[Advance Care Planning-further development of the patient advance directive : What the specialist in internal medicine must know]. / Behandlung im Voraus Planen ­ Weiterentwicklung der Patientenverfügung : Was die Internistin/der Internist dazu wissen muss.

Despite the availability of the instruments of advance directives, power of attorney and healthcare proxy, the patient's preferences for life-sustaining medical treatment in a specific situation often remain unknown. The aim of the systemically designed German Advance Care Planning (ACP) program is the reflection, documentation and implementation of patients' preferences regarding future medical treatment in case they are incapable of legally binding decision-making. A specially trained ACP facilitator initially supports the verbalization of the attitudes towards life, severe illness and death on an individual level. Based on these principal views, concrete preferences on how to be treated under defined medical circumstances can be discussed and documented in an advance directive. This includes the three scenarios medical emergency, inpatient hospital treatment in situations with decisional incapability of unknown duration and the situation of permanent cognitive impairment. Through cautious, nondirective conversational techniques in the sense of shared decision-making, the person is enabled to reflect and decide well-informed according to the informed consent standard. All persons participating in decisions regarding future medical treatment, especially future surrogate decision makers, are involved in the process as early as possible. A systematic institutional and regional implementation of the concept is necessary to ensure that the carefully assessed and documented preferences of the patients will be known and honored. The new German § 132g of the Social Code Book V (SGB V) enables institutions for long-term care and for the care of disabled persons, to offer facilitated ACP to all residents at the expense of the statutory health insurance funds. An increased dissemination of this concept is to be expected.

[Advance Care Planning-further development of the patient advance directive : What the anesthetist must know]. / Behandlung im Voraus Planen ­ Weiterentwicklung der Patientenverfügung : Was die Anästhesistin/der Anästhesist dazu wissen muss.

Despite the availability of the instruments of advance directives, power of attorney and healthcare proxy, the patient's preferences for life-sustaining medical treatment in a specific situation often remain unknown. The aim of the systemically designed German Advance Care Planning (ACP) program is the reflection, documentation and implementation of patients' preferences regarding future medical treatment in case they are incapable of legally binding decision-making. A specially trained ACP facilitator initially supports the verbalization of the attitudes towards life, severe illness and death on an individual level. Based on these principal views, concrete preferences on how to be treated under defined medical circumstances can be discussed and documented in an advance directive. This includes the three scenarios medical emergency, inpatient hospital treatment in situations with decisional incapability of unknown duration and the situation of permanent cognitive impairment. Through cautious, nondirective conversational techniques in the sense of shared decision-making, the person is enabled to reflect and decide well-informed according to the informed consent standard. All persons participating in decisions regarding future medical treatment, especially future surrogate decision makers, are involved in the process as early as possible. A systematic institutional and regional implementation of the concept is necessary to ensure that the carefully assessed and documented preferences of the patients will be known and honored. The new German § 132g of the Social Code Book V (SGB V) enables institutions for long-term care and for the care of disabled persons, to offer facilitated ACP to all residents at the expense of the statutory health insurance funds. An increased dissemination of this concept is to be expected.

[Cost-conscious medical decisions. Normative guidance within the conflicting demands of ethics and economics]. / Kostenbewusste ärztliche Entscheidungen. Normative Orientierung im Spannungsfeld zwischen Ethik und Ökonomie.

BACKGROUND: Under the current conditions in the health care system, physicians inevitably have to take responsibility for the cost dimension of their decisions on the level of single cases. This article, therefore, discusses the question how physicians can integrate cost considerations into their clinical decisions at the microlevel in a medically rational and ethically justified way. DISCUSSION: We propose a four-step model for "ethical cost-consciousness": (1) forego ineffective interventions as required by good evidence-based medicine, (2) respect individual patient preferences, (3) minimize the diagnostic and therapeutic effort to achieve a certain treatment goal, and (4) forego expensive interventions that have only a small or unlikely (net) benefit for the patient. Steps 1-3 are ethically justified by the principles of beneficence, nonmaleficence, and respect for autonomy, step 4 by the principles of justice. For decisions on step 4, explicit cost-conscious guidelines should be developed locally or regionally. Following the four-step model can contribute to ethically defensible, cost-conscious decision-making at the microlevel. In addition, physicians' rationing decisions should meet basic standards of procedural fairness. Regular cost-case discussions and clinical ethics consultation should be available as decision support. Implementing step 4, however, requires first of all a clear political legitimation with the corresponding legal framework.

[Cancer screening from the perspective of public health ethics]. / Krebsfrüherkennung aus Sicht der Public-Health-Ethik.

Cancer screening programs aim at reducing the tumor-related morbidity and mortality by early detection of malignant tumors or precancerous lesions. The basic ethical dilemma in cancer screening is, however, that many people have to be exposed to the burdens and risks of the intervention for a few people to benefit from early cancer diagnosis. This article discusses under which conditions it is ethically acceptable to offer or even recommend cancer screening. First, the benefit of the program in terms of a reduced cancer-related mortality should be proven by randomized controlled trials. The risks and burdens of the program related to the side effects of the investigation itself, false-positive findings, as well as overdiagnoses and overtherapy should be in an acceptable relationship to the expected benefit of the program. In addition to a solid empirical scientific basis, the benefit-harm evaluation necessarily involves value judgments. The potential participants in the screening program therefore should receive transparent, objective, unbiased, and understandable information to enable them to make a truly informed choice about participation. Given the complex benefit-risk assessment, it is discussed whether-and if so under which circumstances-it is ethically acceptable to make a recommendation for or against participation in a cancer screening program. Socioempirical research, such as focus group studies and public deliberations, can be used to elicit the preferences and value judgments of members of the target population that should be taken into consideration in recommendations about a cancer screening program.

Implementation of the interdisciplinary curriculum Teaching and Assessing Communicative Competence in the fourth academic year of medical studies (CoMeD).

INTRODUCTION: Implementation of a longitudinal curriculum for training in advanced communications skills represents an unmet need in most German medical faculties, especially in the 4rth and 5th years of medical studies. The CoMeD project (communication in medical education Düsseldorf) attempted to establish an interdisciplinary program to teach and to assess communicative competence in the 4th academic year. In this paper, we describe the development of the project and report results of its evaluation by medical students. METHODS: Teaching objectives and lesson formats were developed in a multistage process. A teaching program for simulated patients (SP) was built up and continuous lecturer trainings were estabilshed. Several clinical disciplines co-operated for the purpose of integrating the communication training into the pre-existing clinical teaching curriculum. The CoMeD project was evaluated using feedback-forms after each course. RESULTS: Until now, six training units for especially challenging communication tasks like "dealing with aggression" or "breaking bad news" were implemented, each unit connected with a preliminary tutorial or e-learning course. An OSCE (objective structured clinical examination) with 4 stations was introduced. The students' evaluation of the six CoMeD training units showed the top or second-best rating in more than 80% of the answers. DISCUSSION: Introducing an interdisciplinary communication training and a corresponding OSCE into the 4th year medical curriculum is feasible. Embedding communication teaching in a clinical context and involvement of clinicians as lecturers seem to be important factors for ensuring practical relevance and achieving high acceptance by medical students.