ABSTRACT
BACKGROUND AND CHALLENGE: Injuries, 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 a patient'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 anymore-which 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. METHOD: The 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 a telephone conference and have arrived at a decision-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 a complete 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 a judgement as to whether a continuation or possibly an expansion of intensive care measures is ethically justified, questionable or even inappropriate. RESULT: The aid described can help mitigate ethical conflicts as to the extent of intensive care treatment for moribund patients, when organ donation is a medically sound option. NOTE: Gerald Neitzke und Annette Rogge contributed equally to this paper and should be considered co-first authors.
Subject(s)
Decision Making , Emergency Medicine , Organ Transplantation , Tissue and Organ Procurement , Critical Care , Humans , Organ Transplantation/ethics , Tissue Donors , Tissue and Organ Procurement/ethicsABSTRACT
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.
Subject(s)
Critical Care , Emergency Medicine , Medical Overuse , Critical Care/statistics & numerical data , Germany , HumansABSTRACT
During the 17th annual meeting, the German Interdisciplinary Association of Critical Care Medicine (DIVI) celebrated its 40th anniversary. On this occasion a speech was given with the following content. In 1977, the DIVI was founded as an umbrella association for medical societies involved in critical care. It became a well-respected representative for matters of critical care medicine. During the following period, many important recommendations for critical care were issued, such as on structural and staffing standards, further education, treatment concepts, etc. In 2007, DIVI was changed into a membership society. The activities within the society are mostly done within the sections where members of the various disciplines (internists, anesthesiologists, neurologists, etc.) and professions (physicians, nurses) cooperate together on special topics. Currently, critical care in Germany has to overcome severe problems: rigorous economic pressure, critical lack of staff, missing professional long-term perspectives for intensivists, weak representation at international conferences. DIVI and its contributing societies must urgently join together in order to overcome these existential problems.
Subject(s)
Anniversaries and Special Events , Critical Care , Germany , Humans , Societies, MedicalABSTRACT
BACKGROUND: The German "Hospital Structure Act" intends to align the state hospital planning on quality criteria. Within this process cost-utility analyses (CUAs) shall be used to assess the efficacy of medical care. To be objective, CUAs of intensive care units (ICUs) require standardization (adjustment) of costs. The present study analyzed the extent to which treatment costs are related to patient-specific baseline variables (such as type and severity of the primary disease). METHODS: From 2000-2004, a bottom-up procedure was used to quantify total costs on 14 ICUs in nine German university hospitals. Results were combined with demographic data, and data indicating type (ICD-10 codes) and severity (ICU scoring systems) of the primary disease at ICU admission. Various statistical models were tested to identify that which best described the associations between baseline variables and costs. RESULTS: In all, 3803 critically ill patients could be examined. The median of treatment costs per patient was 3199 (IQR 1768-6659 ). No model allowed an acceptably precise adjustment of costs; the estimated mean absolute prognostic error was at least 3860 (mean relative prognostic error 66%), when we tested an Extreme Gradient Boosting Model. CONCLUSION: Instruments which are currently available (cost adjustment based on patient-specific baseline variables) do not allow a standardization of costs, and an objective CUA of ICUs. Factors unknown at baseline may cause a large portion of treatment costs.
Subject(s)
Critical Illness , Health Care Costs , Intensive Care Units , Cost-Benefit Analysis , Hospitalization , Humans , Intensive Care Units/economics , Intensive Care Units/standardsABSTRACT
With the new millenium, "Gesundsheitsreform 2000" (Health Reform 2000) fundamentally changed the principles for reimbursement of hospital treatment costs in Germany. Before then, hospital treatment was completely reimbursed by the health insurance companies. Now, reimbursement is entirely based on a new diagnosis-related group (DRG) payment system. The aim was a reduction of the expanding cost of the health care system, more efficient economics, and better control. This concept was unique, since until now reimbursement had nowhere been based 100% on a DRG system. For critical care medicine, this became a special problem because standardization of treatment procedures is nearly impossible and is not related to specific diagnoses. Therefore, completely new solutions had to be found for a fair reimbursement of critical care treatment. The difficult search for a good solution is described here. The DIVI (German Interdisciplinary Association of Critical Care and Emergency Medicine) was able to present good arguments and concepts based on actual and realistic cost analyses. However, the solutions found remain insufficient, and fundamental problems are still not solved.
