care knowledge, and assessment of palliative care training during the PY). These results are compared with previously published data from the same collective that had been collected at the beginning of the PY. RESULTS: Overall, 92 of 318 students participated (28.9 %). Less than 10 % of students said that they were more confident regarding palliative care topics at the end of their medical studies. Improvements in the self-assessment could only be observed in the recognition of and screening for cancer pain (increase from 36 % to 65%). With regard to the palliative care knowledge, only the knowledge of how to treat symptoms other than pain improved significantly; however, knowledge in this regard prior to the PY was particularly low (an increase from 25 % to 35 %, p < 0.05). In the only multiple-choice question about ethics, the correct answer rose slightly from 51 % (before) to 55 % (after the PY). Of participating students, 21% (prior to the PY 27 %) stated that not providing fluids to dying patients is a form of euthanasia. In terms of palliative care training, between 36 and 83 % of participants stated having insufficient opportunities to gain knowledge and experience on various topics in the treatment of patients with advanced and incurable diseases during their PY. CONCLUSION: In the present study, considerable deficits in confidence and knowledge regarding palliative care issues were also observed at the end of PY. Integration of palliative care into the medical school curriculums should be given special attention in terms of a longitudinal training of the PY.

[Pain medicine as a cross-sectional subject in German medical schools. An opportunity for general pain management]. / Das Querschnittsfach "Schmerzmedizin". Chance für die Allgemeine Schmerzmedizin.

BACKGROUND: Unrelieved pain is a substantial public health concern owing in part to deficits in clinical expertise among physicians. In most medical faculties worldwide, teaching on pain and pain management is either nonexistent or limited to a small number of students attending voluntary courses. In light of the fact that pain is the most frequent reason to seek medical advice, the lack of formal training of pain medicine is considered the leading reason for inadequate pain management. Therefore, the patients' unmet needs for adequate diagnosis and therapy call for action. SITUATION: Pain assessment and effective pain management should be a priority in the health care system. The limited number of pain specialists available in hospitals and primary care and CME (continuous medical education) activities focusing on pain are not sufficient to solve the problem. Every practicing physician should, therefore, have basic knowledge of the most prominent painful conditions and management strategies. To achieve this goal, pain medicine should become an integral part of the undergraduate curriculum for medical students. In Germany, pain medicine became a mandatory subject in undergraduate medical studies in 2012. PERSPECTIVE: The introduction of pain medicine into the undergraduate curriculum in Germany is a major challenge regarding the development and implementation processes. This article describes current instruments and implementation strategies for pain medicine as a new cross-sectional subject in Germany.

'Curative' treatments and palliative care: the lack of consensus.

PURPOSE OF REVIEW: A survey was performed to assess whether authors who report about palliative treatments or palliative care share a common understanding of 'curative' treatments. RECENT FINDINGS: Of 107 authors from publications about cancer who used both 'palliative' and 'curative' in the same abstract, 42 (39%) responded. The majority (n=24; 57%) understood 'curative' treatments as 'aimed at complete absence of disease for the rest of life', but 43% (n=18) did not share this view. For example, 19% (n=7) stated that the term describes cancer-directed therapy for prolongation of life or even regardless of the aspired goal. SUMMARY: In the care for cancer patients, unambiguous terminology is essential for the participatory and interdisciplinary decision-making process. Clinicians, researchers and policy makers should be aware of the difference between curative and disease-modifying therapies. Otherwise, this may be a major source of misunderstandings as disease-modifying therapy may be indicated in the incurable stages of the disease as well. In these palliative situations, it is essential to identify the realistic aim(s) of the therapy: prolongation of life, alleviation of suffering or both.

[Pain therapy in oncology: results of a nationwide survey]. / Schmerztherapie in der Onkologie : Ergebnisse einer bundesweiten Umfrage.

BACKGROUND: Pain is one of the most prevalent and distressing symptoms of patients suffering from cancer. In the field of oncology comprehensive expertise is pursued not only with respect to the administration of anticancer treatment but to all fields that relate to the needs of cancer patients. However, the results of studies have revealed persisting and relevant deficits in pain therapy in the setting of oncology. MATERIALS AND METHODS: An online survey was performed involving all members of the German Society for Hematology and Medical Oncology (DGHO) with respect to training and continuing education in pain therapy, the relevance for routine oncology and knowledge, to determine the level of expertise in pain therapy and the assessment of tumor-specific therapy. RESULTS: A total of 183 out of 1,962 questionnaires could be evaluated. Oncologists are often engaged in pain therapy and 80 % of the respondents perceived themselves as being primarily responsible for pain control. Education and assessment were identified as barriers to sufficient pain therapy. Case vignettes revealed only few relevant therapeutic misinterpretations. CONCLUSION: This first survey of German oncologists exploring expertise in cancer pain therapy, showed similar problems in education and pain assessment as previous international studies. Despite the claimed responsibility for pain management, there were a small but relevant number of oncologists who showed serious therapeutic misinterpretations in case studies.

