The development of a standardised core documentation for palliative care was initiated in Germany in 1996. Results from previous evaluations have shown the wide variability of the documentation in participating units. A different documentation form was used in 2001 using free text entries to find out what problems palliative care specialists perceive in their patients. Fifty-five of the 83 palliative inpatient units in Germany (66% of the units) as well as one unit each from Austria and Switzerland, documented 1304 patients in the core documentation in 2001. Inpatient care was continued until death for 531 patients, 604 patients were discharged home and 169 patients were transferred to other places of care. Palliative care treatment effectively reduced mean physical symptom intensity. Mean intensities of psychological and social problems also were reduced although not as much as physical symptom load. Nursing problems were reduced for those patients discharged but not for those who died in the unit. Anxiety and depression were the most frequent psychological problems. Nursing problems were focussed on impairment of mobility and other activities of daily living such as washing, nutrition and drinking. Excessive distress on caregivers and the organisation of home care were the predominant social problems. In conclusion, this representative prospective survey with the majority of palliative care units in Germany showed the high effectiveness of symptom relief. Using the categories identified in this study, checklists were constructed and included in the documentation forms that are currently used for the core documentation project.

The development of palliative medicine in inpatient units in Germany has been impressive in the last years. As a first step of quality assurance, a core documentation form was developed in 1996. In 2001, 55 of the 83 palliative inpatient units in Germany and one unit each in Switzerland and Austria participated in the third phase of the evaluation of the core documentation. A total of 1304 patients were documented consecutively in the 57 units for a period of up to three months. This study investigates the frequency of drugs used in palliative care units in Germany. During inpatient treatment, the most common drug classes were strong opioids (68% of the patients), nonopioids (59%), corticosteroids (32%), laxatives (31%), antiemetics (27%), gastric protection agents (24%), neuroleptics (19%), sedatives/anxiolytics (18%), antidepressants (16%) and diuretics (15%). These ten drug classes made up for 72% of all prescriptions in the palliative care units. The substances used most frequently were dipyrone (47% of the patients), morphine (42%), fentanyl (28%), dexamethasone (27%), metoclopramide (21%), sodium picosulfate (15%), haloperidol (13%), pantoprazole (11%), macrogol (11%), amtriptyline (11%), furosemide (10%), omeprazole (9%), lactulose (8%), rofecoxib (8%) and lorazepam (7%). The 15 most commonly used drugs accounted for 54% of the prescriptions in the palliative care units in Germany. Drug treatment was related to sex, age and functional status of the patients. Patients who died in a palliative care unit had received significantly more frequent doses of neuroleptics (P < 0.001), corticosteroids (P < 0.001), sedatives/anxiolytics (P < 0.001) and strong opioids (P < 0.001). This study is the first representative and systematic evaluation of drug treatment in palliative care units in a European country. Many of the 'top 15' drugs were drugs included in the list of essential drugs of the World Health Organisation though availability and cultural differences have an effect on the use of drugs, e.g., the high usage of dipyrone in Germany. Age and sex-related differences in drug therapy were seen, and more research is needed to recognize possible undertreatment of symptoms in subgroups of patients, e.g., treatment of depression in older or male patients.

The recent development of palliative care inpatient units in Germany has been impressive. As a first step for quality assurance, a core documentation form was developed in 1996. The core documentation form consisted of 4 pages with 35 items documenting physical and psychosocial symptoms at the time of admission, diagnostic and therapeutic procedures before and during inpatient treatment, and outcome of physical and psychosocial dimensions. Checklists were used for most items and free text entries could be added. Of the 65 palliative inpatient units in Germany, 44 participated in the second phase of the evaluation of the core documentation in 2000. Eight units were affiliated with anesthesiology departments, 31 with internal medicine, two with radiotherapy, 1 with a surgical department, and 2 units were not affiliated with a department of the hospital. A total of 1087 patients were assessed in the 44 units during a period of up to 3 months. There was a high variability between units in all checklist items of the core documentation. Compared to units affiliated with internal medicine departments, units affiliated with anesthesiology departments performed less chemotherapy, but more immunotherapy; gave fewer infusions and blood transfusions but more skin and wound care, and more lymphatic drainage and massage; and documented psychosocial interventions more frequently for patients as well as for relatives. In one-third of the patients, a consent for omission of therapeutic options was documented. Inpatient treatment ended with the death of the patient in 45.3% of patients and with discharge in 51.6% (not documented 3.1%). The efficacy of inpatient treatment was rated very high by the staff. In conclusion, we found large variation in the documentation pertaining to palliative care patients at the time of admission, as well as for inpatient treatment, among palliative care units in Germany. This was related to the affiliation of the units at least to some degree, but also to differences in interests and documentation discipline. We suggest that training procedures for documentation should be included in crossectional surveys, as the results may not be comparable otherwise. However, common documentation instruments may be the first step towards an interdisciplinary discussion on aims and methods in palliative care.

The purpose of this study was to investigate psychosocial stress in a large sample of cancer patients using an expert rating scale. Specific aims were to analyse the relevance of setting variables (type of clinic, contact initiative, therapy) and gender. A total of 6365 patients were assessed in 105 institutions. Univariate and multivariate statistical analysis of setting variables indicated that patients treated in palliative care settings showed highest distress scores compared to patients recruited from hospitals and outpatient clinics (Po0.001). Significant differences were also found for contact initiative (Po0.001); lowest distress was found in patients who were recruited by routine contact. Patients who asked for psychosocial support or who were recruited by the medical staff showed the highest distress scores. The analysis of therapy groups showed that patients receiving radiotherapy or surgery were not more distressed than patients without therapy. The most distressing treatment was chemotherapy. Gender had differential effects on clinic type (Po0.001) and contact initiative (Po0.001) but not on treatment and diagnosis. Expert rating scales are an important complement for self-assessment questionnaires to evaluate psychological distress of cancer patients in psychosocial studies as well as in routine medical care.

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