[Providing or withholding treatment: the role of the patient's wish and priorities in palliative care]. / Behandlungsgebot und Behandlungsbegrenzung: Einfluss des Patientenwillens und Prioritäten in der palliativen Versorgung.

BACKGROUND AND OBJECTIVE: Medical law and ethics require that intervention be based on patients' wishes. However, in particular the presumed wish of the patient, is often difficult to establish. Discussions with patients may want to inform or influence the patient's wishes. We investigated how far clinical decisions recognize the patient's wishes and how the presumed wishes of the patient is established and respected. PATIENTS AND METHODS: 503 physicians (25.6 % women; mean age 36.3) in 49 departments of the universities Bochum and Magdeburg filled in a validated questionnaire. RESULTS: 86,2 % of the physicians questioned ranked the patient's wish as important or very important. However, 54,4 % tried to modify it. Advanced directives play the most important role when the patient is unable to communicate. Danger to life and suicide are reasons for clinical decisions against the patient's wishes. But it is the main reason to end a causal therapy in terminally ill patients, especially in experienced physicians' opinion. CONCLUSIONS: Patients will plays a prominent role in treatment decisions; Even more so, physicians follow patients' wishes when withholding or withdrawing treatment. Our study could not find out how widely information of the patient plays a role in altering the patient's wishes in a paternalistic manner. Given a relative unfamiliarity with advance directives, affirmative attitudes towards their recognition are remarkable. As far as palliative and comfort care for terminal patients is concerned, contrary to widely voiced concern, clinicians do not have priorities different from those used in hospice care.

[Treatment regulations and treatment limits: factors influencing clinical decision-making]. / Behandlungsgebot und Behandlungsbegrenzung: Einflussfaktoren klinischer Entscheidungsprozesse.

BACKGROUND: Providing or withholding of treatment is based on a variety of factors. We sought for criteria in clinical decision making and reviewed attitudes towards clinical intuition and the patient's will. METHODS: 503 physicians (25.6 % females; mean age 36.3) in 49 departments at nine hospitals of the universities Bochum and Magdeburg filled in a validated questionnaire. RESULTS: The most important factors in the decision to carry out a therapy were "international standards" and "own experience". The decision to omit a therapy was mainly influenced by the "patient's wish". Physicians with a higher status judged their own experience higher than young physicians, who considered the experience of colleagues more important. "Severe accompanying illnesses" and "multimorbidity" were the most frequently named reasons to withdraw a therapy. Intuitive decision-making was rare, especially in young physicians, although these decisions were seldom risky and often successful. CONCLUSIONS: A patient's will plays a prominent role in clinical decision making, especially in decisions to withdraw or to withhold treatment. Cost containment and research interest have been called less important, a remarkable response from research-based university hospitals. Also remarkable is the recognition and importance of clinical intuition in situations of complex or missing information. This important aspect is rarely discussed in the literature or in medical education. The widely voiced concern that priorities in clinical care are guided by scientific interest, financial or technical possibilities could not be confirmed.

[Acceptance and validation of advanced directives--ethical and clinical considerations]. / Akzeptanz und Validierung von Betreuungsverfügungen--ethische und klinische Uberlegungen.

Crucial decisions of end-of-life treatment quite often are handed over to machines and other technical capabilities of prolonging life at any cost. Various forms of advance directives have been developed, but not widely accepted by the lay public and rarely recognized by physicians and the health care establishment. We discuss the benefits and risks of different forms of advance directives and present, based on own experience and on evaluating the clinical-ethical and clinical-legal debates, a model combining information on value-and-wish status, the designation of a surrogate decision maker, and a limited number of recommendations or directives for crucial end-of-life decisions. We call for further research on physician's and patient's attitudes towards end-of-life decisions and the development and validation of advance directives, as we feel that it will be the culture of physician-patient interaction rather than legal measures that will change ethical and cultural attitudes and medical procedures.

