[Palliative aspects in clinical acute and emergency medicine as well as intensive care medicine: consensus paper of the DGIIN, DGK, DGP, DGHO, DGfN, DGNI, DGG, DGAI, DGINA and DGPalliativmedizin]. / Palliativmedizinische Aspekte in der klinischen Akut- und Notfallmedizin sowie Intensivmedizin: Konsensuspapier der DGIIN, DGK, DGP, DGHO, DGfN, DGNI, DGG, DGAI, DGINA und DGPalliativmedizin.

The timely integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S-3-guideline on palliative medicine exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for palliative patients being treated in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.

[Palliative aspects in clinical acute and emergency medicine as well as intensive care medicine : Consensus paper of the DGIIN, DGK, DGP, DGHO, DGfN, DGNI, DGG, DGAI, DGINA and DGPalliativmedizin]. / Palliativmedizinische Aspekte in der klinischen Akut- und Notfallmedizin sowie Intensivmedizin : Konsensuspapier der DGIIN, DGK, DGP, DGHO, DGfN, DGNI, DGG, DGAI, DGINA und DGPalliativmedizin.

The timely integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S­3-guideline on palliative medicine exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for palliative patients presenting in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.

[Palliative aspects in clinical acute and emergency medicine as well as intensive care medicine : Consensus paper of the DGIIN, DGK, DGP, DGHO, DGfN, DGNI, DGG, DGAI, DGINA and DGPalliativmedizin]. / Palliativmedizinische Aspekte in der klinischen Akut- und Notfallmedizin sowie Intensivmedizin : Konsensuspapier der DGIIN, DGK, DGP, DGHO, DGfN, DGNI, DGG, DGAI, DGINA und DGPalliativmedizin.

The timely integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S­3-guideline on palliative medicine exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for palliative patients presenting in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.

[Palliative aspects in clinical acute and emergency medicine as well as intensive care medicine : Consensus paper of the DGIIN, DGK, DGP, DGHO, DGfN, DGNI, DGG, DGAI, DGINA and DG Palliativmedizin]. / Palliativmedizinische Aspekte in der klinischen Akut- und Notfallmedizin sowie Intensivmedizin : Konsensuspapier der DGIIN, DGK, DGP, DGHO, DGfN, DGNI, DGG, DGAI, DGINA und DG Palliativmedizin.

The integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S3 guideline on palliative medicine exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for palliative patients presenting in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.

Effects of Lidocaine on HT-29 and SW480 Colon Cancer Cells In Vitro.

BACKGROUND: Evidence is growing that the risk of cancer dissemination may be enhanced during the perioperative period. Whether particular anesthetic techniques influence oncological outcome is still under discussion. For pain management, lidocaine can be administered perioperatively by intravenous, intraperitoneal or epidural infusion. Here we investigated the effect of lidocaine on colon carcinoma cell lines (HT-29 and SW480) in vitro. MATERIALS AND METHODS: ELISA BrdU (Roche) for cell proliferation and FITC Annexin V detection kit (BD Pharming) for apoptosis analysis were applied. Cell-cycle profiles were investigated by flow cytometry. RESULTS: Cell-cycle arrest was induced in both cell lines by 1000 µM lidocaine, while no inhibition of cell proliferation was detected. Apoptosis decreased in SW480 but not in HT-29 cells. CONCLUSION: Lidocaine induces cell-cycle arrest in both colon carcinoma cell lines in vitro. The effective drug concentration can be obtained by local infiltration.

The expenditure of computer-related worktime using clinical decision support systems in chronic pain therapy.

