ABSTRACT
Coercive treatment in medicine includes measures taken against a current or previous expression of the will of the person concerned. It can include overcoming manifested resistance, especially in patients who no longer have the capacity to consent. Even though coercive measurements are common in psychiatry, they are also used in intensive care units (ICU). Use of coercive measurements in the ICU has always been a conflict between providing best medical care and restriction of free will/patient will. Medical staff is generally only partially aware of the moral conflict of these measures. However, patients have described coercion as an active loss of free will which they experience to be dehumanizing, stressful and traumatizing. The challenge in the ICU is to focus on the individual needs of the patients and involve them as much as possible while providing high-quality, highly specialized medical care. In order to avoid coersion in the ICU and to do justice to the individual patient, the focus must shift to building awareness. Models that have been shown to improve awareness such as the ethical reflection within the team, supervision and psychological support for patients and internal hospital standards have also been shown to reduce coercive measurements taken. The aim of this paper is to describe causes, different methods and frequencies of coercive measures used in the ICU. Legal aspects are also taken into account. This paper attempts to identify which procedures undertaken in the ICU can be associated with coercive measurements and how coercion is experienced by patients and the team.
Subject(s)
Coercion , Psychiatry , Humans , Intensive Care Units , Personal AutonomyABSTRACT
BACKGROUND AND CHALLENGE: Injuries, especially traumatic brain injury, or specific illnesses and their respective sequelae can result in the demise of the patients afflicted despite all efforts of modern intensive care medicine. If in principle organ donation is an option after a patient's death, intensive therapeutic measures are regularly required in order to maintain the homeostasis of the organs. These measures, however, cannot benefit the patient afflicted anymore-which in turn might lead to an ethical conflict between dignified palliative care for him/her and expanded intensive treatment to facilitate organ donation for others, especially if the patient has opted for the limitation of life-sustaining therapies in an advance directive. METHOD: The Ethics Section and the Organ Donation and Transplantation Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) have convened several meetings and a telephone conference and have arrived at a decision-making aid as to the extent of treatment for potential organ donors. This instrument focusses first on the assessment of five individual dimensions regarding organ donation, namely the certitude of a complete and irreversible loss of all brain function, the patient's wishes as to organ donation, his or her wishes as to limiting life-sustaining therapies, the intensity of expanded intensive treatment for organ protection and the odds of its successful attainment. Then, the combination of the individual assessments, as graphically shown in a {Netzdiagramm}, will allow for a judgement as to whether a continuation or possibly an expansion of intensive care measures is ethically justified, questionable or even inappropriate. RESULT: The aid described can help mitigate ethical conflicts as to the extent of intensive care treatment for moribund patients, when organ donation is a medically sound option. NOTE: Gerald Neitzke und Annette Rogge contributed equally to this paper and should be considered co-first authors.
Subject(s)
Decision Making , Emergency Medicine , Organ Transplantation , Tissue and Organ Procurement , Critical Care , Humans , Organ Transplantation/ethics , Tissue Donors , Tissue and Organ Procurement/ethicsABSTRACT
The Ethics Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) recently published a documentation for decisions to withhold or withdraw life-sustaining therapies. The wish to donate organs was not considered explicitly. Therefore the Ethics Section and the Organ Donation and Transplantation Section of the DIVI together with the Ethics Section of the German Society of Medical Intensive Care Medicine and Emergency Medicine worked out a supplementary footnote for the documentation form to address the individual case of a patient's wish to donate organs.
ABSTRACT
BACKGROUND: Communication with relatives is a central part of the decision-making process. In the absence of the patient's direct consent to a potential organ donation, the next of kin must provide information about a potential wish to donate and give permission in the context of an extended consent solution. At the same time, family members must also cope with the death of a loved one. OBJECTIVE: To determine how relatives can be optimally supported during the decision-making process. MATERIALS AND METHODS: Narrative review. RESULTS: In the context of potential or confirmed irreversible brain death, communication with family members or legal representatives serves to deliver bad news as well as to determine whether the patient had a wish to donate his/her organs and to clarify the resultant steps. Communication strategies such as the SPIKES or VALUE models provide emotional and cognitive support for relatives and strengthen clinicians' communication skills. Clinicians' behavior towards patients, deceased, and next of kin may influence relatives' decision-making; respectful and competent behavior seems to contribute towards relatives granting permission for organ donation. CONCLUSION: Clinicians must be trained and skilled in communication strategies which are used in critical situations to provide emotional support to relatives during the organ donation decision-making process. Relatives are more likely to achieve a satisfying and sustainable decision if a strong relationship exists between clinicians and relatives based on information giving, openness, trust, and empathy.
Subject(s)
Communication , Family/psychology , Tissue Donors , Tissue and Organ Procurement , Brain Death , Death , Decision Making , Female , Humans , Male , Third-Party ConsentABSTRACT
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.
