[Definitions and recommendations for palliative sedation].
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Ethics, Medical↗
Biomedical subjects
L Radbruch
Publications and source records attributed to L Radbruch.
[Treatment discontinuation and obligation to treat: an extended model for the decision-making process].
Social developments and medical progress in the last decades have led to a significant change of values in medicine, which spans from the cornerstone of the patient's autonomy to the increasingly difficult decision-making process related to available medical treatments. This conflict exaggerates with end-of-life situations, where a purely palliative approach to the therapy is applied, or in cases of reduced ability for patient's consent. From a legal point of view, many uncertainties have been clarified in recent years. The patient's autonomy has been strengthened, however, the law requires the doctor to review and carefully balance the treatment options so that a new and modified patient-doctor relationship is often necessary in this difficult decision-making process. The doctor should no longer retreat into the classical role of a neutral advisor and leave the complete responsibility of medical decisions to the patient. Instead, in order for the patient to be able to make a balanced and individually tailored autonomous decision, the doctor needs to bring in his medical expertise along with his own personal experiences and personal opinions, as long as he clearly differentiates between personal and professional views. This way the patient will be empowered to make complex medical decisions, considering his personal situation and previous experiences as well as his own set of values. For complex situations medical practitioners can find support from reflection within the treatment team, or through an external ethical advisory panel. Algorithms can be helpful to illustrate the steps in a decision-making process and thus support medical staff in situations of difficult medical decisions.
Aged↗
[Oral controlled-release oxycodone for the treatment of chronic pain. Data from 4196 patients].
Oral controlled-release oxycodone has been available for the treatment of chronic pain in Germany since 1998. Controlled trials have shown good clinical efficacy and tolerability. This survey reports results from six open prospective multicenter trials. In these trials 4196 patients suffering from cancer pain and non-cancer-related pain with inadequate pain relief were treated with oral controlled-release oxycodone for 3-4 weeks. Only a few participating physicians were pain specialists. A total of 356 patients suffering from pain of the musculoskeletal system and receiving oxycodone therapy were monitored for 6 months. Exclusion from the studies was due mainly to inadequate analgesia, side effects, and noncompliance. The efficacy of oxycodone was rated to be better than moderate by most of the patients, quality of life parameters increased significantly, and patient satisfaction was high. The treatment with oral controlled-release oxycodone was a safe and effective option even when used by nonspecialized physicians.
Administration, Oral↗
[Efficacy of opioid analgesia at the superior cervical ganglion in neuropathic head and facial pain].
The efficacy of ganglionic local opioid analgesia (GLOA) at the superior cervical ganglion (SCG) was retrospectively investigated in 74 consecutive patients with neuropathic pain in the head and face region. It was possible to retrospectively analyze the short-term and medium-term treatment results in 64 of 74 patients. The long-term effect was subsequently determined using a standardized questionnaire. The short-term analgesic effect of the first blockade by GLOA was significant with a mean pain reduction of 52% (p < 0.001). Within a span of 20 min the mean pain intensity decreased from 65 to 28 on a visual analogue scale. A clinically relevant pain reduction (> or = 30%) was observed in 73% of the patients. The proportion of responders (pain reduction > or = 50%) was 59% after the first blockade. Patients with zoster or trigeminal neuralgia experienced greater pain relief than patients with atypical facial pain or longer lasting postzoster neuralgia. During the course of the blockade series with an average duration of 33 days, a significant medium-term pain reduction of 30% was noted. In the first 3 treatment days, the level of continuous pain declined from 6.3 to 4.3 on a numerical rating scale. Short-term responders reported a better medium-term pain reduction than nonresponders. After 3 years (range: 5 months to 6 years), 21% of 52 patients remained free of pain. The other patients reported often only minimal residual pain or a decrease of pain severity and duration. According to these results, GLOA at the SCG can represent a suitable and simple treatment option for neuropathic facial pain.
Adult↗
[The capsaicin receptor--a milestone in fundamentally oriented pain research].
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Central Nervous System↗
Assessing cognition and psychomotor function under long-term treatment with controlled release oxycodone in non-cancer pain patients.
