When Frail Individuals or Their Families Request Nonindicated Interventions: Usefulness of the Four-Box Ethical Approach

A beginner's view of end of life care on German intensive care units

Background

Little is known about importance and implementation of end-of-life care (EOLC) in German intensive care units (ICU). This survey analyses preferences and differences in training between “medical” (internal medicine, neurology) and “surgical” (surgery, anaesthesiology) residents during intensive care rotation.

Methods

This is a point-prevalence study, in which intensive care medicine course participants of one educational course were surveyed. Physicians from multiple ICU and university as well as non-university hospitals and all care levels were asked to participate. The questionnaire was composed of a paper and an electronic part. Demographic and structural data were prompted and EOLC data (48 questions) were grouped into six categories considering importance and implementation: category 1 (important, always implemented), 2 (important, sometimes implemented), 3 (important, never implemented) and 4–6 (unimportant, implementation always, sometimes, never). The trial is registered at the “Deutsches Register für klinische Studien (DRKS)”, Study number DRKS00026619, registered on September 10th 2021, www.drks.de.

Results

Overall, 194/ 220 (88%) participants responded. Mean age was 29.7 years, 55% were female and 60% had scant ICU working experience. There were 64% medical and 35% surgical residents. Level of care and size of ICU differed significantly between medical and surgical (both p < 0.001). Sufficient implementation was stated for 66% of EOLC questions, room for improvement (category 2 and 3) was seen in 25, and 8% were classified as irrelevant (category 6). Areas with the most potential for improvement included prognosis and outcome and patient autonomy. There were no significant differences between medical and surgical residents.

Conclusions

Even though EOLC is predominantly regarded as sufficiently implemented in German ICU of all specialties, our survey unveiled still 25% room for improvement for medical as well as surgical ICU residents. This is important, as areas of improvement potential may be addressed with reasonable effort, like individualizing EOLC procedures or setting up EOLC teams. Health care providers as well as medical societies should emphasize EOLC training in their curricula.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01684-8.

A Systematic Literature Review of Relational Autonomy in Dialysis Decision Making

Nephrology interdisciplinary guidelines, professional codes of ethics, principle-based ethical standards, and literature promote patient autonomy and self-determination through shared decision making as ethical practice. Healthcare professionals are accountable for practice that is mindful of the impact of cultural diversity and community on the values and beliefs of the patient, an important part of shared decision making (SDM). Despite previous research regarding dialysis decision making, relational autonomy in chronic kidney disease (CKD) and end-stage kidney disease SDM conversations is not well understood. This systematic literature review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework for identifying peer-reviewed literature on SDM for CKD. The findings were summarized into four broad themes: (1) promoting autonomy is a foundation of medical caring; (2) providers have a responsibility to respond to their asymmetrical social power; (3) autonomy is situated within the context of the patient; and (4) dialogue is a tool that negotiates clinical recommendations and patient goals. The caring practices of promoting autonomy with a dialogical resolution of a conflict acknowledging the interdependence of the parties and the patient's social-relational situatedness support a perspective of relational autonomy in dialysis decision-making practice and research.

Is the four quadrant approach to military medical ethics a cargo cult? A call for more unity between philosophers and practitioners

Moral theory should be practically useful, but without oversight from the philosophical community, the practical application of ethics by other institutions such as the military may drift into forms that are not theoretically robust. Ethical approaches that drift in this way run the risk of becoming 'cargo cults': simulations that will never properly fulfil their intended purpose. The four quadrant approach, a systematic method of ethical analysis that applies moral principles to clinical cases, has gained popularity in the last 10 years in a variety of medical contexts, especially the military. This paper considers whether the four quadrant approach is a cargo cult or whether it has theoretical value, with particular reference to the more popular four principles approach. This analysis concludes that the four quadrant approach has theoretical advantages over the four principles approach, if used in the right way (namely, with all four quadrants being used). The principal advantage is that the four quadrant approach leaves more room for clinical judgement, and thus avoids the charge of being too algorithmic, which has been levelled at the four principles approach. I suggest that it is the fourth quadrant, which invites the user to consider wider, contextual features of the case, which gives the approach this key advantage. Finally, I make a more general proposal that theoretical ethicists should work closely with those practitioners who apply ethics in the world, and I call for a symbiotic relationship between these two camps.

End-of-life perceptions among physicians in intensive care units managed by anesthesiologists in Germany: a survey about structure, current implementation and deficits

Background

Structural aspects and current practice about end-of-life (EOL) decisions in German intensive care units (ICUs) managed by anesthesiologists are unknown. A survey among intensive care anesthesiologists has been conducted to explore current practice, barriers and opinions on EOL decisions in ICU.

Methods

In November 2015, all members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthesiologists (BDA) were asked to participate in an online survey to rate the presence or absence and the importance of 50 items. Answers were grouped into three categories considering implementation and relevance: Category 1 reflects high implementation and high relevance, Category 2 low and low, and Category 3 low and high.

Results

Five-hundred and forty-one anesthesiologists responded. Only four items reached ≥90% agreement as being performed “yes, always” or “mostly”, and 29 items were rated “very” or “more important”. A profound discrepancy between current practice and attributed importance was revealed. Twenty-eight items attributed to Category 1, six to Category 2 and sixteen to Category 3. Items characterizing the most urgent need for improvement (Category 3) referred to patient outcome data, preparation of health care directives and interdisciplinary discussion, standard operating procedures, implementation of practical instructions and inclusion of nursing staff and families in the process.

Conclusion

The present survey affirms an urgent need for improvement in EOL practice in German ICUs focusing on advanced care planning, distinct aspects of changing goals of care, implementation of standard operating procedures, continuing education and reporting of outcome data.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-017-0384-5) contains supplementary material, which is available to authorized users.