Assisted Suicide: A Future Task for Physicians? A Survey of 271 German Medical Students.

Background: In February 2020, the German Federal Constitutional Court revoked a law that had made assisted suicide (AS) a potentially punishable offense. As a result, appropriate legal regulations for AS, including physician-assisted suicide (PAS), must be made. The medical curriculum should be adapted correspondingly. Objective: To explore medical students' knowledge of the legal situation, attitudes toward PAS and wishes regarding PAS education. Design: A cross-sectional survey was conducted. Setting: A questionnaire was distributed to all fourth-year students (n = 331) at a German medical school. Results: Students had a predominantly favorable attitude toward PAS. A majority considered AS to be a task that should be assigned to doctors (71%) and were willing to perform PAS (68%). Education on PAS was explicitly desired. Most participants had only limited knowledge of the legal situation. Conclusions: Medical students are largely in favor of PAS. A structured and interdisciplinary approach to PAS education is needed.

Dying patients with COVID-19: What should Hospital Palliative Care Teams (HPCTs) be prepared for?

OBJECTIVE: The COVID-19 pandemic is a care crisis of unknown duration which has seemingly not yet reached its peak in many countries. A significant number of elderly and frail people and those with underlying serious illness will continue to develop severe forms of the COVID-19 infection. Most of them are not eligible for intensive care treatment but can still expect palliative care - in many cases provided by a Hospital Palliative Care Team (HPCT). Several teams have already gained experience in caring for these patients and their families, others are preparing for it. METHOD: We report on a COVID-19 patient with pre-existing acute myeloid leukemia who was looked after by a HPCT until death. We discuss the challenges and difficulties while caring for COVID-19-positive palliative patients in a non-ICU setting. RESULTS: Hospitalization of the patient in an isolation ward caused an enormous burden for the dying patient and his family. Symptom control was particularly difficult because of rapid deteriorating dyspnea and the scarce presence of medical staff in the patient's room. SIGNIFICANCE OF RESULTS: COVID-19 patients who are not eligible for ICU treatment may have a particularly high need for palliative care. Since beds in specialist palliative care units are limited, the HPCT should be prepared to care for these patients. They may offer support in decision-making, optimize symptom control, and provide psychosocial care for patients and their families. Visiting restrictions aimed to protect the general public must be weighted against the patient's and family's suffering.

Medical Students' Experiences of Moral Distress in End-of-Life Care.

Background: Moral distress is a frequent phenomenon in end-of-life care. It occurs when one knows the morally correct response to an ethically challenging situation, but cannot act because of internal or external constraints. Medical students-having a perceived low level in the hospital hierarchy-may be particularly vulnerable to moral distress. Objective: To assess the frequency and intensity of medical students' moral distress occurring in end-of-life care. Design: We developed a questionnaire describing 10 potentially morally distressing scenarios in end-of-life care. Setting: The questionnaire was distributed to all fourth-year students of a German medical school. Measurements: We asked students (1) if they had ever witnessed the described scenarios and (2) to rate the extent (numeric rating scale 0-4) of moral distress for each situation. Results: Of 340 students, 217 (64%) completed the survey. On average, students had experienced 2.51 morally distressing situations (standard deviation = ±2.23). The majority of students (N = 163, 75%) had experienced at least one morally distressing situation. Providing futile care with the basic intention to make money was the item with the highest levels of experienced distress (2.88 ± 1.05), witnessed by 54 (25%) participants. Twenty-five students (12%) reported that they had thought about dropping out of medical school or choosing a nonclinical specialty because of moral distress. Conclusions: Medical students experience moral distress regularly and most frequently in scenarios of futile care. This may be an underestimated factor for medical school attrition. Interventions should identify the sources of moral distress and empower students to address their moral concerns.

Physicians' attitudes toward end-of-life decisions in amyotrophic lateral sclerosis.

