Palliative medicine

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Palliative medicine (derived from palliativ , from cura palliativa , first documented around 1363 by Guy de Chauliac , from Latin palliare "to enclose with a coat", "coat", "hide", "protect", from pallium "coat") is according to the Definitions of the World Health Organization and the German Society for Palliative Medicine “the active, holistic treatment of patients with a progressive (advancing), well advanced disease and a limited life expectancy at the time when the disease no longer responds to curative treatment or no curative treatment more can be done and the control of pain, other illnesses, psychological, social and spiritual problems has the highest priority ”. As part of palliative care, it goes beyond purely palliative therapy or palliation . The patient's quality of life - their subjective well-being, their desires and goals - are at the fore of the treatment. The essential components of palliative medicine are symptom control, psychosocial competence, teamwork and support for the dying person and their relatives.

history

Beginnings

Relieving the suffering and supporting the patient has always been the focus of the doctor's tasks, as a French proverb from the 16th century sums up: Guérir quelquefois, soulager souvent, consoler toujours (sometimes healing, often relieving, always comforting). The demand that the doctor should also treat incurable diseases can already be derived from the Hippocratic writings, and since the late Middle Ages it has been regarded as part of the field of responsibility of doctors, including treatment for seriously ill and dying patients who no longer had any prospect of a cure and to provide care. Like visiting the sick, medicine is also one of the works of mercy and accordingly (for example in a medical ordinance issued by the prince-bishop of Würzburg in 1502) it was taken for granted that no doctor should refuse to treat a patient, even if there was no prospect of a cure. In the medieval and early modern hospices and hospitals, the elderly, the paralyzed and the disabled, the chronically ill and those in need of care found refuge. However, medical care and support or even (palliative) medical terminal care were usually not offered to them there.

Since the end of the 16th century, doctors have increasingly dealt with questions of palliative disease treatment, called "Cura palliativa" in Latin. The first major treatise on palliative medicine was written by Elias Küchler in 1692 with his doctoral thesis De cura palliativa , published in Erfurt , whereupon further works on the subject were published in the 18th century. In the 19th century dozens of papers appeared specifically on medical care for the dying, the so-called "Euthanasia medica". In 1819 the French term “Médicine palliative” was first found and in 1880 the English term “Palliative medicine” was already in use. However, the cura palliativa, which was used in early modern times to alleviate the symptoms of severe, but not necessarily fatal diseases, and a cura mortis palliativa, which explicitly refers to the suffering of terminally ill patients , are not to be equated as a special form of palliative treatment. In this way, modern palliative medicine benefits not only the terminally ill, but also the seriously ill, for whom - for example, after they have been stopped using medication - a life and even work outside of inpatient palliative care facilities can be made possible again.

Around 1817, surgeons such as the surgeon Schmidt administered "palliative agents" for relief in Nuremberg and ordered them in German. In the late 19th and early 20th centuries, however, these efforts faded into the background with the rise of modern medicine. The care of patients with very advanced fatal illnesses focused one-sidedly on healing efforts until the end, even if there was almost no more chance of success. At the same time, patients were often left alone with their symptoms and their fear of dying and death. (As early as 1882 , August Stöhr regarded the lack of human attention in the hospital as the "most important reason" for patients' fear of death in the hospital.) Against this background, Cicely Saunders in 1967 modeled older dying hospices like St. Luke's in London founded the St Christopher's Hospice , which is the nucleus of the modern hospice movement .

In 1990 the World Health Organization formulated its trend-setting definition of palliative medicine, which was adapted in 2002.

Developments in Germany

The experiences from the London St. Christopher Hospice had an impact on the development of palliative medicine in the Federal Republic. The first palliative medical facility in Germany was a five-bed model ward, which was opened (financed by the German Cancer Aid founded by Mildred Scheel ) on April 7, 1983 in the Clinic for Surgery at the University Clinic in Cologne. It is considered a model for palliative wards and similar palliative care facilities. The project was supplemented with the first Mildred Scheel House and another such facility in Dresden . There are now more than 300 palliative care wards and inpatient hospices in Germany. However, the need is far from being covered by this, as the German Cancer Aid, as the representative of those affected, continues to focus on palliative medicine.

