Evaluating palliative care case conferences in primary care for patients with advanced non-malignant chronic conditions: a cluster-randomised controlled trial (KOPAL).

BACKGROUND: Patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and dementia are underrepresented in specialist palliative home care (SPHC). However, the complexity of their conditions requires collaboration between general practitioners (GPs) and SPHC teams and timely integration into SPHC to effectively meet their needs. OBJECTIVE: To facilitate joint palliative care planning and the timely transfer of patients with advanced chronic non-malignant conditions to SPHC. METHODS: A two-arm, unblinded, cluster-randomised controlled trial. 49 GP practices in northern Germany were randomised using web-based block randomisation. We included patients with advanced CHF, COPD and/or dementia. The KOPAL intervention consisted of a SPHC nurse-patient consultation followed by an interprofessional telephone case conference between SPHC team and GP. The primary outcome was the number of hospital admissions 48 weeks after baseline. Secondary analyses examined the effects on health-related quality of life and self-rated health status, as measured by the EuroQol 5D scale. RESULTS: A total of 172 patients were included in the analyses. 80.4% of GP practices had worked with SHPC before, most of them exclusively for cancer patients. At baseline, patients reported a mean EQ-VAS of 48.4, a mean quality of life index (EQ-5D-5L) of 0.63 and an average of 0.80 hospital admissions in the previous year. The intervention did not significantly reduce hospital admissions (incidence rate ratio = 0.79, 95%CI: [0.49, 1.26], P = 0.31) or the number of days spent in hospital (incidence rate ratio = 0.65, 95%CI: [0.28, 1.49], P = 0.29). There was also no significant effect on quality of life (∆ = -0.02, 95%CI: [-0.09, 0.05], P = 0.53) or self-rated health (∆ = -2.48, 95%CI: [-9.95, 4.99], P = 0.51). CONCLUSIONS: The study did not show the hypothesised effect on hospitalisations and health-related quality of life. Future research should focus on refining this approach, with particular emphasis on optimising the timing of case conferences and implementing discussed changes to treatment plans, to improve collaboration between GPs and SPHC teams.

Consensus-based recommendations for the development and expansion of palliative day care clinics in Germany: results of a Delphi study.

BACKGROUND: Needs-based, patient-oriented palliative care includes palliative day care clinics as a specialized semi-inpatient care offer. However, the establishment and development of these facilities has been unsystematic. Research is needed to strengthen their transparency and ensure their accessibility, quality, and structural adequacy. A national Delphi study was conducted to generate appropriate recommendations for the establishment and development of palliative day care clinics in Germany. METHODS: Recommendations were formulated from focus group data on the development and expansion of palliative day care clinics in Germany. Experts on in- and outpatient palliative care rated 28 recommendations for relevance and feasibility, respectively, using a 4-point Likert-type scale. Suggestions for improvement were captured via free text comments. Items were considered consented when more than 80% of the experts scored them 4 (strongly agree) or 3 (somewhat agree), regarding both relevance and feasibility. RESULTS: A total of 23 experts (32% response rate) completed three Delphi rounds. Following the first round, 10 of 28 recommendations were revised according to participants' comments; 1 recommendation was rejected. After the second round, 3 of these 10 recommendations were revised, while 3 were rejected. Consensus was achieved after the third round for 22 of the initial recommendations. CONCLUSIONS: The Delphi-consented recommendations provide a basis for the targeted evidence- and needs-based development of palliative day care clinics. The findings show a need for standards setting and the meaningful integration of these clinics into existing structures. TRIAL REGISTRATION: The present study was prospectively registered on April 20, 2020, with the German Clinical Trials Register (DRKS00021446).

[A regional comparison of outcomes quality and costs of general and specialized palliative care in Germany: a claims data analysis]. / Ergebnisqualität und Kosten der allgemeinen und spezialisierten Palliativversorgung in Deutschland im regionalen Vergleich: eine GKV-Routinedatenstudie.