OBJECTIVE: This study aims (1) to assess physicians' attitudes toward different palliative end-of-life (EOL) practices in amyotrophic lateral sclerosis (ALS) care, including forgoing artificial nutrition and hydration (FANH), continuous sedation until death (CSD), and withdrawing invasive ventilation (WIV), and toward physician-assisted dying (PAD) including physician-assisted suicide and euthanasia and (2) to explore variables influencing these attitudes. METHODS: We used two clinical vignettes depicting ALS patients in different stages of their disease progression to assess the influence of suffering (physical/psycho-existential) on attitudes toward WIV and the influence of suffering and prognosis (short-term/long-term) on attitudes toward FANH, CSD, and PAD. RESULTS: 50 physicians from European ALS centers and neurological departments completed our survey. Short-term prognosis had a positive impact on attitudes toward offering FANH (p = 0.014) and CSD (p = 0.048) as well as on attitudes toward performing CSD (p = 0.036) and euthanasia (p = 0.023). Predominantly psycho-existential suffering was associated with a more favorable attitude toward WIV but influenced attitudes toward performing CSD negatively. Regression analysis showed that religiosity was associated with more reluctant attitudes toward palliative EOL practices and PAD, whereas training in palliative care was associated with more favorable attitudes toward palliative EOL practices only. CONCLUSION: ALS physicians seem to acknowledge psycho-existential suffering as a highly acceptable motive for WIV but not CSD. Physicians appear to be comfortable with responding to the patient's requests, but more reluctant to assume a proactive role in the decision-making process. Palliative care training may support ALS physicians in these challenging situations.

[Palliative Sedation: Comments on a controversial topic]. / Palliative Sedierung: Anmerkungen zu einem strittigen Thema.

Palliative Sedation: Comments on a controversial topic Abstract. Palliative sedation (PS) is an accepted medical practice for terminally ill patients. It intends the alleviation of unbearable suffering by intentionally lowering the level of consciousness. In contrast to physician assisted suicide and euthanasia, palliative sedation aims to relieve burdensome symptoms with no intention of hastening death. PC can be applied as "intermittent palliative sedation" or "continuous (deep) sedation until death". Most ethical controversies are related to the latter form of PS: 1: Is existential or psychosocial suffering a possible indication for PS? 2: What is the earliest possible time point to start PS? 3: The withdrawal or withholding of artificial nutrition and hydration during PS. A critical reflection of these ethical controversial aspects within the treatment team is highly desirable. However, the patient's well-being and the respect for the patient's decisions that are based on experiences which are made only by him or her, must remain the guiding principle for medical actions.

Neurological Symptoms in Palliative Care Patients.

BACKGROUND: Neurological expertise in palliative care may be required not only for patients with primary neurological disorders but also for patients with non-neurological diseases suffering from burdensome neurological symptoms. The aim of this study was to determine the prevalence of neurological diagnoses and symptoms in palliative care patients, as well as the related burden and impact on everyday life. METHODS: We analyzed retrospectively the medical records of 255 consecutive patients from a tertiary medical center, at the time point of referral to an inpatient palliative care consultation service. In addition, 100 patients prospectively answered a questionnaire which included the assessment of neurological symptoms, as well as numeric rating scales for quality of life, symptom-specific burden, and restrictions in everyday life. RESULTS: Forty-one patients (16%) suffered from a primary neurological disease. Most decisions regarding the termination of life-sustaining measures concerned this group (20/22, 91%). Neurological symptoms (excluding pain) were documented in 122 patients (48%) with an underlying non-neurological disease. In the questionnaire study, 98/100 patients reported at least one neurological or neuropsychiatric symptom, most frequently sleeping problems (N = 63), difficulty concentrating (N = 55), and sensory symptoms (N = 50). Vertigo/dizziness (N = 19) had the greatest impact on everyday life (7.57/10 ± 2.17) and the highest symptom-specific burden (7.14 ± 2.51). Difficulty concentrating (restrictions in everyday life/burden) and pain intensity were the only symptoms significantly correlated with quality of life (r = -0.36, p = 0.009/r = -0.32; p = 0.04; r = -0.327, p = 0.003). CONCLUSION: Neurological diseases and symptoms are frequent among palliative care patients and are often associated with a high symptom burden, which may severely affect the patients' lives. It is thus of paramount importance to implement neurological expertise in palliative care.

[The Development of Palliative Care Hospital Support Teams (HPCTs) in Bavaria from 2011-2015: Tasks, Acceptance, Structure and Funding]. / Entwicklung der Palliativmedizinischen Dienste (PMD) in Bayern 2011­2015: Aufgaben, Akzeptanz, Struktur und Finanzierung.