The German Society for Palliative Medicine (DGP), founded in July 1994, is the first specialist medical society to allow members of other professional groups as well as doctors. Its goal is to promote the development and progress of palliative medicine and to strive for the best possible care for patients. Every two years it holds a congress at which the current developments in palliative medicine are presented and discussed.

In 1997 the German textbook on palliative medicine appeared for the first time ; the first chair for palliative medicine was established in Bonn in 1999. As a result, further professorships were created in Aachen, Göttingen, Cologne, Munich and Erlangen. The first chair for “Pediatric Pain Therapy and Pediatric Palliative Medicine” was established in 2008 at the University of Witten / Herdecke. The medical faculty of the Ludwig Maximilians University in Munich was the first in 2004 to include palliative medicine as a compulsory subject in medical studies; five years before the Bundestag resolution introducing palliative medicine as the 13th cross-sectional area (QB 13) in the licensing regulations for doctors.

Various universities now offer courses that can be completed with the academic degree Master of Science (MSc) in Palliative Care . The courses are open to university graduates who already have a degree in a human science relevant to palliative care (in addition to human medicine, for example, nursing science , psychology , social sciences and theology ).

Additional medical training in palliative medicine

In May 2003, the German Medical Association introduced palliative medicine as additional training in the (model) training regulations. This advanced training for specialists was adopted by all state medical associations in their advanced training regulations for doctors over the course of the next three years.

The additional training in palliative medicine comprises a 40-hour basic course as well as a year-long training at a palliative medicine facility (usually in a palliative medicine department of a hospital) and is completed with an examination. The one-year practical training can be partially replaced by special case seminars. The basic course in palliative medicine is organized by trainers from various professional groups in palliative care . In addition to basic knowledge and skills in symptom control, aspects of conversation management and interprofessional teamwork (nursing, physiotherapy / occupational therapy, music therapy , social workers, psychologists, pastors, doctors) are discussed. The perception for the psychosocial and spiritual needs of terminally ill patients is trained; Further focal points are dealing with dying, death and mourning, dealing with therapy limitations and living wills, end-of-life care and recognizing and encountering overuse syndromes in the treatment team.

Goals of palliative medicine

Palliative medicine is not “dying medicine”: Palliative medicine methods and settings are also required in the earlier stages of the disease, in some cases as soon as the diagnosis is known. The aim is to enable the patient to lead a tolerable life with few symptoms despite his severe illness. The aim of treatment is to control symptoms as comprehensively as possible (e.g. pain, shortness of breath, fear / restlessness / psychological distress, nausea / vomiting, open wounds and many more). Palliative medicine, following Saunder's principles, affirms life and is against shortening it, but also against medically ineffective therapy attempts that burden the patient and prevent the patient from being able to use the remaining lifetime optimally.

Palliative medicine is therefore not only available to patients with cancer , but specifically to all patients with a severe, advanced / progressive disease and a heavy burden of symptoms. These include severe heart and lung diseases (e.g. heart failure , COPD) , severe nerve diseases (e.g. Parkinson's disease , ALS , severe strokes ), severe liver and kidney diseases or infection-related, chronically progressive diseases such as AIDS . The palliative medicine specialist works closely with other therapeutic professions and specialists, whereby the context of palliative medicine teamwork can also include friends of the patient, health insurance companies and pastors.

Attitudes

One focus is on interdisciplinary teamwork. In order to meet the complex requirements that result from the rapidly changing needs of patients and their relatives, close cooperation between several professions is necessary, which work towards a common goal, regardless of professional affiliation or ranking. Communication is an important aspect here. Relatives, especially the family, are included in the palliative medical measures whenever possible (family emergency situations can also make family therapeutic interventions necessary).