BACKGROUND: The main framework conditions for palliative care are set at the regional level. The scope of the forms of care used (outpatient, inpatient, general, specialized) varies widely. What is the quality of outcomes achieved by the palliative care provided on a federal states level? What are the associated costs of care? METHOD: Retrospective observational study using BARMER claims data from 145,372 individuals who died between 2016 and 2019 and had palliative care in the last year of life. Regional comparison with regard to the following outcomes: proportion of palliative care patients who died in the hospital, potentially burdensome care in the last 30 days of life (ambulance calls, [intensive care] hospitalizations, chemotherapy, feeding tubes, parenteral nutrition), total cost of care (last three months), cost of palliative care (last year), and cost-effectiveness ratios. Calculation of patient/resident characteristic adjusted rates, costs, and ratios. RESULTS: Federal states vary significantly with respect to the outcomes (also adjusted) of palliative care. Palliative care costs vary widely, most strongly for specialized outpatient palliative care (SAPV). Across all indicators and the cost-effectiveness ratio of total cost of care to at-home deaths, Westphalia-Lippe shows favorable results. CONCLUSION: Regions with better quality and more favorable cost (ratios) can provide guidance for other regions. The extent to which the new federal SAPV agreement can incorporate the empirical findings should be reviewed. Patient-relevant outcome parameters should be given greater weight than parameters aiming at structures of care.

'She Can't Support Me Because She's so Old': A Mixed-Methods Study of Support Experiences and Needs in Adult Child-Parent Dyads at the End of Life.

Little is known about support experiences and needs in the dyads of (1) terminally ill adult children and their parent caregivers and (2) terminally ill parents and their adult child caregivers. The current study aimed at investigating the experiences and needs of adult children and parents in end of life situations regarding their provision and receipt of support. The study employed a convergent parallel mixed-methods design, combining explorative qualitative interviews with the quantitative self-report Berlin Social Support Scales. Sixty-five patients (dyad 1: 19; dyad 2: 46) and 42 family caregivers (dyad 1: 13; dyad 2: 29) participated in the study (02/2018-11/2019). Results show that ill adult children felt less (well) supported than ill parents. Parent caregivers were often limited in the support they could provide, due to their age and health conditions. Hypotheses were deduced from patients' and family caregivers' notions to inform dyad-specific recommendations for support interventions.

Consensus-based recommendations for psychosocial support measures for parents and adult children at the end of life: results of a Delphi study in Germany.

PURPOSE: The availability of psychosocial support measures has a significant impact on the quality of life of terminally ill and dying patients and the burden experienced by their relatives. To date, no intervention has specifically focused on promoting interaction within the dyads of the following: (1) terminally ill adult children and their parents and (2) terminally ill parents and their adult children. A national Delphi study was conducted to provide appropriate recommendations for dyadic psychosocial support measures. METHODS: Recommendations were formulated from qualitative interview data on the experiences and wishes of patients and family caregivers within these two dyads. Experts from palliative and hospice care providers rated the relevance and feasibility of 21 recommendations on two 4-point Likert-type scales, respectively. Additional suggestions for improvement were captured via free text fields. Individual items were considered consented when ≥ 80% of participants scored 1 (strongly agree) or 2 (somewhat agree) regarding both relevance and feasibility. RESULTS: A total of 27 experts (35% response rate) completed two Delphi rounds. Following the first round, 13 recommendations were adjusted according to participants' comments. After the second round, consensus was achieved for all 21 of the initially presented recommendations. CONCLUSION: The Delphi-consented recommendations for parents and adult children at the end of life provide the first guidance for hands-on dyadic psychosocial support measures for parent-adult child relationships, specifically. The next step could involve the structured implementation of the recommendations, accompanied by scientific research. This study was registered on October 27, 2017, with the German Clinical Trials Register (DRKS00013206).

Nurses' perspectives on the role of relatives in emergency situations in nursing homes: a qualitative study from Germany.