BACKGROUND: The therapeutic use of opioids can be associated with altered cognition and impaired psychomotor function. Several studies have demonstrated the impact of opioid therapy on psychomotor performance and cognition, but no data exist about the effect of long-term treatment with controlled release oxycodone (CRO) on driving ability. METHODS: Thirty patients suffering from chronic non-cancer pain who had been treated with stable doses of CRO where included in a prospective trial and compared with 90 healthy volunteers (matched pairs). A computerized test battery that was developed to assess the driving ability of traffic delinquents in Germany was employed. Attention reaction, visual orientation, motor coordination and vigilance were evaluated. The data from a total of 11 parameters were assessed and for each test a relevant score was defined. As the primary endpoint the sum score of the three relevant scores was determined. A weaker statistical means to assess the patients' performance is to compare the test results with an age-independent control group. Individuals performing worse than the 16th percentile of this control group are considered to be unable to drive according to German legislation. RESULTS: Significant non-inferiority could not be demonstrated for the primary endpoint. However, driving ability as defined as a result above the 16th percentile did not differ significantly between the patients receiving CRO and the age-independent control group. CONCLUSION: The use of CRO does not prohibit driving, but individual assessment is necessary.
Adult↗
[Palliative pain therapy, cannabinoids].
Cancer pain treatment should follow the recommendations of the World Health Organisation. Treatment should be with oral application, regular application times and following the analgesic step-ladder. Non-opioids such as dipyrone or non-steroids are used for slight to moderate pain, step-2 opioids such as tramadol or tilidine/naloxone for moderate pain and step-3 opioids such as morphine, oxycodone or hydromorphone for severe pain. Transdermal application of fentanyl or buprenorphine offer a non-invasive parenteral alternative for patients with stable pain syndromes. Cannabinoids such as tetrahydrocannabinol offer a valuable add-on option for cancer patients with refractory pain, spasticity, nausea or appetite loss.
Analgesics↗
Intravenous versus subcutaneous morphine titration in patients with persisting exacerbation of cancer pain.
BACKGROUND: Patients with cancer pain with initially adequate analgesia under oral sustained-release opioid medication may suffer from persisting pain exacerbations. Sometimes even fast help is needed and then optimally performed by intravenous application (IVA) of immediate-release (IR) opioids. This IVA, however, may only be performed by physicians in Germany. OBJECTIVE: We wanted to find out if subcutaneous application of IR-opioids might be an adequate alternative to IVA in persisting pain exacerbations of patients with cancer pain because this could be performed by the nursing staff in Germany as well. DESIGN: An open randomized controlled trial was used to compare intravenous versus subcutaneous morphine titration in persisting pain exacerbations in patients with cancer pain. SETTING/SUBJECTS: Thirty-nine patients with cancer (21 intravenously, 18 subcutaneously) of the pain management department of the university hospital of Cologne, Germany were included into the study. MEASUREMENTS: Calculated from preexisting analgesic medication boli of morphine were given every 5 minutes (intravenously) or 30 minutes (subcutaneously) up to adequate analgesia or intolerable side effects. Pain intensity, nausea, sedation, and some vital parameters were documented before the start, after each application and at the end of titration. RESULTS: Thirty-five patients were pretreated with oral opioids, 4 patients with nonopioid analgesics. Six patients stopped titration because of intolerable side effects (sedation, vomiting). Thirty patients (77%) reported at least sufficient pain reduction, 3 patients were free of pain (intravenously). Mean pain intensity decreased on a visual analogue scale (VAS, 0-100) from 83 to 32 (intravenously) and from 68 to 42 (subcutaneously). Morphine doses ranged from 4 mg to 32 mg (intravenously; mean, 18.5 +/- 9.2 mg) and from 10 mg to 200 mg (subcutaneously mean, 57.9 +/- 59.6 mg). Mean time up to adequate analgesia was 53 (intravenously) 77 min (subcutaneously), respectively. There was no change in vital parameters but an increase of sedation in both groups. The adaptation of the continuous analgesic medication resulted in a stable and lasting pain relief after 4 days in both groups. CONCLUSIONS: Intravenous and subcutaneous-morphine titration are adequate to antagonize persisting pain exacerbations in cancer pain patients quickly and to adapt the continuous opioid analgesic medication.
