The German version of the Critical-Care Pain Observation Tool for critically ill adults : A prospective validation study.

BACKGROUND: The implementation of the Critical-Care Pain Observation tool (CPOT) in intensive care units (ICU) has been associated with more frequent pain assessments, a reduced number of complications, and improved administration of analgesics and sedatives. So far no German translation exists. Translating this tool into foreign languages requires further validation testing. OBJECTIVE: The aim of this prospective observational validation study was to translate the original version of the CPOT according to scientific principles for translation and to establish the validity and reliability of the German translation of CPOT for critically ill adult patients. MATERIAL AND METHODS: A total of 292 cardiac surgery patients from 2 ICUs of 2 German university teaching hospitals were included (114 patients at center 1 and 178 patients at center 2). Of the included patients 22.6% were female and 76.4% were male with a mean age of 68.5 years ±9.3 SD. Pain was evaluated with the CPOT, the Bhavioral Pain Scale (BPS) and with the Numeric Rating scale (NRS) at three time points (1. intubated + sedated, 2. intubated + awake, 3. extubated + awake) at rest and during nociceptive stimulus (positioning). Assessments were made separately by trained physicians and nursing staff. RESULTS: Good results for interrater reliability and internal consistency could be demonstrated (weighted Cohen's kappa of 0.73, Cronbach's coefficient alpha of 0.8). Spearman correlation between CPOT and NRS was moderate but significant. The receiver operating characteristic (ROC) analysis to obtain optimal thresholds of CPOT to detect pain revealed different results during rest and stimulus and in intubated and extubated patients. CONCLUSION: The validated German CPOT translation is a reliable tool for pain assessment in cardiac ICU patients in the absence of patients' ability for self-reporting. The use of this German version of CPOT now allows a better international comparability of corresponding data in future studies.

Embryonal tumors in Canadian children less than 36 months of age: results from the Canadian Pediatric Brain Tumor Consortium (CPBTC).

Embryonal tumors are a heterogeneous group of central nervous system (CNS) tumors whose subgroups have varying incidence and outcome. Despite these differences, they are often grouped as a single entity for study purposes. To date, there are no Canadian multi-institutional studies examining the incidence and outcome of all embryonal subtypes. The current study is an observational study reviewing embryonal tumors in all patients less than 36 months of age diagnosed with a CNS tumor in Canada from 1990 to 2005. Embryonal tumors accounted for 26.9% of all CNS tumors. Medulloblastomas were the highest proportion of the embryonal tumors at 61.5%. Atypical teratoid/rhabdoid tumors (AT/RT) had the second highest proportion of embryonal tumors at 18%. The proportion of primitive neuroectodermal tumors (PNET) was 16%, with 2.6 and 1.9% for congenital medulloepithelioma and ependymoblastoma tumors, respectively. AT/RT and PNET were more common in younger age groups. Medulloblastoma became more prevalent with increasing age, with its highest prevalence in the 25 to 36 month age group. Survival rates for our Canadian population at 18 and 24 months were 0.74 and 0.68 for medulloblastoma, 0.64 and 0.60 for PNET, and 0.36 and 0.29 for AT/RT, respectively. Overall, our data are comparable with published international rates for embryonal tumors. These incidence and outcome figures can guide future research into these rare tumors.

Does the use of the revised psychosocial assessment tool (PATrev) result in improved quality of life and reduced psychosocial risk in Canadian families with a child newly diagnosed with cancer?

OBJECTIVES: Early psychosocial screening may guide interventions and ameliorate the adverse psychosocial effects of childhood cancer. The revised psychosocial assessment tool provides risk information - Universal (typical distress), Targeted (additional specific distress), and Clinical (severe distress) - about the child with cancer and his or her family. This pilot study investigated the benefits of providing a summary of family psychosocial risk information to the medical team treating the newly diagnosed child (Experimental Group, EG). METHOD: We conducted a pilot randomized control trial with a sample of 67 parents, comparing the EG to the control group (CG) on parental perception of family psychosocial difficulties (revised psychosocial assessment tool risk levels), child behavior (behavior assessment scale for children-2), pediatric quality of life (PedsQL), and parental anxiety (state-anxiety scale of the state-trait anxiety inventory ), 2-4 weeks after diagnosis (Time 1) and 6 months later (Time 2). RESULTS: Compared to the CG, participants in the EG had significantly reduced targeted and clinical risk (p < 0.001), and improved pain related PedsQL at Time 2 (p < 0.05). Scores for PedsQL total and nearly all subscales improved over time in both groups (p < 0.05 to p < 0.001). No changes in behavior scores were noted. CONCLUSION: Preliminary findings suggest that providing a summary of the Psychosocial Assessment Tool to the treating team shortly after diagnosis may help reduce family wide psychosocial risk 6 months later and improve quality of life related to pain for children who are undergoing treatment for cancer.