BACKGROUND: In nursing homes, emergencies often result in unnecessary hospital transfers, which may negatively affect residents' health. Emergency management in nursing homes is complicated by structural conditions, uncertainties and difficulties communicating with the treating healthcare professionals. The present study investigated the role played by relatives in this emergency management, as perceived by nursing staff. METHODS: Within the context of a larger multi-method, interdisciplinary research project, we conducted six focus group discussions and 33 semi-structured interviews with nurses at nursing homes in northern Germany between September 2020 and April 2021. Discussions and interviews focused on emergency management in nursing homes, and were recorded, transcribed and analysed using qualitative content analysis, according to Mayring. RESULTS: Nurses reported that relatives were actively involved in emergency management in the nursing homes. Relatives were informed when there was an emergency situation, and they participated in decision making around the resident's care. Nurses sometimes perceived the involvement of relatives as challenging, due to a lack of time or staff, the opposing views of relatives and/or uncertain communication structures; however, they were willing to involve relatives according to the relatives' preferences. The role played by relatives was seen to range from that of an active supporter to that of a troublemaker. On the one hand, relatives were reported to support nurses in emergency management (i.e. by identifying residents' preferences and advocating for residents' interests). On the other hand, relatives were often perceived by the nurses as overstrained and unprepared in emergency situations, leading them to override residents' wishes, question the emergency plan and put pressure on the nurses' decision making. CONCLUSIONS: Nurses perceive the roles played by relatives in emergency situations in nursing homes as relatively supportive or, alternatively, demanding and troublesome. The timely involvement of relatives in emergency planning, the establishment of clear agreements with general practitioners and the development of trusting relationships between nursing staff and relatives may improve emergency management for nurses.

Long-distance caregiving at the end of life: a protocol for an exploratory qualitative study in Germany.

BACKGROUND: Of the approximately 4.7 million people in Germany caring for a relative, many live at a geographical distance from their loved one. The provision of remote care to a terminally ill patient is associated with specific challenges and burdens. In the German context, research is lacking on the specific experiences and needs of caregivers in end-of-life situations who are geographically distanced from their relative. Thus, the overarching goal of the proposed study is to detail the specifics of long-distance caregiving at the end of life in Germany, determining the role played by physical distance in shaping end-of-life caregiving and identifying the needs of long-distance caregivers in this situation. METHODS: The exploratory qualitative study will be guided by an inductive logic, drawing on one-time semi-structured interviews. To uncover the multiplicity of caregiving experiences, long-distance caregivers of both patients receiving early palliative care and patients at a very advanced stage of disease will be included. The study will be divided into five phases: (1) preparation and pretest, (2) data collection and primary analysis, (3) data analysis and interpretation, (4) advisory board workshop and (5) conclusions and recommendations. DISCUSSION: The study will aim at generating valuable insight regarding the experiences and needs of family caregivers of end-of-life patients. This is particularly relevant, given that families are becoming increasingly geographically dispersed. As this trend continues, it will challenge traditional models of family care and shed light on novel caregiving issues that will need to be addressed through social and health policy. TRIAL REGISTRATION: The study was prospectively registered in the German Clinical Trials Register (Deutsches Register Klinischer Studien) (Registration N° DRKS00024164; date of registration: January 25, 2021), and is searchable under the International Clinical Trials Registry Platform Search Portal of the World Health Organization, under the German Clinical Trials Register number.

Providing palliative care for residents in LTC facilities: an analysis of routine data of LTC facilities in Lower Saxony, Germany.

BACKGROUND: Demographic trends show an increasing number of elderly people and thus a growing need for palliative care (PC). Such care is increasingly being provided by long-term care (LTC) facilities. The present study aimed at exploring PC indicators of residents at LTC facilities belonging to a non-profit provider in Lower Saxony, Germany, in order to identify potential improvements. METHODS: A descriptive cross-sectional study was conducted, drawing on routine nursing chart data. Structural data from 16 participating LTC facilities and the care data of all residents who died in 2019 (N = 471) were collected anonymously between March and May 2020. Based on key literature on quality indicators of PC in LTC facilities in Germany, a structured survey was developed by a multidisciplinary research team. The descriptive, comparative and inferential data analysis was conducted using the SPSS software package. RESULTS: In total, the complete records of 363 (77%) residents who died in the participating LTC facilities in 2019 were retrieved. The records reflected that 45% of the residents had been hospitalized at least once during the last 6 months of their lives, and 19% had died in hospital. Advance care planning (ACP) consultation was offered to 168 (46%) residents, and 64 (38%) declined this offer. A written advance directive was available for 47% of the residents. A specialized PC team and hospice service volunteers were involved in caring for 6% and 14% of the residents, respectively. Cancer patients received support from external services significantly more frequently (p < .001) than did non-cancer patients. Differences emerged in the distribution of PC indicators between LTC facilities. Facilities that have more PC trained staff offered more ACP, supported by more specialized PC teams and hospice services, and had fewer hospitalizations. In addition, more volunteer hospice services were offered in urban facilities. CONCLUSIONS: Overall, a rather positive picture of PC in participating LTC facilities in Germany emerged, although there were differences in the expression of certain indicators between facilities. ACP consultation, volunteer hospice services, and hospital admissions appeared to be superior in LTC facilities with more trained PC staff. Therefore, PC training for staff should be further promoted.

