gms | German Medical Science

GMS Journal for Medical Education

Gesellschaft für Medizinische Ausbildung (GMA)

ISSN 2366-5017

Wolfgang George, Eckhard Dommer, Viktor R. Szymaczak: Sterben im Krankenhaus

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  • corresponding author Matthias Angstwurm - Ludwig-Maximilians-Universität München, Medizinische Klinik und Poliklinik IV, München, Deutschland

GMS Z Med Ausbild 2014;31(3):Doc25

doi: 10.3205/zma000917, urn:nbn:de:0183-zma0009174

This is the English version of the article.
The German version can be found at: http://www.egms.de/de/journals/zma/2014-31/zma000917.shtml

Received: November 14, 2013
Revised: June 5, 2014
Accepted: June 5, 2014
Published: August 15, 2014

© 2014 Angstwurm.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Bibliographical details

Wolfgang George, Eckhard Dommer, Viktor R. Szymaczak

Sterben im Krankenhaus

Psychosozial-Verlag

Erscheinungsjahr: 2013, Seiten: 230, € 29,90

ISBN: 978-3-8379-2331-5


Recension

Dying in the hospital is a topic that unfortunately often comes up short in medical education, the organization of a hospital and in the responsibilities of a hospital physician. The health sector is oriented toward prolonging life; the death of a patient plays a subordinate role.

Depending on structures that differ by region, up to 30% of people die in a hospital. On the other hand, according to surveys, 60% to 75% of the population wishes to pass away in their own homes (representative telephone survey of the Deutscher Hospiz- und Palliativ Verband, press conference, August 20, 2012). From this survey it is also clear that, in contrast to earlier analyses, the topic of dying is no longer taboo.

The German Medical Association states that according to the medical code of ethics, physicians have the duty to preserve life, to protect and restore health, to alleviate pain and attend the dying. The doctor’s obligation to preserve life does not apply to all circumstances. There are situations in which otherwise appropriate diagnostics and therapies are no longer indicated and limits are called for. This is the moment when palliative care comes to the fore, and the decision to pursue palliative measures should not be made dependent on economic considerations (Deutsches Ärzteblatt, vol. 108, issue 7; Feb. 18, 2011).

In the German medical licensure act, it is explicit that medical students must demonstrate knowledge about the management and care of the dying on the second state medical exam. In particular, students must show that they know the general rules of medical conduct toward a patient taking ethical issues into account, know how to respond to the situation, and are able to provide assistance and care, even for the chronically and terminally ill and the dying (§28 ÄAppO subsection 8).

In light of this, it is very gratifying that in this book titled Sterben im Krankenhaus various occupational groups address this topic. The authors describe the current situation in detail, make connections and offer recommendations. Including theologians, sociologists and lawyers, the spectrum of the affected groups ranges from those concretely affected in nursing and physicians to the people in healthcare management. However, medical opinions and attitudes toward this topic play a minor role.

In contrast, the care of terminally ill and dying patients is often a reason for medical consultations, so that this will receive emphasis in the national catalogue of competency-based learning objectives in medical education (NKLM) and importance should be placed on this aspect in the education of medical students. In the professional role of the doctor, the topic of dying is clearly addressed. Specific topics are brought up and formulated as learning objectives: culture and dependence on a particular point in time, ideological differences in dealing with death and dying (chapter on ethics and law), definition of death and its implications for medical decisions, multi-disciplinary approaches in care, differentiated measures at the end of life, symptom control, acceptance of death and dying as a part of life, and the ethical and legal bases for limiting treatment to potentially extend life.

Several of these topics receive cursory mention in this book. Different aspects, such as biological facts and discussions of brain death, organ donation or even non-heart beating donors are excluded.

The following topics are addressed:

  • Hospice
  • Nursing perspectives
  • Role of the palliative ward
  • Intensive care between the process of dying and medical treatment
  • Dying conditions in Germany
  • Recommendations on dying conditions
  • Quality of care
  • Ethical aspects
  • DRG system
  • Death and quality management
  • Death and life
  • Dying with dignity with the help of physicians’ assistants
  • Health care services for the severely ill
  • Healthy dying

The nature and extent of treatment is to be determined by the doctor according to the medical indications. The wishes of the patient must be taken into consideration. When making decisions, the doctor should seek a consensus with the other medical and nursing staff. As it can be seen in the list, two sections deal with dying in the intensive care unit, both written in cooperation with physicians. The relevant issues, backed up by current studies, are addressed and discussed in an excellent manner in these chapters, such as decisions in the case of changes to therapeutic goals. These sections do not limit themselves to a description of the current situation at many intensive care units in Germany, but rather indicate possible approaches for communication and interaction. In future, a palliative care bundle could help (Gruß & Weigand, p. 55), similar to the sepsis bundle, to encourage consideration of aspects of palliative medicine to refocus care and therapy away from maximum, machine-based therapy to more caring assistance. “Human dignity shall be inviolable. To respect and protect it shall be the duty of all state authority” (Article 1, Basic Law for the Federal Republic of Germany). Even in intensive care, death and dying are a part of life (Pargger & Schäfer, p. 64). What is clearly the process of dying should not be artificially extended with life-preserving therapies. In addition, dying may be made possible through ceasing, limiting or ending medical treatment, if this is the patient’s wish.

The task of an acute care hospital is the curing of patients. A dying person stands in diametrical opposition to the learned occupational attitudes of the staff – and is virtually written off as a bed-blocker (V. R. Szymczak, p. 191). This is underlined by the financial calculation of profits, since deductions exist for patients whose hospital stay is shorter or longer than the average, although for a moribund patient or one who dies over the course of a disease, the associated effort of providing care is much higher.

At the focus of this book are the results of a study from Giessen, which describes in more than 70 pages the dying conditions in German hospitals and offers recommendations. Using socio-psychological methods, a survey is presented that is compared with the results of a similar one 25 years ago.

Ultimately, the well-being of the patient should always be the main focus and this can also be death. The options should be discussed within the medical team and a consensus reached. Widely recognized principles, toward which doctors and nurses orient their actions, include respect for autonomy, doing good, not causing harm, and fairness (Simon, p.137). A basic requirement for giving medical treatment is the presence of an appropriate indication (Simon, p. 138).

The book, Sterben im Krankenhaus, provides information on the individual aspects of dying. The proposed recommendations and the chapter on this topic could be the basis of a dialogue that must be engaged in more intensively. It is a credit to the authors and publisher that these aspects have been compiled and presented. Very appreciated are the literature sections following each chapter and the detailed information on authors with place of employment and main areas of research, including publications. Sterben im Krankenhaus can be a basis for an interdisciplinary approach to implement this topic in medical education and to analyze the significance of dying from different points of view. It can be recommended for students, physicians, nursing staff not only for reading, but also as a reference work, since it contains so many incentives for the reader to deal with this topic. However, one should not forget: we should not concentrate on dying in the hospital, but rather on the fact that death and dying belong to life (C. Kranich, p. 184).


Competing interests

The author declares that he has no competing interests.