BackgroundA minority of patients with incurable and advanced disease receive specialised palliative care. Specialised palliative care services that complement the care of difficult and complex cases ought to be integrated with services that deliver general care for most patients. A typical setting in which this integrative concept takes place is the hospital setting, where patients suffering from incurable and advanced disease are treated in many different departments.The aim of the study is to investigate the profile and spectrum of a palliative care consultation service (PCCS) at a German university hospital with special reference to pain therapy.MethodsWe retrospectively analysed the PCCS documentation of three years.ResultsMost patients were referred from non-surgical departments, 72% were inpatients, and 28% were outpatients. 98% of the patients suffered from cancer. Counselling in pain therapy was one of the key aspects of the consultation: For 76% of all consulted patients, modifications of the analgesic regimen were recommended, which involved opioids in 96%. Recommendations on breakthrough-pain medication were made for 70% of the patients; this was an opioid in most cases (68%). The most commonly used opioid was morphine. For 17% of the patients, additional diagnostic procedures were recommended. Besides pain management palliative care consultation implied a wide range of recommendations and services: In addition to organising home care infrastructure, palliative care services supported patients and their families in understanding the life-limiting diseases. They also coordinated physical therapy and social and legal advice.ConclusionThis survey clearly shows that for a consultation service to support patients with incurable or advanced disease, a multi-disciplinary approach is necessary to meet the complex requirements of a needs-adapted palliative care in inpatient or outpatient settings. Timely integration of palliative expertise may support symptom control and may give the required advice to patients, their carers, and their families.

Currently more and more patients with cancer will be treated at home, especially at the final stage of their disease. Relatives and nursing services will therefore be confronted with acute emergency situations concerning these patients. The handling of these acute situations may be beyond the relatives' coping capacity. For that reason the pre-hospital emergency system (2.5% of all emergency calls) will be confronted with very specific needs of these patients. Emergency situations of palliative patients at home are more predictable than other circumstances. It is thus possible to achieve a practicable preparation for such emergency situations. An individual "emergency plan" should be created for these cases.. The plan may be processed in an emergency situation. It may then be possible to avoid emergency calls and make it possible for the patient to remain at home. This promotes the patient's quality of life and his/her predominant desire to stay at home after the emergency. An advance directive should be made which records the patient's wishes. Because of the complexity of an advance directive it is essential to indicated the patient's wishes in a short and quickly read form in case an emergency arises. This is one of the reasons for producing a short version like the "Göttingen palliative emergency card". In acute situations it is then possible quickly to make known the patient's wishes The patient may be given the possibility of remaining at home after an emergency situation has been dealt with successfully.

Einleitung Die Verbesserung der palliativmedi− zinischen Versorgung in Deutschland wird in den letzten Jahren zunehmend von der Öffent− lichkeit und der Politik gefordert. Durch entspre− chende Hilfsangebote besteht für Patienten zu− nehmend die Möglichkeit, in der letzten Phase des Lebens zu Hause zu verbleiben. Allerdings sind betreuende Angehörige in medizinischen Akutsituationen immer wieder überfordert und alarmieren deshalb den Rettungsdienst. In einer derartigen Situation kann es zu Konflikten zwi− schen Prinzipien der Palliativ− und der Notfall− medizin kommen. Situation Wir berichten exemplarisch über die notärztliche Versorgung eines reanimations− pflichtigen Tumorpatienten im finalen Krank− heitsstadium bei bekanntem multipel metasta− sierten Prostatakarzinom. Trotz einer durch den Patienten geäußerten Therapieverweigerung alarmierten die Angehörigen wegen eines Kreis− laufstillstandes den Rettungsdienst. Nach den entsprechenden Maßnahmen durch Notärztin und Rettungsassistenten konnte ein Spontan− kreislauf etabliert werden. Erst hiernach wurde dem Notarzt die Krankengeschichte und der er− klärte Patientenwille mitgeteilt. Vonseiten des Patienten war bei einem weit fortgeschrittenen, metastasierten Karzinomleiden und einer infaus− ten Prognose jede lebensverlängernde Therapie abgelehnt worden. Aufgrund dieser Informatio− nen wurde auf eine Intensivtherapie verzichtet und die direkte Aufnahme auf unsere Palliativ− station veranlasst. Resultat Durch diesen notfall−palliativ−medizi− nischen Einsatz wird deutlich, dass auch Beschäf− tigte des Rettungsdienstes mit palliativmedizi− nisch betreuten Patienten in Krisensituationen konfrontiert werden können. Eine Kooperation der beteiligten medizinischen Fachgebiete (Pal− liativ− und Notfallmedizin) sollte Absprachen er−

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