Structured implementation of the Supportive and Palliative Care Indicators Tool in general practice - A prospective interventional study with follow-up.

BACKGROUND: General practitioners (GPs) play a key role in the provision of primary palliative care (PC). The identification of patients who might benefit from PC and the timely initiation of patient-centred PC measures at the end of life are essential, yet challenging. Although different tools exist to support these key tasks, a structured approach is often missing. OBJECTIVE: The study aimed at implementing the German version of the Supportive and Palliative Care Indicators Tool (SPICT-DE™) in general practices, following a structured and regional approach, in order to evaluate the effects of this tool on the identification of patients with potential PC needs and the initiation of patient-centred PC measures. METHODS: The intervention of this mixed-methods study comprised a standardised training of 52 GPs from 34 general practices in two counties in Lower Saxony, Germany, on the use of the SPICT-DE™. The SPICT-DE™ is a clinical tool which supports the identification of patients with potential PC needs. Subsequently, over a period of 12 months, GPs applied the SPICT-DE™ in daily practice with adult patients with chronic, progressive diseases, and completed a follow-up survey 6 months after the initial patient assessment. The outcome parameters were alterations in the patient's clinical situation, and the type and number of initiated patient-centred PC measures during the follow-up interval. Additionally, 12 months after the standardised training, GPs provided feedback on their application of the SPICT-DE™. RESULTS: A total of 43 GPs (n = 15 female, median age 53 years) out of an initial sample of 52 trained GPs assessed 580 patients (n = 345 female, median age 84 years) with mainly cardiovascular (47%) and cancer (33%) diseases. Follow-up of 412 patients revealed that 231 (56%) experienced at least one critical incident in their disease progression (e.g. acute crisis), 151 (37%) had at least one hospital admission, and 141 (34%) died. A review of current treatment/medication (76%) and a clarification of treatment goals (53%) were the most frequently initiated patient-centred PC measures. The majority of GPs deemed the SPICT-DE™ practical (85%) and stated an intention to continue applying the tool in daily practice (66%). CONCLUSIONS: The SPICT-DE™ is a practical tool that supports the identification of patients at risk of deterioration or dying and promotes the initiation of patient-centred PC measures. TRIAL REGISTRATION: The study was registered in the German Clinical Trials Register (N° DRKS00015108; 22/01/2019).

Perceived stress and study-related behavior and experience patterns of medical students: a cross-sectional study.

BACKGROUND: Distress and burnout are common in physicians. Both may already arise during medical training and persist throughout residency. An analysis of needs is necessary in order to develop target group specific curricular concepts at medical faculties. Aim of this study was to assess the perceived stress of medical students, to explore study-related behavior and experience patterns, and to investigate associated factors. METHODS: We conducted a cross-sectional survey of medical students at the Hannover Medical School. The web-based questionnaire consisted of 74 items and included two standardized instruments: the "Work-related Behavior and Experience Patterns" (Arbeitsbezogene Verhaltens- und Erlebensmuster, AVEM) and the "Perceived Medical School Stress" scale (PMSS). Students were asked to state their self-perceived actual stress level on a scale from 0% (no stress at all) to 100% (maximum stress). We performed a classification and regression tree (CART) analysis to identify factors that can discriminate between the four different AVEM patterns. RESULTS: Five hundred ninety-one medical students (female 75.8%, response rate: 34.0%) participated in the survey. The mean sum score of the PMSS was 37.2 (SD 8.3; median score 37, min.-max. = 18-65). Overall, 68.5% of the students showed a risk pattern (risk pattern A "overexertion": 38.9%; risk pattern B "burnout": 29.6%). Pattern G "healthy" was shown in 8.3% and pattern S "protection" in 23.1% of the students. Multilevel analysis revealed that the self-perceived stress level and the PMSS sum score were the most important predictors for the AVEM pattern assignment. Furthermore, academic year, gender, and financial dependency were relevant influencing factors: students in higher academic years with no financial support had a higher probability to be in risk pattern B whereas male students in the first academic year tended to be in pattern G. CONCLUSIONS: The PMSS sum score could objectify medical students' high self-perceived stress level. The majority of participating students showed a risky study-related behavior and experience pattern. Medical faculties should be aware of the still existing and relevant problem of stress and burnout among medical students. Our results lay the groundwork for an evaluation and further development of medical curricula at the own faculty.

