[Burnout in intensive care units]

Intensive care units are highly stressful for the patients but for the caregivers as well, including nurse-assistants, nurses and physicians. The psychological syndrome of work exhaustion more commonly named burnout threatens these caregivers. The aims of the present paper are to describe: a) the incidence of burnout in intensive care units; b) the factors favoring burnout and c) the impacts of burnout at the individual, at the unit and institutional level. We suggest some possible ways to decrease the incidence of burnout. Finally, since the problematic of burnout is not specific to intensive care, we sought to underline some possible consequences of the burnout of caregivers on health systems.

Medicare and Medicaid programs; reform of hospital and critical access hospital conditions of participation. Final rule

This final rule revises the requirements that hospitals and critical access hospitals (CAHs) must meet to participate in the Medicare and Medicaid programs. These changes are an integral part of our efforts to reduce procedural burdens on providers. This rule reflects the Centers for Medicare and Medicaid Services' (CMS) commitment to the general principles of the President's Executive Order 13563, released January 18, 2011, entitled "Improving Regulation and Regulatory Review.''

[Non invasive ventilation in the ICU for the neuromuscular patient: legal issues]

The legal frame in which chronic mechanical ventilation is placed in Switzerland and France is discussed in this article. Safety of the patients and responsibility of caregivers are considered. We also discuss the ethical and legal aspects of the end-of-life of these patients, particularly when they decide that mechanical ventilation must be interrupted because they do not more tolerate their poor quality of life, and when they deliberately decide to die.

Medicare and Medicaid programs: changes to the hospital and critical access hospital conditions of participation to ensure visitation rights for all patients. Final rule

This final rule will revise the Medicare conditions of participation for hospitals and critical access hospitals (CAHs) to provide visitation rights to Medicare and Medicaid patients. Specifically, Medicare- and Medicaid-participating hospitals and CAHs will be required to have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital or CAH may need to place on such rights as well as the reasons for the clinical restriction or limitation.

Laws can be unethical

ICU teams have the difficult emotional burden of continuing complex life-sustaining therapy beyond the limits of what is felt to be reasonable. Among the reasons leading to a delay in the withdrawal of intensive therapy is the unwillingness or unpreparedness of the team or family members, or inadequate laws. We all have the responsibility to promote a legal framework allowing end-of-life decisions that ensure the autonomy, dignity and integrity of all citizens, in addition to the humane practice of medicine.

The use of mobile computed tomography in intensive care: regulatory compliance and radiation protection

The use of mobile head computed tomography (CT) equipment in intensive care is of benefit to unstable patients with brain injury. However, ionising radiation in a ward environment presents difficulties due to the necessity to restrict the exposure to staff and members of the public according to regulation 8(1-2) of the Ionising Radiation Regulations 1999. The methodology for enabling the use of a mobile head CT unit in an open ward area is discussed and a practical solution given. This required the reduction in scatter doses through the installation of extra internal and external shielding, and a further reduction in annual scatter dose by restricting the use of the equipment based on a simulation of the annual ward workload.

A history of ethics and law in the intensive care unit

Because they provide potential benefit at great personal and public cost, the intensive care unit (ICU) and the interventions rendered therein have become symbols of both the promise and the limitations of medical technology. At the same time, the ICU has served as an arena in which many of the ethical and legal dilemmas created by that technology have been defined and debated. This article outlines major events in the history of ethics and law in the ICU, covering the evolution of ICUs, ethical principles, informed consent and the law, medical decision-making, cardiopulmonary resuscitation, withholding and withdrawing life-sustaining therapy, legal cases involving life support, advance directives, prognostication, and futility and the allocation of medical resources. Advancement of the ethical principle of respect for patient autonomy in ICUs increasingly is in conflict with physicians' concern about their own prerogatives and with the just distribution of medical resources.

[Informed consent for intensive care research in Switzerland: any solution?]

In this article, we describe several aspects of the problems linked with the informed consent for medical research in the particular environment of intensive care. The specific elements of this singular context are analysed in taking account the present laws in Europe as well as in Switzerland, including the future project of law under current discussion.

Ethics review: 'Living wills' and intensive care--an overview of the American experience

Withdrawal and limitation of life support in the intensive care unit is common, although how this decision is reached can be varied and arbitrary. Inevitably, the patient is unable to participate in this discussion because their capacity is limited by the nature of the illness and the effects of its treatment. Physicians often discuss these decisions with relatives in an attempt to respect the patient's wishes despite evidence suggesting that the relatives may not correctly reflect the patient's desires. Advance decisions, commonly known as 'living wills', have been proposed as a way of facilitating the maintenance of an individual's autonomy when they become incapacitated. Others have argued that legalising advance decisions is euthanasia by the back door. In October 2007 in England and Wales, advance decisions will become legally binding as part of the 2005 Mental Capacity Act. This has been the case in the USA for many years. The purpose of the present review is to examine the published literature regarding the effect of advance decisions in relation to the provision of adult critical care.

Advanced directives and treatment decisions in the intensive care unit

Prospective medical decision-making through the use of advanced directives is encouraged and frequently helpful in guiding treatment for the critically ill. It is important to recognize the attendant shortcomings when using such tools in clinical practice.