Equally important is the communication with patients in palliative care treatment in certain conversations, which many doctors find the most difficult and most stressful part of their job: conveying serious diagnostic facts about the disease and prognosis in the sense of clarification ; passing on information in order to obtain consent for further treatment measures, discussing treatment alternatives and addressing psychosocial problems, such as discussing or addressing the situation of relatives, such as children or parents of the patient, and how they deal with the disease, what Information about their knowledge of the patient's situation and the problems arising therefrom is necessary for palliative care. Psychosocial support also includes information and advice on social law. Children of the dying and palliative patients should also be included from the start and not kept away, which gives them the chance to prepare and means further support for the patient. As a prerequisite for effective communication and thus a good exchange of information with those affected, the caregiver, therapist or doctor who conducts the conversation is fundamentally “asking and listening more than talking”, whereby a distinction should be made between what the therapist should ask or say and not say. As a branch of medicine, palliative medicine respects the patient's right to self-determination . He has the right to refuse treatment, even if not treating the patient may lead to earlier death. Communication in the context of palliative medicine also includes addressing topics that are often taboo, such as impending death and dealing with sexuality.

Symptoms and symptom control

See also: Palliative Therapy

General

Not only tumor patients may suffer from shortness of breath , pain , fatigue , weakness, indigestion and other symptoms in advanced stages of the disease . These complaints can be so distressing that life becomes unbearable without adequate relief from such symptoms. Symptom control is used to eliminate or at least alleviate unpleasant side effects of the disease or the side effects of therapy. This is done by perceiving, documenting, assigning and treating the symptoms and accompanying symptoms. Palliative medical care can be provided under inpatient conditions in a hospital or an inpatient care facility (hospice or nursing home) as well as under outpatient conditions in the home.

The symptoms differ in different phases of the disease (rehabilitation phase , pre- terminal phase , terminal phase , final phase ) in terms of their number, frequency and severity.

The prerequisite for efficient symptom control is experienced specialist staff who regularly communicate with each other, including the patient (and, if necessary, his relatives).
The basis is precise patient observation and its precise documentation, on the basis of which the effect or side or non-effect of the selected therapy can be proven. A change in palliative therapy in the event of ineffectiveness or excessive side effects takes place promptly and is checked again until the optimal setting for the respective patient is reached. What is decisive, however, is always what the patient feels is appropriate for himself.

With medication, palliative operations , palliative care , physiotherapy, occupational therapy and physical measures as well as the use of rehabilitation methods, these complaints can often be alleviated to such an extent that the experience is not limited to the suffering, other thoughts and activities are possible again and again for the rest of your life is perceived as worth living.

Supportive, therapeutic discussions about coping with illness and emotional stabilization are also an essential, sometimes the only, part of palliative medical treatment.

Pain

Pain is the second most common and most feared symptom in incurable cancer patients and therefore one of the most important challenges in palliative medicine as an object of symptom control. The pain of each palliative patients requires a thorough recording of the underlying types of pain, to create differentiated treatment plans. The most important types of pain are somatic nociceptor pain, visceral nociceptor pain , neuropathic ( neuralgiform ) pain and neuropathic pain with burning pain. For the treatment of pain, the recommendations of the World Health Organization have proven to be effective, according to which painkillers (long-acting, delayed ) painkillers should be administered by mouth (oral application or other non-invasive form of administration), by the clock (as long-term therapy at fixed time intervals, in contrast to so-called breakthrough pain - additionally used medication ) and on the ladder (according to the WHO ladder ). The analgesic scale recommends level 1 medication (non-opioids such as metamizole) for mild pain, level 2 medication (weak opioids such as tramadol in combination with non- opioids ) for moderate to severe pain and level 3 the strong opioids in combination with non-opioids. Similar step-by-step plans are also available for other symptoms such as B. Breathlessness or nausea.

Particularly in the case of patients treated by palliative medicine, the often reduced need for analgesics in the terminal phase and final phase and the associated dose reduction or discontinuation of analgesics should be noted.

Breathing problems

One of the most important symptoms in palliative medicine is shortness of breath ( dyspnea ), a state of subjectively experienced shortness of breath of various causes. Opioids, among other things, are used to control symptoms. These can bring about an economization of the often rapid breathing, have an anxiety-reducing and calming effect. Other medications available are benzodiazepines, corticosteroids, bronchodilators and, if indicated, antibiotics. Whether therapy with oxygen makes sense must be discussed in each individual case. Further respiratory difficulties can result from edema (also ascites ). Also cough can be unbearable. In the final phase of life, there is often a loud rattle breathing , which is caused by pulmonary edema or increased formation of bronchial secretions that the dying person cannot cough up.

