[Advance directives and mental disorders: a practice recommendation of the Commission for Ethics and Law of the German Association for Psychiatry, Psychotherapy and Psychosomatics]. / Patientenverfügungen und psychische Erkrankung ­ eine Praxisempfehlung der Kommission Ethik und Recht der DGPPN.

BACKGROUND: Since the creation of legal requirements for advance directives by the legislator in 2009, special aspects of their application in the treatment of people with mental illnesses have been discussed. GOAL OF THE PAPER: Important questions on dealing with advance directives in everyday life will be answered in a practice-oriented manner. RESULTS: Among other things, this document answers the question of the conditions under which a patient can refuse or consent to hospitalization and treatment in advance, and in particular how to deal with advance directives whose implementation would also affect the rights of third parties. The German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) has addressed these and other questions in the present document and added practical advice on how to formulate advance directives for people with mental illnesses and how to deal with psychiatric advance directives. DISCUSSION: The DGPPN has developed an advance directive for the area of mental health and published it on its website together with detailed explanations. With the help of this advance directive, people can decide on their treatment in phases of incapacity to consent in the context of a mental crisis or illness.

"That's just Future Medicine" - a qualitative study on users' experiences of symptom checker apps.

BACKGROUND: Symptom checker apps (SCAs) are mobile or online applications for lay people that usually have two main functions: symptom analysis and recommendations. SCAs ask users questions about their symptoms via a chatbot, give a list with possible causes, and provide a recommendation, such as seeing a physician. However, it is unclear whether the actual performance of a SCA corresponds to the users' experiences. This qualitative study investigates the subjective perspectives of SCA users to close the empirical gap identified in the literature and answers the following main research question: How do individuals (healthy users and patients) experience the usage of SCA, including their attitudes, expectations, motivations, and concerns regarding their SCA use? METHODS: A qualitative interview study was chosen to clarify the relatively unknown experience of SCA use. Semi-structured qualitative interviews with SCA users were carried out by two researchers in tandem via video call. Qualitative content analysis was selected as methodology for the data analysis. RESULTS: Fifteen interviews with SCA users were conducted and seven main categories identified: (1) Attitudes towards findings and recommendations, (2) Communication, (3) Contact with physicians, (4) Expectations (prior to use), (5) Motivations, (6) Risks, and (7) SCA-use for others. CONCLUSIONS: The aspects identified in the analysis emphasise the specific perspective of SCA users and, at the same time, the immense scope of different experiences. Moreover, the study reveals ethical issues, such as relational aspects, that are often overlooked in debates on mHealth. Both empirical and ethical research is more needed, as the awareness of the subjective experience of those affected is an essential component in the responsible development and implementation of health apps such as SCA. TRIAL REGISTRATION: German Clinical Trials Register (DRKS): DRKS00022465. 07/08/2020.

[Familiarity with and Dissemination of Advance Directives in Germany: Results of a Representative Survey of the General Population]. / Bekanntheit und Verbreitung von Patientenverfügungen in Deutschland ­ Ergebnisse einer repräsentativen Umfrage in der Allgemeinbevölkerung.

With an advance directive, people can make provisions for the case of incapacity to give consent with regard to future medical and nursing treatment decisions. Currently, there are no data available on how well known and widespread advance directives are in the population in Germany. The aim of the study was, in addition to record awareness and dissemination, to find out more about the reasons for (not) writing an advance directive and about information and support used by people. An online survey of a representative sample of the general population (n=1000) was conducted. The data were analysed descriptively and by means of regression analysis. The survey showed that 92% of the sample knew about advance directives, and 37% had already created one. The probability of having already written an advance directive increases with increasing age. The reported reasons for (not) writing were heterogeneous. Almost 2/3 of all respondents had already accessed information on this topic, mainly via the Internet. The majority of those surveyed was not aware of any support available in drafting the advance directive. These findings provide suggestions for tailoring information and support services.

[Knowledge and misconceptions on advance directives-results of a citizen survey]. / Wissensstand und Fehlvorstellungen zu Vorsorgedokumenten ­ Ergebnisse einer Bürgerbefragung.

