Skip to main content
SpringerLink
Log in

Palliativpatienten und Patienten am Lebensende in Notfallsituationen

Empfehlungen zur ambulanten Versorgungsoptimierung

Paliative care and end-of-life patients in emergency situations

Recommendations on optimization of out-patient care

  • Palliativmedizin
  • Published:
Der Anaesthesist Aims and scope Submit manuscript

Zusammenfassung

Hintergrund

Akute Symptomexazerbationen bei Palliativpatienten und Patienten am Lebensende haben oftmals eine Alarmierung notfallmedizinischer Strukturen zur Folge und können zu Maßnahmen führen, die vom Patienten nicht gewünscht sind. Im vorliegenden Beitrag sollen Möglichkeiten dargestellt werden, die zu einer Optimierung der notfall- und palliativmedizinischen Zusammenarbeit führen und somit eine sich an palliativmedizinischen Therapieprinzipien orientierende Akuttherapie ermöglichen.

Methoden

Es wurden eine offene Diskussion und die Bearbeitung eines Thesen- sowie Fragenkatalogs durch notfall- und palliativmedizinische Experten durchgeführt. Auf Basis der Expertenmeinungen und evidenzbasierter Studienergebnisse erfolgten eine qualitative Auswertung sowie die Erarbeitung und Vorstellung handlungsorientierter Empfehlungen.

Ergebnisse

Als wesentlicher Konsens werden die folgenden Empfehlungen zur Versorgungsoptimierung genannt: (1) palliativmedizinische Aus- und Weiterbildung notfallmedizinischer Mitarbeiter, (2) Ausbau der allgemeinen und der spezialisierten ambulanten Palliativversorgung, (3) Integration ambulanter Palliativdienste in notfallmedizinische Strukturen, (4) Kooperation zwischen Notfallmedizin und Palliativmedizin, (5) Integration von Kriseninterventionskonzepten in die notfallmedizinische Palliativversorgung, (6) Erstellen von palliativspezifischen Notfallplänen und Notfallmedikamentenboxen, (7) Erstellen von Notfallbögen im Sinne verkürzter Patientenverfügungen (z. B. Notfallbogen, „Do not attempt resuscitation order“, „Allow natural death“), (8) psychosoziale Aspekte und (9) Definition der palliativen Erkrankungssituation durch vorbehandelnde Ärzte.

Schlussfolgerung

Notfallmediziner werden in Zukunft vermehrt mit palliativen Notfällen konfrontiert werden. Die Akuttherapie ambulanter palliativer Notfälle enthält durch unterschiedliche therapeutische Konzepte der an diesen Situationen beteiligten Fachdisziplinen ein hohes Konfliktpotenzial. Aus diesem Grund und aufgrund der Ergebnisse der vorgestellten Untersuchung bedarf es in der Notfallmedizin geregelter Kriterien zur Versorgung von Palliativpatienten und Patienten am Lebensende. Diese müssen bezüglich ihrer Effektivität anhand zu definierender Kriterien in weiteren klinischen Arbeiten untersucht werden.

Abstract

Background

At the end of life acute exacerbations of medical symptoms (e.g. dyspnea) in palliative care patients often result in emergency medical services being alerted. The goals of this study were to discuss cooperation between emergency medical and palliative care structures to optimize the quality of care in emergencies involving palliative care patients.

Methods

For data collection an open discussion of the main topics by experts in palliative and emergency medical care was employed. Main outcome measures and recommendations included responses regarding current practices related to expert opinions and international literature sources.

Results

As the essential points of consensus the following recommendations for optimization of care were named: (1) integration of palliative care in the emergency medicine curricula for pre-hospital emergency physicians and paramedics, (2) development of outpatient palliative care, (3) integration of palliative care teams into emergency medical structures, (4) cooperation between palliative and emergency medical care, (5) integration of crisis intervention into outpatient palliative emergency medical care, (6) provision of emergency plans and emergency medical boxes, (7) provision of palliative crisis cards and do not attempt resuscitation (DNAR) orders, (8) psychosocial aspects concerning palliative emergencies and (9) definition of palliative patients and their special situation by the physician responsible for prior treatment.

