End of life care in Italian intensive care units: where are we now?

Most patients in the ICU are unable to make decisions for themselves at the end of life (EOL), and the responsibility for these decisions falls to the medical staff and patients' relatives. Therefore, clinicians must frequently communicate with patients' relatives to understand the patients' values and preferences as they perform medical decision making. The family's role in this process varies: the entire burden of decision making could rest with the family, or family members could be informed of the decisions without admission into the decision-making process. In contrast to these two extremes, clinicians and family members may also enter into shared decision making: an exchange of views and opinions between clinicians and the patient's family to enable the two parties to reach decisions together. In this latter scenario, the effectiveness of the discussions that take place between clinicians and family members becomes a crucial marker of high-quality intensive care. In this review, we provide an overview of the current literature concerning the state of EOL care in European and Italian ICUs and then summarize several European and American recommendations for improving EOL care in the ICU. Finally, we examine the opportunity to use shared decision making to improve EOL care in the ICU through interdisciplinary communication, open and realistic discussion of prognosis with families, and an approach respecting different cultural perspectives.

Managing intensive supports. The attitudes of the health care workers of five Italian Hospitals to institution of CPR and admission to the ICU.

AIM: The aim of the paper was to examine the attitudes of the health care workers (HCW) of five Italian Hospitals towards intensive supports, in the hypothesis that a large involvement could help to solve the problems of a more adequate management of vital supports. DESIGN: Hospital HCWs' attitudes towards cardiopulmonary resuscitation (CPR) and ICU admission were investigated using a self-administered questionnaire. SETTING: five Italian Hospitals. PARTICIPANTS: all the doctors (MD) and nurses (RN), except those working in obstetrics and in paediatrics. INTERVENTION: a questionnaire was offered to all eligible participants (4903 HCW) and 2466 analysable files (50.3%) were obtained. RESULTS: In spite of a great variation in responses among health care givers, the majority of answers is almost in line with current professional and bioethical documents, at both international and national level. This, also when the proposed solution is not clearly recognised by the Italian laws. The statistically significant differences depend on profession (RN/MD), on working area and experiential working characteristics. A strict minority of workers would trust their colleagues in case of hypothetical personal critical illness. CONCLUSIONS: Our data confirm both the importance of communication among HCW, in order to reach the best decision for every patient, and the great need of continuous educational programs which could compensate for lack of experience and help to create/maintain a strong bioethical and patient-oriented attitude.

Informed consent to proposed course of medical treatment: recent case law stances.

Developments in ethics, deontology and case law, along with the related increasing demand for patient autonomy in decision-making in health care, led the President of SIAARTI in 2000 to request the Bioethics Commission to revise the documentation on informed content the Study Group on Anesthesia Safety had issued. In response to the request, a multidisciplinary study group was called to examine the ethical, psychological, clinical, legal and medicolegal issues related to informed consent and to draw up a document that would provide for the implementation of the procedure for information and consent proposed in the model of disclosed information and consent for anesthesia approved by the SIAARTI Advisory Board. The model is to be viewed as evidence for an established anesthetist-patient relationship and as a useful record in case of legal or insurance liability litigation. In Italy, failure to obtain consent to medical treatment has assumed growing legal implications. Since 1992, the failure to obtain consent has become part of case law, an exemplary instance of which is the case of a surgeon that was closed in 2002 with the judgment of the Corte di Cassazione (Italian Supreme Court), section I, of 29/05/2002. The judgment found that, in the absence of express implementation of the Oviedo Convention, a physician is always legitimated to performed therapeutic treatment deemed necessary for preserving the life of a patient in his or her care, even in the absence of explicit consent, with the sole but significant exception of unequivocal refusal of treatment.

Conscious sedation during endoscopic retrograde colangiopancreatography: implementation of SIED-SIAARTI-ANOTE guidelines in Belluno Hospital.

AIM: In this study we describe the results of adoption of local guidelines for conscious sedation (CS) during endoscopic-retrograde-cholangiopancreatography (ERCP) in Belluno Hospital. Local guidelines were created referring to SIED-SIAARTI-ANOTE guidelines for CS in gastrointestinal endoscopy. METHODS: Between January 2002 and February 2004, 300 ERCPs to be performed under CS have been scheduled. According to local guidelines CS was performed by the gastroenterologist assisted by an anesthesia nurse. An anesthesiologist was always on call in the intensive care unit (ICU) for emergencies and could be on the site in less than 5 min. RESULTS: In 278 patients the procedure was performed safely and effectively by the gastroenterologist without any anesthesiological assistance. At follow-up controls patients had either positive or no recollection of the procedure. An anesthesiologist was called in 13 cases to perform deep sedation and in 9 cases to deal with undesired effects (arterial hypertension in 5 patients, 1 episode of bradycardia, 1 of ventricular tachycardia, 1 of atrial fibrillation and 1 of hypoxia). CONCLUSION: In our experience, CS during ERCP can be safely performed autonomously by a gastroenterologist in the majority of cases. Drug prescription protocol and the presence of an anesthesia nurse create ideal conditions for the operator, patient comfort and good results with a low incidence of undesired events and few calls for the anesthesiologist. To allow safe and effective performance of CS, the Department of Anesthesia should promote the in-service training and up dating of gastroenterologists and anesthesia nurses.

