HILE THE PRINCIPLE THAT dying patients should be treated with respect and compassionisbroadlyaccepted among health care professionals, medical practices for end-of-life care differ around the world. In the United States, medicine has moved from a paternalistic model to one that promotes autonomy and self-determination. 1,2 Patient expectations and preferences now help shape end-of-life practices, limiting the use of technologies that may prolong dying rather than facilitate recovery. 1,2 In Europe, patient-physician relationships are still somewhat paternalistic. 3-5 Different cultures and countries deal in diverse ways with the ethical dilemmas arising as a consequence of the wider availability of life-sustaining therapies. 3,4,6 Some have not adopted the Western emphasis on patient autonomy or methods of terminating life support. 3,4,6 In the past, patients died in intensive care units (ICUs) despite ongoing aggressive therapy. 7 Theoretical discussions 7 and attitudes of critical care Author Affiliations and the members of the Ethicus Study Group are listed at the end of this article.

ICU patients typically lack decision-making capacity, and physicians know patients' wishes in only 20% of EOL decisions. There were regional differences in discussions of EOL decisions with families and other physicians. In European ICUs there seems to be a need to improve communication.

Background: Dehydration appears prevalent, costly and associated with adverse outcomes. We sought to generate consensus on such key issues and elucidate need for further scientific enquiry. Materials and Methods: A modified Delphi process combined expert opinion and evidence appraisal. 12 relevant experts addressed dehydration's definition, objective markers and impact on physiology and outcome. Results: Fifteen consensus statements and seven research recommendations were generated. Key findings, evidenced in detail, were that there is no universally-accepted definition for dehydration; hydration assessment is complex and requires combining physiological and laboratory variables; 'dehydration' and 'hypovolaemia' are incorrectly used interchangeably; abnormal hydration status includes relative and/or absolute abnormalities in body water and serum/plasma osmolality (pOsm); raised pOsm usually indicates dehydration; direct measurement of pOsm is the gold standard for determining dehydration; pOsm >300 and ≤280 mOsm/kg classifies a person as hyper or hypo-osmolar; outside extremes, signs of adult dehydration are subtle and unreliable; dehydration is common in hospitals and care homes and associated with poorer outcomes. Discussion: Dehydration poses risk to public health. Dehydration is under-recognised and poorly managed in hospital and community-based care. Further research is required to improve assessment and management of dehydration and the authors have made recommendations to focus academic endeavours.

SummaryDiabetes affects 10–15% of the surgical population and patients with diabetes undergoing surgery have greater complication rates, mortality rates and length of hospital stay. Modern management of the surgical patient with diabetes focuses on: thorough pre‐operative assessment and optimisation of their diabetes (as defined by a HbA1c < 69 mmol.mol−1); deciding if the patient can be managed by simple manipulation of pre‐existing treatment during a short starvation period (maximum of one missed meal) rather than use of a variable‐rate intravenous insulin infusion; and safe use of the latter when it is the only option, for example in emergency patients, patients expected not to return to a normal diet immediately postoperatively, and patients with poorly controlled diabetes. In addition, it is imperative that communication amongst healthcare professionals and between them and the patient is accurate and well informed at all times. Most patients with diabetes have many years of experience of managing their own care. The purpose of this guideline is to provide detailed guidance on the peri‐operative management of the surgical patient with diabetes that is specific to anaesthetists and to ensure that all current national guidance is concordant.

European ICU physicians do not experience difficulties with end-of-life decisions in most cases. Allocation of limited resources is a minor consideration and autonomous choices by patient or family remain unusual. Inter-regional differences were found.