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Experiences when handling sleep medicines: Group discussions with nursing students about benzodiazepines and Z-drugs Abstract.Background and aims: Helping patients who have difficulties falling or staying asleep is one of the challenges of hospital care. The goal of this study was to explore how nursing students experience patients' sleeping problems as well as the usage of sleep-inducing drugs, especially benzodiazepines and Z-drugs in the hospital setting. Methods: In four focus group discussions, we collected data exploring the experiences of nursing students with regards to sleeping problems and sleep-inducing drugs. The transcripts of the discussion were analysed, using documentary method. Results were finally summarized to main categories, using qualitative content analysis. Results: Students experience a generous distribution of sleep-inducing drugs, which are considered as the best possible solution for sleeping problems - in spite of weak evidence. Non-drug alternatives are seldom taught, are often unavailable on the ward and their use is rarely trained. Pharmacological knowledge is too shallow and / or the transfer of theoretical knowledge to practical action is unsuccessful. Sleep and sleeping problems, e. g. in contrast to pain management, are not a topic of priority in the hospital setting. Conclusions: More knowledge and greater sensibility about sleeping problems is needed. For example, nurses' training should incorporate knowledge about medications and non-drug alternatives and how to apply them in critical situations. Doctors and nurses should offer nursing students good role models in these situations.

Zusammenfassung Ziel Ziel der Befragung ist, die Auswirkungen der 2007 eingeführten Spezialisierten ambulanten Palliativversorgung (SAPV) auf die Arbeit ambulanter Hospizdienste (AHD) zu explorieren. Methodik AHD wurden 2015 zu Änderungen der Wahrnehmung von und Erwartungen an die Hospizarbeit sowie zur Kooperation mit SAPV-Teams befragt. Die Auswertung erfolgte statistisch-deskriptiv sowie zusammenfassend qualitativ inhaltsanalytisch (Freitexte). Ergebnisse 214 AHD für Erwachsene nahmen teil. Die Veränderung der Wahrnehmung von Hospizarbeit wurde mehrheitlich positiv bewertet. Fast alle AHD hatten überwiegend gute Erfahrungen in der Zusammenarbeit mit SAPV-Teams. SAPV verbessert die ambulante Palliativversorgung und verändert die Zusammenarbeit im Netzwerk, die Begleitungsanfragen, den Blick auf und die Erwartungen an AHD. Konkurrenz kann entstehen, wenn sich z. B. Aufgaben überschneiden oder sich der AHD verdrängt fühlt. Schlussfolgerungen Die enge Kooperation von Haupt- und Ehrenamt in der Hospiz- und Palliativversorgung kann auch im Rahmen der SAPV zu einer besseren Versorgung schwerkranker und sterbender Patientinnen und ihrer Angehörigen führen. Die Rolle und die Aufgaben ehrenamtlicher Hospizarbeit müssen in den Bildungs- und Qualifizierungsangeboten zur Palliativversorgung adäquat vermittelt werden. Die gegenseitige Wahrnehmung, Kooperation sowie mögliche Konkurrenzen sollten auch aus Sicht der SAPV-Teams, der Patienten und Angehörigen untersucht werden.

Background To develop an aide memoire for patients diagnosed with advanced non-oncological chronic diseases, the KOPAL conversation guide, to foster interprofessional counselling between GPs and specialist palliative home care teams. Methods As part of the multi-centre, two-arm, cluster randomised controlled KOPAL study, the draft of the conversation guide was discussed and consented in three focus groups with 4 patients, 7 health care providers, and 5 stakeholders. Results The final version of the KOPAL conversation guide contains eight key topics: living with the illness, physical situation, emotional situation, personal situation, social situation, information and communication, control and autonomy, emergency management. Each topic refers to different general points, which are listed on top of the respective thematic section. The conversation should start by addressing the patient’s today’s well-being and end by asking for the patient’s main topic based on the discussed issues. Conclusions The KOPAL conversation guide is a broad evaluation and communication tool that covers potential palliative care (PC) needs of non-oncological patients and provides a basis for interprofessional case planning and counselling. Applying the KOPAL conversation guide may help to bridge the communicative gap between general and specialist PC professionals and between professionals and patients.