External validity and reliability of the Psychosocial Assessment Tool (PAT) among Canadian parents of children newly diagnosed with cancer.

BACKGROUND: The Psychosocial Screening Tool (PAT) was developed and validated with a sample of caregivers of children newly diagnosed with cancer in the United States. This study aimed to assess cultural adaptation (Phase 1) and validity and reliability of the revised PAT (PATrev) with a Canadian sample (Phase 2). PROCEDURE: In Phase 1, a convenience sample of seven parents of children who were treated for cancer and six pediatric oncology healthcare experts participated. In Phase 2, 67 parents of children newly diagnosed with cancer from 4 Canadian pediatric cancer centers participated. To assess reliability and validity of the PATrev, parents completed behavioral (BASC-2) and quality of life (PedsQL) instruments about the child and an anxiety inventory (STAI) about themselves. RESULTS: The PAT required minor changes to be culturally adapted for the Canadian population. The PATrev had strong inter-rater (0.77) test-retest (0.75), and internal consistency reliability (0.85), as well as moderate to strong validity comparing PATrev child's problems and PedsQL total (-0.49), PedsQL anxiety (-0.47), BASC-2 internalizing (0.64), behavioral (0.63), and adaptive scores (-0.56). PATrev discriminative validity was confirmed with BASC-2 scores (AUR scores of 0.70-0.74). PATrev parental stressors were strongly correlated to STAI scores (0.53). Finally, agreement between PATrev child's problems and parental anxiety scores was moderate (0.47). CONCLUSION: This study supports the original PAT, demonstrates PATrev is a reliable and valid psychosocial screening tool, and provides unique evidence regarding early psychosocial risk in the family, which have important implications for guiding psychosocial practice.

[Lazarus phenomenon. Spontaneous return of circulation after cardiac arrest and cessation of resuscitation attempts]. / Lazarus-Phänomen. Spontane Kreislauffunktion nach beendeten Reanimationsmassnahmen.

BACKGROUND: In the medical literature the Lazarus phenomenon is defined as the spontaneous return of circulation (SROC) after cessation of cardio-pulmonary resuscitation. Based on published literature recommendations concerning the treatment of patients after cessation of resuscitation and reasons for the Lazarus phenomenon are discussed. METHODS: A literature search in Medline, PubMed, Embase, Google Scholar and Google from 1982 to 2009 was carried out for the terms "Lazarus phenomenon", "cessation of cardiopulmonary resuscitation and return of spontaneous circulation (ROSC)", "spontaneous return of circulation (SROC)", "resuscitation and spontaneous defibrillation", "spontaneous recovery and cardiopulmonary resuscitation". Related secondary literature which was cited in the relevant articles was included as well as publications found in our personal literature base. RESULTS: More than 10,000 articles and comments could be recovered and of these 45 were considered to be medically relevant articles (letters to the Editor, abstracts, case reports and literature reviews). CONCLUSIONS: In the relevant medical literature, the Lazarus phenomenon is a rare occurrence. It seems to be a phenomenon which has often been described in non-medical literature but not published in medical literature. The pathophysiological mechanisms are poorly understood. In the literature several mechanisms are discussed which could be important for this phenomenon, e.g. autopositive end-expiratory pressure, hyperventilation and alkalosis, hyperkalemia, delayed action of drugs and unobserved minimal vital signs. In the literature it is recommended that patients should be passively monitored for at least 10 min after cessation of resuscitation. However, more scientific experimental investigations seem to be necessary to gain a better understanding of this phenomenon.

Treatment of palliative care emergencies by prehospital emergency physicians in Germany: an interview based investigation.

Palliative care medical emergencies as a consequence of advanced cancer account for approximately 3% of all prehospital emergency cases. Therefore, prehospital emergency physicians (EP) are confronted with 'end of life decisions'. No educational content exists concerning palliative medicine in emergency medicine curricula. Over the course of 6 months, we interviewed 150 EPs about their experiences in 'end of life decisions' using a specific questionnaire. The total response rate was 69% (n = 104). Most of the interviewed EPs (89%, n = 93) had been confronted with palliative care medical emergencies and expressed uncertainties in dealing with these difficult situations, especially in the area of psychosocial care of the patients (50%). The emergency treatment of palliative care patients can become a particular challenge for any EP. A large percentage of interviewed EPs felt uncertain about aspects of social care and in the assessment of decisions at the end of life. Further information and training are necessary to amenable EPs to provide adequate patient-oriented care to palliative care patients and their relatives in emergency situations.

