Vorausschauende Behandlungsplanung und Therapiebegrenzung

Zusammenfassung

Entscheidungen zur Therapiebegrenzung sind wichtig, um eine Übertherapie am Lebensende zu verhindern. Sie gehen heute mehr als der Hälfte der erwarteten Todesfälle voraus, werden aber vorher nicht immer mit den Patienten besprochen.

Grund hierfür ist, dass selten Gespräche stattfinden, die Entscheidungen am Lebensende vorbereiten und dabei Patientenpräferenzen für die letzte Lebensphase in Erfahrung bringen. Dabei gibt es mittlerweile eine belastbare Evidenz dafür, dass solche Gespräche die Lebensqualität der Patienten verbessern, Angst und Depression reduzieren und dem Patienten eine realistischere Einschätzung seiner Erkrankungssituation ermöglichen, was wiederum Voraussetzung für gemeinsame Entscheidung zur Therapiebegrenzung ist.

In diesem Artikel wird der Begriff „Therapiebegrenzung“ definiert und seine Rechtfertigung aus medizinethischer Sicht begründet. Vor allem aber werden die Ursachen benannt, die derzeit in der medizinischen Versorgung Hinderungsgründe dafür sind, dass eine vorausschauende Behandlungsplanung und Gespräche zur Therapiebegrenzung selten erfolgen. Abschließend werden Lösungsansätze zur Verbesserung der Situation mit ganz praktischen Vorschlägen vorgestellt.

Abstract

Decisions to limit treatment are important in order to avoid overtreatment at the end of life. They proceed more than half of expected deaths in Europe and the US, but are not always communicated with the patient in advance. One reason for non-involvement is that conversations that prepare patients for end-of-life decisions and work out their preferences do not take place on a regular basis. At the same time there is growing evidence that such communication improves patients’ quality of life, reduces anxiety and depression and allows patients to develop a realistic understanding of their situation – which in turn is a prerequisite for shared decision making about limiting treatment.

In this paper we define „treatment limitation“ and explain the medical ethics perspective. The main focus, however, is on the causes that hinder advanced care planning and conversations about limiting treatment in the care of patients with advanced disease. Finally the evidence for approaches to improve the situation is presented with concrete suggestions for solutions.

Schlüsselwörter

Entscheidungen am Lebensende - Therapiebegrenzung - Kommunikation - vorausschauende Behandlungsplanung - Medizinethik - Psychoonkologie

Keywords

decisions near the end of life - limiting treatment - communication - advanced care planning - medical ethics - psycho-oncology

