[Ethical case discussions in the intensive care unit : from testing to routine]. / Ethische Fallbesprechungen auf der Intensivstation : Vom Versuch zur Routine.

BACKGROUND: The daily work of many healthcare professionals has become more complex and demanding in recent years. Apart from purely medical issues, ethical questions and problems arise quite often. Managing these problems requires ethical knowledge. Questions about the usefulness of a therapy and treatment occur especially at the end of life. So-called medical futility, a useless futile therapy, is often perceived by nurses and physicians in intensive care units who themselves often develop symptoms of depression or burnout. The clinical ethical model METAP (acronym from module, ethics, therapy decision, allocation and process) provides methods and criteria that allow the clinical team to treat and solve ethical issues according to a solution-oriented approach. The ethical decision-making of this model addresses these issues according to a series of sequential stages in the form of a so-called escalation model. When it is not possible to tackle and solve an ethical problem or dilemma in one stage, one moves to the next. The implementation of this approach in everyday practice requires the commitment of all team members in addition to certain basic conditions. MATERIAL AND METHODS: In a surgical intensive care unit a fixed date in the schedule is reserved for ethical case discussions (level 3 of the escalation model). At this level a team member who has been specified according to a quarterly plan is responsible for the organization and performance of the discussion. All protocols of the 44 ethical case discussions in 41 patients between January 2011 and July 2012 were collected and summarized. A short questionnaire to all participants recorded their assessment of the benefits for the patient and the team as well as their perception of personal stress reduction. Also queried was the impact of this method on the collaboration between nurses and physicians and the ethical competence. RESULTS: Ethical case discussions among the care team took place regularly (44 case discussions between January 2011 and June 2012). The duration of these discussions ranged from 30 to 60 min. On average 6.2 persons took part, including 2.7 nurses and 3.2 physicians. Of the 41 patients (16 female, 25 male) for whom a discussion was carried out, 23 died during the continued hospital stay. The respondents (response rate 52 %) assessed the benefit for patients and team as high (slightly higher benefit for physicians than nurses) and 55 % of physicians and 71 % of nurses perceived a reduction in the burden of decision-making in difficult cases due to the case discussions. All physicians and 66 % of the nurses reported an improvement in the cooperation between the professional groups and 80 % of the nurses and more than half of the physicians noticed an increase in their own ethical competence. CONCLUSION: A methodically structured ethical decision-making process can and should be integrated into the clinical routine. This process requires a fixed place in everyday practice and the defined responsibility for the actual organization and performance. Support by medical and nursing management personnel is also essential for the implementation. The regular occurrence of ethical case discussions among the care team relieves the participants and improves collaboration between nurses and physicians.

[Clinical everyday ethics-support in handling moral distress? : Evaluation of an ethical decision-making model for interprofessional clinical teams]. / Klinische Alltagsethik - Unterstützung im Umgang mit moralischem Disstress? : Evaluation eines ethischen Entscheidungsfindungsmodells für interprofessionelle klinische Teams.

BACKGROUND: High-tech medicine and cost rationing provoke moral distress up to burnout syndromes. The consequences are severe, not only for those directly involved but also for the quality of patient care and the institutions. The multimodal model METAP (Modular, Ethical, Treatment, Allocation, Process) was developed as clinical everyday ethics to support the interprofessional ethical decision-making process. The distinctive feature of the model lays in education concerning ethics competence in dealing with difficult treatment decisions. METAP has been evaluated for quality testing. METHODS: The research question of interest was whether METAP supports the handling of moral distress. The evaluation included 3 intensive care units and 3 geriatric units. In all, 33 single and 9 group interviews were held with 24 physicians, 44 nurses, and 9 persons from other disciplines. An additional questionnaire was completed by 122 persons (return rate 57%). RESULTS: Two-thirds of the interview answers and 55% of the questionnaire findings show that clinical everyday ethics supports the handling of moral distress, especially for interdisciplinary communication and collaboration and for the explanation and evaluation of treatment goals. METAP does not provide support for persons who are rarely confronted with ethical problems or have not applied the model long enough yet. CONCLUSION: To a certain degree, moral distress is unavoidable and must be addressed as an interprofessional problem. Herein, clinical everyday ethics may provide targeted support for ethical decision-making competence.