Data Entry: Please note that the research database will be replaced by UNIverse by the end of October 2023. Please enter your data into the system https://universe-intern.unibas.ch. Thanks
Folgt der Ablauf von Therapiebegrenzungen auf einer Intensivstation einem Muster?
Journal
Intensivmedizin und Notfallmedizin
Volume
44
Number
7
Pages / Article-Number
429-437
Keywords
Einführung; Prognose; Unter- und Ungleichversorgung; Ethikberatung; Überversorgung
Abstract
Research question Limitation of treatment (LOT) has been a matter of debate for more than ten years. The frequency of LOT, both the withholding and withdrawing of treatment, was studied in various countries; but one question has received little attention so far: How is LOT carried out in practice, i.e. is there a procedure that can be observed regularly?Method We documented a series of ten cases in which a certain treatment was not started (withholding) or an ongoing treatment was stopped (withdrawing). All medically and ethically relevant information was documented in a three-part protocol adjusted specifically for this study. In addition, we analysed all patient charts to determine in which sequence and at which time a new treatment was initiated or when which treatment was limited. Patients were selected by chance.Results A pattern is described regarding the sequence of treatment limitation. In five cases LOT was carried out rather quickly. Several treatments were stopped almost simultaneously. In all these cases prognosis was very poor. If prognosis was considered very poor with certainty, various treatment decisions were stopped immediately. As long as prognosis was uncertain, treatment limitation was carried out much less quickly. At first, several treatment options were not initiated. Only after this decision was treatment, which had been initiated before, withdrawn. The withdrawal was carried out step-wise in the following sequence: no resuscitation, inotropes and antibiotics only in reduced dosages, no escalation of mechanical ventilation, withdrawal of certain medications, stop artificial nutrition in combination with continued artificial hydration. Despite LOT, new treatment may be initiated.Discussion The sequence of LOT on the studied ward follows a "pattern" that depends on the prognosis of the patient. It is possible that clinical units develop a kind of a ritual that takes place almost automatically. We consider it important to be aware of this possibility and to reflect on the sequences of LOT regularly. It should be decided individually in each case which treatments make sense or create additional burden. In this decision-making we should try to respect the patient's wishes as far as possible - at least the presumed wishes of the patient.