[Palliative medicine. Fifth pillar of anaesthesia departments]. / Palliativmedizin: Fünfte Säule anästhesiologischer Abteilungen?

Palliative medicine has progressed during recent years to an independent medical faculty within the German health system. Despite this development palliative care systems for out-of-hospital and in-hospital palliative care are still insufficient in Germany so that the development of necessary resources must be considered as not yet completed. To support the further national development palliative medicine can be temporarily or permanently coupled to existing departments, which can be advantageous for all concerned and last but not least be profitable to patients and their relatives. Possibilities for participation of anaesthesiologists in this area of medical care are discussed in the study reported here. Anaesthesiologists have always historically been represented in palliative medical departments, e.g. as pain specialists. In the following investigation the special possibilities of anaesthesia departments for supporting the education and development of in-hospital and out-of hospital palliative medical care departments are reported. Previous experience of co-operation between these two departments is well established. Departments of palliative medicine depend on a well working interdisciplinary co-operation between different medical disciplines (e.g. anaesthesiology, radiotherapy, surgery and oncology) and several medical professions (e.g. physicians, nurses, psychologists). The aim of palliative care therapy is to be responsible for the best possible therapy for cancer patients and to give support to their care-giving relatives. Due to the increasing establishment of palliative care procedures in Germany, departments of anaesthesiology should actively take part in the further development. Part of the responsibility of most anaesthesia departments is to practice pain management and critical care medicine, which are reasons why anaesthesiologists are predestined to be part of the system for palliative care patients and their relatives. Anaesthesia departments can be responsible for the organization of in-hospital and out-of-hospital palliative medicine and palliative care. The integration of anaesthesiological expertise into palliative medicine departments and vice versa can be a great opportunity for both medical departments and therefore represents a worthwhile engagement.

Telomere maintenance and dysfunction predict recurrence in paediatric ependymoma.

We have recently described the enzymatic subunit of telomerase (hTERT) as an important prognostic marker for paediatric ependymoma. Because of the lack of good, representative pre-clinical models for ependymoma, we took advantage of our large cohort of ependymoma patients, some with multiple recurrences, to investigate telomere biology in these tumours. Our cohort consisted of 133 ependymomas from 83 paediatric patients and included 31 patients with recurrences. Clinical outcome was measured as overall survival, progression-free survival and response to therapy. In all 133 tumours, hTERT expression correlated with proliferative markers, including MIB-1 index (P<0.0001) and mitotic index (P=0.005), as well as overall tumour grade (P=0.001), but not with other markers of anaplasia. There was no correlation between telomere length and hTERT expression or survival. Surprisingly, prior radiation or chemotherapy neither induced sustained DNA damage nor affected telomere maintenance in recurrent tumours. There was an inverse correlation between hTERT expression and telomere dysfunction as measured by gamma H2AX expression (P=0.016). Combining gamma H2AX and hTERT expressions could segregate tumours into three different survival groups (log rank, P<0.0001) such that those patients whose tumours expressed hTERT and showed no evidence of DNA damage had the worst outcome. This study emphasises the importance of telomere biology as a prognostic tool and telomerase inhibition as a therapeutic target for paediatric ependymoma. Furthermore, we have demonstrated that analysing tumours as they progress in vivo is a viable approach to studying tumour biology in humans.

[Palliative care patients in an advanced state of disease. Cardiopulmonary resuscitation and determination of death]. / Palliativpatienten im weit fortgeschrittenen Krankheitsstadium. Notärztliche Reanimation und Todesfeststellung.

BACKGROUND: Prehospital emergency teams will be confronted with the specific needs of resuscitation in palliative patients in whom a return of spontaneous circulation (ROSC) could be found significantly less frequently than in other emergency situations. The present investigation aims to show medical and judicial problems related to cardiopulmonary resuscitation (CPR), external examination of the corpse and death certification. METHODS: Over a 12-month period all emergency cases involving physicians in an out-of-hospital resuscitation setting in cancer patients were retrospectively analysed for indications for emergency call, situation on-site and prehospital treatment by emergency physicians, external examination of the corpse and determination of death. RESULTS: For the period mentioned 164 (2.7% of the total) emergency calls by cancer patients or their relatives were identified. In the following study 43 patients (26.2%) could be included. In 20 cases (46.5%) the emergency physicians attempted to resuscitate the patient by performing CPR. In the majority of cases (36; 83.7%) death certification and external examination of the corpse were necessary at the scene. CONCLUSIONS: Due to a reduced rate of ROSC in palliative patients, death certification and external examination of the corpse are more often necessary than in other emergency situations. Therefore every emergency physician should be familiar with the ethics of resuscitation of patients in palliative care and with external examination of the corpse to do justice to patients and their caregivers.