Weakness and fatigue

In patients with incurable cancer, general weakness, before pain, is the most common physical symptom. Under Fatigue is meant for the field of palliative care, according to the National Comprehensive Cancer Network , "a stressful, persistent, subjective sense of physical, emotional and / or cognitive tiredness or exhaustion related to cancer or cancer treatment that disproportionately associated with successful, physical Activity occurs and interferes with normal functioning ”. There are several therapeutic approaches that can be considered: for example, treating comorbidities, changing current medication, possibly psychostimulants, correcting hemoglobin levels and physical activity. With humans in the final phase (hours before death), although they often cannot give an answer or react due to their weakness and thus appear unconscious, it can still be assumed that they can hear and understand as well as perceive touch.

Dry mouth

Another symptom that occurs in 70 to 80% of palliative care patients is dry mouth (xerostomia), which is not only age-related or due to fluid loss ( desiccosis ), but also in connection with a malignant tumor (also as a side effect of chemotherapy or radiation therapy ) or drug-related ( opioids or opiates , antidepressants , antiemetics , neuroleptics and others). Severe dehydration of the oral mucosa is often perceived by those affected as a considerable burden (when eating, experiencing taste and communicating) and thus reduces their quality of life. There are various options available for treating dry mouth, from oral care to drug therapy: oral hygiene and dental care, mouth moistening (mouth rinses with water or tea, but chamomile tea should not be used as it has a drying effect itself, use of artificial saliva or spraying of liquid such as cold drinks with an atomizer, keeping the lips moist, room air humidification), adequate fluid intake, stimulation of saliva production (tart teas, chewing lemon pieces or dried fruit, sucking sour candy, lollipops or pieces of ice from favorite drinks, chewing gum, use of essential oils, use of Cholinergics such as pilocarpine ), possibly treatment of mucositis (as it can also occur with palliative radiation therapy in the ENT area) or stomatitis .

Skin problems

Dermatological problems can be caused by palliative care patients both through malignant skin tumors (basal cell carcinoma, squamous cell carcinoma, melanoma) and paraneoplastic skin diseases (acrokeratosis, acanthosis nigricans maligna, erythema gyratum repens, Torre syndrome, dermatomyositis, implanted catheter infections) and Venous catheters, urinary catheters, spinal cord and other pain catheters) or after stoma systems. Skin problems also include itching , jaundice , sweating , visible changes in the skin and mucous membranes, and strong odor formation.

Tumor cachexia and loss of appetite

The cancer cachexia is associated with loss of appetite (anorexia) and weight loss (cachexia) syndrome. Up to 80 percent of people with progressive cancer suffer from tumor cachexia and its effects (fatigue, impaired performance, psychosocial stress on the patient and their relatives). Different forms and stages of tumor cachexia are distinguished in the diagnosis. The measures in the context of a palliative therapy include (as with other forms of nutritional difficulties) nutritional advice, food supplements, drug-based symptom-oriented therapy (e.g. corticosteroids, progestins and prokinetics), treatment of secondary causes, psychosocial support and, if necessary, artificial nutrition (e.g. using PEG or Jejunal probe ) or alternatively, in the terminal phase, a subcutaneously administered fluid supply.

Nausea and vomiting

As a result of illness or therapy, nausea and vomiting are common symptoms in palliative care. Various measures and anti- emetics are available for treatment and symptom control. If the cause is psychogenic (not vomiting due to chemotherapy), neuroleptics of the phenothiazine type such as levopromazine and haloperidol can also be considered.

fear

To treat or cope with fear, which must not be trivialized but addressed (sensitively), palliative medicine primarily offers a dialogue with the patient, whereby individual and family circumstances should be taken into account. Education about medical measures, therapy goals and organizational processes can alleviate fear and create trust. What is important here is as continuous support as possible by trusted doctors and nurses. Psychotherapeutic procedures, relaxation techniques and pharmacological support measures (such as the administration of neuroleptics ) also offer help .

