title: Prehospital emergency physicians' experiences with advance directives in Germany: a questionnaire-based multicenter study.
abstract: BACKGROUND
  Palliative medical emergencies and end-of-life decisions resulting from the exacerbation of cancer account for approximately 3% of all out-of-hospital emergency applications in Germany. Therefore, prehospital emergency physicians (EP) may be confronted with advance directives and ethical and end-of-life decisions. The purpose of the study was to identify EPs' knowledge about ethical and end-of-life decisions and their legal education and experiences concerning advance directives.
  
  
  METHODS
  Over a six-month period, we questioned all 150 EPs from three emergency medical services (Braunschweig, Göttingen und Kaiserslautern). An anonymous, self-administered questionnaire with a mixed-methods design was used. The main outcome measures included responses regarding experiences related to advance directives and end-of-life decisions in palliative care patients. For statistical assessment, EPs were divided into three categories: competent, skilled, and unskilled.
  
  
  RESULTS
  A total of 104 EPs returned the questionnaire (response rate 69%). Eighty-nine percent of the respondents treated patients who had advance directives. The existence of an advance directive influenced the EP's therapy decision in about 77% of their encounters. Eighty-seven percent of the EPs reported the need for defined end-of-life care pathways and/or standard operating procedures. Eighty-two percent desired educational training concerning end-of-life decisions and the validity of advance directives.
  
  
  CONCLUSIONS
  The prehospital emergency treatment of palliative care patients can be particularly challenging for any EP. A high percentage of the EPs in our study felt insecure in dealing with advance directives and ethical and end-of-life decisions in palliative care patients. Our results suggest that EPs may need more information and education about palliative medical care, legal issues and ethical and end-of-life decisions to provide adequate patient-oriented palliative care in prehospital emergency situations.
authors.affiliation: Department of Anesthesiology, University Medical Center Regensburg, Regensburg Germany. christoph.wiese@klinik.uni-regensburg.de
authors.forename: C H R
authors.initials: CH
authors.lastname: Wiese
authors.forename: U E
authors.initials: UE
authors.lastname: Bartels
authors.forename: D B
authors.initials: DB
authors.lastname: Ruppert
authors.forename: B M
authors.initials: BM
authors.lastname: Graf
authors.forename: G G
authors.initials: GG
authors.lastname: Hanekop
mesh_terms: D000328:Adult; D024362:Advance Directive Adherence; D016223:Advance Directives; D004632:Emergency Medical Services / Q000592:standards*; D005260:Female; D005858:Germany; D006801:Humans; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000592:standards; D010820:Physicians; D011795:Surveys and Questionnaires; D013727:Terminal Care