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Palliative care is aimed at patients with incurable oncological and non-oncological diseases and their relatives with the aim of maintaining or improving their quality of life. In order to integrate palliative care into acute care medicine, palliative care training and continuing education for medical and nursing staff is recommended. Appropriate screening tools and standard operating procedures should be implemented to identify and address palliative care needs in emergency situations. For palliative care, established specialist palliative care services can be called upon for advice and/or cotreatment. Symptom control, treatment of malignant wounds, difficult ethical decision-making, and communication difficulties with patients, their legal representatives or relatives are the tasks of palliative care experts.Palliativmedizin richtet sich an Patienten mit inkurablen onkologischen und nichtonkologischen Erkrankungen sowie deren Angehörige mit dem Ziel, die Lebensqualität zu erhalten oder zu verbessern. Zur Integration der Palliativmedizin in die Akutmedizin wird die Palliative-Care-Fort- bzw. Weiterbildungen einiger ärztlicher und pflegerischer Mitarbeiter empfohlen. Für die Ermittlung und Umsetzung des bisher unzureichend erhobenen palliativmedizinischen Behandlungsbedarfs in Notfallsituationen sollten geeignete Screeningtools und „standard operating procedures“ implementiert werden. Für die Palliativversorgung können die zur Verfügung stehenden spezialisierten palliativmedizinischen Dienste zur Beratung und/oder Mitbehandlung hinzugezogen werden. Symptomkontrolle, Versorgung maligner Wunden, schwierige ethische Entscheidungsfindungen und Kommunikationsschwierigkeiten mit Patienten, deren rechtlichen Stellvertretern oder Angehörigen sind Aufgabenbereiche palliativmedizinischer Experten.

Palliativmedizinische Unterstutzung, bereits fruhzeitig in einen inkurablen Erkrankungsverlauf eingebracht, hat durch eine Vielzahl kontrollierter Studien eine breite Evidenzgrundlage gewonnen. Patienten mit Kopf-Hals-Tumoren konnen aufgrund ihrer komplexen Symptomlast und der weitreichenden psychosozialen Belastungssituation von einer solchen multiprofessionellen Unterstutzung in besonderem Mase profitieren, bedurfen aber auch einer besonderen erkrankungsspezifischen Aufmerksamkeit, z. B. mit Blick auf die im Verlauf zu erwartenden Krisen und Notfalle, die in diesem Beitrag erortert werden.

Advance Care Planning (ACP), auf Deutsch unter anderem als gesundheitliche Versorgungsplanung oder Behandlung im Voraus Planen bezeichnet – ist ein systematischer Gesprachsprozess, in dem Patienten zukunftige medizinische und pflegerische Behandlungen sowie psychosoziale Aspekte gesundheitlicher Krisen mit ihren Bevollmachtigten, Angehorigen und dem an der Versorgung beteiligten medizinischen Fachpersonal besprechen konnen. Ziel von ACP ist, einen Patienten im Falle einer eintretenden Einwilligungsunfahigkeit, beispielsweise in akuten gesundheitlichen Krisen oder bei chronischen Erkrankungen, zuverlassig nach seinen individuellen Wunschen behandeln zu konnen, so wie es das Burgerliche Gesetzbuch mit dem § 1901a in Deutschland im Rahmen valider und wirksamer Patientenverfugungen vorsieht.