INTRODUCTION: Palliative care hospital support teams (HPCTs) provide inpatients from all departments palliative medical support. Seriously ill as well as dying patients, who are being treated in facilities that do not have their own palliative care unit, can benefit from these multi-professional teams just as much as patients who do not (yet) need to be admitted to a palliative care unit. At the end of 2015, 53 HPCTs, which were in accordance with the requirements established in the "Program for HPCTs" by the Bavarian Ministry of Health in 2009, had been approved in Bavaria. METHODS: Using a questionnaire that was distributed by mail (2011) and an online survey (2015), we asked all Bavarian HPCTs, which had been approved up until then, to answer questions regarding their tasks, the level of acceptance within their hospital, the structure of their staff and funding. In addition to questions, which were rated on an applicability scale from 0 to 10, there was also room for written comments. RESULTS: The return rate in 2011 was 77% (17 questionnaires) and 53% (28) in 2015. In sum, HPCTs were widely regarded as a suitable instrument for improving in-house palliative care (2011: median 7.8 (0-10) ±1.9, 2015: 7.2 (0-10) ±2.3; n.s.). The level of acceptance among the other departments of the hospital was assessed as being significantly higher in 2015 (7.2±2.3) than it was 4 years earlier (5.7±2.2; p<0.05). HPCTs cover various tasks, most commonly including "supportive conversations," "accompaniment in the dying phase," "pain therapy" and "discharge management." However, a decline in multi-professionalism within the teams could be seen, especially in the fields of psychology/psycho-oncology and spiritual care (p<0.05). Both surveys showed that an essential aspect in funding the teams was the supplementary payment ZE 60 for "complex palliative medical treatments." However, funding in general was predominantly reported as being quite difficult: only 29% of the HPCTs of 2015 indicated that all of their costs were covered. CONCLUSION: HPCTs in Bavaria take over important tasks in caring for seriously ill and dying patients and their families. According to their own appraisal, the level of acceptance within hospitals is improving. The hope is that new regulations, such as the new OPS 8-98 h (specialized complex palliative treatments provided by a HPCT), which was introduced in 2017, will solidify funding without jeopardizing the multi-professionalism that characterizes HPCTs.

Voluntary stopping of eating and drinking: is medical support ethically justified?

BACKGROUND: Physician-assisted dying has been the subject of extensive discussion and legislative activity both in Europe and North America. In this context, dying by voluntary stopping of eating and drinking (VSED) is often proposed, and practiced, as an alternative method of self-determined dying, with medical support for VSED being regarded as ethically and legally justified. ARGUMENT: In our opinion, this view is flawed. First, we argue that VSED falls within the concept of suicide, albeit with certain unique features (non-invasiveness, initial reversibility, resemblance to the natural dying process). Second, we demonstrate, on the basis of paradigmatic clinical cases, that medically supported VSED is, at least in some instances, tantamount to assisted suicide. This is especially the case if a patient's choice of VSED depends on the physician's assurance to provide medical support. CONCLUSION: Thus, for many jurisdictions worldwide, medically supported VSED may fall within the legal prohibitions on suicide assistance. Physicians, lawmakers, and societies should discuss specific ways of regulating medical support for VSED in order to provide clear guidance for both patients and healthcare professionals. Please see related article: http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0951-0 .

Physician-assisted suicide, euthanasia and palliative sedation: attitudes and knowledge of medical students.

OBJECTIVES: In November 2015, the German Federal Parliament voted on a new legal regulation regarding assisted suicide. It was decided to amend the German Criminal Code so that any "regular, repetitive offer" (even on a non-profit basis) of assistance in suicide would now be considered a punishable offense. On July 2, 2015, a date which happened to be accompanied by great media interest in that it was the day that the first draft of said law was presented to Parliament, we surveyed 4th year medical students at the Technical University Munich on "physician-assisted suicide," "euthanasia" and "palliative sedation," based on a fictitious case vignette study. METHOD: The vignette study described two versions of a case in which a patient suffered from a nasopharyngeal carcinoma (physical suffering subjectively perceived as being unbearable vs. emotional suffering). The students were asked about the current legal norms for each respective course of action as well as their attitudes towards the ethical acceptability of these measures. RESULTS: Out of 301 students in total, 241 (80%) participated in the survey; 109 answered the version 1 questionnaire (physical suffering) and 132 answered the version 2 questionnaire (emotional suffering). The majority of students were able to assess the currently prevailing legal norms on palliative sedation (legal) and euthanasia (illegal) correctly (81.2% and 93.7%, respectively), while only a few students knew that physician-assisted suicide, at that point in time, did not constitute a criminal offense. In the case study that was presented, 83.3% of the participants considered palliative sedation and the simultaneous withholding of artificial nutrition and hydration as ethically acceptable, 51.2% considered physician-assisted suicide ethically legitimate, and 19.2% considered euthanasia ethically permissible. When comparing the results of versions 1 and 2, a significant difference could only be seen in the assessment of the legality of palliative sedation: it was considered legal more frequently in the physical suffering version (88.1% vs. 75.8%). CONCLUSION: The majority of the students surveyed wrongly assumed that physician-assisted suicide is a punishable offense in Germany. However, a narrow majority considered physician-assisted suicide ethically acceptable in the case study presented. Compared to euthanasia, more than twice as many participants considered physician-assisted suicide acceptable. There was no significant difference between personal attitudes towards palliative sedation, physician-assisted suicide or euthanasia in light of physical or emotional suffering. Educational programs in this field should be expanded both qualitatively and quantitatively, especially considering the relevance of the subject matter, the deficits within the knowledge of legal norms and the now even higher complexity of the legal situation due to the new law from December 2015.