[Reduction in no flow time using a laryngeal tube: comparison to bag-mask ventilation]. / "No-flow-time"-Reduzierung durch Einsatz des Larynxtubus: Vergleich zur Beutel-Masken-Beatmung.

OBJECTIVE: In 2005 the European Resuscitation Council (ERC) published the new guidelines for Advanced Life Support (ALS). One of the aims was to reduce the no flow time (NFT), without chest compression in the first period of cardiac arrest. Furthermore the guidelines recommend that endotracheal intubation should only be carried out by personnel experienced in this procedure. METHODS: An attempt was made to evaluate whether the use of the laryngeal tube suction (LTS-D) for emergency airway management could contribute to reduce NFT compared to bag-mask ventilation (BMV). In a randomised prospective study 50 participants were asked to perform standardised simulated cardiac arrest management on a full-scale simulator following a one-day cardiac arrest training. Each participant was randomised into the LTS-D and the BMV group for airway management. At the end of each scenario an evaluation of the use of each ventilation procedure by the participants was made by means of a questionnaire. RESULTS: During the manikin scenario (430 s for LTS-D and 420 s for BMV) there was a significant difference in the overall NFT comparing the use of the LTS-D vs. BMV (105.8 s, range 94-124 s vs. 150.7 s, range 124-179 s; p<0.01). This corresponded during the whole scenario to a proportion of 24.6% (LTS-D) or 35.9% (BMV). Using the LTS-D all participants were able to ventilate the manikin successfully (tidal volume 500-600 ml). In a subjective evaluation of the different airway management procedures by the participants more than 90% expressed a positive opinion about the LTS-D with respect to ease of insertion and safety of ventilation. CONCLUSION: The use of the LTS-D on a manikin by emergency physicians after standardised cardiac arrest training significantly reduces the NFT in comparison to BMV. Therefore the LTS-D seems to be a good alternative to BMV during a simulated cardiac arrest scenario.

Exercise training improves physical function and fitness in long-term paediatric brain tumour survivors treated with cranial irradiation.

AIMS: We examined the efficacy of exercise training for improving physical functioning and cardiopulmonary fitness in survivors of paediatric brain tumours (BTs) treated with cranial irradiation. METHODS: We conducted a controlled clinical trial with crossover of exercise training versus no training in the community in either a group or combined group/home setting. A volunteer sample of 28 children treated with cranial irradiation for brain tumours completed training (mean age = 11.53 years; mean time since diagnosis = 5.25 years). end-points were physical functioning assessed by four subtests from the Bruininks-Oseretsky Test of motor performance (BOT-2) and pro-rated work rate from a cycle ergometer. Linear mixed modelling was used to evaluate time, training, training setting, and carryover effects. RESULTS: Adherence to training was 84%. Performance on the BOT-2 was below average for all assessments. However, training resulted in improvement in bilateral coordination (F (1, 30) = 6.59, p = 0.02), irrespective of training setting and improved performance was maintained even approximately 12°weeks after training had ended (F (1, 24) = 9.60, p = 0.005). Training resulted in increased pro-rated work rate for participants in the group training setting only (F (1, 25) = 4.57, p = 0.04) and these participants maintained their improved work rate approximately 12°weeks after training had ended (F (1, 20) = 8.38, p = 0.01). CONCLUSION: Exercise training improves physical functioning and fitness in paediatric BT survivors. Exercise interventions that ameliorate adverse physical effects and promote health in long-term survivors are highly recommended in this vulnerable population. (ClinicalTrials.gov, NCT01944761).

PO-18 - Fibronectin EDA/EDB is expressed in adherent SCLC NCI-H69 cells and in pleural effusions of lung cancer patients: possible implication for drug resistance.