More symptoms

Frequently, the symptoms in question seriously ill and terminally ill digestive tract that can be alleviated with palliative medical treatment or resolved, in addition to nausea and vomiting also are thirst , fever , constipation (constipation) , diarrhea , halitosis , mucositis, dysphagia (difficulty swallowing), hiccups , vomiting blood and Ascites . This also includes symptom control of urological, urogenital and neurological symptoms (for example dizziness ) and psychiatric symptoms (motor restlessness, sleep disorders (insomnia), depression and others) as well as the procedure for tumor bleeding ( e.g. surgery or high-dose radiation ) and pathological bone fractures . on the field of palliative medicine.

Situation in Germany

This article or paragraph presents the situation in Germany . Help us to describe the situation in other countries.

Health insurance coverage

Palliative medical treatment is currently provided from different sources. Like other hospital departments, the palliative care wards are either financed according to flat rates ( DRG ) - since 2007 supplemented by an additional remuneration differentiated according to the duration of treatment and treatment concept - or as special facilities according to daily rates that are freely negotiated by the respective hospital with the payers. Currently, only some of the palliative care wards can cover their costs.

Resident specialists who, as palliative physicians, treat patients in inpatient hospices in the form of home visits , settle accounts with the insured person's respective health insurance company via the Association of Statutory Health Insurance Physicians. In many places, cost agreements have been made for integrated care, with very different financing and supply models. The North Rhine National Association of Statutory Health Insurance Physicians has meanwhile concluded financing agreements in several places within the framework of the family doctor contract, with which resident doctors can provide continuous care for palliative patients.

With the entry into force of the GKV Competition Strengthening Act (GKV-WSG) , specialized outpatient palliative care ( Section 37b SGB ​​V) became a mandatory service within the scope of the statutory health insurance service catalog from April 2007.

The Hospice and Palliative Care Act (HPG) was enacted on December 1, 2015 ( Federal Law Gazette I p. 2114 ). Above all, the new regulations are intended to help meet the desire of many people to spend the end of their lives at home. Above all, the expansion of outpatient palliative care with additionally reimbursed services in the area of ​​contract doctors should help to achieve this goal. Nursing homes are legally obliged to conclude cooperation agreements with specialists to ensure the required palliative care. The doctors involved receive additional remuneration.

Solidarity through education

The German Cancer Aid has triggered exemplary solidarity among citizens through a nationwide education about the increasing importance of palliative medicine. The non-profit organization was able to significantly support the development of palliative care structures in Germany with more than 70 million euros in donations up to 2015. This included endowed professorships, research projects with palliative medicine content and funding for academies for palliative medicine education and training.

In 1974, when she founded the aid organization “Deutsche Krebshilfe” , the X-ray doctor Mildred Scheel supported palliative medicine by providing specialist training for carers. This corresponded to the conviction: "The holistic care approach requires special training and further education from the professional groups active in palliative medicine". Since then, this has been provided by the association of academies for palliative medicine and hospice work such as the Mildred-Scheel Academy of German Cancer Aid (Cologne) and academies in Bonn, Dresden, Göttingen and Munich. Further palliative academies have been set up in Magdeburg and Regensburg, for example.

literature

Textbooks and monographs

  • AS Lübbe, Isabell-Annett Beckmann: Palliative medicine. Answers - Help - Perspectives (= The blue counselors. Volume 57). German Cancer Aid Foundation, Bonn 2018.
  • Martin W. Schnell, Christian Schulz (ed.): Basic knowledge of palliative medicine. 2nd Edition. Springer Medicine, Berlin a. Heidelberg 2014, ISBN 978-3-642-38689-3 .
  • Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 3rd, updated edition. Schattauer Verlag, Stuttgart 2012, ISBN 978-3-7945-2666-6 .
  • Claudia Bausewein , Susanne Roller , Raymond Voltz (eds.): Guide to Palliative Care: Palliative Medicine and Hospice Care. 4th edition. Urban & Fischer, Munich 2010, ISBN 978-3-437-23312-8 .
  • Stein Husebø , Eberhard Klaschik : Palliative medicine - basics and practice. 5th edition. Springer, Heidelberg 2009, ISBN 978-3-642-01548-9 .
  • Federal Working Group Hospice e. V. (Ed.): Help at the end of life. Hospice work and palliative care in Europe. The Hospiz Verlag, Wuppertal 2004, ISBN 3-9810020-0-8 .
  • Franco Rest , Hartmut Reiners, Eberhard Klaschik: Life to the end - final care for tumor patients. Walter de Gruyter Verlag, Berlin / New York 2001, ISBN 3-11-017183-X .
  • Michael Stolberg: The History of Palliative Medicine. Medical care for the dying from 1500 until today. Mabuse-Verlag, Frankfurt am Main 2011, ISBN 978-3-940529-79-4 .
  • World Health Organization: Cancer pain relief and palliative care - report of a WHO expert commitee. World Health Organization, Geneva 1990.

