[Supportive Therapie und Palliative Konzepte bei Dyspnoe]. / Supportive Therapie und Palliative Konzepte bei Dyspnoe.

INTRODUCTION: Palliative care aims to treat patients who symptomatically are affected by an advanced, incurable disease. Dyspnoea is one of the most common symptoms in various diseases, not only the oncological ones. The treatment of these symptoms requires consideration from different points of view. In palliative care, the bio-psycho-socio-spiritual and cultural model is often applied. Here, different dimensions of the disease are considered, which are especially involved in the case of dyspnoea. The physiology of dyspnoea is very complex and is influenced by various neuronal as well as pulmonary anatomical structures. Various non-pharmacological as well as pharmacological treatment approaches can lead to a decrease in dyspnoea. In particular, active physiotherapy and assistive devices optimise the symptoms. From the pharmacological side, mainly opioids but also benzodiazepines, oxygen and Butylscopolamin are used. In the case of very advanced disease, the use of deep continuous sedation to relieve symptoms may be justified if the symptoms are refractory to therapy. Successful treatment of dyspnoea leads to a substantial improvement in the quality of life of palliative care patients.

Palliative Sedation-The Last Resort in Case of Difficult Symptom Control: A Narrative Review and Experiences from Palliative Care in Switzerland.

Palliative sedation can be considered as "the last resort" in order to treat unbearable, refractory symptoms or suffering in end-of-life patients. The aim is symptom relief and not to induce death as in the case of euthanasia. The treatment might be one of the most challenging therapeutic options in the field of palliative care, involving both ethical and practical issues. Still, studies have shown that it is a safe and valuable treatment and in general does not shorten the life of the patient. Since patients in Switzerland have the legal option of assisted suicide, palliative sedation is an alternative that has become increasingly important. The use of palliative sedation was reported in 17.5% of all patients admitted to palliative care in Switzerland, making the country of those with the highest use of this treatment. The aim of this narrative review is to discuss ethical and practical issues in palliative sedation, with specific focus on experiences from Switzerland. Indications, ethical considerations, drugs of choice and duration are discussed. Decision making should be based on solid guidelines. When used correctly, palliative sedation is an important and useful tool in palliative care in order to provide good symptom relief.

[Often Only a Side Event, but Sometimes Groundbreaking - an Ectopic ACTH Secretion as an Example of a Paraneoplastic Syndrome]. / Oft nur Nebenschauplatz, manchmal aber wegweisend ­ eine ektope ACTH-Sekretion als Beispiel eines paraneoplastischen Syndroms.

Often Only a Side Event, but Sometimes Groundbreaking - an Ectopic ACTH Secretion as an Example of a Paraneoplastic Syndrome Abstract. Various tumors can cause a paraneoplastic ACTH production, particularly small-cell lung cancers. Patients suffer from a secondary Cushing syndrome with hypokalemia, hypertension, hyperglycemia and edema. There are three therapeutic approaches: treatment of the underlying disease, hormonal inhibition and symptomatic treatment. The prognosis of an ACTH-producing lung cancer is poor due to numerous complications. In the presented case study, the patient refused treatment of the underlying disease, therefore a palliative symptomatic treatment became of great importance.

[CME: Dehydration and Artificial Hydration for Terminally Ill Patients]. / CME: Dehydratation und Flüssigkeitstherapie bei sterbenden Patienten.

CME: Dehydration and Artificial Hydration for Terminally Ill Patients Abstract. Parenteral hydration in dying patients is a controversial therapy and leads to different attitudes in caregivers as well as in relatives. A reduced liquid intake should be understood as part of the natural dying process. An artificial hydration can lead to adverse effects in some situations, but also to a benefit in others. Nevertheless, there are indications that justify artificial hydration and others that rather forbid it. In case of uncertainty about hydration, there is the option for a limited trial of therapy. Subcutaneous application is the preferred way of hydration.

[Delirium in Palliative Care: Evidence and Practice]. / Das Delirante Syndrom in der Palliative Care: Frische Evidenz und alte Weisheiten.