'Mums are sacred, and mums don't die': A mixed-methods study of adult child-parent dyadic relationships at the end of life.

OBJECTIVES: The aim of the present study was to report the specific challenges pertaining to the experiences and needs of (1) terminally ill adult children and their parents and (2) terminally ill parents and their adult children, regarding their relationship and relationship roles. The study sought to identify similar and differing relationship patterns between the two dyadic types. DESIGN: This prospective observational study used an exploratory mixed-methods approach. PARTICIPANTS: Patients and caregivers were recruited (Feb. 2018 - Nov. 2019) via general and specialist palliative care providers in Germany. METHODS: The study combined semi-structured interviews with quantitative questionnaires covering socio-demographic details, attachment style and emotional intimacy. FINDINGS: A total of 65 patients and 42 family caregivers participated in the study. Interview data indicate that illness situation and dependencies were perceived in both dyads to represent a relationship role reversal contrary to the 'natural order'. With respect to dyad 1, adult children stressed their need for autonomy, whereas caregiving parents strived for greater intimacy in the relationship. Within dyad 2, terminally ill parents and adult children experienced a new relationship intensity. Questionnaire data showed that emotional intimacy was perceived by patients in both dyads and adult child caregivers as significantly higher in the current illness situation compared to the pre-illness situation. CONCLUSIONS: This was the first study to contribute to an understanding of the different needs of terminally ill adult children/parents and their parent/adult child caregivers, thus contributing to an understanding of the different needs of these parties, both within and between the dyadic forms. The results suggest that the dyads share similar themes, which should be integrated into general support interventions; however, some themes appear more relevant for one dyad, only. IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS: For both dyads, we recommend psychological counseling to support open communication and understanding between parties.

[DNVF Memorandum: Health Services Research in the Last Year of Life]. / DNVF-Memorandum Versorgungsforschung im letzten Lebensjahr.

This memorandum outlines current issues concerning health services research on seriously ill and dying people in the last year of their lives as well as support available for their relatives. Patients in the last phase of life can belong to different disease groups, they may have special characteristics (e. g., people with cognitive and complex impairments, economic disadvantage or migration background) and be in certain phases of life (e. g., parents of minor children, (old) age). The need for a designated memorandum on health services research in the last year of life results from the special situation of those affected and from the special features of health services in this phase of life. With reference to these special features, this memorandum describes methodological and ethical specifics as well as current issues in health services research and how these can be adequately addressed using quantitative, qualitative and mixed methods. It has been developed by the palliative medicine section of the German Network for Health Services Research (DNVF) according to the guidelines for DNVF memoranda.

[Emergency situations and emergency department visits in nursing homes-a scoping review about circumstances and healthcare interventions]. / Notfallsituationen und Krankenhauszuweisungen in Pflegeeinrichtungen ­ ein Scoping-Review zu Begleitumständen und versorgungsrelevanten Maßnahmen.

