BackgroundAdvances in intensive care medicine have enormously improved ability to successfully treat seriously ill patients. However, intensive treatment and prolongation of life is not always in the patient’s best interest, and many ethical dilemmas arise in end-of-life (EOL) situations. We aimed to assess intensive care unit (ICU) physicians’ experiences with EOL decision making and to compare the responses according to ICU type.Material/MethodsA cross-sectional survey was performed in all 35 Slovene ICUs, using a questionnaire designed to assess ICU physician experiences with EOL decision making, focusing on limitations of life-sustaining treatments (LST).ResultsWe distributed 370 questionnaires (approximating the number of Slovene ICU physicians) and 267 were returned (72% response rate). The great majority of ICU physicians reported using do-not-resuscitate (DNR) orders (97%), withholding LST (94%), and withdrawing antibiotics (86%) or inotropes (95%). Fewer ICU physicians reported withdrawing mechanical ventilation (52%) or extubating patients (27%). Hydration was reported to be only rarely terminated (76% of participants reported never terminating it). In addition, 63% of participants had never encountered advance directives, and 39% reported to “never” or “rarely” participating in decision making with relatives of patients. Nurses were reported to be “never” or “rarely” involved in the EOL decision making process by 84% of participants.ConclusionsLimitation of LST was regularly used by Slovene ICU physicians. DNR orders and withholding of LST were the most commonly used measures. Hydration was only rarely terminated. In addition, use of advance directives was almost non-existent in practice, and the patients’ relatives and nurses only infrequently participated in the decision making.

The decision to limit LST measures was found to be ethically acceptable for Slovene paediatricians. No major differences were found among paediatric intensivists, specialist paediatricians and paediatric residents in the attitudes towards the EOL care.

Results The analysis resulted in 4 categories: a. the moment of death in the PICU; b. talking with the attending physicians; c. parental involvement in decision making; d. parental participation in research. The results show that parents lack a peaceful environment where they can adequately carry out the goodbyes at the time of death of their children. They emphasized the solidarity provided by the nursing staff at this point and the little involvement of the medical team. The opportunity to revisit the process of their children's death with the team physician was considered positive. Parents felt that they did not have an effective participation in decision taking. Conclusion The research shows that the difficulty of communication between health staff and parents is a factor that impacts negatively on the decision taking and grieving processes.

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Background and aims Hepcidin, which acts as a negative feedback regulator of iron homeostasis, may in future serve as a non-invasive iron status parameter to monitor iron supplementation in preterm infants. For this, coexisting influencing factors should be taken into account. Our objective was to evaluate in preterm infants whether red blood cell (RBC) transfusions have a short-term effect on hepcidin concentrations in serum (Hep (S) ) and urine (Hep (U) ). Methods Prospective observational study including very preterm infants receiving RBC transfusions. The concentration of the mature, 25 amino-acid form of hepcidin was determined in serum und urine by enzyme-linked immunosorbent assay together with cellular indices before and after RBC transfusion. Results The study was conducted between May 2009 and September 2010 at Tübingen University Hospital. 20 preterm infants born at a mean gestational age of 26.0 (interquartile range: 24.9-27.4) weeks and with a mean postnatal age of 30.8 (interquartile range 29.9-32.1) daysreceived 27 RBC transfusions. When measured shortly after transfusion (mean 10 h), hematocrit values increased from a median of 26.6% (SD 2.8) to 40.9% (SD 3.2; p < 0.0001); Hep (S) also increased (geometric mean: 44.3 ng/mL (95% confidence interval: 30.8-63.8) vs. 58.0 ng/mL (95% confidence interval: 35.7-94.3; p < 0.05) but Hep (U) remained unaffected. Conclusion These data indicate a short-term effect of RBC transfusions on serum hepcidin concentrations in preterm infants. Further longer-term observational studies are needed to understand the dynamics of hepcidin regulation in preterm infants.