BACKGROUND: Estimate the expenditure of computer-related worktime resulting from the use of clinical decision support systems (CDSS) to prevent adverse drug reactions (ADR) among patients undergoing chronic pain therapy and compare the employed check systems with respect to performance and practicability. METHODS: Data were collected retrospectively from 113 medical records of patients under chronic pain therapy during 2012/2013. Patient-specific medications were checked for potential drug-drug interactions (DDI) using two publicly available CDSS, Apotheken Umschau (AU) and Medscape (MS), and a commercially available CDSS AiDKlinik® (AID). The time needed to analyze patient pharmacotherapy for DDIs was taken with a stopwatch. Measurements included the time needed for running the analysis and printing the results. CDSS were compared with respect to the expenditure of time and usability. Only patient pharmacotherapies with at least two prescribed drugs and fitting the criteria of the corresponding CDSS were analyzed. Additionally, a qualitative evaluation of the used check systems was performed, employing a questionnaire asking five pain physicians to compare and rate the performance and practicability of the three CDSSs. RESULTS: The AU tool took a total of 3:55:45 h with an average of 0:02:32 h for 93 analyzed patient regimens and led to the discovery of 261 DDIs. Using the Medscape interaction checker required a total of 1:28:35 h for 38 patients with an average of 0:01:58 h and a yield of 178 interactions. The CDSS AID required a total of 3:12:27 h for 97 patients with an average time of analysis of 0:01:59 h and the discovery of 170 DDIs. According to the pain physicians the CDSS AID was chosen as the preferred tool. CONCLUSIONS: Applying a CDSS to examine a patients drug regimen for potential DDIs causes an average extra expenditure of work time of 2:09 min, which extends patient treatment time by 25 % on average. Nevertheless, the authors believe that the extra expenditure of time employing a CDSS is outweighed by their benefits, including reduced ADR risks and safer clinical drug management.

The possible impact of the German DRGs reimbursement system on end-of-life decision making in a surgical intensive care unit.

BACKGROUND: More than 70 % of critically ill patients die in intensive care units (ICUs) after treatment is reduced. End-of-life decision making in the ICU is a grey area that varies in practice, and there are potential economic consequences of over- and under-treatment. The aim of this study was to describe the end-of-life decisions of critically ill patients in a surgical ICU in Germany and to identify how financial incentives may influence decision making. METHODS: Data on the admission diagnosis, end-of-life decision making and cause of death were obtained for 69 critically ill patients who died in the ICU (Hospital of Bayreuth, Germany) in 2009. A cost-revenue analysis was conducted on the 46 patients who did not die within 3 days of ICU admission. Because we lacked real data on costs, our analysis was based on the average cost for each diagnosis-related group (DRG) from the Institute for the Hospital Remuneration System (InEK). Hospital revenues based on the DRG were considered. Subsequently, we compared the estimated financial impact of earlier and later decisions to withdraw or withhold futile therapy. RESULTS: In this study, we found that end-of-life decision making was poorly documented. Only 11 % of patients had a valid power of attorney and advanced directives, and therapy with presumed consent was performed in 43 % of all cases. From long-stay patients, therapy was withdrawn for 37 % of patients and withheld from 26 % of patients, and 37 % of the patients died receiving maximal therapy. Almost 72 % of DRG-related reimbursements were dependent on ventilation hours. The average total cost estimate (according to InEK) for the 46 long-stay patients was 1,201,000 . The revenues without additional remuneration were 1,358,000 , and the total estimated profit was approximately 157,000 . Only 10 cases were assumed to be non-profitable. In cases where the decision to withdraw or withhold therapy could have occurred 3 days earlier, the estimated profit shrank to 72,000 (46 % of estimated ICU profit). In situations where the decision to withdraw or withhold therapy from patients could have occurred 3 days later, the hypothetical profit rose to 217,000 (138 % of estimated ICU profit). CONCLUSION: There are still few patients with clear self-determination, and almost half of therapies are performed only according to presumed consent. The strong nonlinear dependence of DRG revenues on ventilation hours could influence ethical decision making of medical professionals. The decision-making process and appropriate therapy in the ICU setting need to be defined more clearly and better documented, focusing on the benefits to the patient while respecting patient consent.

Geriatrics in medical students' curricula: questionnaire-based analysis.