Adult↗
[What is the profile of palliative care in Germany. Results of a representative survey].
Since 1996 a working group of palliative care physicians has been developing a core documentation for palliative facilities. The data on a total of 1304 patients were collected in 2001. Treatment in palliative care units was provided for 531 patients until their death (Pat-V), 604 patients could be discharged home, and 169 patients were transferred to other facilities (Pat-E). Infusion therapy, physical therapy, positioning and mobilization, together with counseling and social services were initiated in more than 30% of the patients, while specific measures such as ascites or pleura puncture were instituted in less than 10%. Chemotherapy, radiotherapy, immunotherapy, urinary catheter, physical therapy, mobilization, positioning, psychotherapy, and social services were documented more frequently in the Pat-E group than in the Pat-V group. Chemotherapy was started in only 35 patients and radiotherapy in only 31 patients while they were in the palliative care unit. Parenteral nutrition, infusion therapy, wound management, and counseling were documented more frequently in the Pat-V group. Advanced directives were available for 9,9% of the patients omission or discontinuation of therapies was documented for 28,1%. Specific indications for the quality of palliative care provided could not be identified with the documentation instruments applied. The core documentation does however furnish data from a representative sample of in-patient palliative care in Germany, which can be used as a comparative data pool for other studies and quality assurance measures.
Death↗
[Review of cannabinoids in the treatment of nausea and vomiting].
Cannabinoids are used to treat nausea and vomiting. The effect appears to be mediated by cannabinoid receptors in the nucleus tractus solitarius. Results are available from studies on the use of cannabinoids to manage nausea and vomiting after chemotherapy. None of these studies, however, compared cannabinoids with the newer serotonin antagonists. The antiemetic efficacy of cannabinoids for other indications has not yet been studied sufficiently. Most of the studies report significantly more or stronger side effects with cannabinoid medication in comparison to similar medication. In some of the studies on treatment after chemotherapy or radiotherapy, the patients terminated the cannabinoid therapy more frequently due to side effects. Although clinical studies have provided clear evidence for the antiemetic efficacy of cannabinoids, the frequency and severity of side effects argue against their use as the method of first choice. For patients who cannot be adequately treated with conventional antiemetic agents, cannabinoids can represent a valuable adjunct to the antiemetic regimen.
Antiemetics↗
Breakthrough pain characteristics and syndromes in patients with cancer pain. An international survey.
Breakthrough pain (BKP) is a transitory flare of pain that occurs on a background of relatively well controlled baseline pain. Previous surveys have found that BKP is highly prevalent among patients with cancer pain and predicts more severe pain, pain-related distress and functional impairment, and relatively poor quality of life. An international group of investigators assembled by a task force of the International Association for the Study of Pain (IASP) evaluated the prevalence and characteristics of BKP as part of a prospective, cross-sectional survey of cancer pain. Fifty-eight clinicians in 24 countries evaluated a total of 1095 patients with cancer pain using patient-rated items from the Brief Pain Inventory (BPI) and observer-rated measures. The observer-rated information included demographic and tumor-related data, the occurrence of BKP, and responses on checklists of pain syndromes and pathophysiologies. The clinicians reported BKP in 64.8% of patients. Physicians from English-speaking countries were significantly more likely to report BKP than other physicians. BKP was associated with higher pain scores and functional interference on the BPI. Multivariate analysis showed an independent association of BKP with the presence of more than one pain, a vertebral pain syndrome, pain due to plexopathy, and English-speaking country. These data confirm the high prevalence of BKP, its association with more severe pain and functional impairment, and its relationship to specific cancer pain syndromes. Further studies are needed to characterize subtypes of BKP. The uneven distribution of BKP reporting across pain specialists from different countries suggests that more standardized methods for diagnosing BKP are needed.
Analysis of Variance↗
Pain treatment: a historical overview.
Pain is a common experience of mankind. Pain theories and the management of pain have been modified throughout the history of mankind. This article gives a brief review on pain, pain believes and pain management from early magico-demonic and magico-religious ideas and procedures to more empiric-scientific models; from ancient times and primitive cultures to the 20th century. Due to new anatomical, physiological and biochemical insights, modern pain theories developed in the 19th and 20th century. Modern analgesics were synthesized and new invasive procedures were approved having a major impact on pain management strategies. However, older traditional beliefs and attitudes have not been replaced completely and have survived to some degree in modern patients.