Zusammenfassung Hintergrund Einsätze in Notfallsituationen bei Patienten mit fortgeschrittener, unheilbarer Erkrankung stellen für das Rettungsdienstpersonal eine besondere Belastung dar. Für ersteintreffendes nichtärztliches Rettungsdienstpersonal ergeben sich dabei Situationen, in denen Entscheidungen getroffen werden müssen, die außerhalb des erlernten oder rechtlich zugesicherten Kompetenzbereichs liegen. Ziel dieser Arbeit war daher die Darstellung von Konflikten und deren Belastungsauswirkung sowie die Diskussion über eine mögliche Erweiterung der therapeutischen Entscheidungskompetenz des nichtärztlichen Rettungsdienstpersonals als Entlastungsoption. Material/Methoden Online-Befragung von Rettungsassistenten und Notfallsanitätern („mixed methods design“) zu deren Konflikten und wahrgenommenen Belastungen. Analyse der Freitextantworten mittels qualitativer Inhaltsanalyse (Mayring). Deskriptiv-statistische Analyse der wahrgenommenen Belastungsintensitäten und Belastungshäufigkeiten. Ergebnisse Im Umgang mit Patienten mit fortgeschrittener unheilbarer Erkrankung erlebt das nichtärztliche Rettungsdienstpersonal einen konflikthaften und belastenden Entscheidungs- und Handlungsdruck. Die Konflikte können in vier Dimensionen eingeordnet werden: a) patientenbezogen, b) strukturell, c) persönlich und d) interprofessionell. Eine Erweiterung der therapeutischen Entscheidungskompetenz des nichtärztlichen Rettungsdienstpersonals zur Therapiebegrenzung wurde kritisch und vorbehaltlich wahrgenommen. Diskussion Die vom nichtärztlichen Rettungsdienstpersonal beschriebenen Konflikte erfordern vielschichtige Lösungsansätze, wie zum Beispiel themenspezifische Fort- und Weiterbildungsprogramme wie auch regional-strukturelle Konzepte einer gesundheitlichen Versorgungsplanung.

Additional file 3. GP perceived valuing of SPHC activities.

Additional file 1. The development of the questionnaire.

Additional file 2. Questionnaire: English version.

Injuries, especially traumatic brain injury, or specific illnesses and their respective sequelae can result in the demise of the patients afflicted despite all efforts of modern intensive care medicine. If in principle organ donation is an option after a patient's death, intensive therapeutic measures are regularly required in order to maintain the homeostasis of the organs. These measures, however, cannot benefit the patient afflicted anymore-which in turn might lead to an ethical conflict between dignified palliative care for him/her and expanded intensive treatment to facilitate organ donation for others, especially if the patient has opted for the limitation of life-sustaining therapies in an advance directive.The Ethics Section and the Organ Donation and Transplantation Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) have convened several meetings and a telephone conference and have arrived at a decision-making aid as to the extent of treatment for potential organ donors. This instrument focusses first on the assessment of five individual dimensions regarding organ donation, namely the certitude of a complete and irreversible loss of all brain function, the patient's wishes as to organ donation, his or her wishes as to limiting life-sustaining therapies, the intensity of expanded intensive treatment for organ protection and the odds of its successful attainment. Then, the combination of the individual assessments, as graphically shown in a {Netzdiagramm}, will allow for a judgement as to whether a continuation or possibly an expansion of intensive care measures is ethically justified, questionable or even inappropriate.The aid described can help mitigate ethical conflicts as to the extent of intensive care treatment for moribund patients, when organ donation is a medically sound option. NOTE: Gerald Neitzke und Annette Rogge contributed equally to this paper and should be considered co-first authors.

The Ethics Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) recently published a documentation for decisions to withhold or withdraw life-sustaining therapies. The wish to donate organs was not considered explicitly. Therefore the Ethics Section and the Organ Donation and Transplantation Section of the DIVI together with the Ethics Section of the German Society of Medical Intensive Care Medicine and Emergency Medicine worked out a supplementary footnote for the documentation form to address the individual case of a patient's wish to donate organs.

When patients suffer from incurable cancer, drug-based, systemic anticancer therapy is usually used with the aim of longer survival, while minimizing toxicity and ensuring a tolerable quality of life. It is unclear to what extent and with what degree of success systemic tumor therapy can be used to specifically improve pre-existing pain and an already compromised quality of life (QoL).Therefore, a systematic review of oncological therapy studies (PubMed) was conducted. Only studies that identified the pain-relieving and QoL-enhancing effects of systemic anticancer therapy as the primary endpoint were selected and evaluated descriptively.Of the 2229 abstracts identified using a piloted search string, only 13 studies met the inclusion criteria. Of these, 10 studies showed an improvement in QoL-parameters through the use of systemic tumor therapies.Only a few studies focused primarily on the improvement of parameters related to quality of life-although this is the primary therapeutic goal for many patients suffering from incurable and advanced cancer. The study results encourage regular inclusion of symptom- and QoL-related data in clinical studies and to more explicitly address the potential of systemic anticancer therapy in relieving pain and other symptoms, thereby supporting the goals of palliative care.