BACKGROUND: Demographic development is accompanied by an increasingly aging society. Concerning medical education, the treatment of older people as well as the scientific research and exploration of ageing aspects in the coming years need to be considered. Aim of the study was to ascertain medical students' knowledge, interest, and attitudes regarding older patients and geriatric medicine. METHODS: Each participant completed a self-designed questionnaire. This questionnaire was based on three validated internationally recognised questionnaires ("Facts on Aging Quiz--FAQ", "Expectations Regarding Aging--ERA" and the "Aging Semantic Differential--ASD"). The inquiry and survey were performed at the beginning of the summer term in 2012 at the University of Regensburg Medical School. RESULTS: A total of n = 184/253 (72.7%) students participated in this survey. The results of the FAQ 25+ showed that respondents were able to answer an average of M = 20.4 of 36 questions (56.7%) correctly (Median, Md = 21; SD ±6.1). The personal attitudes and expectations of ageing averaged M = 41.2 points on the Likert-scale that ranged from 0 to 100 (Md = 40.4; SD ±13.7). Respondents' attitudes towards the elderly (ASD 24) averaged M = 3.5 points on the Likert-scale (range 1-7, Md 3.6, SD ±0.8). CONCLUSIONS: In our investigation, medical students' knowledge of ageing was comparable to previous surveys. Attitudes and expectations of ageing were more positive compared to previous studies. Overall, medical students expect markedly high cognitive capacities towards older people that can actively prevent cognitive impairment. However, medical students' personal interest in medicine of ageing and older people seems to be rather slight.

Bag-mask ventilation and direct laryngoscopy versus intubating laryngeal mask airway: a manikin study of hands-on times during cardiopulmonary resuscitation.

OBJECTIVES: The percentage of hands-on time during cardiopulmonary resuscitation is a major determinant of patient outcome. We hypothesized that airway management with the intubating laryngeal mask airway (ILMA) would give greater hands-on time than with bag-mask ventilation (BMV), followed by direct laryngoscopy (DL), particularly in difficult-to-manage airways. PARTICIPANTS AND METHODS: Thirty paramedics and 40 medical students performed four standardized, 6-min cardiopulmonary resuscitation scenarios with the SimMan3G in a random sequence. These were normal and difficult-to-manage airways using either BMV+DL or ILMA. RESULTS: The time to the first successful ventilation was significantly longer with the ILMA (P<0.001). Hands-on time was lower for the ILMA after 2 min (67±8 vs. 81±8 s for BMV+DL, P<0.001), but was then significantly greater from the third minute onward (115±11 vs. 104±9 s for BMV+DL, P<0.001). The success rate of the first intubation attempt was higher and the time to ET placement was shorter with the ILMA, especially in the difficult-to-manage airway (P<0.001). CONCLUSION: In this manikin-based study, hands-on time was greater with the ILMA than with BMV+DL. The ILMA was particularly useful in increasing hands-on times in the difficult-to-manage airway.

The use of the laryngeal tube disposable by paramedics during out-of-hospital cardiac arrest: a prospectively observational study (2008-2012).

SUMMARY: In the previous and the current guidelines of the European Resuscitation Council (ERC), endotracheal intubation (ETI), as an instrument for ventilation during resuscitation, was confirmed as less important for paramedics not trained in this method. For those, during resuscitation, the laryngeal tube is recommended by the ERC as a supraglottic airway device. The present study investigated prospectively the use of the laryngeal tube disposable (LT-D) by paramedics in prehospital emergency cases. METHODS: During a 42-month period (Sept 2008-Feb 2012), we prospectively registered all prehospital cardiac arrest situations in which the LT-D had been applied by paramedics (from one emergency medical service in Germany). RESULTS: During the defined period, 133 attempts, recorded on standardised data sheets, were enrolled into the investigation. Three were excluded from the study because of use during a trauma situation. Therefore, 130 patients were evaluated in this study. For this, the LT-D was used in 98% of all cases during resuscitation, and in about 2% of other emergencies (eg, trauma). With regard to resuscitation, adequate ventilation/oxygenation was described as possible in 83% of all included cases. In 66% of all cases, no problems concerning the insertion of the LT-D were described by the paramedics. No significant problems were reported in 93%. In 7% (n=9 cases), no insertion of the LT-D was possible. Instead of bag-mask-valve ventilation, the LT-D was used as a first-line airway device in about 66%. Between the two defined groups, no statistically significant differences were found (p>0.05). CONCLUSIONS: As an alternative airway device during resuscitation, recommended by the ERC in 2005 and 2010, the LT-D may enable ventilation rapidly and, as in most of our described cases, effectively. Additionally, by using the LT-D in a case of cardiac arrest, a reduced 'hands-off time' and, therefore, a high chest compression rate may be possible. Our investigation showed that the LT-D was often used as an alternative to bag-mask-ventilation and to ETI as well. However, we were able to describe more problems in the use of the LT-D than earlier investigations. Therefore, in future, more studies concerning the use of alternative airway devices in comparison with ETI and/or video-laryngoscopy seem to be necessary.

