End-of-life practices in 11 German intensive care units : Results from the ETHICUS-2 study.

BACKGROUND: End-of-life care is common in German intensive care units (ICUs) but little is known about daily practice. OBJECTIVES: To study the practice of end-of-life care. METHODS: Prospectively planned, secondary analysis comprising the German subset of the worldwide Ethicus­2 Study (2015-2016) including consecutive ICU patients with limitation of life-sustaining therapy or who died. RESULTS: Among 1092 (13.7%) of 7966 patients from 11 multidisciplinary ICUs, 967 (88.6%) had treatment limitations, 92 (8.4%) died with failed CPR, and 33 (3%) with brain death. Among patients with treatment limitations, 22.3% (216/967) patients were discharged alive from the ICU. More patients had treatments withdrawn than withheld (556 [57.5%] vs. 411 [42.5%], p < 0.001). Patients with treatment limitations were older (median 73 years [interquartile range (IQR) 61-80] vs. 68 years [IQR 54-77]) and more had mental decision-making capacity (12.9 vs. 0.8%), advance directives (28.6 vs. 11.2%), and information about treatment wishes (82.7 vs 33.3%, all p < 0.001). Physicians reported discussing treatment limitations with patients with mental decision-making capacity and families (91.3 and 82.6%, respectively). Patient wishes were unknown in 41.3% of patients. The major reason for decision-making was unresponsiveness to maximal therapy (34.6%). CONCLUSIONS: Treatment limitations are common, based on information about patients' wishes and discussion between stakeholders, patients and families. However, our findings suggest that treatment preferences of nearly half the patients remain unknown which affects guidance for treatment decisions.

[Advance care planning in critical care : Potential and requirements]. / Advance Care Planning in der Intensivmedizin : Potenzial und Voraussetzungen.

BACKGROUND: Lack of knowledge about patient preferences is a contributing factor for inappropriate therapy. Advance care planning (ACP) is a novel concept for meaningful advance directives, but it is still not widely known in Germany. OBJECTIVE: An overview of the concept of ACP, development and its implementation with respect to intensive care is provided. METHODS: A narrative literature review was performed. RESULTS: ACP is a broad concept which requires facilitated discussions with trained medical staff. The process can lead to different ACP documents. It is also possible to facilitate discussions with patient proxies. Furthermore, ACP has potential because of the proven validity of advance directives and the prompt applicability of directives in an emergency. Prerequisites for ACP include the provision of resources, notably for the training of appropriate facilitators, and the implementation or extension of counseling structures. CONCLUSIONS: Advanced care planning (ACP) is a promising concept. However, some requirements must be met to implement ACP into daily practice.

[Burnout-a call for action]. / Ich kann nicht mehr: Burn-out ­ eine Aufrüttelung.

BACKGROUND: Burnout is an emerging topic and has recently been the subject of a position paper of the US American Society of Critical Care Medicine. OBJECTIVES: To give an overview over prevalence, causes, and relevance of burnout in intensive care unit (ICU) clinicians and point to potential prevention strategies MATERIALS AND METHODS: Narrative review. RESULTS AND CONCLUSION: Burnout is a job-related state which results from long-lasting, permanent work overload when short spells of recreation, for instance during the weekend, are not effective to reduce exhaustion, vegetative symptoms, loss of efficiency, and depersonalization. Burnout may be due to (1) work-related factors, such as unmanageable workload and lack of appreciation by superiors and (2) personal factors, such as overly high demand and commitment. Surveys from France and Switzerland suggest that approximately one third to one half of ICU clinicians are affected. Large studies among hospital nurses show an increase in burnout. Burnout impairs patient safety and satisfaction, increases clinicians' intent to quit, and staff turnover. CONCLUSIONS: Burnout is associated with a poor work environment. Burnout prevention or reduction is an important task which demands a multidimensional approach. The goal should be to improve the work environment, achieve good team collaboration, psychological safety, and inclusive leadership.

[Communication with relatives]. / Gesprächsführung mit Angehörigen.

