Der Schmerz
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During the last 20 years a great number of studies have emphasized the potential role of psychological factors as relevant predictors for the first onset of back pain as well as for the development of chronic pain. The formulation of a biopsychosocial perspective of the etiology and chronicity of back pain was a natural consequence. Actual questions concern the relative impact of psychological risk factors in the process of chronicity of back pain compared to biomedical, social and occupational factors. ⋯ 20 years of research, several qualitative reviews and a recently published systematic review of 37 good-quality prospective studies regarding the role of psychological, biomedical, social and objective occupational factors in the process of chronicity of back pain revealed that psychological factors are significantly related to the onset of back pain as well as to the development of chronic pain. Furthermore, the psychological factors displayed more predictive power than biomedical or biomechanical variables. As a consequence for clinical practice, these psychological risk factors have to be considered as "yellow flags" if a back pain problem won't respond to medical treatment for more than four weeks. As a further consequence, special risk factor - based psychosocial interventions should be offered in addition to the medical treatment to patients with high psychological risk factors for the development of chronic pain. The efficacy of such an interdisciplinary care in the very early phases of back pain in order to prevent chronicity of pain and disability has been published recently by our group.
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Back pain causes high costs to society. In Germany, these amount to an estimated total of 5 billion euro of direct costs per year and 13 billion euro of indirect costs, the latter being caused by incapacity to work. The purpose of this study is to develop a concept for economic rehabilitation management. This concept is based on the managed care approach and aims at improving efficiency of care. ⋯ Economic rehabilitation management might help to save money and to improve health outcomes, thus increasing the efficiency of care. The results of our empirical studies show the feasibility of tools for the economic management of rehabilitation. Risk adjustment of the management components is of paramount importance.
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From all symptoms in palliative medicine those concerning respiration are most excruciating and most difficult to treat. No other symptom is more dependent on psychosocial circumstances and on the atmosphere around the patient. ⋯ A team present twenty-four hours a day, the training of relatives and friends, the frank dealing with the patient's anxiety of suffocation are the basis of all therapeutic measures. Dyspnea often is the reason for a longer stay in a palliative care unit.
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Nursing in palliative medicine requires new pathways to secure an appropriate care which focuses on the patients quality of life. Besides accepting the incurability of the life threatening illness competence in pain therapy, symptom control and spiritual and ethical issues are necessary. Flexibility and creativity within the nursing practice are important to ensure that the patients requirements are met in an appropriate way. ⋯ Both are important prerequisites, but they have to be broadened by a specific competence. In Great Britain it is determined that it is the right of every person with a life threatening illness to receive appropriate palliative care and that every health care professional has to be able to practise the palliative care approach. In Germany we have to strive for a development equivalent to Great Britain.
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Within their psychosocial problems, badly ill patients and their families often feel left alone by caregivers, as there are physicians and nurses. It is the caregiver's task to allow patients to communicate all their feelings, not seeking to mollify, or banish them by attempting to cheer up or distract the patient. ⋯ Both of them, caregiver and patient have to find out their primary goals and challenges in the process of dying and come to an agreement. Communicating with a dying patient and being with him in the last period of his life presupposes a deepened communication with oneself and the own hopes and fears.