Der Urologe. Ausg. A
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Terminal illnesses can cause distressing symptoms such as severe pain, mental confusions, feelings of suffocation, and agitation. Despite skilled palliative care in some cases these symptoms may not respond to standard interventions. After all other means to provide comfort and relief to a dying patient have been tried and are unsuccessful, clinical caregivers and patients can consider palliative sedation. ⋯ Palliative sedation is not intended to cause death or shorten life. The patient and family should agree with plans for palliative sedation. Because cases involving palliative sedation are emotionally stressful, the patient, family, and health care workers can all benefit from talking about the complex medical, ethical, and emotional issues they raise.
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The World Health Organization guidelines for cancer pain therapy from 1986 are still valid. A prerequisite for adequate pain palliation is an exact anamnesis and pain diagnosis. A multimodal, staged therapeutic concept then needs to be formulated according to the requirements of the patient. ⋯ In case of persistent pain these are replaced by strong opioids. The availability of new opioids and/or preparations admits a more sophisticated approach to metabolic disorders and specific pain syndromes. Depending on the presenting pain type, co-analgesics might be added.
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In 2002, with its "Off-label verdict", the German Federal Social Court (Bundessozialgericht; BSG) issued a fundamental decision to the effect that in certain circumstances an off-label prescription might be payable by health insurance firms, these circumstances being: severe illness with no prospect of a cure being brought about by any therapy approved for this illness and an evidence-based chance that an off-label treatment could yield a cure. Subsequently, the former German Federal Ministry of Health and Social Security (BMGS) appointed its "expert group on off-label use of treatments". This panel's task was to formulate professional comments and expert recommendations to the Federal Joint Committee (G-BA) on scientific evidence relating to selected medications used for off-label treatment. ⋯ However, the constant increase in the amount of medical evidence available means that off-label use is a continuing process that cannot easily be regulated by expert committees. It would be preferable for reimbursement for off-label prescriptions to be linked to the qualifications of the attendant physician. One suggestion might be that only specifically authorised physicians with special additional skills be permitted to apply and be reimbursed for off-label prescriptions.