Conclusions

Prehospital emergency physicians are confronted with emergencies in palliative care patients every day. In the treatment of these emergencies there are potentially serious conflicts due to the different therapeutic concepts of palliative medical care and emergency medical services. This study demonstrates that there is a need for regulated criteria for the therapy of palliative patients and patients at the end of life in emergency situations. Overall, more clinical investigations concerning end-of-life care and unresponsive palliative care patients in emergency medical situations are necessary.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1

Literatur

  1. American College of Emergency Physicians (2008) Ethical issues in emergency department care at the end of life. Ann Emerg Med 52:592

    Google Scholar 

  2. Ausband SC, March JA, Brown LH (2002) National prevalence of palliative care protocols in emergency medical services. Prehosp Emerg Care 6:36–41

    Article  PubMed  Google Scholar 

  3. Barbera L, Paszat L, Chartier C (2006) Indicators of poor quality end-of-life care in Ontario. J Palliat Care 22:12–17

    PubMed  Google Scholar 

  4. Brindley PG, Markland DM, Mayers I, Kutsogiannis DJ (2002) Predictors of survival following in-hospital adult cardiopulmonary resuscitation. CMAJ 167:343–348

    PubMed  Google Scholar 

  5. Bundesministerium für Gesundheit (2009) Bekanntmachung eines Beschlusses des gemeinsamen Bundesausschusses über die Erstfassung der Richtlinie zur Verordnung von spezialisierter ambulanter Palliativversorgung. BAnz 39:S911; 11.03.2008

    Google Scholar 

  6. Bundesärztekammer (2007) Musterweiterbildungsordnung für Notfallmedizin. BÄK 2007:163

    Google Scholar 

  7. Burge F, Lawson B, Johnston G (2003) Family physician continuity of care and emergency department use in end-of-life cancer care. Med Care 41:992–1001

    Article  PubMed  Google Scholar 

  8. Burge F, Lawson B, Johnston G, Cummings I (2003) Primary care continuity and location of death for those with cancer. J Palliat Med 6:911–918

    Article  PubMed  Google Scholar 

  9. Ciais JF, Ciais C, Pradier C et al (2002) Emergencies in patients undergoing palliative care at home. A qualitative study of telephone calls to Center 15. Presse Med 31:970–972

    PubMed  Google Scholar 

  10. Ciais JF, Pradier C, Ciais C et al (2007) Impact of a hospice home visit team on unwanted hospitalization of terminally-ill patients at home in acute medical emergencies. Presse Med 36:404–409

    Article  PubMed  Google Scholar 

  11. Drury M, Yudkin P, Harcourt J et al (2000) Patients with cancer holding their own records. Br J Gen Pract 50:105–110

    CAS  PubMed  Google Scholar 

  12. Eló G, Diószeghy C, Dobos M, Andorka M (2005) Ethical considerations behind the limitation of cardiopulmonary resuscitation in Hungary – the role of education and training. Resuscitation 64:71–77

    Article  PubMed  Google Scholar 

  13. Emanuel LL, Quest T (Hrsg) (2008) The education in palliative and end-of-life care for emergency medicine (EPEC-EM). The EPEC Project 2008. http://www.epec.net/EPEC/Webpages/epecem.cfm. Gesehen am 07.09.2010

  14. Emanuel LL (2008) Advance directives. Annu Rev Med 59:187–198

    Article  CAS  PubMed  Google Scholar 

  15. Ensink FB, Bautz MT, Hanekop GG (2001) Improvement of palliative outpatient treatment of terminally ill cancer patients – SUPPORT as example – The ethically preferable alternative to euthanasia. Anasthesiol Intensivmed Notfallmed Schmerzther 36:530–537

    Article  CAS  PubMed  Google Scholar 

  16. European Resuscitation Council (2005) European Resuscitation Council Guidelines for Resuscitation 2005. Resuscitation 67 (Suppl 1):1–189

    Article  Google Scholar 

  17. Gerth MA, Kettler D, Mohr M (2005) Patientenverfügungen in der Notfallmedizin. Anasthesiol Intensivmed Notfallmed Schmerzther 40:743–749

    Article  CAS  PubMed  Google Scholar 

  18. Gerth M, Mohr M (2010) Die Patientenanweisung für lebenserhaltende Maßnahmen („PALMA“) – Erste Evaluationsergebnisse. J Anaesth Intensivbehandl 1:52–56

    Google Scholar 

  19. Gisondi MA (2009) A case for education in palliative and end-of-life care in emergency medicine. Acad Emerg Med 16:181–183

    Article  PubMed  Google Scholar 

  20. Gueugniaud PY, Mols P, Goldstein P (1998) A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital. N Engl J Med 339:1595–1601

    Article  CAS  PubMed  Google Scholar 

  21. Guru V, Verbeek RP, Morrison LJ (1999) Response of paramedics to terminally ill patients with cardiac arrest: an ethical dilemma. CMAJ 161:1251–1254

