Zusammenfassung
Hintergrund
Wenn man an medizinische Grenzen stößt, sind Konflikte manchmal unvermeidbar. Die häufigsten Konflikte auf der Intensivstation treten zwischen dem medizinischen Team und den Angehörigen auf. Dabei sind insbesondere Therapieentscheidungen am Lebensende konfliktbeladen und stellen v. a. für Angehörige eine große Belastung dar.
Ziel
Die Studienlage soll dargestellt werden, zudem werden Handlungsempfehlungen zum Umgang mit potenziell konfliktbeladenen Entscheidungen auf der Intensivstation aufgezeigt.
Material und Methoden
Dieser Beitrag basiert auf einer selektiven Literaturrecherche in der Datenbank PubMed.
Ergebnisse
Es liegen Studienergebnisse zu posttraumatischen Belastungsstörungen von Angehörigen vor, welche die Belastung von Angehörigen durch Konfliktsituationen aufzeigen. Es existieren Empfehlungen zur Haltung des Arztes, zum Gesprächsstil und anderen Kontextfaktoren in Gesprächen über Therapieentscheidungen. Studienergebnisse legen nahe, dass eine sich an diesen Empfehlungen orientierende Gesprächsführung die emotionalen Belastungen der Angehörigen reduziert. Klinische Ethikberatungen können Konflikte auf der Intensivstation vermeiden, haben keinen Einfluss auf die Mortalitätsrate, führen aber zu einer Verkürzung letztendlich frustraner lebenserhaltender Maßnahmen.
Schlussfolgerungen
Um Konfliktsituationen auf der Intensivstation zu vermeiden, ist eine zeitnahe, kongruente und empathische Gesprächsführung in einem angemessenen ruhigen Umfeld mit den Angehörigen essenziell. Zur Deeskalation bei Konflikten werden klinische Ethikberatungen empfohlen.
Abstract
Background
If medicine is coming close to its limits conflicts sometimes occur. Most conflicts in the intensive care unit (ICU) involve the medical team and patients’ relatives. In particular decisions about withholding and withdrawing life-sustaining therapy lead to conflicts. Decisions about limiting life-sustaining treatment are burdened by conflicts and put an enormous strain particularly on relatives.
Aim
Illustration of currently available studies and existing recommendations on how to manage potentially conflict-laden decision-finding discussions on the ICU are presented.
Material and methods
This article is based on a selective literature research in the PubMed database.
Results
Studies have been carried out to evaluate posttraumatic stress disorders in relatives who were involved in life-limiting treatment decisions. Conflicts on the ICU put an emotional strain on relatives. Evidence-based recommendations are available regarding physicians’ attitudes during discussions about therapy decisions, communication style and other contextual factors. Study results show that the emotional stress level relatives have to endure can be reduced if conversations between patients’ families and the clinical personnel were conducted according to these recommendations. The involvement of a clinical ethics committee can prevent conflicts and has been shown to have no impact on the mortality rate but does decrease the time life-sustaining measures were unsuccessfully pursued.
Conclusion
To prevent conflicts between the medical personnel and patients’ relatives on the ICU, a timely, congruent and empathic conversation style in an appropriate, quiet environment is essential. Consultation with clinical ethics committees is recommended to de-escalate disputes.
