Ethisch begründet entscheiden in der Intensivmedizin.

The process recommendations of the Ethics Section of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) for ethically based decision-making in intensive care medicine are intended to create the framework for a structured procedure for seriously ill patients in intensive care. The processes require appropriate structures, e.g., for effective communication within the treatment team, with patients and relatives, legal representatives, as well as the availability of palliative medical expertise, ethical advisory committees and integrated psychosocial and spiritual care services. If the necessary competences and structures are not available in a facility, they can be consulted externally or by telemedicine if necessary. The present recommendations are based on an expert consensus and are not the result of a systematic review or a meta-analysis.

[Simulation-based training for a hospital incident command group]. / Simulationstraining für die operative Krankenhauseinsatzleitung.

BACKGROUND: We report on immersive simulation scenarios with video-enhanced debriefing as part of a full day education program for members of a newly implemented hospital incident command group. The hospital incident command group has a key function in the initial phase of a hospital crisis. Simulation exercises were used to provide practical experience for the participants in a yet unknown task area and to support the acquisition of professional and personal competencies. OBJECTIVES: Are immersive simulation scenarios with video-enhanced debriefing a suitable method as part of an education program to change the perceptions of participants about their tasks and enhance their motivation to assume leadership positions? MATERIALS AND METHODS: Participants of a 1­day educational workshop completed immersive simulation scenarios during which they took on roles and responsibilities of a hospital incident command group. A final questionnaire with a 5-point Likert scale was used to capture changes in specific knowledge and perceptions as a result of the simulation experience. RESULTS AND CONCLUSION: The vast majority of participants assessed the immersive simulation scenarios as effective in changing their perceptions and to motivate them to become part of a hospital incident command group. Simulation with video-enhanced debriefing is a suitable method for providing professional and personal competencies to members of a hospital incident command group.

[Dealing with coercion in intensive care medicine : Recommendations from the Ethics Section of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) in collaboration with the Ethics Section of the German Society for Internal Intensive Care and Emergency Medicine (DGIIN)]. / Umgang mit Zwang in der Intensivmedizin : Empfehlung der Sektion Ethik der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI) unter Mitarbeit der Sektion Ethik der Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN).

The treatment situation in intensive care is characterised by a specific asymmetry in the relationship between patients and the team: Patients are particularly dependent on their environment and often show impaired consciousness and capacity to consent. This facilitates the use of coercion or enables and/or provokes it. The aim of this recommendation is to show ways to recognise patients with their wishes and needs and to integrate them into treatment concepts in the intensive care unit in order to reduce and avoid coercion whenever possible. The recommendation shows the variety of possible forms of coercion and discusses the moral standards to be considered in the ethical weighing process as well as legal conditions for justifying its use. It becomes obvious that treatment measures which may involve the use of coercion always require a careful and self-critical review of the measures in relation to the indication and the therapeutic goal. The recommendation's intention therefore is not to disapprove the use of coercion by interprofessional teams. Instead, it aims to contribute to a sensitive perception of coercion and to a critical and caring approach to formal and especially informal (indirect) coercion.

[Overtreatment in intensive care medicine-recognition, designation, and avoidance : Position paper of the Ethics Section of the DIVI and the Ethics section of the DGIIN]. / Überversorgung in der Intensivmedizin: erkennen, benennen, vermeiden : Positionspapier der Sektion Ethik der DIVI und der Sektion Ethik der DGIIN.

Despite social laws, overtreatment, undertreatment, and incorrect treatment are all present in the German health care system. Overtreatment denotes diagnostic and therapeutic measures that are not appropriate because they do not improve the patients' length or quality of life, cause more harm than benefit, and/or are not consented to by the patient. Overtreatment can result in considerable burden for patients, their families, the treating teams, and society. This position paper describes causes of overtreatment in intensive care medicine and makes specific recommendations to identify and prevent it. Recognition and avoidance of overtreatment in intensive care medicine requires measures on the micro-, meso- and macrolevels, especially the following: (1) frequent (re-)evaluation of the therapeutic goal within the treating team while taking the patient's will into consideration, while simultaneously attending to the patients and their families; (2) fostering a patient-centered corporate culture in the hospital, giving priority to high-quality patient care; (3) minimizing improper incentives in health care financing, supported by reform of the reimbursement system that is still based on diagnose-related groups; (4) strengthening of interprofessional co-operation via education and training; and (5) initiating and advancing a societal discourse on overtreatment.

Spinal cord stimulation in sympathetically maintained complex regional pain syndrome type I with severe disability. A prospective clinical study.