Knowledge levels of pharmaceutical sales representatives in pain therapy: a descriptive questionnaire-based study.

PURPOSE: Pain is a common physiological reaction. The development and sale of medication against pain is a main focus of pharmaceutical companies, with total sales of prescription analgesics amounting to US$50 billion in 2009. In this market, advertising is necessary. One way to market both new and old drugs is through direct physician-to-pharmaceutical sales representative (PSR) contact. PSRs see themselves ideally as equal partners to the physicians they advise, thereby setting high standards for themselves. In this setting, PSRs should therefore have an adequate knowledge of pain therapy. The aim of this study was to evaluate whether these standards can be met by PSRs working in the area of pain medicine in terms of their level of education and knowledge of pain topics. METHODS: We distributed 114 questionnaires that were divided into demographic and knowledge sections. Of these, 90 questionnaires (79%) were returned completed. Since there is no complete list of PSRs working in pain medicine in Germany, we could not draw a representative sample for our study. RESULTS: We collected general demographic data on PSRs as well as on their educational backgrounds. Analysis of the completed questionnaires revealed that there was a high requirement for PSRs to acquire further education in pain therapy. In the knowledge section, PSRs were asked to rate a total of 70 statements on pain therapy as to whether they were true or false. The mean total of correctly rated statements was 48 (69%). CONCLUSIONS: Based on the results, we conclude that most PSRs do not meet their ideal high standards of being equal partners to the specialist physicians they visit. More education is needed to achieve this goal.

Paramedics experiences and expectations concerning advance directives: a prospective, questionnaire-based, bi-centre study.

BACKGROUND: Advance directives and palliative crisis cards are means by which palliative care patients can exert their autonomy in end-of-life decisions. AIM: To examine paramedics' attitudes towards advance directives and end-of-life care. DESIGN: Questionnaire-based investigation using a self-administered survey instrument. SETTING/PARTICIPANTS: Paramedics of two cities (Hamburg and Goettingen, Germany) were included. Participants were questioned as to (1) their attitudes about advance directives, (2) their clinical experiences in connection with end-of-life situations (e.g. resuscitation), (3) their suggestions in regard to advance directives, 'Do not attempt resuscitation' orders and palliative crisis cards. RESULTS: Questionnaires were returned by 728 paramedics (response rate: 81%). The majority of paramedics (71%) had dealt with advance directives and end-of-life decisions in emergency situations. Most participants (84%) found that cardiopulmonary resuscitation in end-of-life patients is not useful and 75% stated that they would withhold cardiopulmonary resuscitation in the case of legal possibility. Participants also mentioned that more extensive discussion of legal aspects concerning advance directives should be included in paramedic training curricula. They suggested that palliative crisis cards should be integrated into end-of-life care. CONCLUSIONS: Decision making in prehospital end-of-life care is a challenge for all paramedics. The present investigation demonstrates that a dialogue bridging emergency medical and palliative care issues is necessary. The paramedics indicated that improved guidelines on end-of-life decisions and the termination of cardiopulmonary resuscitation in palliative care patients may be essential. Participants do not feel adequately trained in end-of-life care and the content of advance directives. Other recent studies have also demonstrated that there is a need for training curricula in end-of-life care for paramedics.

[Strategic planning: an important economic action for German hospitals]. / Strategische Planung - Eine wichtige ökonomische Handlungsweise für deutsche Krankenhäuser.