BACKGROUND: Advance directives (ADs) such as living wills or healthcare powers of attorney are important tools to anticipate medical treatment decisions when decision-making capacity is lost in the future. Although a rising number of citizens in Germany are creating such documents, little is known about their knowledge of the purpose, types, and use of ADs. After more than 10 years since legislation on ADs came into force, this study intends to measure the objective knowledge of citizens and detect deficits in knowledge. METHODS: We conducted a cross-sectional quantitative survey of citizens aged 18+ in the city and county of Wuerzburg. The questionnaire included, among other things, possession, experience, and knowledge of ADs. Sampling was conducted via advertising and local networking. RESULTS: Of the 282 participants who took part in the survey (Mage = 50 years, 2/3 female), 43.4% reported having created a minimum of one document. In the knowledge test, an average of 22/34 points was achieved. While questions about the specific application of ADs based on a case study were often answered correctly, we found deficits about the single document types. The results in the knowledge test and the variables on the subjective level of knowledge correlate positively. DISCUSSION: The relatively high rate of ADs in this sample indicates their rapid dissemination during the past few years in Germany. Overall, the level of knowledge ADs appears to be low, revealing misconceptions about the creator's and involved people's rights and obligations. The measured knowledge level contradicts with the frequently expressed desire of citizens to preserve their autonomy by creating ADs for themselves.

[What do health care professionals know about advance directives?] / Was wissen Fachkräfte im Gesundheitswesen über Vorsorgedokumente?

BACKGROUND: Advance directives are important to preserve the autonomy of patients for future situations in which they are uncapable of expressing their will. They are considered helpful by many healthcare professionals in their professional practice. However, their knowledge on these documents is not well known. Misconceptions can adversely affect decisions at the end of life. This study examines healthcare professionals' knowledge of advance directives and relevant correlates. METHODS: In 2021 healthcare professionals from various professions and institutions in Wuerzburg were surveyed using a standardized questionnaire on previous experiences with, advice on and use of advance directives, as well as an objective knowledge test containing 30 questions. Apart from the descriptive analysis of single questions out of the knowledge test, various parameters were screened for their influence on knowledge level. RESULTS: 363 healthcare professionals from different care settings participated in the study, including physicians, social workers, nurses and emergency services personnel. 77.5% work in patient care, of which 39.8% make decisions based on living wills daily to several times a month. High rates of incorrect answers in the knowledge test show lack in knowledge about decisions concerning patients who are unable to give consent; an average of 18 out of 30 points was achieved. Physicians, male healthcare professionals and respondents with more personal experience regarding advance directives had significantly better results in the knowledge test. CONCLUSION: Healthcare professionals have ethically and practically relevant knowledge deficits and a high need for further training on advance directives. Advance directives play an important role in maintaining patient autonomy and should receive more attention in training and further education equally involving non-medical professional groups.

[Are too Many Temporarily Placed Non-culpable Offenders Committed to Forensic Psychiatric Hospitals in Germany? Thoughts on the Relationship of Forensic and General Psychiatry]. / Gibt es zu viele Unterbringungen nach § 126a StPO? Überlegungen zum Zusammenspiel von forensischer und allgemeiner Psychiatrie unter Beachtung rechtlicher Gesichtspunkte.

From the perspective of the forensic clinics, the judiciary is increasingly ordering temporary placements according to Sec. 126a of the Code of Criminal Procedure. Three hypotheses are proposed that could (partly) explain this increase: 1) Courts' tendency to hand down this decision even in cases involving minor offences. 2) Courts' tendency to hand down this decision despite positive prognoses. 3) Changes in the reporting practices of psychiatric clinics. Overly simple explanations for the increase in temporary placements, therefore, fall short. This makes it more urgent to strengthen the primary-prevention approach. It is imperative that the small percentage of people with mental illness and an increased propensity to violence be identified and treated to prevent violence in the general psychiatric care stage. For this forensic psychiatry and general psychiatric care must be interlinked more closely.