ZusammenfassungVersorgungsforschung im letzten Lebensjahr beschäftigt sich mit der wissenschaftlichen Erfassung der Begleitung und Betreuung von schwerstkranken und sterbenden Menschen sowie ihrer An- und Zugehörigen. Patientinnen und Patienten in der letzten Lebensphase können unterschiedlichen Erkrankungsgruppen angehören, besondere Charakteristika aufweisen (z. B. Menschen mit kognitiver und komplexer Beeinträchtigung, ökonomischer Benachteiligung oder Migrationshintergrund) sowie in bestimmten Lebensphasen sein (z. B. Eltern minderjähriger Kinder, (hohes) Alter). Aus der besonderen Situation der Betroffenen sowie aus den Besonderheiten der Versorgung im letzten Lebensjahr ergibt sich das Erfordernis für ein eigenes Memorandum zur Versorgungsforschung in dieser Lebensphase. Dieses Memorandum beschreibt diesbezüglich ethische und methodische Spezifika sowie aktuelle Fragestellungen der Versorgungsforschung und wie diese angemessen mittels quantitativer, qualitativer und gemischter Methoden bearbeitet werden können. Es wurde von der Fachgruppe Palliativmedizin des Deutschen Netzwerk für Versorgungsforschung e.V. (DNVF) entsprechend der Vorgaben für DNVF-Memoranden erarbeitet.

This memorandum outlines current issues concerning health services research on seriously ill and dying people in the last year of their lives as well as support available for their relatives. Patients in the last phase of life can belong to different disease groups, they may have special characteristics (e. g., people with cognitive and complex impairments, economic disadvantage or migration background) and be in certain phases of life (e. g., parents of minor children, (old) age). The need for a designated memorandum on health services research in the last year of life results from the special situation of those affected and from the special features of health services in this phase of life. With reference to these special features, this memorandum describes methodological and ethical specifics as well as current issues in health services research and how these can be adequately addressed using quantitative, qualitative and mixed methods. It has been developed by the palliative medicine section of the German Network for Health Services Research (DNVF) according to the guidelines for DNVF memoranda.Versorgungsforschung im letzten Lebensjahr beschäftigt sich mit der wissenschaftlichen Erfassung der Begleitung und Betreuung von schwerstkranken und sterbenden Menschen sowie ihrer An- und Zugehörigen. Patientinnen und Patienten in der letzten Lebensphase können unterschiedlichen Erkrankungsgruppen angehören, besondere Charakteristika aufweisen (z. B. Menschen mit kognitiver und komplexer Beeinträchtigung, ökonomischer Benachteiligung oder Migrationshintergrund) sowie in bestimmten Lebensphasen sein (z. B. Eltern minderjähriger Kinder, (hohes) Alter). Aus der besonderen Situation der Betroffenen sowie aus den Besonderheiten der Versorgung im letzten Lebensjahr ergibt sich das Erfordernis für ein eigenes Memorandum zur Versorgungsforschung in dieser Lebensphase. Dieses Memorandum beschreibt diesbezüglich ethische und methodische Spezifika sowie aktuelle Fragestellungen der Versorgungsforschung und wie diese angemessen mittels quantitativer, qualitativer und gemischter Methoden bearbeitet werden können. Es wurde von der Fachgruppe Palliativmedizin des Deutschen Netzwerk für Versorgungsforschung e.V. (DNVF) entsprechend der Vorgaben für DNVF-Memoranden erarbeitet.

Warum ein Memorandum zur Versorgungsforschung im letzten Lebensjahr?Mit den Fortschritten der Medizin und dem demographischen Wandel wird nicht nur die Lebensspanne in der Bevölkerung verlängert, sondern bei dem zunehmenden Anteil von alten und hochaltrigen Menschen auch immer häufiger die letzte Lebenszeit mit Multimorbidität, Demenz oder mit schweren beeinträchtigenden Erkrankungen verbracht. Daraus resultiert ein wachsender Bedarf an palliativer Versorgung, der auch mit einer zunehmenden Relevanz qualitativ hochwertiger Versorgungsforschung auf diesem Gebiet einhergeht. Über die letzten Jahrzehnte hat die Forschung zu palliativer Versorgung und ihren Besonderheiten enorm zugenommen, so dass mittlerweile ein beachtlicher Korpus an empirischen Erkenntnissen dazu entstanden ist. Eine strukturierte, systematische Übersicht und Bewertung der verwendeten Methoden in diesem Bereich liegt jedoch im deutschsprachigen Raum bisher noch nicht vor. Das Memorandum zur „Versorgungsforschung im letzten Lebensjahr“ will diese Lücke schließen.