In medical systems, economic issues and means of action are in the course of dwindling human (physicians and nurses) and financial resources are more important. For this reason, physicians must understand basic economic principles. Only in this way, there may be medical autonomy from social systems and hospital administrators. The current work is an approach to present a model for strategic planning of an anesthesia department. For this, a "strengths", "weaknesses", "opportunities", and "threats" (SWOT) analysis is used. This display is an example of an exemplary anaesthetic department.

Using a laryngeal tube suction-device (LTS-D) reduces the "no flow time" in a single rescuer manikin study.

BACKGROUND: In 2005, the European Resuscitation Council and the American Heart Association published new guidelines for Advanced Life Support. One of the points was to reduce the time without chest compressions in the first phase of cardiac arrest. OBJECTIVE: We evaluated in a manikin model whether using the single-use laryngeal tube with suction option (LTS-D) instead of endotracheal intubation (ET) and bag-mask-valve ventilation (BMV) for emergency airway management could reduce the "no-flow time" (NFT). The NFT is defined as the time during resuscitation when no chest compressions take place. METHODS: A randomized, prospective study was undertaken with 150 volunteers who performed management of a standardized simulated cardiac arrest in a manikin. Every participant was randomized to one of three different airway management groups (LTS-D vs. ET vs. BMV). RESULTS: The LTS-D was inserted significantly faster than the ET tube (15 s vs. 44 s, respectively, p < 0.01). During the cardiac arrest simulation, establishing and performing ventilation took an average of 57 s with the LTS-D compared to 116 s with ET and 111 s with the BMV. Using the LTS-D significantly reduced NFT compared to ET and the BMV (125 s vs. 207 s vs. 160 s; p < 0.01). CONCLUSIONS: In our manikin study, NFT was reduced significantly when the LTS-D was used when compared to ET and BMV. The results of our manikin study suggest that for personnel not experienced in tracheal intubation, the LTS-D offers a good alternative to ET and BMV to manage the airway during resuscitation, and to avoid the failure to achieve tracheal intubation with the ET, and the failure to achieve adequate ventilation with the BMV.

Post-mortal bereavement of family caregivers in Germany: a prospective interview-based investigation.

BACKGROUND: Care aspects of outpatient palliative-care teams involve the medical, psychological, and spiritual needs of patients and their caregivers. The objective of our study was to examine the post-mortal bereavement of family caregivers. METHODS: The investigation was based on interviews with 50 family caregivers of 50 palliative-care patients assessed by a palliative-care team. Each caregiver was interviewed using interview sheets (mixed method designs) in accordance with three groups of validated criteria for complicated grief: Prigerson, Horowitz, and ICD-10. RESULTS: Forty-six family caregivers of terminally ill patients participated in the study. Complicated grief existed in up to 30% of the caregivers, based on the three sets of criteria. There was no significant difference (P > 0.05) among the three groups and no significant differences were found (P > 0.05) in relation to age, sex, psychosocial distress, primary cancer disease, and duration of illness or quality of care. Overall, 97% of the care-giving relatives were satisfied with the help given by the palliative-care team. CONCLUSION: The results of the study suggest that care from a specialized palliative-care team providing psychological and social support may reduce the risk of complicated grief. Careful exploration of possible risk factors for complicated grief is important for optimal care. Our study shows that healthcare providers play an important role in helping family caregivers to manage the multiple burdens and the grieving reaction. Family-focused grief therapy may prevent complicated grieving reactions.

[Emergency medical treatment of paediatric palliative care patients: a problem for emergency medical care services? A retrospective, multicentre observational study]. / Notärztliche Betreuung kinderpalliativ- medizinischer Notfallsituationen--ein Problem für den Rettungsdienst?--Eine retrospektive, multizentrische Beobachtungsstudie.

