Ethische Kompetenz im Rettungsdienst: Ausbildung professioneller Helfer - Ergebnisse einer Interviewstudie in Basel

Zusammenfassung: Fragestellung: Ziel der Studie war es, die ethischen Dimensionen von Reanimationsentscheidungen im Rettungsdienst zu untersuchen. Methode: Ein qualitatives Studiendesign wurde entwickelt, um ethische Entscheidungskriterien, persönliche Wertvorstellungen und Bedarf an Aus- und Weiterbildung zu erfragen. Mit Rettungsdienstmitarbeitern in Basel wurden 30 strukturierte Interviews geführt und nach der qualitativen Inhaltsanalyse ausgewertet. Ergebnisse: Notärzte und Rettungssanitäter beziehen eine Vielzahl ethischer Überlegungen in ihre Entscheidungen mit ein. Die Mehrheit äußerte Interesse an ethischer Schulung oder forderte sogar eine stärkere Verankerung ethischer Inhalte in Aus- und Weiterbildung. Schlussfolgerung: Konzepte für die Vermittlung medizinischer Ethik sollten den Bedürfnissen professioneller Helfer und den besonderen Gegebenheiten des Rettungsdienstes Rechnung trage

The role of relatives in decisions concerning life-prolonging treatment in patients with end-stage malignant disorders: informants, advocates or surrogate decision-makers?

Background: This study examines the extent to which relatives of severely ill cancer patients are involved in the decision to limit treatment (DLT), their role in communicating patient wishes and the incidence of and reasons for disagreement with relatives. Patients and methods: This cohort study followed 70 patients with terminal cancer, for whom a limitation of life-prolonging treatment was being considered. ‘Embedded researchers' recorded patients' wishes and the relatives' roles and disagreements with DLT. Results: Although 63 out of 70 patients had relatives present during their care, only 32% of relatives were involved in DLT. Physicians were more likely to know the end-of-life (EOL) preferences for those patients who had visiting relatives than those without them (78% versus 29%, P = 0.014). Most relatives supported patients in voicing their preferences (68%), but one-third acted against the known or presumed wishes of patients (32%). Disagreements with patients' relatives occurred in 21% of cases, and predominantly when relatives held views that contradicted known patient preferences (71% versus 7%, P = 0.001). Conclusion: If relatives are to play an important part in EOL decision making, we must devise strategies to recognise their potential as patients' advocates as well as their own need

Klinische Ethik als Partnerschaft - oder wie eine ethische Leitlinie für den patientengerechten Einsatz von Ressourcen entwickelt und implementiert werden kann

Zusammenfassung: Ethische Leitlinien für die klinische Praxis erfreuen sich zunehmender Beliebtheit. Damit klinisch-ethische Leitlinien aber überhaupt erfolgreich wirksam werden können, ist noch Pionierarbeit zu leisten. Solche Leitlinien müssen wissenschaftlich stärker fundiert und ihre praktische Anwendbarkeit muss verbessert werden. In dieser Arbeit werden die ersten Schritte des Projekts METAP zur methodischen Entwicklung und praktischen Implementierung einer Leitlinie für eine patientengerechte Versorgung am Krankenbett beschrieben und zur Diskussion gestellt. Das Projekt orientiert sich methodisch an der Entwicklung medizinischer Leitlinien und generiert damit eine forschungs- und konsensgestützte Leitlinie, die systematischer Evaluation und Modifikation unterliegt und Rechenschaft über ihre wissenschaftliche Fundierung gibt. Zusätzlich zur Leitlinie bietet das Projekt in der Form eines Handbuchs ein Entscheidungsfindungsverfahren an, welches unter anderem deliberative Aspekte unterstützt. Das Handbuch konzentriert sich auf ethische Fragen der Mikroallokation und liefert darüber hinaus Informationen über empirische, ethische und rechtliche Grundlagen für Therapieentscheidungen. Anhand eines Eskalationsmodells können unterschiedliche Instrumente nach Bedarf als ethische Lösungsstrategien eingesetzt werden, von der Kurzfassung im Kitteltaschenformat ("Leporello") mit den wichtigsten Fakten, weiterführenden Texten und Empfehlungen mit normativen und prozeduralen Hinweisen, über stationsinterne Lösungsversuche bis hin zum Ethikkonsil. Klinische Partner sind von Beginn an aktiv in den Entwicklungsprozess eingebunden und verbessern so die Praxistauglichkeit und Akzeptanz sowie die Ausrichtung des Instrumentariums an den tatsächlichen Bedürfnissen. Dieses partnerschaftliche, partizipative Vorgehen scheint eine wichtige Voraussetzung dafür zu sein, dass METAP in der Klinik Fuß fassen konnt