Objective Desires for hastened death (DHD; wish to hasten death is also in use) are prevalent in terminally ill patients. Studies show that health professionals (HP) are often underprepared when presented with DHD. HPs in specialized palliative care (SPC-HP) often encounter DHD. This study aimed to identify SPC-HP responses to DHD in daily practice and their corresponding functions. Methods Narrative interviews were conducted with 19 SPC-HPs at four German University Hospitals. Transcripts were analyzed using the documentary method. An inventory of established responses to DHD was compiled, and their corresponding functions in the context of the patient–SPC-HP interaction were reconstructed. Results Twelve response categories and six corresponding functions were identified. On the patient level, responses categorized as symptom control, exploring the reasons and generating perspective, reorientation, and hope were particularly used to ease the patient's burden. On the interaction level, creating a relationship was fundamental. On the SPC-HP level, various methods served the functions self-protection and showed professional expertise. Conclusions Profound personal and professional development is necessary to respond to the inherent challenges presented by DHD. Establishing helpful relationships with patients is essential regardless of SPC-HP specialization. SPC-HPs should maximize their skills in establishing and maintaining relationships as well as strengthening their own resilience, possibly in specific training courses. Copyright © 2015 John Wiley & Sons, Ltd.

The aim of this analysis was to describe the role of anesthesiology departments in pain medicine and palliative care services in German hospitals.In the year 2012, all heads of departments of anesthesiology registered with the German Society of Anesthesiology and Intensive Care Medicine were surveyed about structures of pain medicine and palliative care services in their hospitals using a standardized postal questionnaire.Out of 408 returned questionnaires (response rate 47%) 403 could be evaluated. Of the hospitals 58% had a designated pain medicine service, in 36 (9%) of the hospitals this was organized as an independent department and in 195 (57%) as part of another department, mostly the department of anesthesiology. The "pain clinic" as an outpatient service was the most common form of structure for pain medicine services (41%). Inpatient pain medicine units were available in 77 (19%) of the hospitals and a partial inpatient unit in the form of a day hospital in 26 (7%) of the hospitals. For the care of inpatients from other departments, there was an intrahospital pain consultation service in 166 of the hospitals, which was the only structure for pain medicine in 32 of the 231 hospitals that reported having a designated pain medicine service. In 160 pain medicine services anesthesiologists were the only medical practitioners and in a further 18 both anesthesiologists and other specialists were available (orthopedist/orthopedic surgeons n = 6, internal medicine n = 4, psychiatrist n = 2, general practitioner = 1 and neurologist n = 1). Only two hospitals had no anesthesiologist in the pain medicine team and for the remaining 51 hospitals no information was provided. In 189 of the 231 hospitals with pain medicine services, there was at least 1 physician with special qualifications in pain management. In 97 (44%) of the hospitals psychologists were part of the team with 53 having at least 1 psychologist with a special qualification in chronic pain management. Of the hospitals, 16% had a specialized department for palliative care, in 32% a specialized palliative care service was part of another department, which was the department of anesthesiology in 30%. Of the hospitals 56% had a palliative care consultation service, 41% had a specialized inpatient palliative care unit, 6% an outpatient clinic, 4% a day hospital and in 16% a specialized outpatient palliative care (SOPC) serving the community was incorporated. Inpatient consultation services and the SOPC were more common when the department of anesthesiology was involved in the palliative care services.In German hospitals, the departments of anesthesiology make a significant contribution to the provision of both pain medicine and palliative care services. Nevertheless, the respective structures of care are often incomplete or even lacking. There were shortcomings in terms of organization and qualification of the team in pain medicine services (e.g. no doctor with special qualifications in pain management or no psychologist). Palliative care services are more often organized as independent departments than as pain medicine services. Engagement of the anesthesiology department in palliative care is linked to a broader scope of the services provided, which might reflect the capacity of many anesthesiologists to work in an interdisciplinary manner and across interfaces.