items

Web links

Individual evidence

  1. ↑ Michael Stolberg: The history of palliative medicine. 2011, pp. 16 and 29–42.
  2. ↑ Palliative medicine. ( Memento from June 21, 2012 in the Internet Archive ) German Ethics Council
  3. ↑ G. Bollig, M. Unger, P. Pani: Is there a difference between palliative care and palliative medicine? In: Journal of Palliative Medicine. 06/2010, p. 309, abstract or summary (German and English)
  4. ^ 1 German Society for Palliative Medicine: Definitions for hospice and palliative care. (PDF) Retrieved April 18, 2017 .
  5. ↑ Communication in the team. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. With a foreword by Heinz Pichlmaier. 3rd, updated edition. Schattauer, Stuttgart 2012, ISBN 978-3-7945-2666-6 , pp. 77-103.
  6. ^ AS Lübbe, Isabell-Annett Beckmann: Palliative Medicine. 2018, pp. 4–7 and 69.
  7. ^ Renate Wittern : The omission of medical assistance in Greek medicine of the classical period. In: Munich medical weekly. Volume 121, 1979, pp. 731-734.
  8. ↑ Guido Guidi: De curatione generatim. In: Guido Guidi [1508–1569]: Opera omnia sive ars medicinalis. Frankfurt 1626, p. 121.
  9. ↑ Michael Stolberg: The history of palliative medicine. 2011, p. 9 f. and 21 f.
  10. ^ Peter Kolb: The hospital and health system. In: Ulrich Wagner (Hrsg.): History of the city of Würzburg. 4 volumes, Volume I-III / 2 (I: From the beginnings to the outbreak of the Peasant War. 2001, ISBN 3-8062-1465-4 ; II: From the Peasant War 1525 to the transition to the Kingdom of Bavaria 1814. 2004, ISBN 3 -8062-1477-8 ; III / 1–2: From the transition to Bavaria to the 21st century. 2007, ISBN 978-3-8062-1478-9 ), Theiss, Stuttgart 2001–2007, Volume 1, 2001, p 386-409 and 647-653, here: p. 405.
  11. ↑ Michael Stolberg: The history of palliative medicine. 2011, pp. 34-38.
  12. ↑ Michael Stolberg: The history of palliative medicine. 2011, pp. 119–132 ( Rise and Fall of Euthanasia Medica ).
  13. ↑ Michael Stolberg: The history of palliative medicine. 2011, p. 124.
  14. ↑ Michael Stolberg: The history of palliative medicine. 2011, p. 43.
  15. ^ Manfred Vasold: On the situation of the Nuremberg public hospitals and hospitals from 1770 to 1845. In: Würzburger medical-historical reports. 17, 1998, pp. 399-438; here: p. 408 f.
  16. ↑ August Stöhr: Manual of Pastoral Medicine with special consideration of hygiene. 2nd Edition. Freiburg im Breisgau 1882, p. 290.
  17. ↑ Michael Stolberg: The history of palliative medicine. 2011, p. 220.
  18. ↑ Michael Stolberg: The history of palliative medicine. 2011, pp. 219–226 ( Death in the hospital - the patient's perspective ).
  19. ^ Center for Palliative Medicine Cologne - The first palliative ward in Germany
  20. ↑ Munich declaration on teaching in the new compulsory subject palliative medicine. (PDF) on dgpalliativmedizin.de; accessed on January 19, 2019.
  21. ↑ Federal Medical Association (Working Group of German Medical Associations) (Sample) Further Education Regulations 2003 in the version dated June 28, 2013. (PDF) Federal Medical Association, accessed on April 18, 2017 .
  22. ↑ Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Acquired immunodeficiency (AIDS). In: Textbook of palliative medicine. 3rd, updated edition. Schattauer, Stuttgart 2012, ISBN 978-3-7945-2666-6 , pp. 710-750.
  23. ↑ Monika Müller, Martina Kern: Teamwork in palliative medicine. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. Schattauer, Stuttgart (1997) 3rd, updated edition 2012, ISBN 978-3-7945-2666-6 , pp. 77-89, especially p. 78.