[Quadriplegia and prolonged respiratory insufficiency due to tick-borne encephalomyelitis. Case report]. / Tetraplegia ed insufficienza respiratoria prolungata conseguenti ad encefalomielite virale da puntura di zecca. Descrizione di un caso.

Tick-borne encephalitis (TBE) is an uncommon and potentially severe illness. TBE virus is transmitted to the humans by an infected tick and it spreads to the central nervous system determining various clinical pictures. A case in which TBE virus caused an encephalomyelitis with quadriplegia and respiratory insufficiency that persist one year after the diagnosis, is reported. Such a clinical manifestation of TBE has never been described in Italy till now.

[Critical aspects of communication in intensive care]. / Aspetti critici della comunicazione in terapia intensiva.

The poor quality of interpersonal communication is the main reason for the dissatisfaction intensive care patients and their family members often experience. Yet interpersonal communication is considered an important means of conveying information, providing psychological support, and preventing conflicts which can arise when communication is ineffective and information is misunderstood. Good communication is, therefore, an essential part of therapy. This study examines the factors that can hinder communication between clinicians, patients and their family members and the strategies needed to overcome the obstacles to good communication. The results of the study showed that training in the development of relational skills and communicative competence within the intensive care setting should be directed towards the promotion of decision-making processes shared among medical personnel, patients and their family members. In this way, conflict can be reduced and the quality of medical care improved.

[Guidelines in clinical practice. Bioethical considerations]. / Le Linee-Guida nella pratica clinica. Riflessioni bioetiche.

The adoption of guidelines in clinical practice raises questions that can be answered against a background in which professional conduct is compared with deontology, law, and the specific sociocultural context and health policies of institutions. In the scientific community, doubts are raised regarding the relationships between the general recommendations laid down in the Guidelines and the specific nature of every clinical condition; between the "duty of adhering" to Guidelines and the doctor's autonomy, as well as between the adoption, discrepancy and non-adoption of Guidelines and the juridical evaluation of medical liability. The information and individual consent of patients and citizens is of particular importance both with regard to clinical procedures and choices of allocation. In the light of these comments, the authors conclude that Guidelines should not be reduced to a form of automated procedure lacking any responsibility, but should represent a correct synthesis between the objective nature of scientific findings, the subjective condition of the patient and the doctor's autonomy. The application of correctly formulated Guidelines shared by the community means acting in such a way that the "right to health" and "freedom of treatment" can be exercised in respect of shared bioethical principles based on beneficence, autonomy and justice.

[The medical deontological code and ethical questions regarding the end of life. A contribution to clarity from anesthesiologists and intensive care personnel]. / Il codice di Deontologia Medica e le questioni etiche di fine vita. Un contributo alla chiarezza da parte degli Anestesisti-Rianimatori.

The Medical Deontological Code (MDC) discusses ethical questions regarding the end of life, which often require anesthetists and intensive care operators to take decisions regarding patients with terminal diseases in Article 14: Intensity of diagnostic-therapeutic procedures under heading IV (Diagnostic and therapeutic procedures) and Article 37: Caring for the terminally ill under heading V (Caring for the terminally ill). The original formulation of Article 37 prompted immediate dissent among numerous anesthetists-IC operators and bioethics experts who signed a petition addressed to the Permanent Commission for the Revision of the Deontological Code in which they asked of Article 37 and proposed a reformulation. In this paper the authors outline the arguments used to back up this requests and its broad acceptance by the Commission, as shown by the amendments made to Articles 37 and 38 of the MDC and the clarifications given un the Commentary to the MDC approved on 1/9/99. These amendments correct a deontological regulation whose original formulation appeared to be contradictory and inapplicable to the terminally ill patients. This matter clearly shows the importance of bioethical questions facing. Anesthetists and Intensive Care operators and underlines the need for reflection on these themes within the profession and a more active participation in the general debate on ethical and deontological aspects of the medical profession.

[Bioethical interpretation of intensive care] . / Per una lettura in chiave bioetica delle terapie intensive.

The bioethical interpretation concerns both those receiving intensive care (IC) and the nature of the treatment itself. The principle of autonomy expressed in the doctor-patient relationship is achieved through the use of informed consent and may also be used in the unique context of patients in IC. Organ-function replacement treatment raises the ethical question of the definition and management of the limit to treatment. The appropriateness of IC can be defined by clinical and ethical criteria and aims to avoid inappropriately excessive treatment. In order to improve the decision-making process involving bioethical questions, the authors outline a number of working approaches: the use of informed consent even in IC, the possible role of Advanced Directives in IC, epidemiological studies, operator training.

Upper airway obstruction by retropharyngeal hematoma after cervical spine trauma: report of a case treated with percutaneous dilational tracheostomy.

The authors report the case of a patient affected by a cervical spine trauma who developed upper airway obstruction as a result of a retropharyngeal hematoma. An endotracheal intubation with a small-diameter tube was performed, but ventilation and oxygenation were not adequate. An early Percutaneous Dilational Tracheostomy with the Ciaglia technique was then performed. The risk of upper airway obstruction by retropharyngeal hematoma after cervical spine trauma is discussed in this article, as are the feasibility and benefits of using Percutaneous Dilational Tracheostomy in emergency cases of upper airway obstruction.