According to current research data, individuals with migration background rarely utilize palliative care services. The potential reasons remain largely unclear, with cultural differences being suggested most frequently. A study focusing on the needs of cancer patients with migration background in Germany provides an overview of the care problems encountered.The qualitative study design focuses on biographic narratives by patients, their relatives and medical care providers (n = 57). Data were analyzed with "grounded theory" which disclosed various categories and coping strategies in dealing with both the disease and the care provided.Arriving in palliative care, severely ill patients with migration background experience social exclusion. These migration-specific effects have a negative impact on coping with the disease and on palliative treatment and end-of-life care. Relatives and medical care providers face a challenge when they fail to meet the patients' expectations. Many problems are attributed to cultural differences although patients nearing the end of their lifes tend to articulate rather generic needs.Individuals with migration background frequently receive palliative care without their care givers having any specific knowledge of their migration biography. In order to do justice to societal effects, the support given must go beyond the mere medical expertise.Menschen mit Migrationshintergrund nutzen nach dem Stand der Forschung das palliative Versorgungsangebot wenig. Die möglichen Gründe sind weitgehend unklar. Häufig werden kulturelle Unterschiede geltend gemacht. Eine Untersuchung der Bedürfnisse von krebskranken Patienten mit Migrationshintergrund, ihren Angehörigen und medizinischen und pflegenden Versorgenden in Deutschland bietet einen Überblick über die Versorgungsprobleme.In dem qualitativen Forschungsdesign stehen biografische Erzählungen der Patienten, ihrer Angehörigen und der medizinischen und pflegenden Versorgenden im Vordergrund. Mit der Grounded Theory wurde eine Zeile-für-Zeile-Analyse der Daten durchgeführt, mit der verschiedene Kategorien und Handlungsstrategien im Umgang mit der Krankheit und der Versorgungssituation gefunden werden konnten.Wenn schwerkranke Patienten mit Migrationshintergrund in einer palliativen Versorgungsstruktur ankommen, erleben sie in dieser politische und soziale Abgrenzungen. Migrationsspezifische Einflüsse erschweren deshalb die Bearbeitung der Krankheit und die palliativmedizinische Behandlung und Versorgung am Lebensende. Angehörige und medizinische und pflegende Versorgende erleben die Situation als eine Herausforderung, weil sie den Erwartungen der Patienten nicht entsprechen können und auf Übersetzer und Vermittler angewiesen sind. Viele Probleme werden kulturellen Unterschieden zugerechnet, obwohl die Patienten am Lebensende eher allgemeine Bedürfnisse formulieren.Die Palliativversorgung von Menschen mit Migrationshintergrund findet häufig ohne spezifische Kenntnisse der Migrationsbiografie statt. Um den politischen und sozialen Einflüssen gerecht zu werden, bedarf es einer Unterstützung, die die Migrationsbiografie berücksichtigt.

Background Psychological distress has a negative impact on the prognosis and quality of life for patients with heart failure. We investigated the association between psychological distress and the patients’ adherence to medical treatment (medication adherence) and self-care advice (lifestyle adherence) in heart failure. We further examined whether there are different factors associated with low medication compared to low lifestyle adherence. Method This secondary analysis of the RECODE-HF cohort study analyzed baseline data of 3099 primary care heart failure patients aged 74 ± 10 years, 44.5 % female. Using multivariable regression, factors relating to medication and lifestyle adherence were investigated in order to estimate the extent to which these factors confound the association between psychological distress and adherence. Results Psychological distress was significantly associated with poorer medication adherence but not with lifestyle adherence after controlling for confounders. We identified different factors associated with medication compared to lifestyle adherence. A higher body mass index, a less developed social network, living alone, fewer chronic co-morbidities and unawareness of the heart failure diagnosis were only related to lower lifestyle adherence. Higher education was associated with poorer medication adherence. Male sex, younger age, lower self-efficacy and less familiar relation with the general practitioner were common factors associated with both lower medication and lifestyle adherence. Conclusion Promising factors for increasing medication adherence (reduction of psychological distress) and lifestyle adherence (explaining the patient his/her heart failure diagnosis more than once and increase in the patients’ self-efficacy), which were found in this cross-sectional study, must be further investigated in longitudinal studies.

Background Caring for patients with advanced or terminal diseases can confront family caregivers (FC) with ethical challenges. The present study aims at tracing paths connected to ethical challenges among FC of advanced cancer patients by exploring morally troubling situations and related burden, as well as strategies to handle the situation and experience of moral distress from the grieving FC’s perspective. Methods Within a qualitative design, interviews with 12 grieving FC were conducted using a semi-structured interview guide. Data were analysed using grounded theory and abductive reasoning. Results Core phenomena identified were two paths connected to ethical challenges among FC. Ethical challenges occurred in the context of difficult decision-making (Path 1) and in the context of lacking decision-making options when no decision was to be made by FC (Path 2). We found each path to be triggered by distinct sets of morally troubling situations that occurred during the patient’s disease trajectory. In the course of difficult decision-making (Path 1), detrimental external factors could add emotional stress, thus making the decision-making process burdensome. FC used various proactive strategies to overcome those detrimental factors and/or to make the decision. Decisions in conflict with FCs' own moral expectations and values led to moral distress, generating painful emotions. When no decision was to be made by FC (Path 2), FC felt powerless and overrun, which was associated with major emotionality in terms of anxiety and confusion. Either detrimental factors aggravated these feelings to paralyzing shock, or internal resources enabled FC to accept the situation. While acceptance prevented moral distress, paralyzing shock often caused a sense of not meeting their their own moral expectations and values, resulting in moral distress. In both paths, factors were identified that helped FC finding closure and prevented moral residue. Nevertheless, some FC experienced residual moral distress months after the morally troubling situation had occurred. Conclusion Findings provide first information towards understanding paths leading to ethical challenges in FC and can help clinicians to minimize associated emotional burden and moral distress.