[Public mental health and patient autonomy-an area of conflict?] / Public Mental Health und Patientenautonomie ­ ein Spannungsfeld?

Public mental health (PMH) interventions aim to promote and improve the well-being of members of a society. PMH is based on a normative understanding of what well-being is and what factors contribute to it. Without necessarily disclosing it, measures of a PMH program may affect the autonomy of individuals if their personal perceptions regarding their own individual well-being differ from PMH's prescriptions for well-being oriented toward societal goals. In this paper, we discuss this potential tension between the possible goals of PMH and those of the addressees.

[Factors of endangering and violation of autonomy in residential nursing homes: results of a scoping review]. / Faktoren der Autonomiegefährdung und -verletzung in stationären Altenpflegeeinrichtungen: Ergebnisse eines Scoping Review.

Background: Respecting autonomy is one of the guiding principles of medical and nursing ethics. Nursing home residents represent a particularly relevant target group whose autonomy can be endangered or violated. Aim: The study aimed to identify factors that endanger or violate the nursing home residents' autonomy and to determine specific life situations and contexts in which these factors are located. Methods: A scoping review was carried out according to the Joanna Briggs Institute-method. Empirical results from journal articles from the publication period 2000-2021 were included. The articles were analyzed using qualitative content analysis. Results: A total of 75 articles were finally included in the review. Identified factors of the endangerment and violation of autonomy are assigned to topic areas located at the level of actors, (care) relationships and structures. Factors that can violate or endanger the residents' autonomy were found in the entire everyday life of the residents. Conclusion: The localization of the identified endangerments/violations on various actor and structural levels indicates the need for comprehensive preservation and promotion of residents' autonomy in nursing homes.

[Generalist palliative care in hospitals during the first wave of the COVID-19 pandemic]. / Allgemeine Palliativversorgung im Krankenhaus während der ersten Welle der COVID-19-Pandemie.

BACKGROUND: In the research network of German university palliative care centers (PallPan), as part of Network University Medicine (NUM), recommendations for action were developed in regard to the care provided for seriously ill and dying patients during a pandemic. For this purpose, the experiences and needs of hospital staff working closely with patients outside of specialized palliative care units during the first wave of the COVID-19 pandemic were also examined. MATERIALS AND METHODS: Nationwide online survey of 8,882 physicians, nurses and therapists working in acute inpatient care in the period from December 2020 to January 2021 by means of a newly developed and piloted questionnaire on changes, burdens and cooperation with specialized palliative care. Grouping based on the changes in the number of seriously ill and dying people in the first wave of the pandemic. Due to the exploratory character of the survey, the data were analyzed descriptively. RESULTS: 505/8882 completed questionnaires were evaluated (5.7 %). 167/505 (33.1 %) of the respondents reported a lower quality of care for the critically ill and dying. 464/505 (91.8 %) reported exemptions in place for visiting the dying. The most frequently mentioned stress factor was the perceived loneliness of the seriously ill and dying 437/505 (86.5 %), followed by stricter hygiene rules 409/505 (81 %), increased workload 372/505 (73.3 %) and perceived psychological stress on relatives and survivors 395/505 (78.2 %). 141/505 (27.9 %) of respondents used Tablet PCs to support patient-family communication. 310/505 (61.4 %) involved palliative care professionals in patient care, and 356/505 (70.5 %) of respondents found other palliative care services helpful. CONCLUSION: Experiences and suggestions for improving palliative care in pandemic times are integrated into the PallPan recommendations for action. Family visits should be allowed and supplemented by digital offers. Palliative Care should also be integrated into both pandemic and contingency plans.

Ethical, legal, and social aspects of symptom checker applications: a scoping review.