Fractionated external beam radiotherapy of skull base metastases with cranial nerve involvement.

BACKGROUND AND PURPOSE: Skull base metastases frequently appear in a late stage of various tumor entities and cause pain and neurological disorders which strongly impair patient quality of life. This study retrospectively analyzed fractionated external beam radiotherapy (EBRT) as a palliative treatment approach with special respect to neurological outcome, feasibility and acute toxicity. PATIENTS AND METHODS: A total of 30 patients with skull base metastases and cranial nerve disorders underwent EBRT with a mean total dose of 31.6 Gy. Neurological status was assessed before radiotherapy, during radiotherapy and 2 weeks afterwards categorizing orbital, parasellar, middle fossa, jugular foramen and occipital condyle involvement and associated clinical syndromes. Neurological outcome was scored as persistence of symptoms, partial response, good response and complete remission. Treatment-related toxicity and overall survival were assessed. RESULTS: Before EBRT 37 skull base involvement syndromes were determined with 4 patients showing more than 1 syndrome. Of the patients 81.1 % responded to radiotherapy with 10.8 % in complete remission, 48.6 % with good response and 21.6 % with partial response. Grade 1 toxicity of the skin occurred in two patients and grade 1 hematological toxicity in 1 patient under concurrent chemoradiotherapy. Median overall survival was 3.9 months with a median follow-up of 45 months. CONCLUSION: The use of EBRT for skull base metastases with symptomatic involvement of cranial nerves is marked by good therapeutic success in terms of neurological outcome, high feasibility and low toxicity rates. These findings underline EBRT as the standard therapeutic approach in the palliative setting.

[Implementation of intersectional field 13: a survey of medical faculties in Germany]. / Implementierung des Querschnittsbereichs 13: Umfrage an den medizinischen Fakultäten in Deutschland.

BACKGROUND: In 2013 palliative medicine (PM) will be integrated into the undergraduate curriculum as part of the mandatory education in German medical universities. The aim of this study is to determine the current state of implementation at German medical faculties (MF). METHODS: All German MFs were contacted using a written postal survey in June 2012. RESULTS: A total of 32 out of 36 MFs participated. Teaching staff consists of 15 or more lecturers in 8 MFs (30 %) and includes psychologists in 24 MFs (75 %) and also nurses in 18 MFs (56 %). Participating physicians are specialized in anesthesiology, internal medicine and general medicine. Teaching staff include palliative outpatient (20 MFs, 63 %) and consultation services (22 MFs, 69 %). Bedside teaching is provided in 15 MFs (47 %). Multiple choice tests are the major form of assessment (29 MFs, 84 %). The total number of teaching units in PM is between 12 and 43 and is usually provided at the end of medical school education. Nurses are employed in the education significantly more in MFs with a chair in PM. General practitioners were engaged only by faculties without a chair in PM. CONCLUSIONS: The implementation of the mandatory training in PM at MFs in Germany is inhomogeneous. Further steps include in particular the development of a competence-based curriculum and assessment.

[Treatment of nausea and vomiting with 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatinantagonists, benzodiazepines and cannabinoids in palliative care patients : a systematic review]. / Behandlung von übelkeit und erbrechen mit 5HT3-antagonisten, steroiden, antihistaminika, anticholinergika, somatostatinanaloga, benzodiazepinen und cannabinoiden bei palliativpatienten : ein systematisches review.