BACKGROUND: In Germany a few specialised palliative care teams (PCTs) enable paediatric palliative care patients to stay at home in the final stage of their life. During this stage patients often experience episodes of acute symptoms requiring rapid medical intervention. In this case care-giving relatives can call emergency medical care services. The present investigation aims to show the meaning of emergency medical care services in treating paediatric palliative care patients in a home-care setting. Moreover, mental strain of emergency medical staff in paediatric medical emergencies and end-of-life care will be discussed. METHODS: In a multi-centre retrospective study we analyse all paediatric emergency medical care cases of four emergency sites over a 24-month period. In particular, all cases of acute palliative care in terminal paediatric cancer patients up to the age of 14 were evaluated. RESULTS: In the defined period we analysed 738 paediatric emergency documents (5.7% of all emergency cases); of these we identified two (0.3%) emergency calls by paediatric palliative care patients or their caregiving relatives. In both cases there was no specialised outpatient PCT involved in the treatment of the patients or the assistance to their caregiving relatives. CONCLUSIONS: Our data demonstrate that emergency medical treatment is less frequently provided to paediatric than to adult palliative care patients. However, these paediatric patients also need help that is based on the principles of palliative care like adult patients do. In the context of quality standard optimisation, specialised PCTs should get more involved in paediatric palliative home and pre-hospital care, even in cases of medical emergencies in these patients. After end-of-life decisions relating to paediatric patients, psychological support to the emergency medical team seems to be both helpful and reasonable.

[Ambulatory pain therapy in penetrating rectal cancer via epidural anesthesia]. / Ambulante Schmerztherapie. Behandlung bei penetrierendem Rektum-Karzinom mittels Periduralkatheter.

Treatment of cancer pain includes invasive techniques of pain therapy if necessary. Here we report the management of a 55-year-old female patient with penetrating rectal cancer using continuous lumbal epidural anesthesia. After placement and dose-finding our patient was discharged from hospital and further treatment occurred at home.

[Quality characteristics concerning pain therapy]. / Qualität in der Therapie chronischer Schmerzen - Methoden zur Messung des Therapieerfolges.

The Institute of Medicine (IOM) reports "Crossing the Quality Chasm proposed 7 aims for high-quality healthcare: effective, safe, timely, efficient, equitable, patient-centred, and emphasized care coordination. The quality of pain treatment can also be shown by structure quality, process quality, and outcome quality. The present investigation shows methods of the qualitative capture of pain therapy. On this occasion, it is shown whether such a pain measurement with the available parameters is generally possible and which parameters are necessary for this. However, quality parameter and quality outcome must be regarded individually for every patient. Quality measurement concerning the therapy of chronic pain diseases is an interaction of several quality and outcome parameters. Furthermore patients' aims concerning his individual pain treatment must be taken into account.

Prehospital emergency treatment of palliative care patients with cardiac arrest: a retrolective investigation.

BACKGROUND: Today, prehospital emergency medical teams (EMTs) are confronted with emergent situations of cardiac arrest in palliative care patients. However, little is known about the out-of-hospital approach in this situation and the long-term survival rate of this specific patient type. The aim of the present investigation was to provide information about the strategic and therapeutic approach employed by EMTs in outpatient palliative care patients in cardiac arrest. METHODS: During a period of 2 years, we retrolectively analysed emergency medical calls with regard to palliative care emergency situations dealing with cardiac arrest. We evaluated the numbers of patients who were resuscitated, the prevalence of an advance directive or other end-of-life protocol, the first responder on cardiac arrest, the return of spontaneous circulation (ROSC) and the survival rate. RESULTS: Eighty-eight palliative care patients in cardiac arrest were analysed. In 19 patients (22%), no resuscitation was started. Paramedics and prehospital emergency physicians began resuscitation in 61 cases (69%) and in 8 cases (9%), respectively. A total of 10 patients (11%) showed a ROSC; none survived after 48 h. Advance directives were available in 43% of cases. The start of resuscitation was independent of the presence of an advance directive or other end-of-life protocol. CONCLUSIONS: Strategic and therapeutic approaches in outpatient palliative care patients with cardiac arrest differ depending on medical qualification. Although many of these patients do not wish to be resuscitated, resuscitation was started independent of the presence of advance directive. To reduce legal insecurity and to avoid resuscitation and a possible lengthening of the dying process, advance directives and/or "Do not attempt resuscitation" orders should be more readily available and should be adhered to more closely.