Analgesics↗
[Opioids and driving ability -- a problem unsolved?].
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Accidents, Traffic↗
[The Cologne internet-manual of pain therapy--33 months online, experiences and evaluation].
OBJECTIVE: The improvement of ambulant treatment for patients with chronic headache or cancer pain. METHODS: Distribution of accepted guidelines and standards by means of the internet in order to make this knowledge known among general practitioners and to give patients better access to this information. RESULTS: We have built an internet manual about the treatment of chronic headache and cancer pain. About 9100 readers accessed the manual during a period of 33 months. The manual has been completely downloaded 279 times. Physicians and patients very often used search engines to access the manual in their search for information about headache. The terms "migraine" and "tension type headache" were looked up the most. CONCLUSIONS: It is worthwhile editing medical information for use on the internet and thus making it available to the public.
Ambulatory Care Facilities↗
[Assisted death: open discussion in connection with pain therapy and palliative medicine applicable to germany. Letter in response to W. Sohn in Der Schmerz 16 (2002):150-2].
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Germany↗
[A review of side effects and complications with cannabinoid treatment].
In the last few years, the use of cannabinoids has been advocated for several indications, and evaluation of the side effect profile is necessary. Euphoric mood changes are among the most frequent side effects, while dysphoric reactions are less frequent. Triggering of acute psychotic episodes has been reported. Cannabinoids can initiate or exacerbate schizophrenic psychosis in predisposed persons. Cannabinoids impede cognitive and psychomotor performance, resulting in impaired driving ability. Chronic use can lead to the development of tolerance. Tachycardia and hypotension frequently are documented as adverse events in the cardiovascular system. A few cases of myocardial ischemia have been reported in young and previously healthy patients. Side effects on the respiratory system are induced by inhaling the smoke of cannabis cigarettes. Some reports have indicated a carcinogenic risk for the children when cannabis was used during pregnancy. In summary, a low risk profile is evident from the literature available. Life-threatening complications are very rare and were not reported after use of cannabinoids for medical indications. Cannabinoids are contraindicated during pregnancy or for patients with a history of cardiac ischemias.
Aged↗
[Application of guidelines for the treatment of headache and cancer pain by private practitioners].
In a regional pain management network in Cologne, sponsored by the German Ministry of Health, structures of outpatient pain treatment in general practice and the adherence to pain management guidelines were examined. The 3-year project was divided into a 1-year observational period to analyze the present state of outpatient pain management followed by a 2-year period of interventions such as consultations and educational training programs in pain treatment. Eighty physicians with different specializations working in general practice took part in the network. The knowledge of and adherence to the guidelines for the treatment of headache and cancer pain were examined by questionnaire surveys and six simulated patient cases. These investigations were performed yearly from 1997 to 2000. The adherence to the guidelines for the treatment of headache and cancer pain by the physicians participating in the network was low. The levels achieved for simulated cases of headache were higher than for cancer pain. The results of simulated patient cases from the beginning and the end of the project were available for comparison for 28 physicians. Evaluation of the physicians' assessment of the simulated patient cases increased only fractionally and was not significant in headache patients (median change of 0.67) and cancer pain patients (median change of 0.17). The network interventions resulted in a slight improvement in the knowledge of and attitudes to the treatment of headache and cancer pain as judged by simulated patient cases. This improvement, however, did not reach statistical significance. The small number of physicians answering at the beginning and at the end of the project made it difficult to draw a general conclusion on whether the interventions had led to an improvement in outpatient pain management in a larger group of physicians.
Adult↗
[Morphine and alternative opioids in cancer pain: the EAPC recommendations].
An expert working group of the European Association for Palliative Care (EAPC) has revised and updated its guidelines on the use of morphine in the management of cancer pain. The revised recommendations presented here give guidance on the use of morphine and the alternative strong opioid analgesics which have been introduced in many parts of the world in recent years. Practical strategies for dealing with difficult situations are described presenting a consensus view where supporting evidence is lacking. The strength of the evidence on which each recommendation is based is indicated.
Analgesics, Opioid↗