BACKGROUND: Various recommendations exist for the treatment of nausea and vomiting in palliative care but only few studies and even less systematic reviews look into antiemetic therapy for patients receiving palliative care. OBJECTIVES: This systematic review aims to analyze the current evidence for antiemetic treatment with 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatin analogs, benzodiazepines and cannabinoids in palliative care patients with far advanced cancer not receiving chemotherapy or radiotherapy, acquired immune deficiency syndrome (AIDS), chronic obstructive pulmonary disease (COPD), progressive heart failure, amyotrophic lateral sclerosis (ALS) or multiple sclerosis (MS). Results regarding evidence of treatment with prokinetic and neuroleptic agents will be published separately. METHODS: The electronic databases PubMed and EmBase were systematically searched for studies (published 1966-2011) dealing with antiemetic therapy in palliative care and electronic retrieval was completed by manual searching. Studies with patients undergoing chemotherapy or radiotherapy, pediatric studies and studies published in languages other than English or German were excluded. Studies addressing therapy with 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatin analogs, benzodiazepines or cannabinoids were identified and selected for this systematic review. RESULTS: In the general search 75 relevant studies were found. Of those 36 addressed 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatin analogs, benzodiazepines and cannabinoids, 13 considered 5HT3 receptor antagonists, 10 somatostatin antagonists, 9 steroids, 5 cannabinoids, 4 anticholinergics, 1 antihistamines and none benzodiazepines. Furthermore six systematic reviews exist. Evidence for any drug used as an antiemetic is low. Concerning 5HT3 receptor antagonists data are insufficient for recommendations on the treatment of patients with AIDS and MS due to the small size of included patient groups. For patients with cancer contradictory results were published: the larger studies showed a positive effect of 5HT3 receptor antagonists and better efficacy, as compared to metoclopramide, dexamethasone and neuroleptics. Heterogeneous results were found for steroids, with a positive trend for patients with cancer. Data are insufficient for antihistamines. Studies prove effectiveness of butylscopolammonium in the treatment of nausea and vomiting caused by malignant gastrointestinal obstruction, whereas octreotide is superior to butylscopolammonium. Regarding benzodiazepines for symptom control of nausea and vomiting in palliative care patients no studies were detected. Cannabinoids were found to relieve nausea and vomiting in patients with cancer and AIDS but with notable side effects. Furthermore, the studies compared cannabinoids to less recent antiemetic drugs but not, for example to 5HT3 receptor antagonists. Regarding symptom control of nausea and vomiting in patients with COPD, progressive heart failure and ALS no studies were undertaken in patients receiving palliative care. CONCLUSIONS: In palliative care patients with nausea and vomiting 5HT3 receptor antagonists can be used if treatment with other antiemetics, such as metoclopramide and neuroleptics is not sufficient. There is a trend that steroids in combination with other antiemetics improve symptom relief. Cannabinoids rather have a status as a second line antiemetic. In cases of nausea and vomiting caused by malignant gastrointestinal obstruction octreotide showed the best and butylscopolammonium bromide the second best results. Concerning antihistamines and benzodiazepines insufficient data was found. Recommendations in the literature are mainly based on studies in patients with cancer. The overall strength of evidence is low. More well designed studies in palliative care patients are needed in order to provide evidence-based therapy. The English full text version of this article will be available in SpringerLink as of November 2012 (under "Supplemental").

[Treatment of nausea and vomiting with prokinetics and neuroleptics in palliative care patients : a review]. / Behandlung von übelkeit und erbrechen mit prokinetika und neuroleptika bei palliativpatienten : ein review.

BACKGROUND: Many recommendations concerning the treatment of nausea and vomiting in palliative care patients exist but what is the evidence for this? Most studies dealing with this topic have focused on cancer patients under chemotherapy and/or radiation therapy or on patients with postoperative nausea. Cancer patients without chemotherapy or radiation therapy, patients without postoperative nausea, and patients having other diseases with palliative care aspects, such as acquired immunodeficiency syndrome (AIDS), chronic obstructive pulmonary disease (COPD), progressive heart failure, amyotrophic lateral sclerosis (ALS) and multiple sclerosis (MS) have been underrepresented in studies on nausea and vomiting so far. OBJECTIVES: The aim of this review was to determine the level of evidence for the treatment of nausea and vomiting with prokinetics and neuroleptics in palliative care patients suffering from far advanced cancer and no longer being treated with chemotherapy or radiation therapy, AIDS, COPD, progressive heart failure, ALS or MS. METHODS: Two different electronic databases (PubMed und Embase) were used to identify studies. Furthermore, a hand search for related articles was performed. No restriction was made concerning study types. Studies with patients undergoing chemotherapy radiation therapy or suffering from postoperative nausea, pediatric studies and studies published neither in English nor in German were excluded. RESULTS: A total of 30 studies fulfilling the inclusion criteria were found. All studies focused on cancer patients. Despite intensive research studies in patients with AIDS, COPD, heart failure, ALS or MS were not detected. Metoclopramide is seen as an effective drug in many studies whereas the evidence for it is moderate at best. Within the group of neuroleptics, levosupiride and levomepromazine seem to have good antiemetic potential but the evidence level is low. CONCLUSION: In patients with advanced cancer not being treated with chemotherapy or radiation therapy, metoclopramide can be used to reduce nausea and vomiting. Neuroleptics, such as levosulpiride or levomepromazine are alternatives but their adverse effects have to be considered carefully. The evidence level for prokinetics and neuroleptics is moderate to low. Concerning palliative care of patients with diseases other than cancer no studies exist. More well designed studies in palliative care patients are needed in order to facilitate evidence based antiemetic therapy. The English full text version of this article will be available in SpringerLink as of November 2012 (under "Supplemental").

[Methods and development of therapy recommendations for symptom control in palliative medicine]. / Methodik und entwicklung von therapieempfehlungen zur symptomkontrolle in der palliativmedizin.

