[Decision-making support in Intensive Care to facilitate organ donation : Position paper of the Ethics Section and the Organ Donation and Transplantation Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) in collaboration with the Ethics Section of the German Society of Medical Intensive Care Medicine and Emergency Medicine (DGIIN)]. / Entscheidungshilfe bei erweitertem intensivmedizinischem Behandlungsbedarf auf dem Weg zur Organspende : Positionspapier der Sektion Ethik und der Sektion Organspende und -transplantation der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI) unter Mitarbeit der Sektion Ethik der Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN).

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.

[Amendment to the documentation of decisions to withhold or withdraw life-sustaining therapies in consideration of wish to donate organs : Recommendation of the Ethics Section and the Organ Donation and Transplantation Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) in collaboration with the Ethics Section of the German Society of Medical Intensive Care Medicine and Emergency Medicine (DGIIN)]. / Ergänzung des Dokumentationsbogens "Therapiebegrenzung" unter Berücksichtigung eines möglichen Organspendewunsches : Empfehlung der Sektion Ethik sowie der Sektion Organspende und Organtransplantation der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI) unter Mitarbeit der Sektion Ethik der Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN).

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.

[Management of an elderly patient in the emergency room at the end of life : A medical ethics challenge]. / Management eines älteren Patienten in der Notaufnahme am Lebensende : Eine medizinethische Herausforderung.

A 94-year-old patient with cardiogenic shock due to myocardial infarction was admitted via the emergency room. A coronary angiography and intensive care were requested. The need for care due to dementia was known. After case discussion in the interdisciplinary and multiprofessional treatment team, the decision for a palliative care concept in the form of symptom control was made in the emergency room, taking into account the patient's medical history, the current situation, and the presumed patient consent. The integration of medical ethics aspects and palliative medicine into "geriatric emergency medicine" will present a challenge in the future.

[Autonomy and welfare in intensive care medicine : Practical approach in difficult situations]. / Autonomie und Fürsorge in der Intensivmedizin : Praktisches Vorgehen in schwierigen Situationen.

In intensive care units far-reaching decisions are often made at short notice that require the consent of the informed patient. If this is not possible due to the patient's condition, physicians and legal representatives must ascertain the previously expressed or presumed will of the patient and act accordingly. The legal principles are specified in the Patient Advance Directives Act and the Patient Rights Act. Any indications for medical treatment need a clearly defined aim of the therapy, which can be questioned during the progress of the disease. To avoid conflicts between patient autonomy and medical treatment, the aims of therapy must be regularly discussed with the patient, representatives or relatives and documented in a written form. Checklists can be useful for structured consultations, to promote transparency and to avoid misunderstandings. Ethics consultations can help to deescalate critical situations.

Challenges of modelling real nanoparticles: Ni@Pt electrocatalysts for the oxygen reduction reaction.

Theoretical/computational methods have been extensively applied to screen possible nano-structures attempting to maximize catalytic and stability properties for applications in electrochemical devices. This work shows that the method used to model core@shell structures is of fundamental importance in order to truly represent the physicochemical changes arising from the formation of a core-shell structure. We demonstrate that using a slab approach for modelling nanoparticles the oxygen adsorption energies are qualitatively well represented. Although this is a good descriptor for the catalytic activity, huge differences are found for the calculated surface stability between the results of a nano-cluster and those of a slab approach. Moreover, for the slab method depending on the geometric properties of the core and their similarity to the elements of the core or shell, contradictory effects are obtained. In order to determine the changes occurring as the number of layers and nano particle size are increased, clusters of Ni@Pt from 13 to 260 atoms were constructed and analyzed in terms of geometric parameters, oxygen adsorption, and dissolution potential shift. It is shown that the results of modelling the Ni@Pt nanoparticles with a cluster approach are in good agreement with experimental geometrical parameters, catalytic activity, and stability of a carefully prepared series of Ni@Pt nanostructures where the shell thickness is systematically changed. The maximum catalytic activity and stability are found for a monolayer of Pt whereas adding a second and third layer the behavior is almost the same than that in pure Pt nanoparticles.