INTRODUCTION: Small cell lung cancer (SCLC) is an extremely aggressive tumour which metastasizes early. Even if chemotherapy can achieve an initial regression, relapses due to chemo-resistance are almost inevitable. Sethi et al (Nat Med. 1999;5:662-668) reported that matrix proteins are essentially involved in the development of drug resistance. SCLC cells in suspension culture secrete negligible amounts of matrix proteins AIM: For a more detailed study of the SCLC ability to produce matrix proteins we applied a recently introduced cell culture model of adherence selected SCLC (Salge et al. J Cancer Res Clin Oncol. 2001;127(2):139-411) and analysed pleural effusions form lung cancer patients. MATERIALS AND METHODS: Adherent cells were selected from the SCLC cell line NCI-H69 after exposure to cellular stress. Pleural effusion were obtained from lung cancer patients (SCLC and NSCLC) and from pleural effusions (PE) with congestive heart failure Protein expression was analysed by western blotting (WB) and flow cytometry using specific antibodies against the fibronectin extra domain A (FnEDA) and B (FnEDB) (Sirius, Italy), and for integrins alpha 1-5 and beta 1-3. Drug resistance was assessed with the metabolic stain MTT (3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium-bromid). RESULTS: SCLC suspension cells expressed negligible amounts of fibronectin. In contrast, adherent H69 cells, which showed a significantly reduced chemo-sensitivity against carboplatin and doxorubicin, strongly expressed FnEDA and to a lesser extent FnEDB. Furthermore, in adherent cells expression of various integrins was up-regulated, in particular integrins alpha5/beta3, representing potential binding sites for FnEDA/FnEDB. Analysis of pleural effusions clearly showed the presence of FnEDA/ FnEDB in those of lung cancer patients, whereas in benign pleural effusion almost no FnEDA/ FnEDB was found. CONCLUSIONS: Our data reveal the presence of Fn, and its splice variants FnEDA/EDB in particular, in adherent SCLC cells as well as in malignant PE. We assume that the splice variants FnEDA/ FnEDB are linked to cancer progression and chemo-resistance in this tumour type.

Central nervous system tumours in adolescents.

Adolescents with brain tumours have been, and in most cases still are, haphazardly assigned, on referral, to either 'paediatric' or 'adult'-based treatment centres. In this age group, there is therefore a history of inconsistent treatment, delivery of inappropriate 'maturity-related' care and a reduced chance of gathering vital biological, clinical and treatment-related information germane to this group of patients and their tumours. These days, adolescents with brain tumours should be actively targeted for recruitment into clinical trials and admission into dedicated neuro-oncology centres or programmes that can deliver the necessary and age appropriate multidisciplinary management.

Cholinergic dysfunction of heart, pupil, salivary glands, and urinary bladder in healthy volunteers during long-term treatment with clomipramine.

Cholinergic functions were studied in ten non-depressed healthy volunteers who were treated with 50 mg clomipramine daily for 3 weeks and subsequently with 100 mg daily for a further 3 weeks. Impairments in heart rate variation (HRV) at rest and standing, of the pupillary light response and of salivation were related to serum levels of clomipramine. Since reduction of HRV is closely related to dose (r = -0.83, P less than 10(-2] and is a better predictor of serum levels than the other measures examined, it is suggested that the easy obtainable function test of HRV at standing can be used as an estimate of over-all cholinergic dysfunction during treatment with tricyclic antidepressants.

Zuclopenthixol levels in serum and breast milk.

Breast milk and serum samples were obtained from six psychotic patients 3 days-10 months after delivery. Five of the women were given zuclopenthixol PO daily, and one was given zuclopenthixol decanoate IM every 2 weeks. Zuclopenthixol was estimated in breast milk and serum by high performance liquid chromatography. The zuclopenthixol levels in milk were found to be 29% of the serum levels on average. Based on the drug levels found in milk, the daily dose to a suckling infant was estimated to be 0.5-5 micrograms zuclopenthixol, corresponding to a dose of 0.01-0.1 mg to an adult. It is not likely that such a low dose would cause any effects or side effects in the infant unless infants are very different from adults concerning metabolism or sensitivity to the drug. The suckling infants included in this study were apparently not influenced by the intake of zuclopenthixol with the milk.

Flow-cytometric DNA analysis of intracranial tumors in children.

The objective of this study was to investigate flow-cytometric DNA values of pediatric intracranial tumors, and to establish DNA analysis as a potential prognostic parameter. Twenty-nine brain tumor specimens from 26 pediatric patients were cryo-preserved within a 3-year period. The DNA content was measured by flow cytometry. Six of the tumor specimens had aneuploid DNA patterns. The median of the proliferation index was lower in the survivor group compared with the non-survivor group (36.4% and 47.5%, respectively). Ten of the 26 patients are still alive, eight were lost to follow up, and eight died. Flow-cytometric DNA analysis may be a helpful tool for examining brain tumors in children. The small size of this study could not establish flow cytometry as a definite prognostic factor, but further prospective multicenter studies will evaluate the prognostic significance of flow-cytometric DNA analysis.