  24. ^ Claudia Bausewein, Susanne Roller: Interdisciplinary team. In: Claudia Bausewein, Susanne Roller, Raymond Voltz (eds.): Guideline Palliative Care. Palliative medicine and hospice care. Elsevier, Munich 2015, p. 418.
  25. ^ Gerhard Strittmatter: Inclusion of the family in the care of the sick and accompanying family therapy. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 2012, pp. 1106-1138.
  26. ^ Stein Husebø: Communication. Backgrounds. In: Stein Husebø, Eberhard Klaschik (ed.): Palliative medicine. Springer, Berlin / Heidelberg 2000, ISBN 3-540-66605-2 , p. 108.
  27. ^ Stein Husebø: Communication. In: Stein Husebø, Eberhard Klaschik (ed.): Palliative medicine. 2009, pp. 147-205.
  28. ↑ Ursula Fülbier: Social work in palliative medicine. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 2012, pp. 1249-1256.
  29. ↑ Medico Consult: self-determination .
  30. ↑ dgpalliativmedizin.de (PDF)
  31. ^ Christof Müller-Busch: patient autonomy at the end of life. Theses on the subject of patient autonomy at the end of life from a (palliative) medical perspective . ( Memento from May 14, 2011 in the Internet Archive ; PDF; 532 kB) In: Bt-Prax. 2/2005, p. 51; Retrieved May 3, 2012.
  32. ↑ L. Radbruch, S. Payne: Standards and guidelines for hospice and palliative care in Europe: Part 1 . In: Journal of Palliative Medicine . tape 12 , no. 05 , September 1, 2011, ISSN  1615-2921 , p. 216-227 , doi : 10.1055 / s-0031-1276909 .
  33. ↑ Martina Kern: Sexuality and intimacy in the seriously ill. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 2012, pp. 1096-1105.
  34. ^ A b Ingeborg Jonen-Thielemann: Dying phase in palliative medicine: terminal phase. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 2012, pp. 989-997, here: pp. 991 f.
  35. ↑ Aulbert et al. a .: Treatment of symptoms in palliative medicine. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 2nd Edition. Schattauer-Verlag, Stuttgart 2007, pp. 139–147.
  36. ↑ Peter Nieland, Wolf Schönleiter: Physiotherapy and physical therapy. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 3rd, updated edition. Schattauer, Stuttgart 2012, ISBN 978-3-7945-2666-6 , pp. 1199-1207.
  37. ^ Wolfgang von Renteln-Kruse: Rehabilitation in palliative medicine. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 3rd, updated edition. Schattauer, Stuttgart 2012, ISBN 978-3-7945-2666-6 , pp. 1195-1198.
  38. ^ Eberhard Aulbert: Communication with patients and relatives. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 2012, pp. 1037-1058, here: pp. 1045-1051.
  39. ^ A b Ingeborg Jonen-Thielemann: Dying phase in palliative medicine: terminal phase. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 2012, pp. 989-997, here: p. 991.
  40. ↑ Eberhard Klaschik: Pain therapy and symptom control in palliative medicine. In: Stein Husebø, Eberhard Klaschik (ed.): Palliative medicine. 2009, pp. 207-313.
  41. ↑ Russell K. Portenoy, Neil A. Hagen: Breakthrough pain: definition, prevalence and characteristics. In: Pain. Volume 41, No. 3, (June) 1990, pp. 273-281.
  42. ^ Friedemann Nauck: Symptom control in the final phase. In: pain. Volume 15, 2001, pp. 362-369.
  43. ↑ Katri Elina Clemens, Eberhard Klaschik: Respiratory symptoms. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 2012, pp. 366-384.
  44. ^ Ingeborg Jonen-Thielemann: Dying phase in palliative medicine: terminal phase. 2012, p. 991 f.
  45. ↑ Agnes Glaus: Fatigue - the unusual tiredness. In: Eberhard Aulbert u. a. (Ed.): Textbook of palliative medicine. 2012, pp. 398-409.
  46. ^ Ingeborg Jonen-Thielemann: Dying phase in palliative medicine: terminal phase. 2012, p. 992.