Breathlessness is a common and distressing symptom in patients with advanced life-limiting disease. The aim of this study was to describe demographical and clinical characteristics of patients with breathlessness in Germany.We conducted a secondary analysis of hospice and palliative care inpatient data from 2006 to 2008. The Hospice and Palliative Care Evaluation (HOPE) is an annual prospective German survey, that includes a validated 16-item symptom-and-problem checklist (severity score 0-3). Characteristics of patients with or without breathlessness were compared in a pure descriptive manner. Interpretation of given p-values takes the error inflation due to multiple testing into account.Breathlessness was recorded in 2860/5320 (53.8 %) patients (mean age 67.2 years (SD 12.4), 51.4 % female, 93.6 % malignant disease (female / male lung cancer 15.7/29.5 %, breast cancer 20.3/0.3 %, colon 10.3/8.7 %)). Breathless patients compared with those without breathless ness had a significantly worse functional status (ECOG 3-4: 78.4 % vs. 70.8 %, p0.001), suffered from a larger number (11.1 vs. 9.5, p0.001) of symptoms and the symptoms were of higher intensity (except confusion). Breathless patients had a higher risk to die during inpatient stay (43.5 % vs. 32.4 %, p0.001).Based on this large sample of hospice and palliative care inpatients, breathlessness is associated with a high symptom burden and shortened survival. Breathless patients need more attention in health care.

Die Betreuung hochbetagter schwerstkranker und sterbender Menschen und ihrer Angehorigen stellt besondere Anforderungen an das medizinische und pflegerische Personal sowie an die Einrichtungen, in denen diese Menschen leben. Da immer mehr alte Menschen ihr Lebensende in einer stationaren Pflegeeinrichtung verbringen, ist hier die Implementierung von Hospizkultur und Palliativkompetenz von grundlegender Bedeutung. Um die Pflegeeinrichtungen in Deutschland bei der Umsetzung von Palliative Care zu unterstutzen, haben die Deutsche Gesellschaft fur Palliativmedizin e. V. und der Deutsche Hospiz und PalliativVerband e. V. eine gemeinsame Arbeitsgruppe eingerichtet. Diese Arbeitsgruppe hat dieses Grundsatzpapier zur Betreuung schwerstkranker und sterbender Menschen im hohen Lebensalter in Pflegeeinrichtungen erstellt. Die Ziele des Grundsatzpapieres stehen in enger Verknupfung mit dem weiteren Umsetzungsprozess der „Charta zur Betreuung schwerstkranker und sterbender Menschen in Deutschland“. Im Folgenden werden die momentane Situation der Palliativversorgung in Pflegeeinrichtungen, Ziele der Integration von Hospizkultur und Palliativkompetenz und die notigen Masnahmen, um diese zu erreichen, beschrieben. Hospizkultur und Palliativversorgung sollen zum integrativen Bestandteil des Versorgungsauftrags jeder Einrichtung werden. Die Entwicklung regionaler Netzwerke (z. B. Hospizdienste, ambulante Palliativdienste) zur palliativmedizinisch-hospizlichen Versorgung ist von grundlegender Bedeutung. Aufgabe aller Beteiligten ist es, die hochbetagten schwerstkranken Bewohner in den Mittelpunkt des ethisch-reflektierten Handelns zu stellen. Den Betroffenen soll eine angemessene und umfassende palliativmedizinisch-hospizliche Versorgung zuganglich sein. Dazu gehoren die Behandlung und Linderung von korperlichen Symptomen, die umfassende palliativpflegerische Versorgung und die psychosoziale und spirituelle Begleitung. Angehorige gilt es mit ihren Sorgen und Angsten ernst zu nehmen, sie in das Konzept einzubeziehen und ihnen Unterstutzung und Entlastung zu bieten.

Therapieentscheidungen im Rahmen der Behandlung schwerstkranker und sterbender Patienten in der Intensiv- und Notfallmedizin stehen im Spannungsfeld von medizinischer Indikation, ethischen Fragestellungen und rechtlichen Vorgaben. Dies ist besonders relevant, wenn die Behandlungspraferenzen von Patienten nicht bekannt sind oder diese den ethischen Grunduberzeugungen der Behandler widersprechen. Schwierigkeiten bei der Prognosestellung oder bei der Beurteilung, ab wann ein unumkehrbarer Sterbeprozess beginnt, konnen zu Behandlungssituationen fuhren, die auch einer ethischen Diskussion bedurfen. Fur die Reflexion und Bearbeitung medizinethischer Fragestellungen wird die Auseinandersetzung mit Begriffsdefinitionen, medizinethischen Prinzipien, dem beruflichen Selbstverstandnis, der Sterbebegleitung und mit Methoden der moderierten Problemlosung empfohlen.