    CAS  PubMed  Google Scholar 

  22. Gyllenhammar E, Thoren-Todoulos E, Strang P et al (2003) Predictive factors for home deaths among cancer patients in Swedish palliative home care. Support Care Cancer 11:560–567

    Article  CAS  PubMed  Google Scholar 

  23. Haugen DF, Jordhøy MS, Engstrand P et al (2006) Organisation of palliative care in and outside hospital. Tidsskr Nor Laegeforen 26:329–332

    Google Scholar 

  24. Hobgood C, Harward D, Newton K, Davis W (2005) The educational intervention „GRIEV_ING“ improves the death notification skills of residents. Acad Emerg Med 12:296–301

    Article  PubMed  Google Scholar 

  25. Knox C, Vereb JA (2005) Allow natural death: a more human approach to discussing end-of-life directives. J Emerg Nurs 31:560–561

    Article  PubMed  Google Scholar 

  26. LeGrand SB, Tropiano P, Marx JD et al (2001) Dying at home: emergency medications for terminal symptoms. Am J Hosp Palliat Care 18:421–423

    Article  CAS  PubMed  Google Scholar 

  27. Longstreth WT Jr, Cobb LA, Fahrenbruch CE, Copass MK (1990) Does age effect outcomes of out-of-hospital cardiopulmonary resuscitation? JAMA 264:2109–2110

    Article  PubMed  Google Scholar 

  28. McMillan SC, Small BJ (2007) Using the COPE intervention for family caregivers to improve symptoms of hospice homecare patients. Oncol Nurs Forum 34:313–321

    Article  PubMed  Google Scholar 

  29. Mengual RP, Feldman MJ, Jones GR (2007) Implementation of a novel prehospital advance directive protocol in southeastern Ontario. CJEM 9:250–259

    PubMed  Google Scholar 

  30. Nauck F, Alt-Epping B (2008) Crises in palliative care – a comprehensive approach. Lancet Oncol 9:1086–1091

    Article  PubMed  Google Scholar 

  31. Plaissance P, Lurie KG, Vicaut E (1999) A comparison of standard cardiopulmonary resuscitation and active compression-decompression resuscitation for out-of-hospital cardiac arrest. N Engl J Med 341:569–575

    Article  Google Scholar 

  32. Quest TE, Marco CA, Derse AR (2009) Hospice and palliative medicine: new subspecialty, new opportunities. Ann Emerg Med 54:94–102

    Article  PubMed  Google Scholar 

  33. Radbruch L, Voltz R (2008) Was ist speziell an der speziellen ambulanten Palliativversorgung? Schmerz 22:7–8

    Article  CAS  PubMed  Google Scholar 

  34. Rausch PG, Ramzy AI (1991) Development of a palliative care protocol for emergency medical services. Ann Emerg Med 20:1383–1386

    Article  CAS  PubMed  Google Scholar 

  35. Salomon F (2005) Kompetenz in Palliativmedizin. Der alleingelassene Notarzt. Notfall Rettungsmed 8:542–547

    Article  Google Scholar 

  36. Savory EA, Marco CA (2009) End-of-life issues in the acute and critically ill patient. Scand J Trauma Resusc Emerg Med 17:21

    Article  PubMed  Google Scholar 

  37. Schindler T, Ewald H (2005) Ambulante und stationäre palliativmedizinische Strukturen in Deutschland. Onkologe 11:376–383

    Article  Google Scholar 

  38. Sherbino J, Guru V, Verbeek PR, Morrison LJ (2000) Prehospital emergency medical services‘ ethical dilemma with do-not-resuscitate orders. CJEM 2:246–251

    CAS  PubMed  Google Scholar 

  39. Smith AK, Fisher J, Schonberg MA et al (2009) Am I doing the right thing? Provider perspectives on improving palliative care in the emergency department. Ann Emerg Med 54:86–93

    Article  PubMed  Google Scholar 

  40. Smith AK, Schonberg MA, Fisher J et al (2010) Emergency department of acutely symptomatic patients with terminal illness and their family caregivers. J Pain Symptom Manage 39:972–981

    Article  PubMed  Google Scholar 

  41. Sommer J, Müller-Busch C, Flender HJ et al (2008) Palliativpatienten im Rettungsdienst. Eine zunehmende und neue Herausforderung? Abstract. Kongress der Deutschen Interdisziplinären Vereinigung für Intensivmedizin (DIVI), Hamburg 2008

  42. Sonneck G (2000) Krisenintervention und Suizidverhütung. Facultas, Wien

  43. Stepan R, Sitte T, Graf BM, Wiese CHR (2010) Kooperation von ambulanten palliativ- und notfallmedizinischen Strukturen. Z Palliativmed 11:94–96

