[Geriatric patients in intensive care medicine. Ethical aspects]

Why are there so many hospital beds in Germany?

The place of hospitals in health systems is undergoing rapid change worldwide due to the high cost of hospital care and the changing health needs of the population. The Covid-19 pandemic has recently drawn public attention towards hospital capacity and has added new urgency to discussions on the future role of hospitals. In this context, recent experience in Germany provides valuable information for health systems seeking to manage hospital capacity. Despite reform efforts to reduce hospital capacity, Germany has the highest rates of intensive care beds among high-income countries and the highest overall hospital capacity in Europe. The capacity of the German hospital system can be explained in large part by the high number of elderly in-patients. This, in turn, is driven by (1) a fragmented ambulatory care system; (2) physicians admitting and maintaining elderly patients in hospital at a high rate; (3) a hospital market adding incentives to admit patients; and (4) a political commitment to egalitarian access and universal care. Additionally, recent policies to reduce hospital capacity have had limited impact because hospitals have not responded to financial incentives in the expected manner. Countries looking to learn from Germany's hospital capacity must therefore consider systemic features, political commitments, and unintended policy consequences.

[Geriatric patients in the intensive care unit]

The percentage of geriatric patients treated in intensive care units continues to increase, comprising up to 30%. Age per se is not of great relevance for the outcome of intensive care treatment. Functional status and geriatric syndromes are crucial for prognosis. Frailty and delirium are very important and should be screened using the Clinical Frailty Scale (CFS) and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), respectively. Furthermore, age-physiological organ changes as well as multimorbidity and associated polypharmacy play an important role. The latter should be assessed at the time of admission. Another goal of intensive care treatment of geriatric patients is to maintain and improve the nutritional status, which can be assessed with the help of an established tool (e.g. NRS 2002). In the treatment of critically ill geriatric patients with coronavirus disease 2019 (COVID-19), frailty is also crucial. It is particularly important in the intensive medical treatment of critically ill geriatric patients to clarify the question whether the patient benefits from each intensive care therapy, e.g., whether a desired therapeutic goal can be achieved, whether intensive care is in the (presumed) patient's will and whether the burdens during treatment are justified by the perspective of life. Furthermore, interdepartmental cooperation plays an important role in the intensive medical care of geriatric patients.

[Mortality in sepsis and septic shock in Germany. Results of a systematic review and meta-analysis]

Hintergrund

Verschiedene Autoren diskutieren, ob fehlende Qualitätsinitiativen und Behandlungsstandards in Deutschland im internationalen Vergleich zu höherer Sterblichkeit bei Sepsis und septischem Schock führen könnten. Dem gegenüber steht eine international anerkannte intensivmedizinische Versorgung in Deutschland, z. B. während der COVID-19-Pandemie.

Ziel der Arbeit

Ziel dieser Studie war es, die Sterblichkeit bei Sepsis und septischem Schock in Deutschland zu ermitteln und mit anderen Industrienationen zu vergleichen.

Material und Methoden

In eine systematischen Literaturrecherche wurden alle zwischen 2009 und 2020 veröffentlichten Interventions- und Beobachtungsstudien aus den Datenbanken PubMed und Cochrane Library eingeschlossen. Die 30- und 90-Tages-Sterblichkeit bei Sepsis und septischem Schock wurde in einer Metaanalyse mittels „Random-effects“-Modells gepoolt.

Ergebnisse

Insgesamt wurden 134 Studien in die Meta-Analyse eingeschlossen. Die 30-Tages-Sterblichkeit bei Sepsis betrug in Deutschland 26,50 % (95 %-KI: 19,86–33,15 %), in Europa (ohne Deutschland) 23,85 % (95%-KI: 20,49–27,21 %) und in Nordamerika 19,58 % (95%-KI: 14,03–25,14 %). Die 30-Tages-Sterblichkeit bei septischem Schock betrug 30,48 % (95 %-KI: 29,30–31,67 %), 34,57 % (95 %-KI: 33,51–35,64 %) bzw. 33,69 % (95 %-KI: 31,51–35,86 %). Die 90-Tages-Sterblichkeit bei septischem Schock betrug 38,78 % (95 %-KI: 32,70–44,86 %), 41,90 % (95 %-KI: 38,88–44,91 %) beziehungsweise 34,41 % (95 %-KI: 25,66–43,16 %).