BACKGROUND: Nursing home residents are more likely to be hospitalized as non-institutionalized peers. A large number of emergency medical services (EMS) and emergency department visits are classified as potentially avoidable. OBJECTIVES: To identify circumstances that increase the number of emergency situations in nursing homes and approaches to reduce hospital admissions in order to illustrate the complexity and opportunities for action. MATERIALS AND METHODS: Scoping review with analysis of current original and peer-reviewed papers (2015-2020) in PubMed, CINAHL, and hand-search databases. RESULTS: From 2486 identified studies, 302 studies were included. Injuries, fractures, cardiovascular, respiratory, and infectious diseases are the most frequent diagnostic groups that have been retrospectively recorded. Different aspects could be identified as circumstances inducing emergency department visits: resident-related (e.g., multimorbidity, lack of volition, and advance directives), facility-related (e.g., staff turnover, uncertainties), physician-related (lack of accessibility, challenging access to specialists), and system-related circumstances (e.g., limited possibilities for diagnostics and treatment in facilities). Multiple approaches to reduce emergency department visits are being explored. CONCLUSIONS: A variety of circumstances influence the course of action in emergency situations in nursing facilities. Therefore, interventions to reduce emergency department visits address, among other things, strengthening the competence of nursing staff, interprofessional communication, and systemic approaches. A comprehensive understanding of the complex processes of care is essential for developing and implementing effective interventions.

[Structuring emergency management in nursing homes: Results of interprofessional focus group interviews]. / Strukturierung des Notfallmanagements in Pflegeheimen: Ergebnisse interprofessioneller Fokusgruppeninterviews.

BACKGROUND: Emergencies in nursing homes lead to frequent utilization of emergency medical services and emergency department visits, which are frequently assessed as avoidable and do not comply with the patients' wishes. Emergency management is complicated by structural conditions, uncertainty and difficulties in communication between the treating healthcare professionals. OBJECTIVE: In the framework of the NOVELLE research project a model for a recommendation for action was developed in an interprofessional process to structure the emergency management in nursing homes. MATERIAL AND METHODS: The research process was organized according to the grounded theory as a constant interplay of data collection, analysis and concept development. From January to April 2021 a total of 6 focus group interviews were conducted with 24 nurses, physicians and experts from medical ethics and 1 guideline interview with an expert from the field of medical law. All interviews were performed as video conferences. They were digitally recorded, transcribed verbatim and coded with MAXQDA software. RESULTS: Recommendations for organizing and improving the emergency management are structured into three components: 1) initial assessment, 2) structured assessment including nursing evaluation and integration of patient treatment preferences and 3) organization of further treatment. Components include actions, results and consequences and can be arranged in the form of an algorithm. DISCUSSION: Recommendations for improvement of emergency management should enhance the competences of nursing staff, respect patient treatment preferences, consider situational conditions and support communication with external medical and care providers.

Communication in dyads of adult children at the end of life with their parents and parents at the end of life with their adult children: Findings from a mixed-methods study.

OBJECTIVE: Patient-family member communication plays a decisive role in coping with an end-of-life situation and is strongly influenced by the dyadic relationship. There is a lack of research exploring and comparing the specifics of communication between (1) terminally ill adult children and their parents and (2) terminally ill parents and their adult children. The present study aimed at describing and comparing communication specifics within these two dyads. METHODS: As part of the research project Dy@EoL on parent-adult child interactions, this mixed-methods study combined qualitative interviews and the Berlin Social Support Scales self-report questionnaire. Participants in both dyads were recruited via 12 inpatient and ambulatory palliative/hospice care providers between February 2018 and September 2019. RESULTS: Participants included 65 patients (dyad 1: 19; dyad 2: 46) and 42 family members (dyad 1: 13; dyad 2: 29). Qualitative interviews revealed communication changes in the terminal illness situation and provided insight into each dyad partner's perception of openness and avoidance in the dyadic communication. The quantitative results showed that patients in both dyads provided significantly less informational support relative to family members. A strong similarity present in both dyads was the central motivation for limiting information sharing. CONCLUSIONS: Individual preferences for information sharing suggest that the divergent needs of dyad partners must be carefully negotiated to ensure that patients are able to address important topics without putting too great an emotional burden on their family members. Tailored psychosocial support measures are needed to achieve this goal. The study was registered prospectively in the German Clinical Trials Register (registration N° DRKS00013206).

Exploring the status of and demand for palliative day-care clinics and day hospices in Germany: a protocol for a mixed-methods study.