Background Patient and public involvement (PPI) is increasingly required in mental health services research. To empower patients to actively address depression, the GET.FEEDBACK.GP study evaluates a patient-targeted feedback intervention after depression screening using the Patient Health Questionnaire (PHQ-9). Objective To refine the patient-targeted feedback from a previous study within a participatory research team (PRT) by conducting workshops to investigate patients' needs and preferences for feedback. To evaluate the process and outcome of PPI. Design Patient and public involvement was carried out on the levels of collaboration and consultation. A PRT of patient partners and researchers planned and conducted three workshops with patients. Patients' needs were investigated using a focus group. Participants prioritized needs, discussed feedback drafts and evaluated two drafts using cognitive debriefings. Researchers of the PRT communicated the results at project level. PPI was evaluated using the Public and Patient Engagement Evaluation Tools (PPEET). Setting and participants A purposeful sampling of N = 12 patients with experiences of depression participated in at least one workshop. Results Relevant content-related needs about feedback (eg no distinction between severe and moderate symptoms), recommendations for action and patient-relevant information were considered. Needs for comprehensible, valuing, nonstigmatizing language and design elements (eg dimensional bar) were implemented. Workshops and PRT were positively evaluated. Discussion and conclusions Patient and public involvement influenced the content, wording and design of the feedback. Strengths include two levels of PPI, methodical diversity and purposeful sampling. Limitations include the lack of inclusion of patients who are unaware of their depression. The evaluated PPI concept can be useful for future studies.

Experiences when handling sleep medicines: Group discussions with nursing students about benzodiazepines and Z-drugs

Objective: To investigate prevalence and predictors of postloss distress, depressive and anxiety symptoms, and quality of life among bereaved family caregivers of patients with advanced cancer. Methods: Prospective multicenter study. Family caregivers (N = 160, mean age 56.8 years, 66% female) completed validated outcome measures (Distress Thermometer, Generalized Anxiety Disorder 7-item scale, Patient Health Questionnaire depression module 9-item scale, SF-8 Health Survey Questionnaire) 6 months after patient’s discharge or death at specialist inpatient palliative care ward. Results: Clinically relevant distress was observed in 82% with sadness (89%), exhaustion (74%), sleeping problems (68%), loneliness (53%), and sorrows (52%) being the most common distress-causing problems. Moderate/severe anxiety and depressive symptoms were observed in 27% and 35%, respectively. Compared to an adjusted norm sample, quality of life was significantly impaired with exception of “bodily pain” and physical component score. Preloss caregiving (odds ratio [OR] 2.195) and higher preloss distress (OR 1.345) predicted high postloss distress. Utilization of psychosocial support services (OR 2.936) and higher preloss anxiety symptoms (OR 1.292) predicted moderate/severe anxiety symptoms, lower preloss physical quality of life (OR 0.952), and higher preloss depressive symptoms (OR 1.115) predicted moderate/severe depressive symptoms. Conclusion: Preloss mental burden showed to be a consistent predictor for postloss burden and should be addressed during palliative care. Future research should examine specific caregiver-directed interventions during specialist palliative care.