[Values anamnesis: a narrative approach to determining and interpreting advance directives]. / Die Wertanamnese: ein narrativer Ansatz zur Erstellung und Interpretation von Betreuungsverfügungen.

Quite a number of conceptual, clinical, ethical and legal arguments have been made to agree in favour of advance directives for medical treatment and care. But not many patients execute advance directives and physicians and nurses are quite reluctant to accept advance medical directives as authoritative guidance for clinical decision making in cases of dementia, terminal illness or in the case of the dying.

Advance directives and withdrawal of dialysis in the United States, Germany, and Japan.

OBJECTIVE: To determine the role of advance directives in decisions to withdraw chronic dialysis in the United States, Germany, and Japan. DESIGN: Survey by questionnaire. PARTICIPANTS: Seventy-two American, 87 German, and 73 Japanese nephrologists. MAIN OUTCOME MEASURES: Each nephrologist's total number of (1) dialysis patients, (2) cases of withdrawal of dialysis, (3) patients with advance directives, and (4) uses of such directives. Nephrologists also stated whether they would continue or stop dialysis in 8 hypothetical cases. RESULTS: American, German, and Japanese nephrologists reported withdrawing dialysis for 5.1%, 1.6%, and 0.7% of their patients in the last year, respectively. Thirty percent of American patients had advance directives, and such directives were used in decision making for 3.2% of all patients. Only 0.3% of German and Japanese patients had advance directives, and such directives were used in decision making for 0.09% of patients. When asked about a hypothetical mentally incompetent patient whose family requests withdrawal of dialysis, American nephrologists were much more likely to stop dialysis in the absence of an advance directive than German or Japanese nephrologists. However, almost all nephrologists from the 3 countries would stop dialysis when a family request to withdraw was supported by a patient advance directive. CONCLUSIONS: There is a high prevalence of advance directives among American dialysis patients, and such directives frequently play a role in decision making. German and Japanese nephrologists appear willing to follow advance directives, but the low prevalence of such directives limits the frequency of their use.

From wooden limbs to biomaterial organs: the ethics of organ replacement and artificial organs.

This paper discussed issues of ethical assessment and moral concern associated with organ replacement and physical enhancement: research, allocation, organ donation, artificial organs, xenografts, biomaterials, and neuromaterials. While emphasizing the medical and moral benefits over associated risks, it calls for a better integration of moral assessment into technology assessment and for the establishment of a cross-cultural and interdisciplinary International Ethics Committee for Organ Replacement Therapy.

Using stories to assess values and establish medical directives.

While still developing in Germany, a consensus has emerged in the United States on the use of advance directives for guiding future medical decision making. This article outlines three phases in the evolution of advance directive forms--the legal phase, the checklist phase, and the story phase. The story-based approach is discussed as the best method for assessing patient values and incorporating them into advance directives, and a story-based advance directive form, which has been developed and tested during the past two years, is presented.

Right not to know or duty to know? Prenatal screening for polycystic renal disease.

New dimensions in different ethical scenarios following genetic information require new medical-ethical Action Guides for physician-patient interaction. This paper discusses the ambiguity in moral choice between a "right not to know" and "a duty to know", regarding parental decision-making pro or contra selective abortion following prenatal screening for autosomal dominant polycystic kidney disease (Potter III) and related public policy issues.

[Blood purification procedures in acute exogenous poisonings]. / Blutreinigungsverfahren bei akuten exogenen Vergiftungen.

The contribution explains the value of the techniques of blood purification on the basis of national numbers and own experiences. By reason of the great number of chemical substances which may give rise to intoxications within such a close compass it is of course impossible to mention details. Even so eminent books of reference such as the book by Seyffart need not only the permanent actualization, but by virtue of new scientific or experimental knowledge occasionally lead to changed conceptions. This, for instance, also concerns the somewhat more reserved assessment of the digitalis glycoside poisoning. On principle should be recorded that always then, when during intoxications vital functions are potentially or actively disturbed, or, however, the danger of lasting damage is occurring, because of the small complication rate of the haemodialysis or haemoperfusion in all unclear intoxications in case of doubt always such a blood purification technique should be performed in order to grant better changes of treatment to these patients and still further to reduce the mortality rate of acute intoxications.