2007 begannen Verhandlungen zwischen den Kostentragern und Leistungserbringern in Deutschland zum Abschluss von (Muster-)Vertragen uber die spezialisierte ambulante Palliativversorgung (SAPV). Mittlerweile sind in allen Regionen Mustervertrage geschlossen und meist veroffentlicht worden. Die Vertragsbedingungen werden Einfluss auf die Palliativversorgung haben, deshalb ist ihre Analyse als Vorbereitung fur eine uberregionale Evaluation der SAPV notwendig. Methode Die Mustervertrage wurden bezuglich der anspruchsberechtigten Patienten, Leistungserbringer, Versorgung, Kooperation, Qualitatssicherung und Dokumentation sowie Vergutung verglichen. Mit 22 Palliative-Care-Teams (PCTs) wurden – die Vertragsinformationen erganzend – semistrukturierte Interviews zu ihrer Arbeitsweise hinsichtlich Versorgungsablauf und Dokumentation gefuhrt. Ergebnisse Die Vertrage weichen stark voneinander ab: die SAPV-Leistungen – Beratung, Koordination, Teil- und Vollversorgung – werden unterschiedlich definiert, in der Praxis wird die Differenzierung von der jeweiligen Vergutungsregelung mitbestimmt. Die befragten Teams kooperieren oft mit Hausarzt, Pflegedienst und Hospizdienst, wenig Zusammenarbeit gibt es bisher mit psychosozialen Berufsgruppen (Seelsorge, Sozialarbeit, Psychologen). Die Dokumentationsvorschriften in den Vertragen reichen von keiner Festlegung auf Dokumentationsgrundlagen bis zu umfangreichen Musterbogen. Die Vergutungsregelungen sind kaum miteinander vergleichbar und umfassen Einzelleistungsvergutung, Fall- und Zeitpauschalen sowie gemischte Modelle. Schlussfolgerung Die unterschiedlichen Bedingungen konnen zu Unterschieden in der Versorgungsgestaltung fuhren, erschweren die Vergleichbarkeit und erfordern zeitnah eine bundesweite Evaluation, was von Palliativpatienten benotigt wird und unter den gegenwartigen Bedingungen durch SAPV geleistet werden kann. Contracts for specialized out-patient palliative care (SAPV) have been negotiated between health funds and palliative care providers in Germany since 2007. Currently model contracts exist in all regions, the majority has been disclosed. Since significant differences in the terms of these contracts may lead to differences in palliative care provision we studied the contracts to provide a basis for a national evaluation of SAPV. Method The contracts were comparatively analyzed in regard to patients entitled to benefit from SAPV, team structure demanded in the contract, models of care provision, cooperation between specialized care providers and other health care professionals (e. g. general practitioners, social workers), quality control and documentation strategy as well as reimbursement. To reveal the impact of the contracts semi-structured interviews were carried out on 22 palliative care teams (PCTs) to assess team structure, organization and work flow and deployed documentation systems. Outcome The model contracts differ remarkably. SAPV may be provided as counseling, coordination of care, additive partial care provision and full care provision by the specialized providers. There is no sufficient definition of the respective terms in the contracts, resulting in discrimination being mostly determined by the mode of reimbursement. Palliative care providers cooperate with general practitioners, home care nurses and hospice services, less with professionals working in the psycho-social field (e. g. spiritual care, social work, psychologists). Regulations for documentation differ strongly, ranging from no specification on required documentation at all to extensive forms. Given substantially different payment models service reimbursement is barely comparable. Conclusion SAPV contracts may influence care provision and differences complicate comparisons, thus a national evaluation of SAPV quality is urgently needed. Such a study should assess palliative patient demands and SAPV service quality.