Subject(s)
Diagnosis-Related Groups , Health Care Reform , Insurance, Health, Reimbursement , Costs and Cost Analysis , Critical Care , Germany , Health Care Reform/economics , HumansSubject(s)
Critical Care , Decision Making , Emergency Medicine , Withholding Treatment , Documentation , HumansABSTRACT
Intensive care medicine has made great contributions to the immense success of modern curative medicine. However, emotional care and empathy for the patient and his family seem to be sparse. There is an assumed constraint to objectivity and efficiency, as well as a massive economic pressure which transfers the physician into an agent of the disease instead of a trustee of the ill human being. The physician struggles against the disease and feels the death of his patient as his personal defeat. However, in futile situations the intensivist must learn to let go. He is responsible for futile overtreatment as well as for successful treatment. Today, in futile situations in the intensive care unit (ICU), it is possible to change the goal from curative treatment to palliative care. This is a consequent further development from critical care medicine. In end-of-life situations in the intensive care unit, emotional care and empathy are mandatory using intensive dialogues with the family. Despite great workload stress enough time for such conversation should be taken, because the physician will generously be repaid by the way he sees his medical activity. The maintenance of a culture of empathy within the intensive care team is a major task for the leader. In this manner, the ICU will become and remain a place for living humanity.
Subject(s)
Affect , Critical Care/psychology , Empathy , Palliative Care/psychology , Physician-Patient Relations , Psychological Distance , Cooperative Behavior , Counseling , Germany , Humans , Interdisciplinary Communication , Medical Futility/psychology , Palliative Care/methods , Patient Care Team , Professional-Family Relations , Workload/psychologySubject(s)
Cooperative Behavior , Critical Care/ethics , Ethics, Medical , Interdisciplinary Communication , Advance Directive Adherence/ethics , Beneficence , Decision Support Techniques , Germany , Humans , Informed Consent/ethics , Medical Futility/ethics , Personal Autonomy , Societies, Medical , Terminal Care/ethics , Third-Party Consent/ethicsABSTRACT
The task of physicians is to maintain life, to protect and re-establish health as well as to alleviate suffering and to accompany the dying until death, under consideration of the self-determination rights of patients. Increasingly more and differentiated options for this are becoming available in intensive care medicine. Within the framework of professional responsibility physicians must decide which of the available treatment options are indicated. This process of decision-making is determined by answering the following question: when and under which circumstances is induction or continuation of intensive care treatment justified? In addition to the indications, the advance directive of the patient is the deciding factor. Medical indications represent a scientifically based estimation that a therapeutic measure is suitable in order to achieve a defined therapy target with a given probability. The ascertainment of the patient directive is achieved in a graded process depending on the state of consciousness of the patient. The present article offers orientation assistance to physicians for these decisions which are an individual responsibility.
Subject(s)
Critical Care/ethics , Case Management/ethics , Case Management/standards , Critical Care/standards , Emergency Medicine , Germany , Humans , Interdisciplinary Communication , Physician's Role , PhysiciansABSTRACT
In recent years great efforts in clinical sepsis research have led to a better understanding of the underlying pathophysiology and new therapeutic approaches including drugs and supportive care. Despite this success, severe sepsis remains a serious health care problem. Each year approximately 75,000 patients in Germany and approximately 750,000 patients in the USA suffer from severe sepsis. The length of stay and the cost of laborious therapies lead to high intensive care unit (ICU) costs. Sepsis causes a significant national socioeconomic burden if indirect costs due to productivity loss are included and in Germany severe sepsis has been estimated to generate costs between 3.6 and 7.7 billion Euro annually. Thus, this complex and life-threatening disease has been identified as a high cost driver not only for the ICU, but also from the perspectives of hospitals and society. To improve the outcome of severe sepsis, innovative drugs and treatment strategies are urgently needed. Some drugs and strategies already offer promising results and will probably play a major role in the future. Even though their cost-effectiveness is likely, intensive care medicine has to carry a substantial economic burden. This article summarizes studies focusing on the evaluation of direct or indirect costs of sepsis and the cost-effectiveness of new therapies.
Subject(s)
Sepsis/economics , Cost-Benefit Analysis , Critical Care/economics , Europe , Humans , Long-Term Care/economics , Sepsis/drug therapy , Sepsis/prevention & control , United StatesABSTRACT
The objective of this study was to evaluate a non-volitional measurement to assess diaphragmatic function in intubated and mechanically ventilated patients in a prospective pilot interventional clinical trial. The study was conducted in an 18-bed postoperative intensive care unit based at a university hospital. Patients were prospectively assigned to two groups. Group 1 consisted of eight patients with ventilator weaning failure. Group 2 consisted of eight intubated and ventilated patients who were studied shortly after major surgery and were successfully extubated there-after The twitch pressure response after cervical magnetic stimulation of the phrenic nerves was measured at the endotracheal tube at different PEEP levels. In group 2 the twitch transdiaphragmatic pressure, defined as the difference between twitch gastric and twitch oesophageal pressure was also evaluated. In group 1 the mean twitch pressure at the endotracheal tube on PEEP 0, 5 and 10 cmH2O was 5.2, 4.5 and 2.6 cmH2O: In group 2 this was significantly higher (15.1 cmH2O on PEEP 0 and 12.2 cmH2O on PEEP 5). A good correlation was found between twitch diaphragmatic pressure and twitch pressure at the endotracheal tube (r2 = 0.96) and between twitch oesophageal pressure and twitch pressure at the endotracheal tube (r2 = 0.98). Patients with weaning failure have significantly lower twitch pressure at the endotracheal tube suggesting diaphragmatic dysfunction. Twitch pressure at the endotracheal tube may be a useful parameter to screen for diaphragmatic dysfunction in intubated critically ill patients. Further studies are needed to confirm these preliminary findings.