Zusammenfassung Hintergrund Lungenkrebs wird häufig in einem fortgeschrittenen Stadium diagnostiziert und geht mit einer Vielzahl belastender Symptome einher. Um den Bedürfnissen der Patienten gerecht zu werden, ist eine vertiefte Kenntnis dieser Lebenssituation erforderlich. Methodik Die qualitative prospektive Längsschnittstudie mit teilstrukturierten Leitfadeninterviews fand im Zeitraum von Februar 2013 bis Mai 2014 mit 4 Erhebungszeitpunkten statt. Insgesamt wurden 43 Interviews mit 17 Patienten geführt und ausgewertet. Ergebnisse Patienten mit Lungenkrebs erfahren Belastungen wie körperliche Schwäche und Distress, die einen Autonomieverlust verdeutlichen. Aufbauend auf diesen Erfahrungen, möchten Patienten mit fortschreitender Erkrankung über die Fragen des zu erwartenden Krankheitsverlaufs aufgeklärt werden, um möglichen körperlichen sowie seelischen Belastungen durch eine gezielte medizinische aber auch lebensweltliche Vorausplanung entgegenwirken zu können. Die Analyse ergab vier Bedürfnistypen: 1) ‚Der emotional Handelnde‘, 2) ‚Der genügsame Einsame‘, 3) ‚Der gefangene Rationalist‘, 4) ‚Der soziale Kämpfer‘. Typenbedingt weisen die Patienten unterschiedliche Bedürfnisse darin auf, welche Themen sie partizipativ mitentscheiden möchten: bei Typ 2) und 4) kann nicht die Planung der nächsten tumortherapeutischen Schritte, sondern die Planung zur Bewältigung des alltäglichen Lebens im Fokus liegen. Schlussfolgerung Patienten mit Lungenkrebs würde ein frühzeitiges und wiederholtes Gesprächsangebot nach dem Advance Care Planning-Konzept zugutekommen, um künftige Behandlungen nach ihren individuellen Bedürfnissen planen zu können.

IntroductionProgressive chronic, non-malignant diseases (CNMD) like congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and dementia are of growing relevance in primary care. Most of these patients suffer from severe symptoms, reduced quality of life and increased numbers of hospitalisations. Outpatient palliative care can help to reduce hospitalisation rate by up to 50%. Due to the complex medical conditions and prognostic uncertainty of the course of CNMD, early interprofessional care planning among general practitioners who provide general palliative care and specialist palliative home care (SPHC) teams seems mandatory. The KOPAL study (a concept for strenghtening interprofessional collaboration for patients with palliative care needs) will test the effectiveness of a SPHC nurse–patient consultation followed by an interprofessional telephone case conference.Methods and analysisMulticentre two-arm cluster randomised controlled trial KOPAL with usual care as control arm. The study is located in Northern Germany and aims to recruit 616 patients in 56 GP practices (because of pandemic reasons reduced to 191 participants). Randomisation will take place on GP practice level immediately after inclusion (intervention group/control group). Allocation concealment is carried out on confirmation of participation. Patients diagnosed with CHF (New York Heart Association (NYHA) classification 3–4), COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage classification 3–4, group D) or dementia GDS stage 4 or above). Primary outcome is a reduced hospital admission within 48 weeks after baseline, secondary outcomes include symptom burden, quality of life and health costs. The primary analysis will follow the intention-to-treat principle. Intervention will be evaluated after the observation period using qualitative methods.Ethics and disseminationThe responsible ethics committees of the cooperating centres approved the study. All steps of data collection, quality assurance and data analysis will continuously be monitored. The concept of KOPAL could serve as a blueprint for other regions and meet the challenges of geographical equity in end-of-life care.Trial registration numberDRKS00017795; German Clinical Trials Register.

Purpose The first aim of this qualitative study was to identify general practitioners’ (GPs’) views on depression screening combined with GP-targeted feedback in primary care. The second aim was to determine the needs and preferences of GPs with respect to GP-targeted feedback to enhance the efficacy of depression screening. Methods A semistructured qualitative interview was conducted with officially registered GPs in Hamburg (Germany). Interviews were audio recorded and transcribed verbatim. An inductive approach was used to code the transcripts. Results Nine GPs (27 to 70 years; 5 male) from Hamburg, Germany, participated. Regarding depression screening combined with GP-targeted feedback, five thematic groups were identified: application of screening; screening and patient–physician relationships; GPs’ attitudes towards screening; benefits and concerns related to screening; and GPs’ needs and preferences regarding feedback. While the negative aspects of screening can be described in rather general terms (e.g., screening determines the mental health competence, screening threatens the doctor–patient relationship, revealing questions harm the patients), its advantages were very specific (e.g., promoting the identification of undetected cases, relief of the daily workload, wider communication channel to reach more patients). Standardized GP-targeted feedback of the screening results was perceived as helpful and purposeful. GPs preferred feedback materials that eased their clinical workload (e.g., short text with visuals, pictures, or images). Conclusion Addressing GPs’ needs is essential when implementing depression screening tools in clinical practice. To overcome prejudices and enhance the efficacy of screening, further education for GPs on the purpose and application on depression screening may be needed. Standardized GP-targeted feedback in combination with depression screening could be the missing link to improve the detection of depression in primary care.