BACKGROUND: Communication with relatives is a central part of the decision-making process. In the absence of the patient's direct consent to a potential organ donation, the next of kin must provide information about a potential wish to donate and give permission in the context of an extended consent solution. At the same time, family members must also cope with the death of a loved one. OBJECTIVE: To determine how relatives can be optimally supported during the decision-making process. MATERIALS AND METHODS: Narrative review. RESULTS: In the context of potential or confirmed irreversible brain death, communication with family members or legal representatives serves to deliver bad news as well as to determine whether the patient had a wish to donate his/her organs and to clarify the resultant steps. Communication strategies such as the SPIKES or VALUE models provide emotional and cognitive support for relatives and strengthen clinicians' communication skills. Clinicians' behavior towards patients, deceased, and next of kin may influence relatives' decision-making; respectful and competent behavior seems to contribute towards relatives granting permission for organ donation. CONCLUSION: Clinicians must be trained and skilled in communication strategies which are used in critical situations to provide emotional support to relatives during the organ donation decision-making process. Relatives are more likely to achieve a satisfying and sustainable decision if a strong relationship exists between clinicians and relatives based on information giving, openness, trust, and empathy.

Challenges in assessing the burden of sepsis and understanding the inequalities of sepsis outcomes between National Health Systems: secular trends in sepsis and infection incidence and mortality in Germany.

PURPOSE: Sepsis contributes considerably to global morbidity and mortality, while reasons for its increasing incidence remain unclear. We assessed risk adjusted secular trends in sepsis and infection epidemiology in Germany. METHODS: Retrospective cohort study using nationwide German hospital discharge data. We assessed incidence, outcomes and trends of hospital-treated sepsis and infections between 2010 and 2015. Sepsis was identified by explicit ICD-10 sepsis codes. As sensitivity analysis, results were compared with sepsis cases identified by implicit sepsis coding (combined infection and organ dysfunction codes). RESULTS: Among 18 664 877 hospital admissions in 2015, 4 213 116 (22.6%) patients had at least one infection code. There were 320 198 patients that had explicit sepsis codes including 136 542 patients with severe sepsis and septic shock; 183 656 patients were coded as sepsis without organ dysfunction. For patients with explicitly coded sepsis (including severe sepsis), or with severe sepsis alone, mortality rates over the period 2010-2015 decreased from 26.6 to 23.5%, and from 47.8 to 41.7%, respectively. CONCLUSIONS: Sepsis and infection remain significant causes of hospital admission and death in Germany. Sepsis-related mortality is higher and has declined to a lesser degree than in other high-income countries. Although infection rates steadily increased, the observed annual increase of sepsis cases seems to result, to a considerable degree, from improved coding of sepsis.

[Communicating with families in the ICU : Background and practical recommendations]. / Das Angehörigengespräch in der Intensivmedizin : Grundlagen und Empfehlungen für die Praxis.

Family members of adult intensive care patients are partners of the interdisciplinary team. Family members provide important contributions to patient-centered care in the intensive care unit (ICU) and beyond. At the same time, family members are stressed and are themselves in need of support ("family-centered care"). This is mainly provided through family conferences. Family members must always be treated respectfully and with consideration for their acute stress syndrome. A structured communication is recommended as well as written standard operating procedures (SOPs) or guidelines for the ICU team and brochures and written guidelines for relatives. Documentation of structured family conferences is an established quality indicator of intensive care.

[Sepsis masquerading as delirium]. / Listeriensepsis mit Leitsymptom Delir.

A previously healthy 60-year-old patient presented to the emergency department with severe headache, altered personality and fever. He was treated for bacterial meningitis with delirium of unknown cause but presumed to be due to alcohol withdrawal. Despite receiving the antibiotic therapy regimen recommended for bacterial meningitis the patient's condition rapidly deteriorated with profound delirium and tachypnea. The intensivist who was consulted immediately suspected sepsis-associated organ failure and admitted the patient to the intensive care unit (ICU). The blood culture was positive for Listeria. After 10 days the patient could be discharged from the ICU and ultimately recovered completely. In patients presenting with unexplained delirium or altered personality the suspicion of septic encephalopathy should always be considered. They should be admitted to the ICU and sepsis treatment should be initiated without delay.