BACKGROUND: The completion of an advanced directive is paired with a high degree of self-responsibility of the signatory. It requires anticipation of probably complex medical situations. In the literature, the family physician is often seen as the most important person for advice when writing an advance directive. But little is known about whether or not patients want to involve medical advisors and to what extent physicians are willing to give advice. The aim of this study was to analyse whether or not individuals approached advisors for the completion of their advance directive, whom they chose and which reasons were given for seeking or foregoing assistance. METHODS: Semi-structured interviews with healthy individuals, chronically ill individuals and patients in palliative care including questions associated with advice for completing an advance directive (8/2008–7/2009). Inclusion criteria: age 55–70 years and advance directive ≥3 months old. The interviews were fully transcribed according to standard transcription rules and analysed applying an inductive category development. RESULTS: Interviews were conducted with 53 probands (healthy n = 20, chronically ill n = 17, palliative care patients n = 16); 18 probands were male. Mean age was 63.2 ± 4.4 years (range 55–70 years). Professional advice was sought by 12 probands (physician = 2, nurse = 1, lawyer/notary = 8, self-employed advisor = 1), another 8 probands included family members. In 17 cases, the physician knew the proband's advance directive, 36 probands never told their doctor about its existence. Categories of reasons for seeking or foregoing advice were trust/lack of trust, autonomy, rejection and financial considerations. CONCLUSIONS: Information about the medical implications concerning patient preferences for end-of-life care seems not to be the main focus of interest when individuals write an advance directive. Autonomy and trust into notarially certified documents seem to be more important matters. If family physicians want to have a role in their patients' completing of an advance directive, they should proactively get in touch with them.

Schmerzen gehoren zu den haufigsten Symptomen bei Patienten mit Tumorerkrankungen. Grundvoraussetzungen fur eine suffiziente und sorgfaltige Tumorschmerztherapie sind eine exakte Anamnese, eine klinische Untersuchung und die Diagnosestellung der Schmerzursache sowie die Beachtung der Grundregeln des WHO-Stufenschemas. Nur danach lasst sich eine differenzierte und individuell an die Bedurfnisse des Patienten angepasste Schmerztherapie durchfuhren. Neben einer Ubersicht uber die Grundlagen der Tumorschmerztherapie nach dem WHO-Stufenschema enthalt der vorliegende Beitrag einen Uberblick uber die Epidemiologie von Schmerzen bei Tumorpatienten sowie neue Aspekte der Diagnose und Grundlagen der Therapie von tumorbedingten Dauer- und Durchbruchschmerzen.

Patienten mit soliden Tumoren und hamatologischen Neoplasien konnen fur den Anasthesisten mit seinen vielschichtigen Kernkompetenzen (Narkosefuhrung, Intensiv-/Notfallmedizin, Schmerztherapie und Palliativmedizin) eine besondere Herausforderung darstellen, die u. a. auf systemische Krankheitsmanifestationen, insbesondere in metastasierten Stadien, auf komplexe Folgewirkungen toxischer onkologischer Therapien, insbesondere in kurativ intendierten Behandlungskonzepten, auf schwierige ethische Entscheidungsfindungen, insbesondere in Akutsituationen, und auf die besondere emotionale Situation des Patienten, die sich durch den gesamten Erkrankungsverlauf hindurchziehen kann, zuruckzufuhren ist. Hinzu kommt eine Vielzahl neuer Entwicklungen in der modernen Onkologie, die diese Besonderheiten onkologischer Patienten erschweren und direkten Einfluss auf anasthesiologisches Tun haben konnen und daher im Folgenden dargestellt werden.

In therapiebezogenen Entscheidungssituationen bei Patienten mit weit fortgeschrittenem Tumorleiden stehen Masnahmen mit dem Ziel der bestmoglichen Symptomkontrolle und Lebensqualitat im Vordergrund. Jedoch rucken erst seit Mitte der 1990er Jahre symptomkontrollierende Effekte zytotoxischer Chemotherapeutika ins Blickfeld klinischer Studien. Die besonderen Eigenschaften von sog. „targeted therapies“ werfen ein weiteres, neues Licht auf Intention und Erfolgskriterien von Tumortherapien. Der folgende Beitrag beschreibt nachgewiesene symptomkontrollierende Effekte von chemotherapeutischen und anderen tumormodifizierenden Substanzen bei einer Auswahl solider Tumoren und versucht, deren Stellenwert sowohl in der palliativen Onkologie als auch in der Palliativmedizin zu definieren.

