Ethische Betrachtungen zur Beatmungsmedizin unter besonderer Berücksichtigung des Lebensendes

Abstract

Invasiveness of interventions, complexity of diseases and patients' age are increasing in intensive care medicine. Ethical and legal issues are particularly challenging at the end of life of critically ill patients. At the borderline between intensive care and palliative medicine a significant amount of patients suffer from respiratory failure. Modern modes of mechanical ventilation may be able to improve ventilation and quality of life. On the other hand they may oppose a dignified death at the end of a long lasting chronic disease and e. g. prolong the suffering. In contrast to endotracheal intubation and invasive mechanical ventilation NIV enables patients to participate in the decision making process. While under normal circumstances, ethical standards dictate that patients themselves participate in the medical decision making process. For several reasons this is not always possible in intensive care medicine. However, chronically ill patients should get information from experts already at an early stage of the disease, go through a shared decision process and declare their will concerning interventions of intensive care medicine, e. g. mechanical ventilation. With respect to ethical and legal aspects of end of life this paper deals with chances of mechanical ventilation, including its withdrawal and withholding.

Weaning vom Respirator beginnt mit der Intubation

“…Berücksichtigt man die demographische Entwicklung unserer Gesellschaft, steigt der Bedarf an Optionen zur Betreuung von definitiv langzeitbeatmeten Patienten, und die damit verbundenen ethischen Fragen [122] werden immer drängender. In unserem Patientenkollektiv aus einem Beobachtungszeitraum von 10 Jahren waren 32% der Patienten nicht entwöhnbar [13].…”

“…Es ist aber streng darauf zu achten, dass NIV bei dieser Indikation nicht zur Verlängerung des Leidensweges bzw. des Sterbevorganges führt [122].…”

Umgang mit Therapiereduktion/-abbruch

“…Zwischen dem Vorenthalten einer Therapie und deren Reduktion oder Abbruch bestehen aus ethischer und juristischer Sicht keine prinzipiellen Unterschiede (Nä-heres hierzu s. [21]). Dennoch ist ein Therapieabbruch für alle Beteiligten emotional stärker belastend.…”

Overcoming a stigma: the lung cancer patient in the intensive care unit

“…for establishing criteria for limiting treatment [14]. If lung cancer that can no longer be treated curatively is classified as belonging to the group of advanced chronic lung diseases, we find that among the features that these diseases share are not only a clearly reduced life expectation, but also a permanently impaired quality of life [15]. We need to attach far more weight to these factors when evaluating intensive care than in the past.…”

“…without any prospects of or intent to prolong life [17]. However, from an ethical point of view, even though the level of invasiveness is lower, it is still necessary to inform the patient about it just as for intubation, since it is definitely a form of full ventilation [15]. Caution is required especially where the use of noninvasive ventilation is a routine measure as, for example, in a specialised hospital department, since there is a risk that mask ventilation will be used in patients with multiple conditions without consulting them sufficiently beforehand.…”