Occurrence of the "applause sign" in patients with amyotrophic lateral sclerosis.

The applause sign was originally described as a quick bedside test to discriminate progressive supranuclear palsy (PSP) (positive applause sign, PAS) from Parkinson's disease (PD) and frontotemporal dementia (FTD) (negative applause sign). However, recent research demonstrated that the test is positive not only in a subset of patients with PD and FTD, but also in other neurodegenerative diseases. We tested 22 patients with amyotrophic lateral sclerosis (ALS) together with 22 healthy sex- and age-matched controls for the occurrence of PAS. Furthermore, we performed neuropsychological testing with the EXIT-25 battery to correlate PAS with neuropsychological deficits, especially frontal lobe dysfunction. Five ALS patients (23%) and none of the controls displayed PAS (p≤0.05). The occurrence of PAS in ALS patients was not correlated with pathologic EXIT-25 scores or subtests for aberrant motor behaviour. We describe for the first time the occurrence of the applause sign in ALS and provide additional evidence that PAS is not specific for Parkinsonian disorders. Although its occurrence has been related to aberrant motor behaviour due to frontal involvement, in our study PAS did not correlate with executive dysfunction as tested by the EXIT-25 test battery, or with subtests of aberrant motor behaviour.

Needs, expectations, and concerns of medical students regarding end-of-life issues before the introduction of a mandatory undergraduate palliative care curriculum.

BACKGROUND: In the past, implementation of effective palliative care curricula has emerged as a priority in medical education. In order to gain insight into medical students' needs and expectations, we conducted a survey before mandatory palliative care education was introduced in our faculty. METHODS: Seven hundred nine students answered a questionnaire mainly consisting of numeric rating scales (0-10). RESULTS: Participants attributed a high importance to palliative care for their future professional life (mean, 7.51 ± 2.2). For most students, symptom control was crucial (7.72 ± 2.2). However, even higher importance was assigned to ethical and legal issues (8.16 ± 1.9). "Self-reflection regarding their own role as a physician caring for the terminally ill along with psychological support" was also regarded as highly important (7.25 ± 2.4). Most students were moderately concerned at the prospect of being confronted with suffering and death (5.13 ± 2.4). This emotional distress was rated significantly higher by female students (5.4 ± 2.4 versus 4.6 ± 2.4; p < 0.001). Seventeen percent of all students rated their distress as being 7 of 10 or higher, which indicates a considerable psychological strain in terms of dealing with end-of-life issues in the future. Professional or personal experience with terminally ill persons lowered these anxieties significantly (4.99 ± 2.34 versus 5.47 ± 2.5, p < 0.05). CONCLUSIONS: Medical students stated a remarkably high interest in learning palliative care competencies. Responding to their specific concerns and needs-especially with regard to the acquisition of emotional coping skills-may be key for the development of successful palliative care curricula.

No evidence of association of FLJ10986 and ITPR2 with ALS in a large German cohort.

A recent genome-wide association study (GWAS) found significant association of six single nucleotide polymorphisms (SNPs) in the gene FLJ10986 with sporadic amyotrophic lateral sclerosis (SALS). Another independent GWAS reported significant association of one SNP in the gene inositol 1,4,5-triphosphate receptor 2 (ITPR2) with SALS. These studies provided conflicting results. We examined the six most significant SNPs in FLJ10986 and one SNP in ITPR2 in a large cohort consisting of 595 SALS cases and 681 controls ascertained from Germany. Our results did not provide evidence for the association of these SNPs with SALS, suggesting a possible population-specific effect for FLJ10986 and ITPR2 that do not modulate the risk for SALS in the German population.

Meaning in life in patients with amyotrophic lateral sclerosis.