Delirium in Palliative Care: Evidence and Practice Abstract. Delirium is a frequent condition in Palliative Care. For patients, their families and the formal caregivers it is associated with substantial burden, fears and challenges. It is also associated with increased morbidity and mortality and often irreversible. Of utmost importance is the identification of patients and threat for delirium and prophylactic measures to avoid delirium whenever possible. For this, risk factors should be identified and eliminated whenever possible. The correct identification of delirium is challenging and especially the hypoactive form of delirium is often unrecognised. When delirium is diagnosed, the etiology must be explored thoroughly and potentially reversible causes should be treated and eliminated whenever feasible and appropriate. The pharmacologic therapy is based on benzodiazepines and neuroleptics. Yet, the use of the substances should be restricted to severe psychotic episodes of the hyperactive form of delirium. It is of utmost importance to know that "disorientation", "restlessness" or delirium alone are no indication for pharmacotherapy. Recently two landmark randomized controlled clinical trials concerning pharmacotherapy for delirium in palliative care have been published. This review presents a practical overview of the prevention, diagnosis and therapy of delirium in palliative care alongside the presentation and discussion of the recently published trials.

Advance directives and end-of-life decisions in Switzerland: role of patients, relatives and health professionals.

BACKGROUND: Little is known in Europe about end-of-life (EOL) decisions and advance directives (AD), particularly in patients with severe advanced disease. Switzerland is a multicultural and multilingual federal country and has the particularity of being divided into four linguistic and cultural regions OBJECTIVE: To understand better in different regions of Switzerland which specific patient's characteristics could have an impact on their decision to complete AD or not. DESIGN/SETTING/PARTICIPANTS: Prospective study conducted in four palliative care units. Patients with an advanced oncological disease, fluent in French, German or Italian and with a Mini-Mental State Examination >20 were included. Demographic data, symptom burden (Edmonton Symptom Assessment System, ESAS; Hospital Anxiety and Depression Scale, HADS) and spiritual well-being (Functional Assessment of Chronic Illness Therapy-Spiritual well-being, FACIT-sp) have been assessed. A structured questionnaire has been completed by patients, their relatives and health professionals. RESULTS: 143 patients were included (mean age 68.3 years; 62 male). 41 completed ADs. No particular features were associated with the completion of ADs. Most patients were satisfied with the medical information received. A third of them were not worrying about their future, especially those living in the German-speaking part. Should they become unable to communicate, 87 expected their relative to transmit their own wishes, but only 38 had spoken recently with them about what they wanted. 23 of the 69 included relatives would like to play a more active role in decision-making. CONCLUSIONS: These results illustrate the fact that terminally ill patients wish to be active in decision-making, but only seldom transmit their wishes to their relative or complete a written document. The discussion about ACP should be defined according to the particularity of each region and the role of healthcare professionals' attitudes towards ADs, but we should also be creative and find other ways to promote shared decision-making.

[Case report - interprofessional teamwork in palliative care]. / Die interprofessionelle Zusammenarbeit als typisches Merkmal der Palliative Care - eine Falldiskussion.

Interprofessional teamwork is a characteristic feature of palliative care. Palliative Care is a subspeciality/ discipline in health care that cares for patients with a life threatening illness. The patient determines individual goals and the extent of further treatment. The team supports patients in decision making, practical advice in symptom management and composition of the future care network. The case of a 58-year-old woman suffering from metastastic breast cancer is an extraordinary example of interprofessional teamwork in palliative care. The patient was hospitalized in a palliative care unit with a malignant bowel obstruction. She underwent ileostomy and chemotherapy. She required total parenteral nutrition and was suffering from anorexia-cachexia syndrome. During her stay in the palliative care unit, her condition deteriorated. Subsequently, her needs changed and she requested to leave the hospital for some days to see her daughter's new domicile. It was by the coordinated effort of the interprofessional palliative care team that this last wish got fulfilled and she died peacefully a few days after her return to the palliative care unit.