[Use of coercive measures in the intensive care unit]

[Dealing with coercion in intensive care medicine : Recommendations from the Ethics Section of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) in collaboration with the Ethics Section of the German Society for Internal Intensive Care and Emergency Medicine (DGIIN)]

The treatment situation in intensive care is characterised by a specific asymmetry in the relationship between patients and the team: Patients are particularly dependent on their environment and often show impaired consciousness and capacity to consent. This facilitates the use of coercion or enables and/or provokes it. The aim of this recommendation is to show ways to recognise patients with their wishes and needs and to integrate them into treatment concepts in the intensive care unit in order to reduce and avoid coercion whenever possible. The recommendation shows the variety of possible forms of coercion and discusses the moral standards to be considered in the ethical weighing process as well as legal conditions for justifying its use. It becomes obvious that treatment measures which may involve the use of coercion always require a careful and self-critical review of the measures in relation to the indication and the therapeutic goal. The recommendation's intention therefore is not to disapprove the use of coercion by interprofessional teams. Instead, it aims to contribute to a sensitive perception of coercion and to a critical and caring approach to formal and especially informal (indirect) coercion.

What does coercion in intensive care mean for patients and their relatives? A thematic qualitative study

Background

The need for an ethical debate about the use of coercion in intensive care units (ICU) may not be as obvious as in other areas of medicine, such as psychiatry. Coercive measures are often necessary to treat critically ill patients in the ICU. It is nevertheless important to keep these measures to a minimum in order to respect the dignity of patients and the cohesion of the clinical team. A deeper understanding of what patients and their relatives perceive during their ICU stay will shed different light on intensive care management. Patients' experiences of loss of control, dependency and abandonment may lead to a new approach towards a broader approach to the concept of coercion in intensive care. The aim of our research is to explore the experiences of patients and relatives in the ICU and to determine when it might be possible to reduce feelings and memories of coercion.

Methods

We conducted and analysed 29 semi-structured interviews with patients and relatives who had been in the ICU a few months previously. Following a coding and categorisation process in MAXQDA™, a rigorous qualitative methodology was used to identify themes relevant to our research.

Results

Five main themes emerged: memory issues; interviewees’ experiences of restricting measures and coercive treatment; patients’ negative perception of situational and relational dependency with the risk of informal coercion; patients’ perceptions of good care in a context of perceived dependency; progression from perception of coercion and dependency to respect for the person. All patients were grateful to have survived. However, coercion in the form of restraint, restriction of movement, and coercive treatment in the ICU was also acknowledged by patients and relatives. These included elements of informal coercion beyond restraints, such as a perceived negative sense of dependence, surrender, and asymmetrical interaction between the patient and health providers.

Conclusions

To capture the full range of patients' experiences of coercion, it is necessary to expand the concept of coercion to include less obvious forms of informal coercion that may occur in dependency situations. This will help identify solutions to avoid or reduce negative recollections that may persist long after discharge and negatively affect the patients' quality of life.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-022-00748-1.

[Influence of nurses on the experience of noninvasive ventilation]

Noninvasive ventilation (NIV) is established as an integral part of intensive care therapy for respiratory insufficiency. However, it is associated with restrictions on patient autonomy and comfort. A successful course of therapy is largely dependent on the acceptance and adherence of the patients concerned. Intensive care nurses can have a significant influence on the success of the therapy by dealing with the subjective experience of the patients and by maintaining close contact with them. The prerequisite for this is profound knowledge of the different technical aspects of therapy and equipment as well as positive and negative factors influencing NIV tolerance in order to be able to offer and implement an individual intervention.