Diskussion

Es ergaben sich somit keine Anhaltspunkte dafür, dass die Sterblichkeit bei Sepsis/septischem Schock im internationalen Vergleich in Deutschland erhöht ist.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00101-021-00917-8) enthält zusätzliche Informationen zu den eingeschlossenen Studien. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.

[Geriatric intensive care : Consensus paper of DGIIN, DIVI, DGAI, DGGG, ÖGGG, ÖGIAIN, DGP, DGEM, DGD, DGNI, DGIM, DGKliPha and DGG]

The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.

[Geriatric intensive care : Consensus paper of DGIIN, DIVI, DGAI, DGGG, ÖGGG, ÖGIAIN, DGP, DGEM, DGD, DGNI, DGIM, DGKliPha and DGG]

The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.

[Non-beneficial therapy and emotional exhaustion in end-of-life care : Results of a survey among intensive care unit personnel]

BACKGROUND

End-of-life care (EOLC) in the intensive care unit (ICU) is becoming increasingly more common but ethical standards are compromised by growing economic pressure. It was previously found that perception of non-beneficial treatment (NBT) was independently associated with the core burnout dimension of emotional exhaustion. It is unknown whether factors of the work environment also play a role in the context of EOLC.

OBJECTIVE

Is the working environment associated with perception of NBT or clinician burnout?

MATERIAL AND METHODS

Physicians and nursing personnel from 11 German ICUs who took part in an international, longitudinal prospective observational study on EOLC in 2015-2016 were surveyed using validated instruments. Risk factors were obtained by multivariate multilevel analysis.

RESULTS

The participation rate was 49.8% of personnel working in the ICU at the time of the survey. Overall, 325 nursing personnel, 91 residents and 26 consulting physicians participated. Nurses perceived NBT more frequently than physicians. Predictors for the perception of NBT were profession, collaboration in the EOLC context, excessively high workload (each p ≤ 0.001) and the numbers of weekend working days per month (p = 0.012). Protective factors against burnout included intensive care specialization (p = 0.001) and emotional support within the team (p ≤ 0.001), while emotional exhaustion through contact with relatives at the end of life and a high workload were both increased (each p ≤ 0.001).

DISCUSSION

Using the example of EOLC, deficits in the work environment and stress factors were uncovered. Factors of the work environment are associated with perceived NBT. To reduce NBT and burnout, the quality of the work environment should be improved and intensive care specialization and emotional support within the team enhanced. Interprofessional decision-making among the ICU team and interprofessional collaboration should be improved by regular joint rounds and interprofessional case discussions. Mitigating stressful factors such as communication with relatives and high workload require allocation of respective resources.

[Prognostic assessment as the basis for limiting therapy in unconscious patients after cardiopulmonary resuscitation]

BACKGROUND

The prognosis of patients who have been resuscitated after cardiac arrest is still unfavourable and long-term results have only slightly improved. As a consequence, intensivists are frequently confronted with the question of limiting active therapeutic efforts for patients in prolonged coma. The history of the patient and circumstances of the resuscitation are of limited value with regard to reliable decisions.

THERAPEUTIC DECISION-MAKING

Clinical and electrophysiological neurologic techniques as well as biomarkers and diagnostic imaging are, therefore, the basis for prognostication and potential consecutive therapeutic decisions. Sedation, relaxation and particularly therapeutic hypothermia have great influence on the test results. These influences have to be excluded before results can be validated. With regard to therapeutic hypothermia a reliable neurologic evaluation as a basis for limiting treatment is only possible after rewarming. Moreover results of multiple tests should be in agreement before a decision to limit treatment can be made. Finally it must be kept in mind that the absence of unfavourable test results is not proof of a good prognosis.

CONCLUSION

The decision to limit treatment can not be made on the basis of a single adverse prognostic sign, but requires a comprehensive clinical diagnostic assessment.