The Drug Commission of the German Medical Association has decided to develop treatment guidelines for palliative care. A series of systematic reviews was commissioned to evaluate the evidence for interventions of common symptoms that burden patients and care givers. A common methodology for all reviews is described in this paper. The methodology was based on the work of the European Palliative Care Research Collaborative. Standardized search strategies were identified in PubMed and Embase and these templates were then adapted by the authors of the reviews according to their needs. The template included the target group (patients and disease entities), indications (symptoms) and interventions (medicines and classes of medicines). Target groups included search terms on palliative or hospice care, cancer, neurodegenerative diseases, HIV/AIDS as well as cardiac and pulmonary failure. The number of relevant hits was surveyed in the first 40 hits in some exemplary searches. This was used for fine tuning the search templates and to optimize the search strategy in order to achieve the highest possible yield with the minimum possible effort. The review series was performed using this search strategy. Every review graded the quality of the included evidence following categories of the Drug Commission of the German Medical Association. Based on these results and recommendations the treatment guidelines will be formulated which will offer concise and evidence-based guidelines for general palliative medicine, offering primary care givers guidance for adequate palliative care in severely ill and dying patients. The English full text version of this article will be available in SpringerLink as of November 2012 (under "Supplemental").

Anticancer therapies in specialized palliative care--a multicenter survey.

INTRODUCTION: Anticancer therapies gain increasing attention and discussion in specialized palliative care institutions. Frequency, indication, attitude of team members, and modes of these therapies implemented in specialized palliative care settings are still under investigation. METHODS: Descriptive analysis of the nationwide Hospice and Palliative Care Evaluation 2007 that collected data from palliative medicine, hospice care, and oncology institutions concerning the use of anticancer therapies. RESULTS: Three thousand one hundred eighty-four patients from 67 palliative care units, eight oncology wards, and other in- and outpatient institutions were registered. Two hundred eleven therapeutic interventions, mostly i.v. chemotherapy (28.9%), have been documented in all institutions except from inpatient hospices. Although all institutions were asked to keep records from "palliative patients", those patients treated in oncology services differed from patients on palliative care units with respect to prognosis, therapeutic intention (symptom control versus tumor remission), and team attitude. DISCUSSION: Anticancer therapies are incorporated into palliative care concepts. The described differences in palliative patients that are treated in specialized palliative care as compared to oncology services will have to be discussed with regard to selection of patients for specialized palliative care and the range of suitable treatment modalities in palliative care concepts.

[How much diagnostics is required in palliative care? Results from a representative survey and own experiences]. / Wieviel Diagnostik braucht die Palliativmedizin? Ergebnisse einer multizentrischen Studie und Fallserie.

BACKGROUND: Applying diagnostic techniques in palliative care (PC) requires a thorough balance between a physical, psychosocial (and financial) burden and its therapeutic relevance in far advanced diseases. The extent of diagnostic employment in PC, preferred techniques, application problems, its informative value and therapeutic significance still have to be described. METHODS: The Hospice and Palliative Care Evaluation (HOPE) 2007 collected data from the application of microbiological and imaging techniques in German PC institutions. Furthermore, 70 consecutive ultrasound scans in our PC unit have been retrospectively analyzed.In 691 PC patients (from a total of 3184 in HOPE), diagnostic techniques (DIA) were applied and documented. RESULTS: In-patients with DIA (86,1 %) and the HOPE collective showed a comparable age and duration of hospital stay. Microbiological techniques contributed to 26,1 % of all documented in-patient investigations, imaging techniques 69,1 %. Ultrasound was the preferred imaging technique on PC units (67,1 %), whilst radiography, CT or MRI scans were rather employed on oncology wards. Nuclear imaging was rarely documented. In 80,8 %, imaging diagnostics were considered relevant for further treatment decisions (in-patients only); transportation problems and pain during imaging were relevant obstacles. In our own patient cohort, ultrasound was applied rather for general prognostic purposes, less often resulting in immediate therapeutic actions. Transportation problems could be almost entirely avoided by using a mobile ultrasound device. CONCLUSION: DIA in PC are applied independently of age or duration of hospital stay; its therapeutic significance is considered to be high; procedural problems may be resolvable. Therefore, this survey might challenge the tradition of low technology in PC.

[Venous thrombembolism in tumour patients]. / Venöse Thrombembolien bei Tumorpatienten.

Venous thrombembolism (VTE) is one of the most frequent complication in cancer patients. The current options in prophylaxis and therapy have to be balanced against the risks of major bleeding and the burden for the patients. The Gesellschaft für Thrombose- und Hämostaseforschung, the Deutsche Gesellschaft für Palliativmedizin and the German speaking Societies of Hematology and Oncology have recently published guidelines on VTE in cancer patients. Recommendations include diagnostics, individual prophylaxis and treatment.