ObjectivesMen and women at any age show similar symptoms and signs of heart failure (HF). Since early HF symptoms are ambiguous, doctors may overlook HF as possible cause and misinterpret the signs. The aim was to analyse differences in general practitioners’ (GPs) HF diagnosis and diagnostic certainty by patient age and gender and to identify reasons for possible differences.DesignFactorial design with video vignettes presenting patients (played by professional actors) with early HF symptoms was used. Video vignettes differed regarding patients’ gender (male/female), age (55 years/75 years) and migration background (no/yes: Turkish), while the dialogue was identical. GPs were asked about possible diagnoses and certainty of diagnoses (quantitative) and to narrate their thoughts on considered diagnoses (qualitative).SettingGeneral practices in northern Germany.Participants128 GPs stratified by gender and length of clinical experience (≤15 years or >15 years).ResultsGPs considered HF more often in women than men (predicted probabilities with 95% CI: 0.83 (0.68 to 0.92) vs 0.63 (0.44 to 0.79), p=0.02), especially in older women compared with younger men (predicted probabilities with 95% CI: 0.89 (0.68 to 0.96) vs 0.52 (0.31 to 0.72), p=0,03). Suspected HF was not reasoned by the patient’s gender and only seldom by the patient’s age, but by reported symptoms. Diagnostic certainty of HF was higher in women than in men (predicted proportions with 95% CI: 0.48 (0.39 to 0.58) vs 0.36 (0.27 to 0.45), p=0.01), with highest certainty in older women and lowest in younger men (0.57 (0.45 to 0.69) vs 0.27 (0.17 to 0.37), pConclusionDespite an identical dialogue, the study showed differences by patients’ gender and age in frequency and certainty of HF diagnosis. In order to avoid that GPs overlook or misinterpret early signs of HF, it is important to critically reflect diagnostic decisions and possible social influences.

IntroductionApproximately one out of six patients in primary care suffers from depression, which often remains undetected. Evidence regarding the efficacy of depression screening in primary care, however, is inconsistent. A previous single-centre randomised controlled trial (RCT) in cardiac patients, the DEPSCREEN-INFO trial, provided the first evidence that written feedback to patients following a positive depression screening reduces depression severity and leads to more comprehensive patient engagement in mental healthcare. To amplify these effects, the feedback should be tailored according to patients’ needs and preferences. The GET.FEEDBACK.GP RCT will test the efficacy of this patient-targeted feedback intervention in primary care.Methods and analysisThe multicentre three-arm GET.FEEDBACK.GP RCT aims to recruit a total of 1074 primary care patients from North, East and South Germany. Patients will be screened for depression using the Patient Health Questionnaire-9 (PHQ-9). In the case of a positive depression screening result (PHQ-9 score ≥10), the participant will be randomised into one of three groups to either receive (a) patient-targeted and general practitioner (GP)-targeted feedback regarding the depression screening results, (b) only GP-targeted feedback or (c) no feedback. Patients will be followed over a period of 12 months. The primary outcome is depression severity (PHQ-9) 6 months after screening. Secondary outcomes include patient engagement in mental healthcare, professional depression care and cost-effectiveness. According to a statistical analysis plan, the primary endpoint of all randomised patients will be analysed regarding the intention-to-treat principle.Ethics and disseminationThe Ethics Committee of the Hamburg Medical Association approved the study. A clinical trial company will ensure data safety, monitoring and supervision. The multicentre GET.FEEDBACK.GP RCT is the first trial in primary care that tests the efficacy of a patient-targeted feedback intervention as an adjunct to depression screening. Its results have the potential to influence future depression guidelines and will be disseminated in scientific as well as patient-friendly language.Trial registration numberNCT03988985.

Background Some studies, mainly coming from the U.S., indicate disparities in heart failure (HF) treatment according to migration/ethnicity. However, respective results are inconsistent and cannot be transferred to other health care systems. Thus, we will address the following research question: Are there differences in the diagnosis and management of HF between patients with and without a Turkish migration background in Germany? Methods A factorial experimental design with video vignettes was applied. In the filmed simulated initial encounters, professional actors played patients, who consulted a primary care physician because of typical HF symptoms. While the dialog was identical in all videos, patients differed in terms of Turkish migration history (no/yes), sex (male/female), and age (55 years/75 years). After viewing the video, primary care physicians (N = 128) were asked standardized and open ended questions concerning their decisions on diagnosis and therapy. Results Analyses revealed no statistically significant differences (p Conclusions Our results indicate that are no significant inequalities in diagnosis and management of HF according to a Turkish migration background in Germany. Primary care physicians’ behaviour and medical decision making do not seem to be influenced by the migration background of the patients. Future studies are needed to verify this result and to address inequalities in HF therapy in an advanced disease stage.

