Angehörigenkonferenz

Notvertretungsrecht in der Intensivmedizin

Mit Wirkung zum 1.1.2023 werden Ehegatten kraft Gesetzes (automatisch) zu Stellvertretern in sämtlichen „Angelegenheiten der Gesundheitssorge“, d.h. auch für Therapieentscheidungen nahe dem Lebensende. Einer vorausgehenden Bevollmächtigung ad personam durch den Patienten (soweit er noch geschäftsfähig ist, sog. „Gesundheitsvollmacht“) bedarf es dann nicht mehr. Um möglichem Missbrauch entgegenzuwirken, hat sich der Gesetzgeber jedoch zugleich darum bemüht, Sicherungsvorkehrungen zu etablieren. Insbesondere ist eine zeitliche Befristung und eine generelle Nachrangigkeit der gesetzlichen Stellvertretung gegenüber Vollmacht und gerichtlicher Betreuung vorgesehen, was die neue Vertretungsbefugnis für Ehegatten eher zu einer Maßnahme der Überbrückung in Notlagen macht. Blickt man auf den für Klinikeinrichtungen und Ärzteschaft damit verbundenen bürokratischen Aufwand, wird man allerdings am Sinn des neuen Rechts zweifeln.

[Medical ethics : The pioneering role of critical care medicine]

The development of intensive care medicine started over more than 50 years. Effective organ system support for ventilation initially and subsequently for circulation, nutrition and renal function resulted in improved outcomes in patients with a variety of severe medical conditions. One of the unfortunate consequences of this development was that it did not allow dying or prolonged the dying process and without the possibility of recovery to a quality of life acceptable to the patients. The early realization of this dilemma ultimately led to broad ethical discussions concerning withholding and withdrawal of curative therapies in intensive care units, and introducing palliative care.

[Communicating with families in the ICU : Background and practical recommendations]

Family members of adult intensive care patients are partners of the interdisciplinary team. Family members provide important contributions to patient-centered care in the intensive care unit (ICU) and beyond. At the same time, family members are stressed and are themselves in need of support ("family-centered care"). This is mainly provided through family conferences. Family members must always be treated respectfully and with consideration for their acute stress syndrome. A structured communication is recommended as well as written standard operating procedures (SOPs) or guidelines for the ICU team and brochures and written guidelines for relatives. Documentation of structured family conferences is an established quality indicator of intensive care.

[Autonomy and welfare in intensive care medicine : Practical approach in difficult situations]

In intensive care units far-reaching decisions are often made at short notice that require the consent of the informed patient. If this is not possible due to the patient's condition, physicians and legal representatives must ascertain the previously expressed or presumed will of the patient and act accordingly. The legal principles are specified in the Patient Advance Directives Act and the Patient Rights Act. Any indications for medical treatment need a clearly defined aim of the therapy, which can be questioned during the progress of the disease. To avoid conflicts between patient autonomy and medical treatment, the aims of therapy must be regularly discussed with the patient, representatives or relatives and documented in a written form. Checklists can be useful for structured consultations, to promote transparency and to avoid misunderstandings. Ethics consultations can help to deescalate critical situations.

[Dying in the intensive care unit]

Modern intensive care is responsible both for curative interventions in critical health situations and palliative terminal care for the dying ICU patient. By applying an integrated ethics approach, this article examines organizational and cultural factors shaping good terminal care in the ICU. Starting with a reflection on what it means to be human, ethical goals for care of the dying are formulated. Among them, the article focuses on practices ensuring a dignified dying process, on the structured engagement of patients' families, on respecting cultural and spiritual values, and on a clinical pathway for terminal care as an institutional framework. In conclusion, it becomes evident that good terminal care in the ICU not only depends on ethically sound decisions on withholding or withdrawing medical interventions but also on organizational and cultural aspects which must be acknowledged and shaped.

[Ethics consultations in intensive care medicine]

INTRODUCTION

An increase in ethical conflicts is being observed in the modern intensive care setting, as more complex therapeutic strategies are available and the treatment of old and very old patients is integrated into the clinical routine due to changes in medical options and social epidemiology. Physicians, nurses and families need ethical support to come to a decision about medical treatment when value conflicts are involved.

METHODS

The basis of medical ethics is reported followed by a presentation of personal experiences and a reference overview regarding the impact of ethics consultations.

RESULTS

Common ethical conflicts in the intensive care setting result from the lack of precise knowledge on patient preferences and due the use of modern "high-tech" intensive care medicine the prognosis of recovery and quality of life of (old) patients seems to be difficult to assess. Ethical definitions of treatment perspectives will find an important and increasing place in intensive care competence in the future, although currently there is a lack of theoretical and practical instruction in ethics. The goal of ethics consultations is to help physicians, nurses and family members by a structuration of the problem and by a moderation of discussion and problem resolution including a special ethical workflow. Ethics consultations seem to be useful in resolving conflicts that may inappropriately prolong unwanted treatment.

CONCLUSIONS

The increase of the incidence of ethical conflicts in the intensive care setting may impact ethics consultations which help the integration of ethical principles into the clinical practice.

[Communication in intensive care medicine]

Communication plays a crucial role in the intensive care unit. Posttraumatic stress syndromes develop in a significant number of patients and their relatives after being in an intensive care unit. The syndromes may persist for several years. Regular open and empathic communication with patients and family members reduces the frequency and severity of the disease. Among the physicians and nurses in the intensive care unit, there is a high prevalence of burnout syndrome. The precipitating factors are mostly conflicts within the working staff, work overload and end-of-life situations. Working team communication reduces the rate of exhaustion syndromes. Rounds of discussions among the work groups are the basis for a healthy team structure. Inadequate communication, e.g., during emergencies or shift change, endangers the safety of patients and in the worst case, results in treatment mistakes. Measures for improved communication in the intensive care unit should always be implemented.