The construct 'meaning in life' (MiL) has become increasingly important in palliative care. Several meaning-focused interventions have been developed recently. The aim of this study was to investigate MiL in patients with amyotrophic lateral sclerosis (ALS) and compare the findings with a representative sample of the German population. In the newly developed 'Schedule for Meaning in Life Evaluation' (SMiLE), respondents first list individual areas that provide meaning to their life before rating their current level of importance and satisfaction with each area. Overall indices of weighting (IoW, range 20-100), satisfaction (IoS, range 0-100), and weighted satisfaction (IoWS, range 0-100) are calculated. Results of our study showed that 46 ALS patients completed the SMiLE: the IoS was 74.7 ± 20.2, the IoW 88.1 ± 10.1, and the IoWS 76.3 ± 20.5. Satisfaction with MiL was negatively associated with disease duration and degree of functional impairment. After adjustment for age, sex, and marital status, the representative sample (n = 977) scored significantly higher in the IoS (82.8 ± 14.7) and the IoWS (83.3 ± 14.8). Compared to the general population, ALS patients list more meaning-relevant areas, are more likely to list partner, and less likely to list health. Thus, response shift seems to be a central coping mechanism in ALS patients. Regarding their major MiL areas, they shift their focus away from decreasing health status and towards supportive relationships.

Identification of novel Angiogenin (ANG) gene missense variants in German patients with amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a fatal progressive neurodegenerative disease characterized by the selective death of motor neurons in the motor cortex, brain stem and spinal cord. Recently, missense variants in the angiogenin gene (ANG), an angiogenic factor expressed in ventral horn motor neurons that is up-regulated by hypoxia, have been found in ALS patients of Irish/Scottish, North American, Italian, French and Dutch descent. To investigate the role of ANG in the German population, we screened for mutations by sequencing the entire coding region of the ANG gene in a large sample of 581 German ALS cases and 616 sex- and age-matched healthy controls. We identified two heterozygous missense variants, F(-13)L and K54E, in two German sporadic ALS cases but not in controls. Both missense variants are novel and have not been previously found in ALS cases. Our results suggest that missense variants in the ANG gene play a role in ALS in the German population and provide further evidence to support the hypothesis that angiogenic factors up-regulated by hypoxia are involved in the pathophysiology of ALS.

Inappropriate sexual behaviour in a case of ALS and FTD: successful treatment with sertraline.

In a subset of patients, ALS is associated with frontotemporal dysfunction (ALS-FTD). Clinically, ALS-FTD may present with a variable spectrum of cognitive and behavioural deficits. We report a 53-year-old ALS-FTD patient developing inappropriate sexual behaviour (ISB) manifesting as a vigorous sexual drive with exhausting demands for sexual intercourse and physical aggressions against his wife. This distressing symptom could be alleviated with the selective serotonin reuptake inhibitor sertraline. ISB is an embarrassing symptom for most patients and their caregivers and may therefore be under-reported. Since effective treatment is available, we suggest an open and proactive discussion of sexual issues in this patient group.

Glial proliferation and metabotropic glutamate receptor expression in amyotrophic lateral sclerosis.

Accumulating evidence indicates that alterations in glial activation and disturbances in glial glutamate metabolism may contribute to the pathogenesis of amyotrophic lateral sclerosis (ALS). Metabotropic glutamate receptors (mGluRs) are involved in glutamate homeostasis as well as in glial proliferation. Using in situ hybridization and immunohistochemistry we found a strong upregulation of group I and group II mGluR mRNA and protein in ALS spinal cord as compared to controls (mGluR5 > mGluR1 > mGluR2/3). In vitro, the mGluR group I agonist 3,5-dihydroxyphenylglycine induced proliferation in chick spinal cord astroglial cultures. Moreover, addition of cerebrospinal fluid (CSF) from ALS patients resulted in significantly higher proliferation rates than control CSF. In both cases, the effect could be blocked by addition of the mGluR group I antagonist 1-aminoindan-1,5-dicarboxylic acid. Taken together, our data suggest that stimulation of glial mGluRs through mediators present in the CSF may contribute to glial proliferation and astrogliosis in ALS.

Differential expression of mGluR5 in human lumbosacral motoneurons.

Glutamatergic excitotoxicity is one of the main hypotheses to explain motoneuronal degeneration in amyotrophic lateral sclerosis (ALS). Interestingly, autonomic motoneurons remain almost unaffected, even in late stages of the disease. Since glutamate receptors may mediate neurotoxic as well as neuroprotective effects, different expression patterns may contribute to neuronal vulnerability. We and others have previously described a significantly higher expression of group I metabotropic glutamate receptors (mGluRs) in rat autonomic motoneurons compared to somatic motoneurons. Here we show a selective expression of the group I receptor mGluR5 in human parasympathetic Onuf's nucleus. These results are in accordance with previous findings in rat and strengthen the hypothesis that mGluR expression may provide a possible clue to the selective vulnerability in ALS.