In Reply

We welcome the positive feedback on and recognition of the S3 guideline on palliative care expressed in the correspondence formulated by Professors Kratz and Diefenbacher, as well as by Dr. Wörz.

Kratz and Diefenbacher confirm that recognizing and treating delirium in the dying phase is an important clinical task. They point out that in particular the prevention of delirium is key in palliative care of cancer patients and recommend the use of specially trained nurses. However, the extent to which recommendations on the prevention of postoperative delirium can be extrapolated to the dying phase first needs to be investigated before recommendations can be derived on this basis.

Wörz suggests that the recommendation relating to constipation prevention under opioid therapy is subject to restrictions. Guideline recommendations should never be “adopted without critical assessment”: for this reason, there are no key recommendations formulated with “have to, or to be obliged,” the strongest level of recommendation is “must.” As such, any deviation from these recommendations should be well founded.

The key recommendation on the prevention of constipation is as follows: “In patient with incurable cancer, drug-based prophylaxis must be started alongside the use of opioids and be regularly adjusted as needed.”

This recommendation applies to the vast majority of patients receiving opioid treatment. One of the few exceptions was mentioned (diarrhea), in the case of which no constipation prophylaxis should be undertaken—this, however, should be regularly monitored in the further course. The absence of constipation in opioid treatment should not, under any circumstances, automatically result in the discontinuation of constipation prophylaxis, but as a rule rather represents the effective prophylaxis of precisely this treatment. This key recommendation is, in our opinion, extremely relevant in clinical routine, since constipation prophylaxis is often forgotten during opioid treatment.