Symptom Checker Applications (SCA) are mobile applications often designed for the end-user to assist with symptom assessment and self-triage. SCA are meant to provide the user with easily accessible information about their own health conditions. However, SCA raise questions regarding ethical, legal, and social aspects (ELSA), for example, regarding fair access to this new technology. The aim of this scoping review is to identify the ELSA of SCA in the scientific literature. A scoping review was conducted to identify the ELSA of SCA. Ten databases (e.g., Web of Science and PubMed) were used. Studies on SCA that address ELSA, written in English or German, were included in the review. The ELSA of SCA were extracted and synthesized using qualitative content analysis. A total of 25,061 references were identified, of which 39 were included in the analysis. The identified aspects were allotted to three main categories: (1) Technology; (2) Individual Level; and (3) Healthcare system. The results show that there are controversial debates in the literature on the ethical and social challenges of SCA usage. Furthermore, the debates are characterised by a lack of a specific legal perspective and empirical data. The review provides an overview on the spectrum of ELSA regarding SCA. It offers guidance to stakeholders in the healthcare system, for example, patients, healthcare professionals, and insurance providers and could be used in future empirical research to investigate the perspectives of those affected, such as users.

[The reform of guardianship law]. / Die Reform des Betreuungsrechts.

The reform of the guardianship law has been decided! The reform will come into force on 1 January 2023. The content of the guardianship law will not be completely restructured. The tense relationship between the protection of the person against decisions not made on his or her own responsibility and the self-determination of the person will be consistently further considered and strengthened in favor of the self-determination of the person concerned. Supportive decision making, the consideration of a person's wishes, the abandonment of the term (and concept of) "well-being" as a measure for guardianship are some examples; however, the new law also sets boundaries in adhering to a person's wishes. Namely, if they are associated with the risk of significant harm to the person or his or her property. The article first presents the main objectives of the reform. Based on this, the focal points are the deletion of the word "well-being", the regulation of the proxy power of attorney and measures for greater consideration and better implementation of the principle of the necessity, which is central to the guardianship law. Critical comments are made on the newly introduced spousal representation law and its significance for the psychiatric practice. As a result, it can be stated that there will be hardly any significant changes in healthcare and even less so in the area of coercive measures. It remains to be seen whether the legislator's welcome concern to avoid guardianship through improved information and counselling on social rights will be achieved in practice. The same certainly applies to the strengthening of supported decision making, the idea of which is also to be welcomed but is still looking for a gold standard for practice.

Law and psychiatry-current and future perspectives.

We describe relevant interfaces between law and psychiatry and current ethical and legal views and changes within the past decades. Ideas of patient autonomy and patients' rights have been major drivers of changes in legal frameworks. We describe developments in the areas of patient information and informed consent, involuntary placement and involuntary treatment, use of coercive measures, forensic psychiatry, digital mental health, data privacy, physician liability, suicide, assisted suicide, euthanasia, end of life decision-making, advance directives, legal and illegal drugs, and delegation and substitution of professional activities. There is no unidirectional pathway between law and ethics. Views, conflicts, and requirements differ between countries and within countries and will need to be balanced according to the societies' changing values also in the future.

Ethical, Legal, and Social Implications of Symptom Checker Apps in Primary Health Care (CHECK.APP): Protocol for an Interdisciplinary Mixed Methods Study.

BACKGROUND: Symptom checker apps (SCAs) are accessible tools that provide early symptom assessment for users. The ethical, legal, and social implications of SCAs and their impact on the patient-physician relationship, the health care providers, and the health care system have sparsely been examined. This study protocol describes an approach to investigate the possible impacts and implications of SCAs on different levels of health care provision. It considers the perspectives of the users, nonusers, general practitioners (GPs), and health care experts. OBJECTIVE: We aim to assess a comprehensive overview of the use of SCAs and address problematic issues, if any. The primary outcomes of this study are empirically informed multi-perspective recommendations for different stakeholders on the ethical, legal, and social implications of SCAs. METHODS: Quantitative and qualitative methods will be used in several overlapping and interconnected study phases. In study phase 1, a comprehensive literature review will be conducted to assess the ethical, legal, social, and systemic impacts of SCAs. Study phase 2 comprises a survey that will be analyzed with a logistic regression. It aims to assess the user degree of SCAs in Germany as well as the predictors for SCA usage. Study phase 3 will investigate self-observational diaries and user interviews, which will be analyzed as integrated cases to assess user perspectives, usage pattern, and arising problems. Study phase 4 will comprise GP interviews to assess their experiences, perspectives, self-image, and concepts and will be analyzed with the basic procedure by Kruse. Moreover, interviews with health care experts will be conducted in study phase 3 and will be analyzed by using the reflexive thematical analysis approach of Braun and Clark. RESULTS: Study phase 1 will be completed in November 2021. We expect the results of study phase 2 in December 2021 and February 2022. In study phase 3, interviews are currently being conducted. The final study endpoint will be in February 2023. CONCLUSIONS: The possible ethical, legal, social, and systemic impacts of a widespread use of SCAs that affect stakeholders and stakeholder groups on different levels of health care will be identified. The proposed methodological approach provides a multifaceted and diverse empirical basis for a broad discussion on these implications. TRIAL REGISTRATION: German Clinical Trials Register (DRKS) DRKS00022465; https://tinyurl.com/yx53er67. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/34026.