[Traumatized relatives of intensive care patients]. / Traumatisierte Angehörige von Intensivpatienten.

Relatives are not only visitors in the intensive care unit, but provide support and care for patients at the end of life, and serve as an important source of information for clinicians. They are confronted, often unexpectedly and unprepared, with life-threatening illness, death and dying and life-threatening decisions to limit therapy. Thus, they are often substantially burdened themselves and are in need of support. It is undisputed that communication with relatives can have an adaptive or also traumatic influence on the experience gained.

[Sepsis : putting knowledge into practice]. / Sepsis : Wissen für die Praxis.

Sepsis is a complex systemic inflammatory reaction in response to an infection and must be treated as an emergency. The diagnosis of sepsis is often delayed even though early goal-directed resuscitation and therapy with antibiotics within the first hours can reduce sepsis-related mortality. This article presents the most important points concerning the pathophysiology, diagnosis and therapy of sepsis.

Safety of gelatin for volume resuscitation--a systematic review and meta-analysis.

PURPOSE: Gelatin is frequently used as a volume expander in critical care. Our goal was to investigate its safety. METHODS: Systematic review of randomized controlled trials (RCT) in patients receiving gelatin for resuscitation in comparison to albumin or crystalloids. RESULTS: We identified 40 RCTs published between 1976 and 2010 with 3,275 patients. Median sample size in the gelatin groups was 15 patients (range 10-249). Median gelatin dose was 17 ml/kg (range 6-57 ml/kg). In 32 RCTs (n = 1,946/3,275, 59 % of all patients), the study period was ≤24.0 h. Twenty-nine RCTs (n = 2,001) investigated elective surgical patients, mostly undergoing cardiac surgery (18 RCTs, n = 819). Three RCTs (n = 723) investigated critically ill adults. Two RCTs (n = 59) were performed in emergency room patients, and six RCTs (n = 492) were performed in neonates or children. No study was adequately powered to investigate the frequency of patient-important outcomes. Risks were not statistically significantly different for mortality (RR 1.12, 95 % confidence interval, 0.87-1.44) and exposure to allogeneic transfusion (RR 1.28, 0.89-1.83). On account of only few included studies and the small number of patients, subgroup analyses (high vs. low dose, >24 h vs. shorter periods, and critically ill patients vs. others) were uninformative. Only three RCTs reported the occurrence of acute renal failure. CONCLUSION: Despite over 60 years of clinical practice, the safety and efficacy of gelatin cannot be reliably assessed in at least some settings in which it is currently used. We suggest the need to investigate and establish such safety.

Room for improvement: nurses' and physicians' views of a post-operative pain management program.

BACKGROUND: The practice of post-operative pain therapy continues to be a problem. We conducted a survey among nurses and physicians about their views of an established post-operative pain management program. METHODS: A questionnaire was sent to all nurses and physicians of nine surgical wards (general, trauma, cardio-thoracic and oromaxillofacial surgery and gynecology). Questions were developed from qualitative interviews with staff. Patient data were derived from a post-operative pain registry. RESULTS: Seventy-eight physicians and nurses answered; the overall response rate was 23%. Post-operative pain therapy had high personal priority on an 11-point numeric rating scale (mean 9.08+/-1.27 standard deviation), but the success of pain management on the ward was rated as 7.32+/-1.37. Staff rating of success tended to correspond with patients' actual pain ratings. Knowledge of pain therapy was assessed as 6.85+/-1.82; nurses consistently rated levels higher than physicians. Staff over- or underestimated the painfulness of typical procedures and females rated procedures as more painful than men. There was considerable confusion about responsibilities and duties. 10.7% of staff perceived time delays exceeding 6 h between a request for acute pain services (APS) consultation and administration of medication to the patient. Invited comments suggested improvement in personnel education, team coordination, communication with patients and speed of action to increase the quality of pain therapy. CONCLUSION: Despite staff's high personal priority and well-established APS and pain management program, post-operative pain therapy still leaves room for improvement. Considerable confusion about responsibilities and duties underlines the importance of better organizational approaches.