Literatur
Studdert DM et al (2003) Conflict in the care of patients with prolonged stay in the ICU: types, sources, and predictors. Intensive Care Med 29(9):1489–1497
Abbott KH et al (2001) Families looking back: one year after discussion of withdrawal or withholding of life-sustaining support. Crit Care Med 29(1):197–201
Breen CM et al (2001) Conflict associated with decisions to limit life-sustaining treatment in intensive care units. J Gen Intern Med 16(5):283–289
Azoulay E et al (2009) Prevalence and factors of intensive care unit conflicts: the conflicus study. Am J Respir Crit Care Med 180(9):853–860
Embriaco N et al (2007) Burnout syndrome among critical care healthcare workers. Curr Opin Crit Care 13(5):482–488
Kentish-Barnes N et al (2009) Assessing burden in families of critical care patients. Crit Care Med 37(10 Suppl):S448–S456
Gries CJ et al (2010) Predictors of symptoms of posttraumatic stress and depression in family members after patient death in the ICU. Chest 137(2):280–287
Burgess L, Irvine F, Wallymahmed A (2010) Personality, stress and coping in intensive care nurses: a descriptive exploratory study. Nurs Crit Care 15(3):129–140
Lee Char SJ et al (2010) A randomized trial of two methods to disclose prognosis to surrogate decision makers in intensive care units. Am J Respir Crit Care Med 182(7):905–909
Boyd EA et al (2010) „It’s not just what the doctor tells me:“ factors that influence surrogate decision-makers’ perceptions of prognosis. Crit Care Med 38(5):1270–1275
Azoulay E et al (2005) Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med 171(9):987–994
Azoulay E et al (2002) Impact of a family information leaflet on effectiveness of information provided to family members of intensive care unit patients: a multicenter, prospective, randomized, controlled trial. Am J Respir Crit Care Med 165(4):438–442
Lilly CM et al (2000) An intensive communication intervention for the critically ill. Am J Med 109(6):469–475
Danjoux Meth N, Lawless B, Hawryluck L (2009) Conflicts in the ICU: perspectives of administrators and clinicians. Intensive Care Med 35(12):2068–2077
Curtis JR, White DB (2008) Practical guidance for evidence-based ICU family conferences. Chest 134(4):835–843
Curtis JR (2010) Life and death decisions in the middle of the night: teaching the assessment of decision-making capacity. Chest 137(2):248–250
Fassier T et al (2005) Care at the end of life in critically ill patients: the European perspective. Curr Opin Crit Care 11(6):616–623
Covinsky KE et al (1994) The impact of serious illness on patients’ families. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. JAMA 272(23):1839–1844
Cuthbertson SJ, Margetts MA, Streat SJ (2000) Bereavement follow-up after critical illness. Crit Care Med 28(4):1196–1201
Malacrida R et al (1998) Reasons for dissatisfaction: a survey of relatives of intensive care patients who died. Crit Care Med 26(7):1187–1193
Heyland DK et al (2003) Dying in the ICU: perspectives of family members. Chest 124(1):392–397
Keenan SP et al (2000) Withdrawal of life support: how the family feels, and why. J Palliat Care 16(Suppl):S40–S44
Lautrette A et al (2007) A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 356(5):469–478
Sprung CL et al (2007) The importance of religious affiliation and culture on end-of-life decisions in European intensive care units. Intensive Care Med 33(10):1732–1739
Bulow HH et al (2008) The world’s major religions’ points of view on end-of-life decisions in the intensive care unit. Intensive Care Med 34(3):423–430
Faith K, Chidwick P (2009) Role of clinical ethicists in making decisions about levels of care in the intensive care unit. Crit Care Nurse 29(2):77–84
Luce JM (2010) End-of-life decision making in the intensive care unit. Am J Respir Crit Care Med 182(1):6–11
Whitehead JM et al (2009) Consultation activities of clinical ethics committees in the United Kingdom: an empirical study and wake-up call. Postgrad Med J 85(1007):451–454
Tapper EB et al (2010) Ethics consultation at a large urban public teaching hospital. Mayo Clin Proc 85(5):433–438
Schneiderman LJ et al (2003) Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial. JAMA 290(9):1166–1172
Glavan BJ et al (2008) Using the medical record to evaluate the quality of end-of-life care in the intensive care unit. Crit Care Med 36(4):1138–1146
Pochard F et al (2001) Symptoms of anxiety and depression in family members of intensive care unit patients: ethical hypothesis regarding decision-making capacity. Crit Care Med 29(10):1893–1897
McDonagh JR et al (2004) Family satisfaction with family conferences about end-of-life care in the intensive care unit: increased proportion of family speech is associated with increased satisfaction. Crit Care Med 32(7):1484–1788
Selph RB et al (2008) Empathy and life support decisions in intensive care units. J Gen Intern Med 23(9):1311–1317
Curtis JR et al (2005) Missed opportunities during family conferences about end-of-life care in the intensive care unit. Am J Respir Crit Care Med 171(8):844–849
Stapleton RD et al (2006) Clinician statements and family satisfaction with family conferences in the intensive care unit. Crit Care Med 34(6):1679–1685
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Interessenkonflikt
M. Ratliff und J.-O. Neumann geben an, dass kein Interessenkonflikt besteht.
Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
Additional information
Redaktion
M. Buerke, Siegen
Rights and permissions
About this article
Cite this article
Ratliff, M., Neumann, JO. Entscheidungskonflikte mit Angehörigen auf der Intensivstation. Med Klin Intensivmed Notfmed 111, 638–643 (2016). https://doi.org/10.1007/s00063-015-0109-9
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00063-015-0109-9
Schlüsselwörter
- Therapiebegrenzungsentscheidung
- Religion
- Kommunikation
- Posttraumatische Belastungsstörungen
- Klinische Ethikberatung