[Accelerating factors in the progression of chronic renal failure]. / Untersuchungen der akzelerierenden Faktoren bei der Progredienz der chronischen Niereninsuffizienz.

A simple and reliable possibility to recognize at once sudden deteriorations of the renal function is the demonstration of IgKr accompanying the disease by means of semilogarithmic paper. Up to now probably no special importance has been attached to an intensive treatment of hypertension. The kinetics of the initial loss of function further remains unclear. The importance and possible influence on the accelerating factors must be defined exactly in a longer period of observation and with a greater number of patients. If we succeed in avoiding the acceleration and even in retarding the progression this would be connected with an essential delay of the time of the dependence upon dialysis for a number of patients.

[Retrospective follow-up control of progressive renal failure with logarithmic transformation of the serum creatinine concentration]. / Retrospektive Verlaufskontrolle der progredienten Niereninsuffizienz mit der logarithmischen Transformation der Serum-Kreatinin-Konzentration (lg Kr).

Of 108 patients with chronic terminal renal insufficiency in 81 patients controls of the course were possible. In 50 patients an lg-linear course of the increase of creatinine against the time was the result. The running through time from 200 to 1,000 mumol/l creatinine was measured. In 31 patients the at first flatter, also linearly recognizable increase of creatinine suddenly changed into a second steeper, also lg-linear part of the straight line. The exact knowledge of the accelerating factors might postpone the time of the dialysis dependence in one part of the patients.

[Catamnestic study of long-term prognosis in patients with acute kidney failure]. / Katamnestische Studie über die Langzeitprognose von Patienten mit akutem Nierenversagen.

Of 250 patients who were haemodialyzed on account of an acute renal insufficiency during a period of 16 years 114 patients survived. A control of the course was performed in 105 patients. Altogether 34 patients dies after their discharge from hospital. Older age and acute renal insufficiency due to urological basic diseases or abscessing pyelonephrititides have clearly worse cumulative survival rates. The risk factors of chronic pyelonephritis and hypertension, respectively, are found in one third of the patients. The long-term prognosis after acute renal insufficiency can be improved by regular dispensary care.

[Dangers of drug and surgical treatment in chronic renal failure (conclusion)]. / Gefahren medikamentöser und operativer Behandlung chronisch Niereninsuffizienter (Fortsetzung).

Patients at the stage of advanced renal insufficiency with and without haemodialytic treatment are in general exclusively treated by the nephrologist. Nevertheless, some of these patients consult other physicians when complications or a second disease appear. According to our experiences to this belong above all emergency cases, such as feverish infections, disturbances of the gastrointestinal tract, fractures, combustions but also gynaecological diseases, inoculations or diseases of the teeth. In these cases the patient at the stage of the compensated retention not infrequently conceals the size of his renal disease, or the physician in charge underestimates the sequels of numerous medicamentous or operative therapies. On account of the dangers therefore the cooperation with the nephrologist is necessary.

[Eye fundus pathology in chronic terminal kidney failure]. / Augenhintergrundsbefunde bei chronisch terminaler Niereninsuffizienz.

On 75 patients with chronic renal insufficiency the relations between renal hypertension due to volume expansion and findings of the fundus of the eye were investigated. In compensated renal insufficiency in 20 of 23 patients a hypertension appeared, hypertensively conditioned changes of the fundus were observed only in about one third of the cases. When the functional disturbances progressed into the stage of the chronic terminal renale insufficiency on the other hand in 27 of 38 patients retina findings conditioned by hypertension were stated. Among 38 haemodialysis patients by regulation of the fluid balance 11 times a normal fundus and 15 times an improvement of the findings of the fundus of the eye could be revealed. In 13 patients the findings of the fundus generally improved after successful renal transplantation. Also our examinations call the usual stage subdivisions after Thiel and Keith and co-workers, respectively, in question.