[Rhabdomyosarcoma of the orbits in childhood]. / Rhabdomyosarkom der Orbita im Kindesalter.

BACKGROUND: Rhabdomyosarcoma is the most common malignant orbital tumor in children. Treatment modalities (individualized therapy or study protocol) have been changed radically. Surgery was supplemented by radiation therapy and chemotherapy. The objective of our retrospective analysis was to define the prognosis in correlation to changes of treatment in an unselected patient group of a single institution. PATIENTS AND METHODS: Between 1954 and 1995, 18 patients (age at presentation 1 month to 17 years, 11 male and 7 females) with orbital rhabdomyosarcoma were diagnosed and treated at our institution. RESULTS: The 5-year survival rate was 76%. Primary exenteration was replaced by tumor resection (microsurgery), radiation therapy and chemotherapy. Favorable outcome in the precytostatic era (with permanent loss of function) was not significantly improved by polychemotherapy. Microsurgery seems to increase the risk of recurrence. CONCLUSION: Considering the high risk of recurrence, primary exenteration in selected patients with expanded primary tumor is still a therapeutic option.

[Reaction of umbilical cord arteries to PGF2 alpha and glycerol trinitrate during the first days post partum]. / Reaktion der Nabelschnurarterien auf PGF2 alpha und Glyzerol-trinitrat innerhalb des ersten Tages post partum.

OBJECTIVE: Are there changes in the reactivity of umbilical cord arteries within the first day after parturition? METHODS: Groups of rings made from umbilical cord arteries were investigated by a force transducer for their reactions to PGF2 alpha and glycerol trinitrate after 1, 6, 12 and 24 hours after parturition. RESULTS: PGF2 alpha induces vasoconstriction, glycerol trinitrate vasodilatation of the umbilical cord arteries. The quantity of these reactions remains the same at each of the investigation times. But the standard deviation decreases 12 and 24 hours after parturition. CONCLUSIONS: There is an increase of the reproducibility of these investigations in the second half of the first day after parturition. The higher standard deviation in the first 6 hours after parturition may be caused by endogenous autacoids.

[Mental stimulation of a patient with Wernicke-Korsakoff's syndrome]. / Mental stimulering af en patient med Wernicke-Korsakoff's syndrom.

A mental stimulation programme employed in a woman aged 37 years suffering from Wernicke-Korsakoff's syndrome is described. This resulted in such improvement of her condition that full-time institutionalization could be avoided.

Prehospital emergency physicians' experiences with advance directives in Germany: a questionnaire-based multicenter study.

BACKGROUND: Palliative medical emergencies and end-of-life decisions resulting from the exacerbation of cancer account for approximately 3% of all out-of-hospital emergency applications in Germany. Therefore, prehospital emergency physicians (EP) may be confronted with advance directives and ethical and end-of-life decisions. The purpose of the study was to identify EPs' knowledge about ethical and end-of-life decisions and their legal education and experiences concerning advance directives. METHODS: Over a six-month period, we questioned all 150 EPs from three emergency medical services (Braunschweig, Göttingen und Kaiserslautern). An anonymous, self-administered questionnaire with a mixed-methods design was used. The main outcome measures included responses regarding experiences related to advance directives and end-of-life decisions in palliative care patients. For statistical assessment, EPs were divided into three categories: competent, skilled, and unskilled. RESULTS: A total of 104 EPs returned the questionnaire (response rate 69%). Eighty-nine percent of the respondents treated patients who had advance directives. The existence of an advance directive influenced the EP's therapy decision in about 77% of their encounters. Eighty-seven percent of the EPs reported the need for defined end-of-life care pathways and/or standard operating procedures. Eighty-two percent desired educational training concerning end-of-life decisions and the validity of advance directives. CONCLUSION: The prehospital emergency treatment of palliative care patients can be particularly challenging for any EP. A high percentage of the EPs in our study felt insecure in dealing with advance directives and ethical and end-of-life decisions in palliative care patients. Our results suggest that EPs may need more information and education about palliative medical care, legal issues and ethical and end-of-life decisions to provide adequate patient-oriented palliative care in prehospital emergency situations.