DÄ internationalArchive25/2016Recommendations Require Critical Appraisal in Individual Cases
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Although the S3 guideline on palliative care (1) and the information contained therein are doubtless of great value, the recommendations cannot and should not be adopted without critical appraisal. The best basis for the appropriate care of advanced-cancer patients comprises a thorough diagnostic work-up involving the investigation of an optionally large number of signs and symptoms relevant in oncology, pain medicine, internal medicine, neurology, psychiatry, and dermatology, among other specialties. This provides an appropriate treatment plan aimed at achieving the best possible quality of life for the patient and their relatives.

For example, the recommendation “When opioids are used, accompanying medication to prevent constipation is recommended” is not universally valid for a number of reasons:

  • Not all cancer patients are affected by constipation. According to ten studies covering 12 438 cancer patients, diarrhea was present in 7.6% (2).
  • Although opioid administration frequently causes constipation, this is not necessarily always the case.
  • According to our own observations, combining the opioid tilidine, which was developed and is frequently used in Germany, with naloxone only rarely causes constipation (3). The similar oxycodone–nalaxone combination developed later also reduces the occurrence of constipation (4), thereby improving quality of life.

Therefore, statistical findings should be extrapolated to the individual case only with critical scrutiny, particularly in the end-of-life setting.

DOI: 10.3238/arztebl.2016.0433b

PD Dr. med. Roland Wörz, M.A. Medical Ethics

Neurologie, Psychiatrie, Spezielle Schmerztherapie,

Klinische Geriatrie, Bad Schönborn

woerz.roland@t-online.de

Conflict of interest statement
The author declares that no conflicts of interest exist.

1.
Bausewein C, Simon ST, Pralong A, Radbruch L, Nauck F, Voltz R:
Clinical practice guideline: Palliative care of adult patients with
cancer. Dtsch Arztebl Int 2015; 112: 863–70 VOLLTEXT
2.
Bernatzky G, Likar R: Der Schmerz: Häufigkeit und Entstehung tumorbedingter Schmerzen. In: Bernatzky G, Sittl R, Likar R (eds.): Schmerzbehandlung in der Palliativmedizin. Wien, New York: Springer 2004; 13–24 CrossRef CrossRef
3.
Wörz R: Karzinomschmerz. In: Wörz R (ed.): Differenzierte medikamentöse Schmerztherapie. 2nd edition. München, Jena: Urban & Fischer 2001; 340.
4.
Meissner W, Leyendecker P, Mueller-Lissner S, Nadstawek JA: A
randomised controlled trial with prolonged-release oral oxycodone and naloxone to prevent and reverse opioid-induced constipation. Europ Pain 2009; 13: 56–64 CrossRef MEDLINE
1.Bausewein C, Simon ST, Pralong A, Radbruch L, Nauck F, Voltz R:
Clinical practice guideline: Palliative care of adult patients with
cancer. Dtsch Arztebl Int 2015; 112: 863–70 VOLLTEXT
2.Bernatzky G, Likar R: Der Schmerz: Häufigkeit und Entstehung tumorbedingter Schmerzen. In: Bernatzky G, Sittl R, Likar R (eds.): Schmerzbehandlung in der Palliativmedizin. Wien, New York: Springer 2004; 13–24 CrossRef CrossRef
3. Wörz R: Karzinomschmerz. In: Wörz R (ed.): Differenzierte medikamentöse Schmerztherapie. 2nd edition. München, Jena: Urban & Fischer 2001; 340.
4.Meissner W, Leyendecker P, Mueller-Lissner S, Nadstawek JA: A
randomised controlled trial with prolonged-release oral oxycodone and naloxone to prevent and reverse opioid-induced constipation. Europ Pain 2009; 13: 56–64 CrossRef MEDLINE

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