Background: The COVID-19 pandemic confronted nursing homes with a variety of challenges to ensure the provision of palliative care for residents. PallPan-Implement aimed to adapt the recommendations ...of the National Strategy for the Care of Seriously Ill, Dying Adults and their Families in Times of Pandemic (PALLPAN) in such a way that nursing facilities can use and implement them. Methods: Based on 33 PALLPAN recommendations, we developed a questionnaire, conducted a pilot implementation for selected nursing homes, and asked for qualitative feedback. Results: The developed questionnaire contains 22 main questions. A three-stage pilot implementation with an introductory event, processing phase, and evaluation event took place in seven facilities. The facilities evaluated the developed questionnaire as helpful. Feedback from the facilities identified three major categories: (a) requirements for facilities should be realistic to avoid frustration, (b) the creation of a pandemic plan for palliative care only is impractical, (c) measures for the psychosocial support of staff is particularly necessary, but was perceived as difficult to implement. Conclusions: The practical implementation of recommendations requires a concept and material tailored to facilities and areas. The strategy of PallPan Implement developed in this project appears to be target-oriented, well-received, and can be recommended for further implementation.
IT systems in the healthcare field can have a marked sociotechnical impact: they modify communication habits, alter clinical processes and may have serious ethical implications. The introduction of ...such systems involves very different groups of stakeholders because of the inherent multi-professionalism in medicine and the role of patients and their relatives that are often underrepresented. Each group contributes distinct perspectives and particular needs, which create specific requirements for IT systems and may strongly influence their acceptance and success. In the past, needs analysis, challenges and requirements for medical IT systems have often been addressed using consensus techniques such as the Delphi technique. Facing the heterogeneous spectrum of stakeholders there is a need to develop these techniques further to control the (strong) influence of the composition of the expert panel on the outcome and to deal systematically with potentially incompatible needs of stakeholder groups. This approach uses the strong advantages a Delphi study has, identifies the disadvantages of traditional Delphi techniques and aims to introduce and evaluate a modified approach called 360-Degree Delphi. Key aspects of 360-Degree Delphi are tested by applying the approach to the needs and requirements analysis of a system for managing patients' advance directives and living wills.
360-Degree Delphi (short 360°D), as a modified Delphi process, is specified as a structured workflow with the optional use of stakeholder groups. The approach redefines the composition of the expert panel by setting up groups of different stakeholders. Consensus is created within individual stakeholder groups, but is also communicated between groups, while the iterative structure of the Delphi process remains unchanged. We hypothesize that (1) 360-Degree Delphi yields complementary statements from different stakeholders, which would be lost in classical Delphi; while (2) the variation of statements within individual stakeholder groups is lower than within the total collective. A user study is performed that addresses five stakeholder groups (patients, relatives, medical doctors, nurses and software developers) on the topic of living will communication in an emergency context. Qualitative open questions are used in a Delphi round 0. Answer texts are coded by independent raters who carry out systematic bottom-up qualitative text analysis. Inter-rater reliability is calculated and the resulting codes are used to test the hypotheses. Qualitative results are transferred into quantitative questions and then surveyed in round 1. The study took place in Germany.
About 25% of the invited experts (stakeholders) agreed to take part in the Delphi round 0 (three patients, two relatives, three medical doctors, two qualified nurses and three developers), forming a structured panel of the five stakeholder groups. Two raters created a bottom-up coding, and 238 thematic codes were identified by the qualitative text analysis. The inter-rater reliability showed that 44.95% of the codes were semantically similar and coded for the same parts of the raw textual replies. Based on a consented coding list, a quantitative online-questionnaire was developed and send to different stakeholder groups. With respect to the hypotheses, Delphi round 0 had the following results: (1) doctors had a completely different focus from all the other stakeholder groups on possible channels of communications with the patient; (2) the dispersion of codes within individual stakeholder groups and within the total collective - visualized by box plots - was approximately 28% higher in the total collective than in the sub-collectives, but without a marked effect size. With respect to the hypotheses, Delphi round 1 had the following results: different stakeholder groups had highly diverging opinions with respect to central questions on IT-development. For example, when asked to rate the importance of access control against high availability of data (likert scale, 1 meaning restrictive data access, 6 easy access to all data), patients (mean 4.862, Stdev +/- 1.866) and caregivers (mean 5.667, Stdev: +/- 0.816) highly favored data availability, while relatives would restrict data access (mean 2.778, stdev +/- 1.093). In comparison, the total group would not be representative of either of these individual stakeholder needs (mean 4.344, stdev +/- 1.870).
