Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

Purpose: Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown. Methods: In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis. Results: Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n = 12, 18%) and poor (n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0–1.00) and 85.9% (75.4–92.0) (P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20–2.92) or receiving a written TLD (HR 2.32, CI 1.11–4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n = 12, 18%) or without (n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former. Conclusion: Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life

Präklinische Post-Cardiac-Arrest-Sedierung und -Behandlung in der Bundesrepublik Deutschland – eine webbasierte Umfrage unter notärztlichem Personal

Jansen G, Latka E, Deicke M, et al. Präklinische Post-Cardiac-Arrest-Sedierung und -Behandlung in der Bundesrepublik Deutschland – eine webbasierte Umfrage unter notärztlichem Personal. Medizinische Klinik - Intensivmedizin und Notfallmedizin. 2023.Hintergrund Die Optimierung der Postreanimationsbehandlung (PRB) rückt in den letzten Jahren zunehmend in den Fokus und erfordert oft eine Post-Cardiac-Arrest-Sedierung (PCAS). Diese Studie evaluiert die Durchführung von PCAS und PRB von deutschen Notarzt*innen. Material und Methoden Auswertung einer Onlineumfrage von Oktober bis November 2022. Gefragt wurde nach Durchführung, eingesetzten Medikamenten, Komplikationen und Beweggründen für die Durchführung oder den Verzicht auf eine PCAS sowie nach Maßnahmen des PRB. Ergebnisse Insgesamt nahmen 500 Notarzt*innen an der Umfrage teil, wovon 367 (73,4 %) Teilnehmende eine PCAS durchführten (Hypnotika: 84,7 %; Analgetika: 71,1 %; ergänzt um Relaxanzien: 29,7 %). Beweggründe waren Pressen (88,3 %), Analgesie (74,1 %), Synchronisation an den Respirator (59,5 %) und Wechsel eines extraglottischen auf einen endotrachealen Atemweg (52,6 %). Bewegründe für den Verzicht waren Bewusstlosigkeit (73,7 %), Sorge vor Hypotonie (31,6 %) bzw. Re-Arrest (26,3 %) und Verschlechterung der neurologischen Beurteilbarkeit (22,5 %). Beobachtete Komplikationen (19,3 %) waren Hypotension (74,6 %) und Re-Arrest (32,4 %). Die PRB umfasste 12-Kanal-Elektrokardiogramm (96,6 %); Kapnographie (91,6 %); Katecholamingabe (77,6 %); Sonographie von Herz (20,6 %), Lungen (12,0 %) und Abdomen (5,6 %), Hypothermie (13,6 %) und Blutgasanalyse (7,4 %). Ein etCO2 von 35–45 mm Hg wurde von 203 (40,6 %), ein SpO2 von 94–98 % von 45 (9,0 %) und ein systolischer Blutdruck von ≥ 100 mm Hg von 194 (19,2 %) angestrebt. Diskussion Die präklinische PRB ist heterogen und Abweichungen von in den Leitlinien empfohlenen Zielparametern sind häufig. Eine PCAS erfolgt häufig und ist mit relevanten Komplikationen verbunden. Die Entwicklung von präklinischen Versorgungsalgorithmen für PCAS und PRB erscheint dringend erforderlich.Background This study evaluates the implementation of postcardiac-arrest-sedation (PCAS) and -care (PRC) by prehospital emergency physicians in Germany. Materials and methods Analysis of a web-based survey from October to November 2022. Questions were asked about implementation, medications used, complications, motivation for implementing or not implementing PCAS, and measures and target parameters of PRC. Results A total of 500 emergency physicians participated in the survey. In all, 73.4% stated that they regularly performed PCAS (hypnotics: 84.7%; analgesics: 71.1%; relaxants: 29.7%). Indications were pressing against the respirator (88.3%), analgesia (74.1%), synchronization to respirator (59.5%), and change of airway device (52.6%). Reasons for not performing PCAS (26.6%) included unconscious patients (73.7%); concern about hypotension (31.6%), re-arrest (26.3%), and worsening neurological assessment (22.5%). Complications of PCAS were observed by 19.3% of participants (acute hypotension [74.6%]); (re-arrest [32.4%]). In addition to baseline monitoring, PRC included 12-lead-electrocardiogram (96.6%); capnography (91.6%); catecholamine therapy (77.6%); focused echocardiography (20.6%), lung ultrasound (12.0%) and abdominal ultrasound (5.6%); induction of hypothermia (13.6%) and blood gas analysis (7.4%). An etCO2 of 35–45 mm Hg was targeted by 40.6%, while 9.0% of participants targeted an SpO2 of 94–98% and 19.2% of participants targeted a systolic blood pressure of ≥ 100 mm Hg. Conclusions Prehospital PRC in Germany is heterogeneous and deviations from its target parameters are frequent. PCAS is frequent and associated with relevant complications. The development of preclinical care algorithms for PCAS and PRC within preclinical care seems urgently needed

Ergänzung des Dokumentationsbogens „Therapiebegrenzung“ unter Berücksichtigung eines möglichen Organspendewunsches: Empfehlung der Sektion Ethik sowie der Sektion Organspende und Organtransplantation der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI) unter Mitarbeit der Sektion Ethik der Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN)

The Ethics Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) recently published a documentation for decisions to withhold or withdraw life-sustaining therapies. The wish to donate organs was not considered explicitly. Therefore the Ethics Section and the Organ Donation and Transplantation Section of the DIVI together with the Ethics Section of the German Society of Medical Intensive Care Medicine and Emergency Medicine worked out a supplementary footnote for the documentation form to address the individual case of a patient's wish to donate organs

Decision-making support in Intensive Care to facilitate organ donation. Position paper of the Ethics Section and the Organ Donation and Transplantation Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) in collaboration with the Ethics Section of the German Society of Medical Intensive Care Medicine and Emergency Medicine (DGIIN)

Background and challengeInjuries, especially traumatic brain injury, or specific illnesses and their respective sequelae can result in the demise of the patients afflicted despite all efforts of modern intensive care medicine. If in principle organ donation is an option after apatient's death, intensive therapeutic measures are regularly required in order to maintain the homeostasis of the organs. These measures, however, cannot benefit the patient afflicted anymorewhich in turn might lead to an ethical conflict between dignified palliative care for him/her and expanded intensive treatment to facilitate organ donation for others, especially if the patient has opted for the limitation of life-sustaining therapies in an advance directive.MethodThe Ethics Section and the Organ Donation and Transplantation Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) have convened several meetings and atelephone conference and have arrived at adecision-making aid as to the extent of treatment for potential organ donors. This instrument focusses first on the assessment of five individual dimensions regarding organ donation, namely the certitude of acomplete and irreversible loss of all brain function, the patient's wishes as to organ donation, his or her wishes as to limiting life-sustaining therapies, the intensity of expanded intensive treatment for organ protection and the odds of its successful attainment. Then, the combination of the individual assessments, as graphically shown in a{Netzdiagramm}, will allow for ajudgement as to whether acontinuation or possibly an expansion of intensive care measures is ethically justified, questionable or even inappropriate.ResultThe aid described can help mitigate ethical conflicts as to the extent of intensive care treatment for moribund patients, when organ donation is amedically sound option.NoteGerald Neitzke und Annette Rogge contributed equally to this paper and should be considered co-first authors