[«State of the Art¼ on Advance Directive Consultations]. / «State of the Art¼ zu Beratungen zu Patientenverfügungen.

«State of the Art¼ on Advance Directive Consultations Abstract. Living wills serve to preserve self-determination at the end of life. They are intended to give patients the opportunity to intervene in their own treatment even if they are no longer able to do so because they are incapable of giving consent. In clinical practice, it is important, particularly in the case of serious illnesses such as cancer, not to work solely with general or standardized directives, but to seek formulations that are as individually suitable as possible. The attending physicians can provide important support in this regard.

[Changes in the Practice of Involuntary Hospitalization During the COVID-19 Pandemic - Experiences and Opinions of Chief Psychiatrists]. / Veränderungen in der psychiatrischen Unterbringungspraxis während der COVID-19-Pandemie.

OBJECTIVE: To collect experiences and opinions of chief psychiatrists in relation to changes in the practice of involuntary hospitalization during the COVID-19 pandemic. METHODS: Online survey among members of the Association of Chief Physicians for Psychiatry and Psychotherapy in North Rhine-Westphalia (LLPP) and analysis of protocols of LLPP board meetings. RESULTS: Changes in the practice of involuntary hospitalization have been perceived in contexts with and without direct reference to COVID-19. These changes have affected, among other things, judicial hearings as well as decisions about the use of coercive measures. CONCLUSION: Procedural standards for involuntary hospitalization must be maintained and coercive measures may only be used if they meet the applicable ethical and legal requirements. It must be ensured that people with mental disorders are not treated unequally both when taking and withdrawing restrictive measures to contain the pandemic.

[The Autonomy of Patients in Inpatient Medical Rehabilitation - Aspects of Endangerment and Preservation]. / Die Autonomie von Rehabilitanden in der stationären medizinischen Rehabilitation ­ Aspekte der Gefährdung und Wahrung.

PURPOSE: The aim of the study is to identify aspects within inpatient medical rehabilitation that may endanger or preserve the autonomy of patients. METHODS: A scoping review was carried out on the basis of the current state of scientific knowledge. The methodological approach was based on the specifications of the Joanna Briggs Institute. The research and generation of findings were logged according to the PRISMA-ScR checklist. RESULTS: The final study inclusion comprises 39 empirical and normative-theoretical contributions. Autonomy-threatening aspects were assigned to the following domains: Rehabilitation system, rehabilitation clinics, staff, patients and third parties. Aspects potentially preserving the autonomy of patients included the following domains: Rehabilitation clinics, staff, concepts and forms of expression as well as instruments. CONCLUSION: A large number of heterogeneous aspects can endanger, but can also preserve or promote the autonomy of patients during their stay in inpatient medical rehabilitation. These are located throughout in the entire rehabilitation process and concern the structural, organizational and personal level. The autonomy of patients should not only be treated as an outcome of rehabilitation, but also as a requirement for structures and actors during the rehabilitation stay.

[Suicide and assisted suicide from a legal and ethical perspective]. / Suizid und Suizidbeihilfe aus rechtlicher und ethischer Perspektive.