360-Degree Delphi is feasible and allows different stakeholder groups within an expert panel to reach agreement individually. Thus, it generates a more detailed consensus which pays more tribute to individual stakeholders needs. This has the potential to improve the time to consensus as well as to produce a more representative and precise needs and requirements analysis. However, the method may create new challenges for the IT development process, which will have to deal with complementary or even contradictory statements from different stakeholder groups.
In healthy individuals, fatigue is a protective response to physical or mental stress, often relieved by rest. By contrast, in palliative care patients fatigue can be severely debilitating, thereby ...impacting daily activity and quality of life, often with rest not counteracting fatigue. Fatigue frequently occurs in patients with advanced disease and modalities treating cancer often contribute or cause fatigue. Further complicating issues are its multidimensionality, subjective nature, and lack of a consensus definition of fatigue. Pathophysiology is not fully understood and evidence-based treatment approaches are needed.
The objective was to determine efficacy of pharmacological treatments on non-specific fatigue in palliative care. The focus was on patients at an advanced stage of disease, including cancer and other chronic diseases associated with fatigue, aiming to relieve fatigue. Studies aiming at curative treatment (e.g. surgical intervention for early breast cancer) were not included.
We searched EMBASE; Psych Lit, CENTRAL and MEDLINE to June 2009.
We considered randomised controlled trials (RCTs) concerning adult palliative care with focus on pharmacological treatment of fatigue. The primary outcome had to be non-specific fatigue (or related terms such as asthenia).
Results were screened and included if they met the selection criteria. If two or more studies were identified that investigated a specific drug in a population with the same disease, meta-analysis was conducted. In addition, comparison of type of drug investigated in a specific population as well as comparison of frequent adverse effects of fatigue treatment was done by creating overview tables.
More than 2000 publications were screened, and 22 met inclusion criteria. In total, data from 11 drugs and 1632 participants were analysed. Studies investigating amantadine, pemoline, and modafinil in participants with Multiple Sclerosis (MS)-associated fatigue and methylphenidate in patients suffering from advanced cancer and fatigue could be used for meta-analysis. Amantadine in MS and methylphenidate in cancer patients showed a superior effect. Most studies had low participant numbers and were heterogenous.
Based on limited evidence, we cannot recommend a specific drug for treatment of fatigue in palliative care patients. Surprisingly, corticosteroids have not been a research focus for fatigue treatment, although these drugs are frequently used. Recent fatigue research seems to focus on modafinil, which may be beneficial although there is no evidence currently. Amantadine and methylphenidate should be further examined. Consensus regarding fatigue assessment in advanced disease is needed.
Opioids efficiently manage pain and dyspnea. However, guidelines on symptom management with opioids differ, which may lead to uncertainty among medical staff concerning opioid indication and ethical ...implication, especially when caring for COVID-19 patients.
We aimed to examine the perception of morphine/opioid (M/O) administration for symptom control within and outside palliative care, including care for COVID-19 patients, among members of the German associations for palliative medicine, internal medicine, anesthesiology and intensive care.
Participants received an anonymized online questionnaire via Survey Monkey® (Momentive Inc., San Mateo, CA, USA) regarding their general perception of symptom management with M/O. These results have been published elsewhere. For systematic and structural analysis of comments in the free-text field, we chose Phillip Mayring's method of summarizing qualitative content analysis.
Of the n = 2202 persons who participated, 339 wrote comments in the free-text field which were categorized as follows: main categories 1) personal perceptions of COVID-19 patients, 2) administration and effect of M/O, 3) observations within the palliative care field, 4) imparting knowledge concerning M/O usage and palliative care, and 5) others.
Some participants reported very personal perceptions and deficits of the healthcare system, especially when caring for COVID-19 patients. Uniform interdisciplinary guidelines for symptom control, more education, and support by trained staff confident in symptom control should be increasingly considered in the future.
