Der Anaesthesist
-
Patients have the right to make decisions concerning their health care. The right to consent to or refuse treatment is based on the ethical principle of autonomy. Respecting a patient's autonomy has emerged as one of the leading principle in medical ethics in the last years. ⋯ I believe that defining accepted and refused interventions in advance is not an appropriate approach to DNR orders during anaesthesia and surgery, as it will be difficult to find a definition of what constitutes resuscitation in this context. Communication with the patient and exchange of information are essential factors promoting ethical decisions. Knowing the individual patient's preferences and fears, a more suitable approach seems to be the perioperative suspension of the DNR order for a limited period of time, with the assurance that therapeutic procedures instituted during surgery will be discontinued postoperatively in reconsideration of the DNR order and if the underlying disease process turns out to be non-reversible.
-
Randomized Controlled Trial Comparative Study Clinical Trial
[Remifentanil with propofol or isoflurane. A comparison of the recovery times after arthroscopic surgery].
Due to its unique pharmacokinetics, the new esterase-metabolised opioid remifentanil results in rapid post-anesthesia recovery. The aim of this clinical investigation was to compare recovery times after remifentanil anaesthesia in combination with hypnotic concentrations of either propofol or isoflurane. Dosages used in the study protocol were based on recommendations by the pharmaceutical manufacturer. ⋯ Using the manufacturer's recommended dosages, emergence after remifentanil anaesthesia is more rapid with 0.5 MAC isoflurane than with 0.1 mg/kg/min propofol. These results are most probably due to the different pharmacological properties of both co-anaesthetics, especially the applied dosages, and to different interactions with remifentanil. Present clinical experience suggests that a further dose reduction, especially for propofol, is possible. For both remifentanil groups emergence was remarkably rapid between return of consciousness and the awake state (on-off phenomenon), which might contribute to post-anaesthesia safety.
-
Thirty years ago, cardiopulmonary resuscitation (CPR) was primarily developed for otherwise healthy individuals who experienced sudden cardiac arrest. Today, CPR is widely viewed as an emergency procedure that can be attempted on any person who undergoes a cessation of cardiorespiratory function. Therefore, the appropriateness of CPR has been questioned as a matter of the outcome, the patient's preferences, and the cost. The objective of this article is to analyse ethical issues in prehospital resuscitation. ⋯ The standard of care remains the prompt initiation of CPR. However, ethical principles such as beneficence, nonmaleficence, autonomy, and justice have to be applied in the unique setting of emergency medicine. Physicians have to consider the therapeutic efficacy of CPR, the potential risks, and the patient's preferences.
-
In more than 30 years of development of intensive care medicine (ICM), our specialty has acquired moral and ethical standpoints, although not without public pressure and discussions. Special commissions dealing, e.g., with brain death, terminal care, ethics of foregoing life-sustaining treatment in the critically ill, withholding or withdrawing mechanical ventilation, and other issues have been formed in a number of medical societies. International consensus conferences have helped to clarify some of the issues. ⋯ From 30 years experience in ICM, there are many more ethical questions and case reports without clear solutions. Care decisions for single patients in unacceptable situations should be made after medical evaluation by the intensivist with the medical team and, if possible, by the patient and/or his or her surrogate. Legislation and solutions cannot be expected for single patients, but ethics committees could be helpful in decision-making.