In 2020, the Federal Constitutional Court declared the ban on assisted suicide unconstitutional and invalid. The court derived a right to self-determined dying from the general right of personality. This right also includes the freedom to take one's own life and to seek help from third parties for this purpose and to make use of help if it is offered. In the meantime, there are several proposals for regulations and draft laws that pursue different concepts of a possible future regulation of assisted suicide. However, from the perspective of criminal law, the search for a new regulation should always be preceded by the question of the necessity of a new regulation. A new regulation must not be limited to certain groups of persons, such as persons with incurable, terminal illnesses, because otherwise the suicide motive would be assessed. This brings with it the particular challenge of finding a regulation that covers the different problem and need situations without assessing the suicide motive and also takes into account that the autonomy of the individual can be endangered in different ways.The article takes its starting point in the right to suicide, sheds light on different concepts, and discusses their advantages and disadvantages without explicitly highlighting individual legislative proposals. This is intended to enrich the further debate with individual aspects. At the same time, it advocates legislative restraint.

[Living wills of residents in nursing homes - which treatment situations and treatment measures are decreed?] / Patientenverfügungen von Bewohnenden in Pflegeeinrichtungen ­ welche Behandlungssituationen und Behandlungsmaßnahmen werden vorausverfügt?

BACKGROUND: The possibility of using a living will to influence later treatment in the event of incapacity to consent is nowadays an important element in safeguarding patients' autonomy at the end of life. Refusing or consenting treatment measures in advance of treatment is of particular importance for nursing home residents, not only against the background of the COVID-19 pandemic. METHODS: We conducted a survey of all resident-documents in 13 nursing homes of different sizes and service providers in the city and district of Wuerzburg. The documents were analysed according to a deductive-inductive procedure using categorical summaries and descriptive frequency counts. RESULTS: In 265 recorded living wills, 2072 treatment situations and 1673 treatment measures could be identified. Residents largely agree to symptom-relieving and nursing measures and often reject life-prolonging or life-substaining treatment measures, the latter mostly being limited to specific, defined situations. The reference to certain treatment situations regarding resuscitation attempts, both in the form of refusal and consent, was identified in 88.6 % of the living wills. 62 % of the living wills could be assigned to a template. DISCUSSION: The study provides information about the content of living wills of nursing home residents. It thus provides information on medical treatment preferences in the case of incapacity to consent and shows that treatment measures (including resuscitation) are mostly related to specific treatment situations.

Wishes and needs of nursing home residents and their relatives regarding end-of-life decision-making and care planning-A qualitative study.

AIMS AND OBJECTIVES: To explore wishes and needs, such as existing and preferred communication processes, of residents and relatives regarding medical and nursing planning at the end of life. BACKGROUND: Nursing home residents are a relevant target group for advance care planning (ACP) due to their high age and multimorbidity. Their relatives seem to be important partners in terms of communication and their documentation of wishes and needs. DESIGN: A qualitative descriptive design was used. METHODS: Thirty-two guideline-based interviews with nursing home residents (n = 24) and relatives (n = 8) were conducted in nursing homes in Germany (n = 7). All interviews were analysed by content-structured content analysis. The COREQ checklist was used to document reporting of the study. RESULTS: Residents particularly express wishes and needs regarding their health, like the desire to maintain or improve one's current state of health and to be active and mobile and also regarding their social situation, for example the well-being of relatives and beloved ones. A limited group of people was identified with whom residents spoke about issues such as preparedness and self-determination. These were mainly their relatives. Relatives themselves have a need for more communication. Various communication barriers could be identified. CONCLUSION: Residents express diverse and partly explicit wishes and needs. Although many of the respondents had already drafted advanced directives, the demand for offers of communication to plan ahead for the end of life remains clear. The results indicate the unconditional participation of relatives and people close to the residents, if they are available. RELEVANCE TO CLINICAL PRACTICE: Derivations for a target group-related ACP concept in the study region are identified. Besides the involvement of relatives, nurses could also be involved in the communication and decision-making process of residents in nursing homes under certain conditions.