[Choosing wisely recommendations in intensive care medicine]

[Overtreatment in intensive care medicine-recognition, designation, and avoidance : Position paper of the Ethics Section of the DIVI and the Ethics section of the DGIIN]

Ungeachtet der sozialgesetzlichen Vorgaben existieren im deutschen Gesundheitssystem in der Patientenversorgung nebeneinander Unter‑, Fehl- und Überversorgung. Überversorgung bezeichnet diagnostische und therapeutische Maßnahmen, die nicht angemessen sind, da sie die Lebensdauer oder Lebensqualität der Patienten nicht verbessern, mehr Schaden als Nutzen verursachen und/oder von den Patienten nicht gewollt werden. Daraus können hohe Belastungen für die Patienten, deren Familien, die Behandlungsteams und die Gesellschaft resultieren. Dieses Positionspapier erläutert Ursachen von Überversorgung in der Intensivmedizin und gibt differenzierte Empfehlungen zu ihrer Erkennung und Vermeidung. Zur Erkennung und Vermeidung von Überversorgung in der Intensivmedizin erfordert es Maßnahmen auf der Mikro‑, Meso- und Makroebene, insbesondere die folgenden: 1) regelmäßige Evaluierung des Therapieziels im Behandlungsteam unter Berücksichtigung des Patientenwillens und unter Begleitung von Patienten und Angehörigen; 2) Förderung einer patientenzentrierten Unternehmenskultur im Krankenhaus mit Vorrang einer qualitativ hochwertigen Patientenversorgung; 3) Minimierung von Fehlanreizen im Krankenhausfinanzierungssystem gestützt auf die notwendige Reformierung des fallpauschalbasierten Vergütungssystems; 4) Stärkung der interdisziplinären/interprofessionellen Zusammenarbeit in Aus‑, Fort- und Weiterbildung; 5) Initiierung und Begleitung eines gesellschaftlichen Diskurses zur Überversorgung.

[Overtreatment in intensive care medicine]

Overtreatment, which is therapy that is neither indicated nor desired by the patient ("non-beneficial"), presents an inherent and huge problem of modern medicine and intensive care medicine in particular. Overtreatment concerns all aspects of intensive care medicine, may start already before admission at the emergency scene, the inappropriate admission to the intensive care unit, overuse in diagnostics and especially in blood sampling, in invasive procedures and in organ support therapies. It manifests itself as "too much" in sedation, relaxation, volume therapy, hemodynamic support, blood products, antibiotics and other drugs and nutrition. Most importantly, overtreatment concerns the care of the patients at the end of life when a causal therapy is no longer available. Overtreatment also has important ethical implications and violates the four fundamental principles of medical ethics. It disregards the autonomy, dignity and integrity of the patient, is by definition nonbeneficial and increases pain, suffering, prolongs dying, increases sorrow of relatives, imposes frustration for the caregivers, disregards distributive justice and harms society in general by wasting principally limited resources. Overtreatment has also become an important legal issue and because of imposing inappropriate suffering may lead to prosecution. Overtreatment is poor medicine, is no trivial offence, all must continuously work together to reduce or avoid overtreatment.

[Choosing Wisely: rationale, implementation, and evaluation]

"Klug entscheiden" (Choosing Wisely) is an initiative launched by the German Society for Internal Medicine (DGIM) to boost the quality of medical indication by identifying both medical/therapeutic over- and underuse. Twelve specialist societies for internal medicine and DGIM associated societies develop corresponding recommendations which are subsequently evaluated and rejected or approved in a structured procedure by a multidisciplinary commission. Since 2016, 115 positive and negative recommendations have been developed and released for print media, radio and television. Physicians can obtain the DGIM/BDI* certificate "Klug entscheiden". First steps have been undertaken to implement "Klug entscheiden" in medical education. The wide dissemination and intense discussions give a reason to hope that positive and negative recommendations will be put into practice and that the awareness towards the relevance of the quality of medical indication will grow. And finally, specific recommendations are to be developed the implementation of which can be evaluated prospectively. * Professional organization of German specialists for internal medicine.