GET.FEEDBACK.GP 1 is a multicenter randomized controlled trial testing the efficacy of patient-oriented depression feedback in primary care. This paper describes the complex methods and procedures of the trial. The primary outcome is depression severity six months after feedback, and we vary who is the target of the feedback as follows: no one receives feedback, only general practitioners receive feedback, and both patients and general practitioners receive feedback. The procedure includes a baseline assessment in primary care practices and three telephone follow-up interviews after one, six, and twelve months. The patients completed a baseline assessment, which determined their depression severity. Those with at least a moderate depression severity (PHQ-95 ≥ 10) were randomly allocated to three groups stratified by depression severity. A standardized mean difference of d = 0.25 with power 1 - β = 0.80 required a total sample size of N = 699. The patients provided responses regarding the primary and secondary outcomes at follow-up. The extensive planning for GET.FEEDBACK.GP involved experts from diverse medical specialties and external corporations. Of particular importance were (a) blinding in the study inclusion and random assignment with data capture software, (b) representative and unbiased patient selection in practice waiting rooms, (c) a data management and safety plan supplied by a specialized trial center, and (d) the use of participant pseudonyms supplied by a specialized service (Mainzelliste). The data collection started in July 2019 and will continue until June 2022. Five university study centers in Germany are participating in the trial.

Zusammenfassung Einleitung 2009 wurde Palliativmedizin als Pflichtlehr- und Prüfungsfach in die Approbationsordnung für Ärzte aufgenommen. Trotz zahlreicher Impulse, das Fach flächendeckend und mit einem Mindestmaß an Qualität und Quantität in das Medizinstudium zu integrieren, legen Längsschnittuntersuchungen nahe, dass zwischen den Fakultäten noch immer deutliche Unterschiede in der palliativmedizinischen Ausbildung bestehen. Ziel dieser Arbeit ist es strukturelle, personelle und inhaltliche Rahmenbedingungen für gelungene palliativmedizinische Lehre zu identifizieren und Realisierungswege in Anbetracht förderlicher und hinderlicher Faktoren aufzuzeigen. Methoden Leitfadengestützte Experteninterviews zu inhaltlicher Ausgestaltung und Stand der Implementierung wurden mit 15 der 36 Lehrbeauftragten für Palliativmedizin geführt. Diese wurden transkribiert und inhaltsanalytisch nach Meuser und Nagel ausgewertet. Ergebnisse Hinderlich für die Implementierung seien die mangelnde Anerkennung des Fachbereichs, die starre Struktur eines ohnehin ausgelasteten Medizinstudiums, mangelnde Erfahrungen sowie mangelnde personelle, finanzielle und zeitliche Ressourcen. Angesichts der Herausforderungen seien Anerkennung und Unterstützung, inner- und interfakultäre Zusammenarbeit, extracurriculares Engagement, Drittmittel und grundlegende Umstrukturierungsprozesse förderlich für den Implementierungsprozess. Diskussion Um die Implementierung voranzutreiben, sollte der Wert von Teamarbeit deutlicher erkannt und ausgebaut werden. So könnte insbesondere die Ausarbeitung kompetenzbasierter und ressourcensparender Lehr- und Prüfungsformate effizient vorangetrieben werden. Grundsätzlich bräuchte es zudem eine Verbesserung der institutionellen Verankerung und Ausstattung. Um Mängel zu objektivieren, sollte eine Bedarfserhebung (Anzahl an Lehrstunden und Unterrichtseinheiten) erstellt werden, die entsprechende Forderungen unterstützen kann.

Hintergrund Die durchschnittliche Lebenserwartung von Menschen mit schwerer geistiger oder korperlicher Behinderung gleicht sich in den letzten Jahrzehnten der Lebenserwartung der Gesamtbevolkerung an. Dadurch gewinnt die Palliativversorgung dieser vulnerablen Patientengruppe zunehmend an Bedeutung. Vor diesem Hintergrund wurde ein Curriculum zur Inhouse-Schulung palliativer Behandlung und Begleitung von Menschen mit Behinderung in einer Wohngruppe entwickelt, implementiert und evaluiert. Methode Vor (t1) und 6 Monate (t2) nach zehn Inhouse-Schulungsterminen a 90 Minuten wurde neben der Erfassung teilnehmerbezogener Daten der Lernzuwachs mittels Fragebogen mit offenen und geschlossenen Fragen erfasst. Themenschwerpunkte waren: Umgang mit Sterbe- und anderen belastenden Situationen, Herausforderungen im Berufsalltag und versorgungsbezogene Sicherheit. Die Angaben wurden deskriptiv statistisch und inhaltsanalytisch analysiert. Ergebnisse An der Schulung nahmen 16 Mitarbeiter teil; 14 fullten den Bogen zum Zeitpunkt t1 aus, von 9 Befragungsteilnehmern konnten t1- und t2-Angaben gewonnen werden. Schulungskonzept, Durchfuhrung und mittelfristige Auswirkungen wurden dabei durchgehend positiv evaluiert; die Mitarbeiter gewannen in der Betreuung sterbender Bewohner und bei der Erfassung und Behandlung von belastenden Symptomen an Handlungssicherheit. Schlussfolgerung Ein Grundverstandnis palliativen Handelns kann in Form einer Inhouse-Schulung alltagskonform und wirkungsvoll vermittelt werden, sodass sich die Handlungssicherheit der Mitarbeiter im Umgang mit schwer kranken, sterbenden und verstorbenen Bewohnern erhoht.

