Schwierige Therapieentscheidungen bei Schlaganfall und Demenz – Aspekte bei schweren vaskulären und fortgeschrittenen degenerativen Hirnerkrankungen

Jürgen Guldner

doi:10.1055/a-1011-9883

DMW - Deutsche Medizinische Wochenschrift, Inhaltsverzeichnis

Dtsch Med Wochenschr 2020; 145(06): 399-405
DOI: 10.1055/a-1011-9883

Übersicht

Schwierige Therapieentscheidungen bei Schlaganfall und Demenz – Aspekte bei schweren vaskulären und fortgeschrittenen degenerativen Hirnerkrankungen

Difficult Decisions in Therapy of Severe Stroke and Progressed Neurodegenerative Disease – Decision process in fields of limited communication and willing capability

Jürgen Guldner

Abstract

Severe stroke and neurodegenerative diseases often cause limitations in communication and willing capability. Decision processes in these conditions assume primarily a positive medical indication for any intervention. If not obtainable from an individual by itself, by a disposal or by a legal custodian, the presumed will of a patient has to be detected carefully. Evidence can be raised by an interview of relatives or an individual case discussion in a local ethical comitee. Stroke and dementia can raise the need for palliative care, especially a sufficient analgesia as well as other severe illnesses. Pain in demented persons is often underrated and undertreated. The diagnosis of dementia alone does not limit the indication for curative therapy in general. Ethical comitees or ethical visits are helpful instruments to find out an adequate decision in difficult situations.

Schwerer Schlaganfall und neurodegenerative Erkrankungen führen häufig zu Kommunikationsstörungen bzw. Beeinträchtigungen der Willensfähigkeit. Entscheidungsprozesse unter diesen Bedingungen setzen in erster Linie eine positive medizinische Indikation für einen Eingriff voraus. Liegt diese vor, muss bei unklarer Verfügung der mutmaßliche Wille eines Patienten sorgfältig ermittelt werden. Dieser Beitrag stellt Entscheidungshilfen vor.

Schlüsselwörter

Schlaganfall - Demenz - Entscheidungsfindung - Palliativmedizin

Key words

stroke - dementia - decision process - palliative care

Volltext

Referenzen

Literatur
1 Kohler M, Deutschbein J, Peschke D. et al Stroke occurence in Germany-on the comparability of insurance data and registry-based data. Fortschr Neurol Psychiatr 2014; 82: 627-633 . doi:10.1055/s-0034-1385231
2 Feigin VL, Norrving B, Mensah GA. Global burden of stroke. Circ Res 2017; 120: 439-448 . doi:10.1161/CIRCRESAHA.116.308413
3 Vahedi K, Hofmeijer J, Juettler E. et al Early decompressive surgery in malignant infarction of the middle cerebral artery. Lancet Neurol 2007; 6: 215-222 . doi:10.1016/S1474-4422(07)70036-4
4 Wilmskoetter J, Bonilha L, Martin-Harris B. et al Factors influencing oral intake improvement and feeding tube dependency in patients with poststroke dysphagia. J Stroke Cerebrovasc Dis 2019; 28: 1421-1430 . doi:10.1016/j.strokecerebrovasdis.2019.03.031
5 Satizabal CL, Beiser AS, Chouraki V. et al Incidence of dementia over three decades in the Framingham Heart Study. N Engl J Med 2016; 374: 523-532 . doi:10.1056/NEJMoa1504327
6 Gripp S, Moeller S, Bölke E. et al Survival prediction in terminally ill cancer patients by clinical estimates, laboratory tests, and self-rated anxiety and depression. J Clin Oncol 2007; 25: 3313-3320 . doi:10.1200/JCO.2006.10-5411
7 Förstl H, Bickel H, Kurz A. et al Sterben mit Demenz: Versorgungssituation und palliativmedizinischer Ausblick. Fortschr Neurol Psychiat 2010; 78: 203-212 . doi:10.1055/s-0029-1245260
8 Kaassalainen S, Middleton J, Knezacek S. et al Pain and cognitive status in the institutionalized elderly: perceptions & interventions. J Gerontol Nurs 1998; 24: 24-31 . doi:10.3928/0098-9134-19980801-07
9 Peisah C, Weaver J, Wong L. et al Silent and suffering: a pilot study exploring gaps between theory and practice in pain management for people with severe dementia in residential aged care facilities. Clin Interv Aging 2014; 9: 1767-1774 . doi:10.2147/CIA.S64598
10 Booij SJ, Rödig V, Engberts DP. et al Euthanasia and advance directives in Huntington’s disease: qualitative analysis of interviews with patients. J Huntington’s Dis 2013; 2: 323-330 . doi:10.3233/JHD-130060
11 Pennington C. To PEG or not to PEG. Clin Med (London) 2002; 2: 250-255 . doi:10.7861/clinmedecine.2-3-250
12 McCann R, Hall WJ, Groth-Juncker A. Comfort care for terminally ill patients. The appropriate use of nutrition and hydration. JAMA 1994; 272: 1263-1266 . doi:10.1001/jama1994.03520160047041
13 Sanders DS, Carter MJ, D‘Silva J. et al Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia. Am J Gastroenterol 2000; 95: 1472-1475 . doi:10.1111/j.1572-0241.2000.02079.x
14 Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev 2009; 15: CD007209 . doi:10.1002/14651858.CD007209.pub2
15 Teno JM, Gozalo P, Mitchell SL. et al Feeding tubes and the prevention or healing of pressure ulcers. Arch Intern Med 2012; 172: 697-701 . doi:10.1001/archinternmed.2012.1200