Zusammenfassung
Hintergrund
Obwohl Opioide wirksam Schmerzen und Dyspnoe lindern, findet dies in Leitlinien zur Symptomkontrolle unterschiedliche Gewichtung. Hierdurch können auch bei COVID-19 ...Unsicherheiten bezüglich Indikationen und ethischer Implikationen im Umgang mit Opioiden entstehen.
Ziel der Arbeit
Wir untersuchten die persönliche Wahrnehmung des Umgangs mit Morphin/Opioiden (M/O) zur Symptomkontrolle
inner- und außerhalb
der Palliativmedizin (PM), auch bei der Betreuung COVID-19-Erkrankter, durch Befragung von Mitgliedern der Fachgesellschaften für Palliativmedizin, Innere Medizin, Anästhesiologie und Intensivmedizin.
Material und Methoden
Mittels Survey Monkey® (Momentive Inc., San Mateo, CA, USA) wurden die Mitglieder anonymisiert nach ihrer eigenen Wahrnehmung des Umgangs mit M/O zur Symptomkontrolle befragt. Diese Ergebnisse wurden bereits publiziert. Zur systematischen und strukturierten Auswertung aller Kommentare des Freitextfelds wurde Phillip Mayrings Methode der zusammenfassenden qualitativen Inhaltsanalyse gewählt.
Ergebnisse und Diskussion
Von 2202 Personen schrieben 339 im Freitextfeld „Weitere Anmerkungen“ zusätzliche Kommentare. Das induktiv entwickelte Kategoriensystem umfasste fünf Hauptkategorien: 1) Eigene Wahrnehmungen mit COVID-19-Erkrankten, 2) Anwendungsgebiet und Wirkung von M/O, 3) Beobachtungen im Bereich der Palliativmedizin, 4) Vermittlung von Wissen zum Umgang mit Opioiden bzw. Palliativmedizin, und 5) Ergänzendes.
Fazit
Einige Teilnehmende berichteten sehr persönliche Wahrnehmungen und wiesen insbesondere im Umgang mit COVID-19 auf Defizite im Gesundheitssystem hin. Einheitliche interdisziplinäre Leitlinien zur Symptomkontrolle, mehr Lehre und Unterstützung durch in der Symptomkontrolle kompetente Expert:innen erscheinen erforderlich.
Zusammenfassung
Hintergrund
Die Verlegung von Patient:innen der Intensivstation (ITS) auf die Palliativstation (PTS) geht meist mit der Festlegung eines palliativen Konzeptes einher. Die Anpassung ...der Therapieziele mit primärem Fokus auf Lebensqualität und Symptomkontrolle kann für medizinisches Personal, Patient:innen und Angehörige herausfordernd sein. Beschreibungen dieser Transition sind jedoch rar.
Fragestellung
Ziel der Studie war die Charakterisierung der von den intensivmedizinischen Stationen gestellten Konsile an die Palliativmedizin sowie der Patient:innen durch Beschreibung der Versorgungspfade und Interventionen.
Methode
Retrospektive, quantitative Analyse aller im Jahr 2019 intensivmedizinisch betreuten Patient:innen der Uniklinik RWTH Aachen, für die ein palliativmedizinisches Konsil angefordert worden war.
Ergebnisse
Es wurden
n
= 102 Konsilanfragen der ITS an die Palliativmedizin ausgewertet. Fünf von 32 (16 %) auf die PTS übernommenen Konsilpatient:innen bzw. 35 (34 %) aller 102 Patient:innen konnten in das häusliche Umfeld oder eine stationäre Einrichtung (Pflegeheim, Hospiz, andere) entlassen werden. Die häufigsten Gründe einer Nichtübernahme waren: fehlende Kapazität der PTS (33 %), Versterben auf der Warteliste (20 %) und Ablehnung durch die Patient:innen (20 %). Die durch die Intensivmediziner:innen angefragten konsiliarischen Leistungen „Symptomkontrolle“ (χ
2
= 10,17;
p
< 0,05) und „Beratung“ (χ
2
= 12,82;
p
< 0,001) zeigten einen signifikanten Zusammenhang mit der jeweils durch die Palliativmediziner:innen durchgeführten Intervention.
