Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA.

PURPOSE: Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown. METHODS: In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis. RESULTS: Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n = 12, 18%) and poor (n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0-1.00) and 85.9% (75.4-92.0) (P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20-2.92) or receiving a written TLD (HR 2.32, CI 1.11-4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n = 12, 18%) or without (n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former. CONCLUSION: Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life.

End-of-life decisions in Hungarian intensive care units.

The awareness of local practice of end-of-life decisions in accordance with the law and ethical principles is essential for intensive care physicians in all countries. The first step for the required social dialogue is to investigate local practice. We performed the first Hungarian survey with the aim of better understanding local practice in end-of-life decisions in intensive care units. Questionnaires were sent out electronically to 743 members of the Hungarian Society of Anaesthesiology and Intensive Care. Respecting anonymity, we have statistically evaluated 103 replies (response rate 13.8%) and compared the results to data from other European countries. The results show that the practice of intensive care physicians in Hungary is rather paternalistic. Intensive care physicians generally make their decisions alone (3.75/5 points) without considering the opinion of the patient (2.57/5 points), the relatives (2.14/5 points) or other medical staff (2.37/5 points). Furthermore, they prefer not to start a form of treatment rather than to withdraw an ongoing one. Nevertheless, the frequency of end-of-life decisions (3 to 9% of intensive care unit patients) made in Hungarian intensive care units is less than in other European countries. End-of-life decisions are part of medical practice. Since the legal and ethical framework is unclear practice varies between locations and mostly depends on individual decisions rather than established protocols or guidance. For end-of-life decisions, self-determination must be supported and a dialogue must be established between lawmakers and physicians.

[Clavicle fracture in the newborn]. / Ujszülöttek kulcscsonttörése.

The authors have found 244 clavicle fractures during 4131 vaginal delivery (5.91%). Both clavicles of three newborns have fractured. The incidence of fracture had relation to weight of newborns, to weakness of pains and to vacuum extraction. The Apgar score of the newborns with fractured clavicle was not less, than one of newborns with unbroken clavicle. None of 704 newborns from cesarean section, and none of 52 newborns, who was born out of the hospital had fracture of the clavicle. The cause of fracture is the violent hurry of delivery, the drawing of the head before birth of shoulders. One of 244 injured newborns had permanent brachial plexus palsy. Late complication was not found. Between the injured newborns was more frequent the jaundice requiring phototherapy.

The adolescent childbirth rate in Hungary.

The rate of childbirth of adolescents in Hungary is reviewed. The rate of childbirth increased among teenagers during the last half century.

Neonatal sex ratio in pregnancies of adolescent mothers.

The authors have reviewed the sex ratio in 353 offspring of adolescent parturients based on a 5-year material of their department. The 174 males and 179 females provided a sex ratio of 97.2; less than the usual ratio of 106. Interestingly, females are prevalent not only among low-birth-weight but also among average-birth-weight babies of adolescents. The hypothesis is presented that the anatomy of the cervix and the chemical composition of the cervical mucus may affect the sex ratio in some manner.

Sex ratio and placenta praevia.

In the authors' Department, 144 cases of placenta praevia were treated in the course of 15 years. This number amounted to 0.54% of all births. The sex ratio of fetuses in association with this complication was 166.6, which exceeds that of all neonates during the same period of time. A preponderance of male babies was noted when the material was further analysed according to maternal age, parity and neonatal birth weight.

Abruptio placentae and fetal sex ratio.

In the authors' department, 175 cases of abruption of the placenta - 0.65% of all births at the department - were treated in the course of 15 years. The sex ratio of fetuses in association with this complication was 131.08; higher than those of all neonates during the same period of time. The material was further analysed by maternal age, parity and neonatal birth weight.

[Significance of blood flow measurement in the cervix uteri in the 1st trimester of pregnancy]. / Bedeutung der Durchblutungsmessung der Cervix uteri in der ersten Hälfte der Schwangerschaft.

The authors examined the blood flow of the portio vaginalis uteri in the first half of pregnancy in 57 cases. Their age was between 16-37 years. 5 groups were established: 1. among healthy pregnant women 69 ml/min/100 g; 2. among hypoplasia 40 ml/min/100 g; 3. among anaemia 122 ml min 100 g; 4. among hyperemesis gravidarum 134 ml/min/100 g; 5. among anaemia + hyperemesis gravidarum 140 ml min 100 g were found. The blood flow of the groups 2-5 has significant differences in comparison to the healthy pregnants.