Maintaining the genuine structure of 2D materials and catalytic nanoparticles at atomic resolution.

The recent development of atomic resolution, low dose-rate electron microscopy allows investigating 2D materials as well as catalytic nano particles without compromising their structural integrity. For graphene and a variety of nanoparticle compositions, it is shown that a critical dose rate exists of <100 e(-)/Å(2) s at 80 keV of electron acceleration that allows maintaining the genuine object structures including their surfaces and edges even if particles are only 3 nm large or smaller. Moreover, it is demonstrated that electron beam-induced phonon excitation from outside the field of view contributes to a contrast degradation in recorded images. These degradation effects can be eliminated by delivering electrons onto the imaged area, only, by using a Nilsonian illumination scheme in combination with a suitable aperture at the electron gun/monochromator assembly.

[Implementation of ethics services. Opportunities and obstacles]. / Einrichtung einer Ethikberatung. Wege und Hindernisse.

BACKGROUND: Medical success in the last century has caused situations, in which the question arises whether therapy is right. In the same time autonomy has become more and more important. Furthermore, human beings want to decide on health, life and dying. APPROACH: Experience of limitations of life and desire of autonomy in healthcare lead to ethical questions. Different ethical services were established to deal with and to solve problems. Ethics committees with multiprofessional members and different qualifications will give guidance in critical decision making. Ethics services do not receive responsibility for the decision, but helps those who are responsible by structured reflection, estimation of values and including all concerned. DISCUSSION: Implementing ethics services also encounters obstructions and scepticism. Time, responsibility for therapy and criticism of customs and structures must be considered to perpetuate success. Instructions for implementing ethics services are presented.

[Change in therapy target and therapy limitations in intensive care medicine. Position paper of the Ethics Section of the German Interdisciplinary Association for Intensive Care and Emergency Medicine]. / Therapiezieländerung und therapiebegrenzung in der intensivmedizin. Positionspapier der Sektion Ethik der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin.

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.

Rotating frame for the in-situ fixation of large animals.

The frame for the in-situ fixation of large animals can be rotated around its longtitudinal axis. Thereby the fixing procedure is improved and the anatomical preparation is easier.

[Clarity and legal authority in decisions to limit therapy]. / Information über Entscheidungen zur Therapiebegrenzung und deren Verbindlichkeit.

The decision to limit a patient's therapy can lead to conflicts in the therapeutic team if their views have not been carefully weighed. Further problems also result if they are not clearly and logically documented. The legal authority of patient will, medical indication, and interaction of the care-giving team for arriving at a common decision are examined here. Using a case history as an example, we discuss ethical and legal questions of documentation and obligations on those faced with concrete decisions whether to continue medical procedures. To widen the basis for such decisions, discussion must include the viewpoints of all participants. The final decision must then be clearly documented without any unclarity or ambivalence. Those finally required to carry out that prospective decision, however, must decide whether it actually applies to the situation at hand.

[Saving life and permitting death. Decision conflicts in intensive medicine]. / Leben erhalten und Sterben ermöglichen. Entscheidungskonflikte in der Intensivmedizin.

Intensive care has achieved major breakthroughs in handling gravely ill patients. However, this has, at least in part, been overshadowed by problems relating to ethical values as well as general psychological conflicts among patients and hospital staff. When dealing with such problems, distinct criteria are required which address the patient's dignity and will to survive. A four-step scheme is suggested, ranging from maximum therapy, via maintenance therapy without adjustments to increased demand and therapy reduction, to cessation of therapy. In the case of therapy reduction, balanced support is maintained ensuring that dehydration is avoided, the respiratory tract is kept clear, pain killers are used to good effect, personal attention is provided, and care is provided to a high standard. A questionnaire tailored to the practical need of how to arrive at an ethically weighted and accepted decision is presented. When searching for a solution involving ethic issues, it is particularly important to involve all individuals concerned in a dialogue until a consensus is reached.