Schlussfolgerung
Der Bedarf palliativmedizinischer Unterstützung der ITS überstieg die Aufnahmekapazität der PTS. Zukünftige Studien sollten Versorgungsmodelle palliativmedizinischer Unterstützung in der Intensivmedizin näher untersuchen.
Opioids efficiently alleviate pain and dyspnea. However, guidelines on symptom management with opioids differ, which may lead to an uncertainty concerning opioid indication and ethical implication ...among medical staff, especially when caring for COVID-19 patients.
We aimed to examine the perception of members of the German Association for Palliative Medicine (DGP) concerning the administration of morphine as the gold standard opioid (subsequently termed M/O) for symptom control within and outside of a palliative care (PC) setting, including care for COVID-19 patients.
DGP members received an anonymized online questionnaire (Survey Monkey®) containing questions regarding their perception of symptom management with M/O in general and in particular concerning COVID-19 patients. Participants were asked to rate their perception within and outside of a PC setting.
Of the 6129 DGP members, N = 506 participated. DGP physicians and nurses perceived handling of M/O as "certain and confident" (98%) and "clearly regulated" within PC (95%) but rated it significantly lower for outside PC (48%/38%). When caring for COVID-19 patients, handling of M/O was even less often rated "certain and confident" (26%) or "clearly regulated" (23%) for outside PC. Dyspnea (99%/52%), relief from the dying process (62%/37%), restlessness (30%/15%) and fear or panic (27%/13%) were more frequently rated as general indications for morphine within versus outside PC. Most participants (89%) wished to involve palliative care consultation teams.
DGP members perceived substantial uncertainty in the handling of M/O for medical fields outside PC. Uniform interdisciplinary guidelines for symptom control, more education, and involvement of a PC consultation team should be increasingly considered in the future.
Zusammenfassung
Hintergrund
Obwohl Opioide wirksam Schmerzen und Dyspnoe lindern, findet dies in Leitlinien zur Symptomkontrolle unterschiedliche Gewichtung. Dies kann zu Unsicherheiten bezüglich ...Indikationen und ethischer Implikationen im Umgang mit Opioiden auch bei COVID-19 führen.
Ziel der Arbeit
Wir untersuchten bei Mitgliedern der Deutschen Gesellschaft für Palliativmedizin (DGP) die persönliche Wahrnehmung des Umgangs mit Morphin/Opioiden (M/O) zur Symptomkontrolle
innerhalb
und
außerhalb
der Palliativmedizin (PM), auch bei der Betreuung COVID-19-Erkrankter.
Material und Methoden
Mittels Survey Monkey® wurden DGP-Mitglieder anonymisiert nach ihrer eigenen Wahrnehmung des Umgangs mit M/O zur Symptomkontrolle befragt.
Ergebnisse und Diskussion
Von den 6192 DGP-Mitgliedern nahmen N = 506 teil. Den Umgang mit M/O
innerhalb
der PM beschrieben 98 % der befragten Ärzt:innen und Pflegekräfte als „sicher und vertraut“ bzw. 95 % als „klar geregelt“, während dies für die Bereiche
außerhalb
der PM von weniger als der Hälfte angegeben wurde (48 %/38 %). Bei der Betreuung COVID-19-Erkrankter wurde der Umgang mit M/O
außerhalb
der PM noch seltener als „sicher und vertraut“ (26 %) oder „klar geregelt“ (23 %) wahrgenommen. Dyspnoe (99 %/52 %), Erleichterung des Sterbeprozesses (62 %/37 %), Unruhe (30 %/15 %) und Angst/Panik (27 %/13 %) wurden häufiger
innerhalb
als
außerhalb
der PM als allgemeine Indikationen genannt. 89 % der Befragten wünschten sich die Einbindung eines PM-Konsilteams.
Schlussfolgerung
Mitglieder der DGP nahmen deutliche Unsicherheiten im Umgang mit M/O
außerhalb
der PM wahr. Einheitliche interdisziplinäre Leitlinien zur Symptomkontrolle etwa bei Dyspnoe, mehr Lehre und die Einbindung eines PM-Konsilteams sollten zukünftig mehr bedacht werden.
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