    Article  Google Scholar 

  44. Tolle SW, Rosenfeld AG, Tilden VP, Park Y (1999) Oregon’s low in-hospital death rates: what determines where people die and satisfaction with decision on place of death? Ann Intern Med 130:681–685

    CAS  PubMed  Google Scholar 

  45. Vennemann SS, Narnor-Harris P, Perish M, Hamilton M (2008) Allow natural death versus „do not resuscitate“: three words that can change life. J Med Ethics 34:2–6

    Article  Google Scholar 

  46. Weinmann M (2003) Everyone dies. Emerg Med Serv 32:40

    PubMed  Google Scholar 

  47. Wiese CHR, Vossen-Wellmann A, Morgenthal HC et al (2008) Emergency calls and need for emergency care in patients looked after by a palliative care team: retrospective interview study with bereaved relatives. BMC Palliat Care 7:11

    Article  PubMed  Google Scholar 

  48. Wiese CHR, Bartels U, Ruppert D et al (2008) Behandlung palliativmedizinischer Notfälle durch Rettungsassistenten. Wien Klin Wochenschr 120:539–546

    Article  PubMed  Google Scholar 

  49. Wiese CHR, Bartels U, Ruppert D et al (2009) Treatment of palliative emergencies by emergency physicians in Germany. Palliat Med 23:369–373

    Article  CAS  PubMed  Google Scholar 

  50. Wiese CHR, Bartels UE, Zausig YA et al (2010) Prehospital emergency treatment of palliative care patients with cardiac arrest: a retrolective investigation. Support Care Cancer 18:1287–1292

    Article  PubMed  Google Scholar 

  51. Wiese CHR, Bartels UE, Marczynska K et al (2009) Quality of out-of-hospital palliative emergency care depends on the expertise of the emergency medical team – A prospective multi-centre analysis. Support Care Cancer 17:1499–1506

    Article  PubMed  Google Scholar 

  52. Wiese CHR, Ruppert D, Graf BM (2010) Die Notfallkarte für Palliativpatienten. J Anaesth Intensivbehandl 1–2010:195–196

  53. Willard C (2000) Cardiopulmonary resuscitation for palliative care patients: a discussion of ethical issues. Palliat Med 14:308–312

    Article  CAS  PubMed  Google Scholar 

Download references

Danksagung

Der Dank gilt allen Teilnehmern, die an dem Expertenkonsens mitgewirkt haben, und der Akademie für Palliativmedizin und Hospizarbeit Dresden für die Organisation, Durchführung und Begleitung der Expertentreffen.

Interessenkonflikt

Der korrespondierende Autor und die Koautoren geben an, dass keine Interessenkonflikte im Zusammenhang mit dem vorliegenden Artikel bestehen. Alle namentlich aufgeführten Koautoren sind mit den Inhalten der endgültigen Version des Manuskripts und dessen Publikation einverstanden.

Author information

Authors and Affiliations

  1. Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland

    C.H.R. Wiese, B.M. Graf & Y.A. Zausig

  2. Klinik für Anästhesiologie, Krankenhaus Hetzelstift Neustadt a.d. Weinstraße, Neustadt a.d. Weinstraße, Deutschland

    D.A. Vagts

  3. Klinik für Anästhesiologie, Evangelisches Krankenhaus Hattingen, Hattingen, Deutschland

    U. Kampa

  4. Klinik für Anästhesiologie, RoMed Kreisklinik Bad Aibling, Bad Aibling, Deutschland

    G. Pfeiffer

  5. Akademie für Palliativmedizin und Hospizarbeit Dresden gGmbH, Dresden, Deutschland

    I.-U. Grom

  6. Klinik für Anästhesiologie, Universitätsmedizin Mainz, Mainz, Deutschland

    M.A. Gerth

Authors
  1. C.H.R. Wiese
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. D.A. Vagts
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. U. Kampa
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. G. Pfeiffer
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. I.-U. Grom
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. M.A. Gerth
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. B.M. Graf
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Y.A. Zausig
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

Expertengruppe Palliativ- und Notfallmedizin Akademie für Palliativmedizin und Hospizarbeit Dresden

Corresponding author

Correspondence to C.H.R. Wiese.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Wiese, C., Vagts, D., Kampa, U. et al. Palliativpatienten und Patienten am Lebensende in Notfallsituationen. Anaesthesist 60, 161–171 (2011). https://doi.org/10.1007/s00101-010-1831-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00101-010-1831-6

Schlüsselwörter

Keywords

Search

Navigation