BACKGROUND: To date, the establishment and development of palliative day-care clinics and day hospices in Germany have been completely unsystematic. Research is needed to gain insight into these services and to ensure their accessibility and quality. Accordingly, the ABPATITE research project aims at: (1) identifying the characteristics of palliative day-care clinics and day hospices in Germany, (2) determining demand and preferences for these services, and (3) proposing recommendations (with expert agreement) for the needs-based establishment and development of these services. METHODS: The research is a multi-perspective, prospective, observational study following a mixed-methods approach across three study phases. In phase 1a, qualitative expert interviews will be conducted to capture the facility-related characteristics of palliative day-care clinics and day hospices in Germany; the results will feed into a questionnaire sent to all such institutions identified nationwide. In phase 1b, a questionnaire will be sent to local statutory health insurance providers, to gain insight into their contracts and accounting and remuneration models. In phase 2a, a service preference survey will be conducted with patients and family caregivers. In phase 2b, semi-structured interviews with management staff will explore the factors that promote and hinder the provision of service. In phase 2c, the external perspective will be surveyed via focus groups with local actors involved in hospice and palliative care. In phase 3a, focus groups with representatives from relevant areas will be conducted to develop recommendations. Finally, in phase 3b, recommendations will be agreed upon through a Delphi survey. DISCUSSION: The empirically developed recommendations should enable the establishment and development of day hospices and palliative day-care clinics in Germany to be better managed, more oriented to actual demand, and more effectively integrated into wider health care services. Importantly, the findings are expected to optimize the overall development of hospice and palliative care services. TRIAL REGISTRATION: The study was prospectively registered in the German Clinical Trials Register (Deutsches Register Klinischer Studien) (Registration N° DRKS00021446; date of registration: April 20, 2020). The study is searchable under the International Clinical Trials Registry Platform Search Portal of the World Health Organization, under the German Clinical Trials Register number.

" darum rufe ich jetzt den Rettungsdienst!"

"… that's why I call the ambulance!" - A qualitative study of emergency scenarios in nursing homes Abstract. Background: In nursing homes, emergencies lead to frequent utilisation of emergency medical services (EMS) and emergency department visits. A broad interprofessional perspective of involved practitioners on emergencies in nursing homes has been little studied so far. Aim: Characterization, identification and prioritization of emergency scenarios by relevance and frequency in nursing homes. Methods: We conducted two multi-method, interprofessional group discussions with a total of 18 participants from nursing, medicine and science in January and February 2020. Group discussions were recorded, transcribed and analyzed using qualitative content analysis according to Mayring. Results: Emergency scenarios in nursing homes arise from interactions between person-related aspects and contextual conditions. The following person-related aspects were named as relevant: Falls, unstable vital signs, abnormal behavior, neurological symptoms and lifelessness. Contextual conditions are classified into organizational-structural, political-legal and ethical aspects. The following were considered to be most relevant: lack of communication between the actors, uncertainties among staff, absent living wills and increasing workload in nursing. Conclusions: Emergencies in nursing homes turn out to be complex emergency scenarios. Contextual conditions are important for dealing with emergency scenarios in nursing homes. Recommended actions should be based on the perspective of involved practitioners on emergencies and take greater account of the contextual conditions.

Anthropogenic electromagnetic noise disrupts magnetic compass orientation in a migratory bird.

Electromagnetic noise is emitted everywhere humans use electronic devices. For decades, it has been hotly debated whether man-made electric and magnetic fields affect biological processes, including human health. So far, no putative effect of anthropogenic electromagnetic noise at intensities below the guidelines adopted by the World Health Organization has withstood the test of independent replication under truly blinded experimental conditions. No effect has therefore been widely accepted as scientifically proven. Here we show that migratory birds are unable to use their magnetic compass in the presence of urban electromagnetic noise. When European robins, Erithacus rubecula, were exposed to the background electromagnetic noise present in unscreened wooden huts at the University of Oldenburg campus, they could not orient using their magnetic compass. Their magnetic orientation capabilities reappeared in electrically grounded, aluminium-screened huts, which attenuated electromagnetic noise in the frequency range from 50 kHz to 5 MHz by approximately two orders of magnitude. When the grounding was removed or when broadband electromagnetic noise was deliberately generated inside the screened and grounded huts, the birds again lost their magnetic orientation capabilities. The disruptive effect of radiofrequency electromagnetic fields is not confined to a narrow frequency band and birds tested far from sources of electromagnetic noise required no screening to orient with their magnetic compass. These fully double-blinded tests document a reproducible effect of anthropogenic electromagnetic noise on the behaviour of an intact vertebrate.