Measurement in Economics and Social Science

The paper discusses measurement, primarily in economics, from both analytical and historical perspectives. The historical section traces the commitment to ordinalism on the part of economic theorists from the doctrinal disputes between classical economics and marginalism, through the struggle of orthodox economics against socialism down to the cold-war alliance between mathematical social science and anti-communist ideology. In economics the commitment to ordinalism led to the separation of theory from the quantitative measures that are computed in practice: price and quantity indexes, consumer surplus and real national product. The commitment to ordinality entered political science, via Arrow’s ‘impossibility theorem’, effectively merging it with economics, and ensuring its sterility. How can a field that has as its central result the impossibility of democracy contribute to the design of democratic institutions? The analytical part of the paper deals with the quantitative measures mentioned above. I begin with the conceptual clarification that what these measures try to achieve is a restoration of the money metric that is lost when prices are variable. I conclude that there is only one measure that can be embedded in a satisfactory economic theory, free from unreasonable restrictions. It is the Törnqvist index as an approximation to its theoretical counterpart the Divisia index. The statistical agencies have at various times produced different measures for real national product and its components, as well as related concepts. I argue that all of these are flawed and that a single deflator should be used for the aggregate and the components. Ideally this should be a chained Törnqvist price index defined on aggregate consumption. The social sciences are split. The economic approach is abstract, focused on the assumption of rational and informed behavior, and tends to the political right. The sociological approach is empirical, stresses the non-rational aspects of human behavior and tends to the political left. I argue that the split is due to the fact that the empirical and theoretical traditions were never joined in the social sciences as they were in the natural sciences. I also argue that measurement can potentially help in healing this split

A Rejoinder on Energy versus Impact Indicators

Citation distributions are so skewed that using the mean or any other central tendency measure is ill-advised. Unlike G. Prathap's scalar measures (Energy, Exergy, and Entropy or EEE), the Integrated Impact Indicator (I3) is based on non-parametric statistics using the (100) percentiles of the distribution. Observed values can be tested against expected ones; impact can be qualified at the article level and then aggregated.Comment: Scientometrics, in pres

Predictability of large future changes in a competitive evolving population

The dynamical evolution of many economic, sociological, biological and physical systems tends to be dominated by a relatively small number of unexpected, large changes (`extreme events'). We study the large, internal changes produced in a generic multi-agent population competing for a limited resource, and find that the level of predictability actually increases prior to a large change. These large changes hence arise as a predictable consequence of information encoded in the system's global state.Comment: 10 pages, 3 figure

CONSENSUS CONFERENCE REPORT ON LIVER* TRANSPLANTATION.

Liver transplantation has been developed to the point of a service operation, the exploitation of which depends upon the establishment of multiple regional centers. The increased use of this procedure will permit the delivery of optimum health care to victims of end stage liver disease

A Mission to Explore the Pioneer Anomaly

The Pioneer 10 and 11 spacecraft yielded the most precise navigation in deep space to date. These spacecraft had exceptional acceleration sensitivity. However, analysis of their radio-metric tracking data has consistently indicated that at heliocentric distances of $\sim 20-70$ astronomical units, the orbit determinations indicated the presence of a small, anomalous, Doppler frequency drift. The drift is a blue-shift, uniformly changing with a rate of $\sim(5.99 \pm 0.01)\times 10^{-9}$ Hz/s, which can be interpreted as a constant sunward acceleration of each particular spacecraft of $a_P = (8.74 \pm 1.33)\times 10^{-10} {\rm m/s^2}$. This signal has become known as the Pioneer anomaly. The inability to explain the anomalous behavior of the Pioneers with conventional physics has contributed to growing discussion about its origin. There is now an increasing number of proposals that attempt to explain the anomaly outside conventional physics. This progress emphasizes the need for a new experiment to explore the detected signal. Furthermore, the recent extensive efforts led to the conclusion that only a dedicated experiment could ultimately determine the nature of the found signal. We discuss the Pioneer anomaly and present the next steps towards an understanding of its origin. We specifically focus on the development of a mission to explore the Pioneer Anomaly in a dedicated experiment conducted in deep space.Comment: 8 pages, 9 figures; invited talk given at the 2005 ESLAB Symposium "Trends in Space Science and Cosmic Vision 2020", 19-21 April 2005, ESTEC, Noordwijk, The Netherland