The practical year (PY) during the final year of medical education is intended to deepen and broaden knowledge, skills, and abilities that were acquired during previous years of their studies. Against this background, this study pursues the question of how the knowledge of future physicians and their confidence in terms of cancer pain therapy and other palliative care issues develops during the PY.At the end of the PY, students from two university hospitals completed a 3-part online questionnaire (self-assessment of the confidence, questions about palliative care knowledge, and assessment of palliative care training during the PY). These results are compared with previously published data from the same collective that had been collected at the beginning of the PY.Overall, 92 of 318 students participated (28.9 %). Less than 10 % of students said that they were more confident regarding palliative care topics at the end of their medical studies. Improvements in the self-assessment could only be observed in the recognition of and screening for cancer pain (increase from 36 % to 65%). With regard to the palliative care knowledge, only the knowledge of how to treat symptoms other than pain improved significantly; however, knowledge in this regard prior to the PY was particularly low (an increase from 25 % to 35 %, p 0.05). In the only multiple-choice question about ethics, the correct answer rose slightly from 51 % (before) to 55 % (after the PY). Of participating students, 21% (prior to the PY 27 %) stated that not providing fluids to dying patients is a form of euthanasia. In terms of palliative care training, between 36 and 83 % of participants stated having insufficient opportunities to gain knowledge and experience on various topics in the treatment of patients with advanced and incurable diseases during their PY.In the present study, considerable deficits in confidence and knowledge regarding palliative care issues were also observed at the end of PY. Integration of palliative care into the medical school curriculums should be given special attention in terms of a longitudinal training of the PY.

Specialized palliative home care ("Spezialisierte Ambulante Palliativversorgung", SAPV) denotes an intensified, multi-professional support system at home for patients suffering from complex symptoms and needs associated with severe and advanced illness. In 2007, a change in legislation guaranteed SAPV to any patient (covered by public health insurance) in need of specialized palliative care. Despite further specifications by federal institutions, SAPV has been transferred into German clinical practice in a very regionally diverse manner. This contribution describes the legislative and conceptual framework of SAPV, the financial and clinical aspects, and its future perspectives for the comprehensive palliative care of patients with complex demands.

It belongs to the distinguishing features of cancer that its disease trajectory and its causative treatment implicate numerous critical situations and emergencies that lead to life-threatening situations, and in a significant proportion of patients, these emergencies (instead of the tumour manifestations themselves) will be life-limiting. Therefore, the care of patients suffering from cancer as well as the respective anticancer treatment requires profound expertise in oncology and in emergency care.

Palliative care aims to improve the quality of life of patients and their families facing life-threatening illness. An overall treatment strategy not only includes prevention, assessment, and treatment of pain and other symptoms but also integrates psychological, social, emotional, and spiritual problems of the patient and his/her relatives. The large majority of patients being managed in palliative medicine are suffering from incurable, far-advanced, and progressive cancer. Pain is the major source of anxiety and distress at the end of life, particularly in cases of end-stage cancer. As in any stage of the disease, cancer pain treatment requires standardized guidelines adapted to the WHO’s three-step ladder of cancer pain relief (WHO 1996). Burdens and suffering of patients and relatives should be minimized, and physical, psychosocial, and spiritual symptoms must be treated even in the terminal phase.

How to organise comprehensive cancer care from the onset of metastatic disease to the end of life is debated. Arguments exist for full integration of palliative services into general oncology care, and some studies have shown that oncologists having insight and knowledge about palliative care result in improved collaboration and early referral (Kaasa 2013). There is strong evidence underscoring the importance of integrating palliative care across the trajectory of cancer (Shin and Temel 2013; Bakitas et al. 2009; Alt-Epping et al. 2012). Recommendations for such integration have been made by oncological societies, among others, the American Society of Clinical Oncology (Smith et al. 2012), and by authors of comprehensive review articles on this matter (Gaertner et al. 2013; Greer et al. 2013). These include triangular cooperation between cancer specialists, primary care services and specialist palliative care teams; communication, congruity and continuity of care; and coordination, cooperation contracts and collegiality. A qualitative study among oncologists showed that they believed that integrating palliative care enhanced patient care, complemented their own practice and enabled them to ‘share the load’ (Bakitas et al. 2013).