Objective To examine differences in the anamnesis in heart failure patients by patient and physician gender. Methods A factorial experimental design with video vignettes was applied. While the dialog of an initial encounter because of heart failure symptoms was identical in all videos, patients, played by professional actors, differed in terms of gender (male/female), age (55 years/75 years) and Turkish migration history (no/yes). After viewing the video, 128 physicians ( 50 % female ) were asked if they wanted to ask additional questions (yes/no) and if so, what they wanted to ask (open ended). A coding frame was conducted for the open ended question. Results Compared to male physicians, female physicians more often said they wanted to ask additional questions, especially about psychosocial aspects. Physicians, particularly female physicians, wanted to ask male patients more often about lifestyle aspects compared to female patients. Conclusion Although the dialog was identical in all videos, some variations in the anamnestic approach regarding physician and patient gender were identified. This is in contrast to current heart failure guidelines that recommend a detailed anamnesis in all patients presenting themselves with heart failure symptoms. Practice Implications Primary care physicians should reflect how possible gender stereotypes may influence their anamnestic behavior.

Purpose This study aimed to investigate the supportive care needs of family caregivers (FCs) of advanced cancer patients and their support service use at the beginning of specialist inpatient palliative care (SIPC), near the patient’s death, and during bereavement. Methods FCs reported their needs using the Family Inventory of Needs (FIN), along with their utilization of psychosocial and bereavement support services at the beginning (N = 232) and 6–9 months after SIPC (N = 160). Results At the beginning of SIPC, mean of 16.9 of 20 needs were reported to be highly important, and 12.2 were reported to be met. At the time of the patient’s death, 16.8 needs were highly important, and 13.8 were met. At both time points, the highest ranked need was related to information about changes in the patient’s condition (100% vs. 99%), and the most frequently unmet need was related to feeling hope (73% vs. 71%). Multivariate linear regression analysis revealed a low education level to be consistently related to a greater number of highly important needs. Higher satisfaction with care and better social support was related to a greater number of met needs. Twenty-five percent of FCs had accessed at least one psychosocial support service prior to SIPC, and 30% had done so during bereavement. Among non-users of support services, > 75% indicated sufficient informal support as a barrier to service use. Conclusions The findings offer a useful guide for adequately addressing FCs’ needs in an effort to optimize FC support. However, only a subgroup of the FCs used support services. Better information and provision of tailored services might improve FCs’ situations in the future.

Background: Clinical ethics committees have been broadly implemented in university hospitals, general hospitals and nursing homes. To ensure the quality of ethics consultations, evaluation should be mandatory. Research question/aim: The aim of this article is to evaluate the perspectives of all people involved and the process of implementation on the wards. Research design and participants: The data were collected in two steps: by means of non-participating observation of four ethics case consultations and by open-guided interviews with 28 participants. Data analysis was performed according to grounded theory. Ethical considerations: The study received approval from the local Ethics Commission (registration no.: 32/11/10). Findings: ‘Communication problems’ and ‘hierarchical team conflicts’ proved to be the main aspects that led to ethics consultation, involving two factors: unresolvable differences arise in the context of team conflicts on the ward and unresolvable differences prevent a solution being found. Hierarchical asymmetries, which are common in the medical field, support this vicious circle. Based on this, minor or major disagreements regarding clinical decisions might be seen as ethical conflicts. The expectation on the clinical ethics committee is to solve this (communication) problem, but the participants experienced that hierarchy is maintained by the clinical ethics committee members. Discussion: The asymmetrical structures of the clinical ethics committee reflect the institutional hierarchical nature. They endure, despite the fact that the clinical ethics committee should be able to detect and overcome them. Disagreements among care givers are described as one of the most difficult ethically relevant situations and should be recognised by the clinical ethics committee. On the contrary, discussion of team conflicts and clinical ethical issues should not be combined, since the first is a mandate for team supervision. Conclusion: To avoid dominance by physicians and an excessively factual character of the presentation, the case or conflict could be presented by both physicians and nurses, a strategy that strengthens the interpersonal and emotional aspects and also integrates both professional perspectives.