  47. ↑ Up to 40% of patients complain of dry mouth while taking opioids. Friedemann Nauck, Lukas Radbruch: Systemic drug pain therapy. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 2012, pp. 175–207, here: 191.
  48. ↑ Martin Klein, Jan D. Raguse: Operations in the head and neck area. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 2012, pp. 572-588, here: p. 585.
  49. ↑ Petra Feyer, Maria Steingräber: Palliative radiation therapy. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 3rd, updated edition. Schattauer, Stuttgart 2012, ISBN 978-3-7945-2666-6 , pp. 607-632, here: pp. 624 f.
  50. ↑ Renate Langenbach, Ilse Delagardelle: Affects der Mundschlimheit . In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 3rd, updated edition. Schattauer, Stuttgart 2012, ISBN 978-3-7945-2666-6 , pp. 265-270, here: pp. 265 f.
  51. ↑ Beate Augustyn, Martina Kern: Nursing measures in symptom treatment. In: Eberhard Aulbert u. a. (Ed.): Textbook of palliative medicine. 2012, pp. 948–958, here: p. 949.
  52. ↑ Martin Klein, Jan D. Raguse: Operations in the head and neck area. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 2012, pp. 572-588, in particular pp. 573 f.
  53. ↑ Gerd-Gunnar Hanekop, Dietmar Beck: Spinal cord near pharmacotherapy. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 2012, pp. 208-223, here: pp. 213-219 ( side effects and complications ).
  54. ↑ Gabriele Gruber, Eberhard Aulbert: Stomapflege. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 2012, pp. 971-988, especially p. 984 ( skin complications ).
  55. ^ A b Ingeborg Jonen-Thielemann: Dying phase in palliative medicine: terminal phase. 2012, p. 991.
  56. ↑ Martin Klein, Jan D. Raguse: Operations in the head and neck area. 2012, p. 584 f. ( Interventions to maintain nutrition ).
  57. ^ Rolf Oberholz, Florian Strasser: Tumorkachexie and Nutrition: Nutritional Problems. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 2012, pp. 301–322.
  58. ↑ Eberhard Aulbert, Wiebke Nehl: Palliative internal-oncological tumor therapy. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. Schattauer, Stuttgart (1997) 3rd, updated edition 2012, ISBN 978-3-7945-2666-6 , pp. 633-663; here: pp. 651–654.
  59. ↑ Gerda Ratsak: Anxiety and coping with fear. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. 2012, pp. 1059-1076.
  60. ↑ Martin Klein, Jan D. Raguse: Operations in the head and neck area. 2012, p. 584 f.
  61. ^ Renate Langenbach, Claudia Bausewein, Susanne Roller: Gastrointestinal symptoms. In: Clauda Bausewein, Susanne Roller, Raymond Voltz (Eds.): Guide to Palliative Medicine - Palliative Care. 3rd edition. Urban & Fischer, Munich / Jena 2007, ISBN 978-3-437-23311-1 , pp. 391-431.
  62. ^ Clauda Bausewein, Susanne Roller, Raymond Voltz (eds.): Guide to Palliative Medicine - Palliative Care. 3rd edition. Urban & Fischer, Munich / Jena 2007, ISBN 978-3-437-23311-1 , pp. 433-496.
  63. ↑ Text, amendments and reasons for the GKV Competition Strengthening Act - GKV-WSG
  64. ^ Text, amendments and reasons for the Hospice and Palliative Care Act - HPG
  65. ↑ Federal Ministry of Health: Bundestag passes a law to improve hospice and palliative care. Retrieved November 26, 2015.
  66. ↑ krebshilfe.de accessed September 10, 2016.
  67. ↑ Current study: Migrants hardly ever use palliative care offers. June 27, 2018, accessed January 16, 2019 .
  68. ↑ Events - palliative and hospice Academy Magdeburg. Retrieved January 16, 2019 .
  69. ↑ Palliative and Hospice Academy Regensburg e. V. Accessed January 16, 2019 .