Quality indicators for the evaluation of end-of-life care in Germany - a retrospective cross-sectional analysis of statutory health insurance data.

BACKGROUND: The provision and quality of end-of-life care (EoLC) in Germany is inconsistent. Therefore, an evaluation of current EoLC based on quality indicators is needed. This study aims to evaluate EoLC in Germany on the basis of quality indicators pertaining to curative overtreatment, palliative undertreatment and delayed palliative care (PC). Results were compared with previous findings. METHODS: Data from a statutory health insurance provider (AOK Lower Saxony) pertaining to deceased members in the years 2016 and 2017 were used to evaluate EoLC. The main indicators were: chemotherapy for cancer patients in the last month of life, first-time percutaneous endoscopic gastrostomy (PEG) for patients with dementia in the last 3 months of life, number of hospitalisations and days spent in inpatient treatment in the last 6 months of life, and provision of generalist and specialist outpatient PC in the last year of life. Data were analysed descriptively. RESULTS: Data for 64,275 deceased members (54.3% female; 35.1% cancer patients) were analysed. With respect to curative overtreatment, 10.4% of the deceased with cancer underwent chemotherapy in the last month and 0.9% with dementia had a new PEG insertion in the last 3 months of life. The mean number of hospitalisations and inpatient treatment days per deceased member was 1.6 and 16.5, respectively, in the last 6 months of life. Concerning palliative undertreatment, generalist outpatient PC was provided for 28.0% and specialist outpatient PC was provided for 9.0% of the deceased. Regarding indicators for delayed PC, the median onset of generalist and specialist outpatient PC was 47.0 and 24.0 days before death, respectively. CONCLUSION: Compared to data from 2010 to 2014, the data analysed in the present study suggest an ongoing curative overtreatment in terms of chemotherapy and hospitalisation, a reduction in new PEG insertions and an increase in specialist PC. The number of patients receiving generalist PC remained low, with delayed onset. Greater awareness of generalist PC and the early integration of PC are recommended. TRIAL REGISTRATION: The study was registered in the German Clinical Trials Register ( DRKS00015108 ; 22 January 2019).

[Structured chest X-ray imaging training with OSCE examination : Results of a feasibility study and follow-up survey]. / Training zur strukturierten Befundung von Radiographien des Thorax mit OSCE-Prüfung : Ergebnisse einer Machbarkeitsstudie und Follow-up-Befragung.

BACKGROUND: The structured diagnosis of chest radiographs is an important basic competence in radiology and will be required in the student teaching with the implementation of the National Competency-Based Learning Catalog Medicine (NKLM) in Germany. AIM: The aim was to evaluate the extent to which second-year students gain confidence in the diagnosis of chest radiographs through a new curricular training for the diagnosis of chest radiographs with subsequent objective structured clinical examination (OSCE) and how confident they feel about meeting the expectations of the supervising medical colleagues during the clinical clerkship. METHODS: The training included four lectures and ten commented instructional films on the diagnosis of radiographs. Two years later, the students were asked how often and in what form they had contact with chest radiographs in their clinical clerkship. They were also asked how confident they felt in dealing in different areas. The students with training were also asked to what extent the lectures and the instructional films were helpful. The results of students in the last year without and the first year with training and OSCE were compared using the Mann-Whitney U test for independent samples. RESULTS: The frequency of dealing with chest radiographs was comparably high among students with and without training. The students with training and OSCE felt more confident and better prepared in dealing with chest radiographs than the students without training (varying between p < 0.001 and p = 0.148). They rated the educational films as more helpful than the lectures (mean 2.85 ± 0.76 vs. 3.41 ± 0.68 on a four-point scale). DISCUSSION: With early training, students' confidence in dealing with chest radiographs can be sustainably increased.