BACKGROUND AND PURPOSE: In this prospective trial we assessed the long-term effect of spinal cord stimulation (SCS) on the improvement of functional status in complex regional pain syndrome type I (CRPS I). METHODS: A prerequisite for eligibility to SCS treatment was the responsiveness of patients to sympathetic nerve block. In 29 patients with chronic sympathetically maintained CRPS I, the efficacy of SCS on deep pain, allodynia and functional disability was determined. Pain intensity was estimated during SCS free intervals of 45 min (inactivation test) every 3 months and compared with that under SCS treatment. RESULTS: On SCS treatment, both deep pain and allodynia could be permanently reduced from 10 to 0-2 on a 10 cm visual analogue scale (VAS) (p<0.01). During the inactivation tests, reoccurrence of pain up to 8 VAS (quartiles 6-8) was measured. Considerable impairments in daily living activities, objectified by the pain disability index, were also restored (p<0.01). After a follow-up period of 35.6+/-21 months, 12 of 16 patients with affected upper limb showed significant increase of the fist grip strength from 0 to 0.35 (quartiles 0.1-0.5) kg compared with 0.9 (quartiles 0.7-1.1) kg on the unaffected side (p<0.01). Eight of ten patients with lower limb disability resumed walking without crutches. Previous pain medication could be significantly reduced (p<0.01). CONCLUSIONS: As a result of permanent pain relief under long-term SCS combined with physiotherapy, the functional status and the quality of life could be significantly improved in sympathetically maintained CRPS I.

Interface between hospital and fire authorities--a concept for management of incidents in hospitals.

INTRODUCTION: Although every hospital needs a security plan for the support of immobile patients who do not possess autonomous escape capabilities, little information exists to assist in the development of practical patient evacuation methods. HYPOTHESIS: 1) In hospitals during disasters, incident leadership of the fire authorities can be supported effectively by hospital executives experienced in the management of mass casualties; and 2) As an alternative for canvas carry sheets, rescue drag sheets can be employed for emergency, elevator-independent, patient evacuation. METHODS: A hospital evacuation exercise was planned and performed to obtain experiences in incident command and to permit calculation of elevator-independent patient transport times. Performance of incident leadership was observed by means of pre-defined checklists. The effectiveness and efficiency of carrying teams with five persons each were compared to those with a rescue drag sheet employed by a single person. RESULTS: Incident command for hospitals during a disaster is enhanced considerably by pre-defined and trained executives who are placed at the immediate disposal of the fire authorities. For elevator-independent patient transport, the rescue drag sheet was superior to conventional carrying measures because of a reduced number of transport personnel required to move each patient. With this method, patient transport times averaged 54 m/min. flat and 18 seconds for one floor descent. CONCLUSION: Experiences from a hospital during an evacuation exercise provided decision criteria for changes in the disaster preparedness plan. Hospital incident leadership was assigned to executives-in-charge in close co-operation with the fire authorities. All beds were equipped with a rescue drag sheet. Both concepts may help to cope with an emergency evacuation of a hospital.

Spinal cord stimulation in postherpetic neuralgia and in acute herpes zoster pain.

UNLABELLED: We studied the effects of spinal cord stimulation (SCS) on postherpetic neuralgia (PHN). Data of 28 patients were prospectively investigated over a median period of 29 (quartiles 9--39) mo. In addition, four patients with acute herpes zoster (HZ) pain were studied simultaneously. After intractable pain for more than 2 yr, long-term pain relief was achieved in 23 (82%) PHN patients (median, 70 yr) during SCS treatment confirmed by a median decrease from 9 to 1 on the visual analog scale (P < 0.001). In five cases with serious comorbidity, the initial pain alleviation could not be stabilized. Spontaneous improvement was always confirmed or excluded by SCS inactivation tests at quarterly intervals. Eight patients discontinued SCS permanently because of complete pain relief after stimulation periods of 3--66 mo, whereas 2 reestablished SCS because of recrudescence after 2 and 6 mo. Considerable impairments in everyday life, objectified by the pain disability index, were also significantly improved (P < 0.001). In 4 patients with acute HZ pain, SCS was promptly effective and after periods of 2.5 (quartiles 2--3) months the pain had subsided. SCS seems to offer a therapeutic option for pharmacological nonresponders. IMPLICATIONS: In many patients with postherpetic neuralgia and acute herpes zoster pain is not satisfactorily alleviated with pharmacological approaches. We report on 23 of 28 patients with postherpetic neuralgia and 4 of 4 with acute herpes zoster whose chronic pain was improved by electrical spinal cord stimulation.