• Literatur

• 1 Connors Jr AF, Dawson NV, Desbiens NA et al. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA 1995; 274: 1591-1598
• 2 Bosshard G, Nilstun T, Bilsen J et al. Forgoing treatment at the end of life in 6 European countries. Arch Intern Med 2005; 165: 401-407
• 3 Sprung CL, Cohen SL, Sjokvist P et al. End-of-life practices in European intensive care units: the Ethicus Study. JAMA 2003; 290: 790-797
• 4 Bundesärztekammer. Grundsätze der Bundesärztekammer zur ärztlichen Sterbebegleitung. Deutsches Ärzteblatt 2011; 108: A346-A348
• 5 Voogt E, van der HA, Rietjens JA et al. Attitudes of patients with incurable cancer toward medical treatment in the last phase of life. J Clin Oncol 2005; 20 (23) 2012-2019
• 6 Winkler EC, Reiter-Theil S, Lange-Riess D et al. Patient involvement in decisions to limit treatment: the crucial role of agreement between physician and patient. J Clin Oncol 2009; 27: 2225-2230
• 7 Truog RD, Brett AS, Frader J. The problem with futility. N Engl J Med 1992; 326: 1560-1564
• 8 Hancock K, Clayton JM, Parker SM et al. Truth-telling in discussing prognosis in advanced life-limiting illnesses: a systematic review. Palliat Med 2007; 21: 507-517
• 9 Wright AA, Zhang B, Ray A et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008; 300: 1665-1673
• 10 Bernacki RE, Block SD for the American College of Physicians High Value Care Task F. Communication about serious illness care goals: A review and synthesis of best practices. JAMA Intern Med 2014; 174: 1994-2003
• 11 Bakitas M, Lyons KD, Hegel MT et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA 2009; 302 (302) 741-749
• 12 Temel JS, Greer JA, Muzikansky A et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010; 363: 733-742
• 13 Temel JS, Greer JA, Admane S et al. Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer: results of a randomized study of early palliative care. J Clin Oncol 2011; 29: 2319-2326
• 14 Weeks JC, Catalano PJ, Cronin A et al. Patients’ Expectations about Effects of Chemotherapy for Advanced Cancer. N Engl J Med 2012; 367: 1616-1625
• 15 van Delden JJ, Lofmark R, Deliens L et al. Do-not-resuscitate decisions in six European countries. Crit Care Med 2006; 34: 1686-1690
• 16 Baile WF, Buckman R, Lenzi R et al. SPIKES-A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. Oncologist 2000; 5: 302-311
• 17 Buss MK, Lessen DS, Sullivan AM et al. Hematology / oncology fellows’ training in palliative care. Cancer 2011; 117: 4304-4311
• 18 Holley JL, Carmody SS, Moss AH et al. The need for end-of-life care training in nephrology: national survey results of nephrology fellows. Am J Kidney Dis 2003; 42: 813-820
• 19 Pfeil TA, Laryionava K, Reiter-Theil S et al. What Keeps Oncologists From Addressing Palliative Care Early on With Incurable Cancer Patients? An Active Stance Seems Key. Oncologist 2015; 20: 56-61
• 20 Wenrich MD, Curtis JR, Ambrozy DA et al. Dying Patients’ Need for Emotional Support and Personalized Care from Physicians: Perspectives of Patients with Terminal Illness, Families, and Health Care Providers. J Pain Symptom Manage 2003; 25: 236-246
• 21 Mack JW, Cronin A, Keating NL et al. Associations Between End-of-Life Discussion Characteristics and Care Received Near Death: A Prospective Cohort Study. J Clin Oncol 2012; 30: 4387-4395
• 22 Mack JW, Smith TJ. Reasons Why Physicians Do Not Have Discussions About Poor Prognosis, Why It Matters, and What Can Be Improved. J Clin Oncol 2012; 30: 2715-2717
• 23 Miovic M, Block S. Psychiatric disorders in advanced cancer. Cancer 2007; 110: 1665-1676
• 24 Clayton JM, Hancock K, Parker S et al. Sustaining hope when communicating with terminally ill patients and their families: a systematic review. Psychooncology 2008; 17: 641-659
• 25 Gysels M, Richardson A, Higginson I. Communication training for health professionals who care for patients with cancer: a systematic review of effectiveness. Support Care Cancer 2004; 12: 692-700
• 26 Stiefel F, Barth J, Bensing J et al. Communication skills training in oncology: a position paper based on a consensus meeting among European experts in 2009. Ann Oncol 2010; 21: 204-207
• 27 Laryionava K, Heußner P, Hiddemann W et al. Framework for timing of the discussion about forgoing cancer-specific treatment based on a qualitative study with oncologists. Support Care Cancer 2015; 23: 715-721
• 28 Moss AH, Lunney JR, Culp S et al. Prognostic significance of the „surprise“ question in cancer patients. J Palliat Med 2010; 13: 837-840
• 29 Moroni M, Zocchi D, Bolognesi D et al. The „surprise“ question in advanced cancer patients: A prospective study among general practitioners. Palliat Med 2014; 28: 959-964
• 30 Greer JA, Pirl WF, Jackson VA et al. Effect of Early Palliative Care on Chemotherapy Use and End-of-Life Care in Patients With Metastatic Non-Small-Cell Lung Cancer. J Clin Oncol 2012; 30: 394-400
• 31 Winkler EC, Marckmann G. Therapieverzicht gegen den Patientenwillen? Eine ethische Orientierungshilfe. Ärzteblatt Baden-Württemberg 2012; 67: 140-144