Subject(s)
Cervical Plexus/physiology , Diaphragm/physiopathology , Magnetics , Physical Stimulation/methods , Respiratory Function Tests/methods , Adult , Aged , Aged, 80 and over , Critical Illness , Diaphragm/innervation , Humans , Intubation, Intratracheal/methods , Middle Aged , Phrenic Nerve/physiology , Pilot Projects , Positive-Pressure Respiration/methods , Prospective Studies , Respiration, Artificial/methods , Respiratory Muscles/physiopathology , Time Factors , Ventilator Weaning/methodsABSTRACT
BACKGROUND AND OBJECTIVE: To compare the accuracy of prognoses made by intensive care physicians with the performance of two indicators, the original Simplified Acute Physiology Score (SAPS) II and a modified version optimized to the patient sample. METHODS: Data from 412 patients consecutively admitted to intensive care units of Göttingen University Hospital, Germany, were collected according to the original score criteria. Information necessary for the computation of SAPS II and the vital status on hospital discharge was recorded. To customize the original SAPS II in our cohort, the database was randomly divided into two subgroups. Logistic regression analysis with physiological values as explanatory variables was used. A bootstrap procedure completed the process. Furthermore, physicians were asked to indicate their prognostic judgement concerning the patients' hospital mortality. RESULTS: Discrimination analysis showed the following areas under receiver operating characteristic curves: physicians' prognoses 0.84 (confidence interval (CI): 0.79-89), SAPS II 0.75 (CI: 0.69-0.80) and customized SAPS 0.72 (CI: 0.66-0.78). The physician's forecast was significantly better, while the customized and the original SAPS were not substantially different as regards their accuracy. CONCLUSIONS: Prognoses made by physicians are superior to objective models. This may result from more extensive knowledge and other kinds of information available to clinicians. A clinician's action also depends on his/her prognosis at the beginning of the treatment, giving raise to a possible correlation between medical outcome and the clinician's prognosis. Our findings indicate that physicians do not limit their prognosis to the objective factors at their disposal, but indicate that they base their decisions on experience and individual observations.
Subject(s)
Critical Care , Prognosis , Treatment Outcome , Aged , Algorithms , Area Under Curve , Critical Illness/mortality , Female , Glasgow Coma Scale , Humans , Likelihood Functions , Male , Middle Aged , Models, Biological , Predictive Value of Tests , ROC CurveABSTRACT
The concept of analgo-sedation in intensive care medicine has changed considerably since the last decades. Deep sedation, keeping patients artificially unconscious, is not necessary anymore, it postpones weaning from mechanical ventilation, it provokes complications, and prolongs the length of ICU stay. On the other hand, recent surveys have shown that patients recall their intensive care experience still as stressing and painful. This need more awareness of patient's pain and the readiness to give analgesics particularly before painful procedures. The frightening environment of the ICU, sleep deprivation, pain and discomfort related not only to the actual dysfunctions, but even more to the stressing procedures of care and treatment, make a certain level of sedation necessary. But patients' discomfort may also originate from many other reasons, such as hypoxaemia, hypotension, cardiac failure, drugs overdose or withdrawal, or simply from an uncomfortable body position. These sometimes non-obvious reasons have to be carefully looked for in order to treat the problem effectively. Delirium and other mental problems are common in critically ill patients. They have to be diagnosed with particular attention and treated specifically. Sedatives must be carefully adapted to the individual needs and the actual situation. Modern modes of mechanical ventilation allows lower levels of sedation. Regularly repeated assessment of the sedation level (e.g. by Ramsay score) is mandatory; a sedation protocol seems advantageous. To avoid inadvertent accumulation and overdose, it is recommended to keep the patient at a sedation level at which communication is still possible. A daily interruption of the sedation has shown to shorten the duration of mechanical ventilation and the length of ICU stay.
