[Considerations for quality assurance of discussions with relatives in direct association with organ donation]. / Überlegungen für eine Qualitätssicherung der Angehörigengespräche in einem unmittelbaren Zusammenhang mit einer Organspende.

BACKGROUND: Discussions with relatives are relevant and crucial aspects of the organ donation process and contribute to a consolidated and sustainable decision by the families of the deceased. Despite the great importance of family care, there is no systematic analysis of the quality of this communication, in contrast to the diagnosis of irreversible loss of brain function, organ retrieval and organ transplantation. For this reason, organ donation experts were interviewed about recurring characteristics of communication with relatives of the deceased. The aim of this qualitative study was to define criteria for the assessment of the structure and quality of the communication process with relatives for internal quality management in Germany. METHODS: Based on a systematic literature review and with the help of the 5­stage S2PS2 (system for creating a questionnaire) procedure according to Kruse, interview guidelines were initially developed. As a second step, in guideline-based interviews 10 experienced organ donation experts were questioned about structural, procedural and ethical aspects of their discussions with relatives. Following the interviews, a software-based qualitative content analysis was carried out with a combined inductive-deductive category system. Finally, the first quality assurance measures for the interviews with relatives were developed in a multistep process, closely following the methodological principles V1.1 of the Institute for Quality Assurance and Transparency in Health Care (IQTIG). The individual research steps were accompanied by an expert group consisting of physicians, nurses, theologians and ethicists utilizing an anonymous Delphi procedure. RESULTS: In the qualitative content analysis, 5 main categories with 30 subcategories on quality relevant aspects could be identified (including, standardization and technique of conversation, interview framework and context factors, professional expertise of the interviewers, wishes of the organ donation experts). On this basis, 6 criteria for the structural quality and 7 criteria for the process quality of the discussions with relatives were formulated and summarized in a respective quality bundle. These criteria address, among other things, interprofessional communication, structured training concepts, regular further training of all team members, use of standardized communication and counselling strategies as well as documented preliminary meetings and debriefings, including supervising elements. They emphasize interdisciplinary professionalism and process management in a protected environment as well as quality assured communication and documentation. Recommendations were made for expanding the existing documentation for the organ donation process and for documenting the preliminary meetings and debriefings. CONCLUSION: Recurring communication and process characteristics as well as requirements for the members of the treatment team who conduct the conversation can be identified for the interviews with relatives, which show potential for improvement to various degrees. This justifies the structured derivation of a quality bundle for the structural and process quality family care related to organ donation, which should enable a low-threshold entry into an institution internal systematic quality assessment of communication with relatives in Germany. Due to the different legal, medical and social specifics in an international context, the study results cannot be directly transferred to other countries.

A European multicenter study on systematic ethics work in nursing homes.

BACKGROUND: There are many existing ethical challenges in nursing homes. Although different methods and approaches to discussing the ethical challenges have been established, systematic ethics work is not yet a standard in all nursing homes. The aim of the present study was to explore ethical challenges and approaches to implementing systematic ethics work in nursing homes. METHODS: Data from five institutions in Austria, Germany and Norway were collected, and a mixed-methods two-tiered study approach was chosen. Documentation of ethics discussions was combined with qualitative focus group interviews with staff members regarding the implementation of systematic ethics work in nursing homes. RESULTS: One hundred and five ethics meetings were documented. The main topics were advance care planning, ethical challenges associated with artificial nutrition, hospitalisation and end-of-life decision-making. Of the meetings, 33% focused mainly on everyday ethical challenges. In 76% of prospective case discussions, agreements about a solution were reached; however, in 29% of these no residents or relatives participated. The advantages of systematic ethics work described by the staff were enhanced openness and dialogue, overall, and a greater ethical awareness. Many voiced a need for structure and support from the administration. CONCLUSIONS: Systematic ethics work is greatly appreciated by the staff and helps to reach a consensus in the majority of case discussions. It should be implemented in all nursing homes. Attention to everyday ethical challenges is important. The participation of relatives and physicians could be improved. The participation of the residents' in ethics discussions should be encouraged to strengthen their autonomy and dignity.

Physician-assisted suicide, euthanasia, and Christian bioethics: moral controversy in Germany.

Discussions in Germany regarding appropriate end-of-life decision-making have been heavily influenced by the liberalization of access to physician-assisted suicide and voluntary active euthanasia in the Netherlands and Belgium. These discussions disclose conflicting moral views regarding the propriety of physician-assisted suicide and euthanasia, threatening conflicts within not only the medical profession, but also the mainline churches in Germany, whose membership now entertains views regarding end-of-life decision-making at odds with traditional Christian doctrine. On the surface, there appears to be a broad consensus supporting the hospice movement and condemning physician-assisted suicide and euthanasia. The German Supreme Court has held that treatment decisions should, in absence of known patients' wishes, be made in light of commonly shared values, unless these violate the principle of "in dubio pro vita". The Roman Catholic church and the Evangelical Lutheran church in Germany have developed an advance directive for treatment choices at the end of life, while condemning physician-assisted suicide and euthanasia. This stance is in tension with the strong emerging support for physician-assisted suicide and euthanasia, a development that promises to open up foundational disagreements within mainline German Christianity regarding the appropriate approach to intentionally terminating human life.