Author
Summary: Gabi Niethammer, as published in Alpha1 Journal 1/2024.
An intensive care unit (ICU) is a ward in a hospital where patients with serious or life-threatening illnesses or injuries receive intensive medical treatment. The ICU differs from other hospital units in its use of a wide range of technical equipment and the presence of more staff.
On the very large intensive care unit 10 II at Nuremberg Hospital, the nursing staff ratio is 2:1 during the day and 3:1 at night, meaning one nurse cares for a maximum of three patients at night. With 38 beds and approximately 5,000 patients per year, care is provided by a chief physician, four senior physicians, 25 resident physicians, 115 nurses and student nurses, coding assistants, and four medical assistants. Trainees from all these professional groups are also part of the team.
In addition, the treatment team is expanded to include microbiologists (infectiology, diagnostics, resistances, etc.), pharmacists (evaluating drug interactions, clarifying the need for economical antibiotic use), physiotherapists (movement, mobilization), speech therapists (speech therapy, swallowing disorders), hospital chaplaincy (for patients, relatives and staff), social services (organizing life after hospitalization) and closely involved cleaning staff, without whose good work the ward could not be maintained.
It's important to understand that people are being treated by other people! These people want the best for their patients, but sometimes they have bad days when things don't go as planned. In Nuremberg, visitors are allowed around the clock; the ward has had good experiences with this policy, and family members are welcome at any time.
Without the machines that support patients, daily life in an intensive care unit would be unthinkable. They provide support, keep patients alive, sometimes offer crucial therapies, or, like the extracorporeal membrane oxygenation (ECMO) machine, simply buy time for the body to heal. A major drawback is the immense noise level caused by the many devices; in particular, the numerous warning tones and alarms create a great deal of noise.
Through the immense combined efforts of human and machine technology, the aim is to provide optimal care for patients and, ideally, to save lives and heal. Where these goals are unattainable, the focus is on alleviating suffering, providing palliative care if necessary, and enabling a pain-free, dignified, and humane death.
Many intensive care patients require mechanical ventilation. Previously, this was accompanied by anesthesia, which was intended to reduce stress by suppressing consciousness and pain. It was common practice at the time to keep patients under anesthesia for extended periods, but this practice was found to be more harmful than beneficial. The medications had side effects, impaired blood flow to the organs, often disrupted bowel function, and the respiratory muscles atrophied (wasted away) after just a few hours on the ventilator. Furthermore, it was discovered that post-traumatic stress disorder (PTSD) following intensive care treatment was more severe than if the patient had experienced the time in the ICU while awake.
These days, completely different approaches are being taken. In many cases, an induced coma is no longer necessary. The goal is to achieve pain relief and keep the patient awake during the day, but free from anxiety and stress. This is usually quite successful with modern, easily controlled medications.
Propofol is usually given as an anesthetic, and many opiates are used as painkillers, such as fentanyl – which is beneficial in this setting (and which, for example, has led to many drug-related deaths in the USA due to misuse).
This allows the patient to actively participate in their recovery process, for example through physiotherapy. Visits from family members also naturally become much more important.
„"Currently, due to staff shortages, only 28 out of 38 beds are operational in my intensive care unit in Nuremberg."“
Pain cannot be directly measured in a coma patient; doctors rely on indirect signs such as body language, facial expressions, and the patient's blood pressure. A conscious patient, on the other hand, can describe where and how intense their pain is, allowing for much more targeted treatment.
It has become common practice to keep intensive care diaries. Patients who spend a long time in intensive care, perhaps even in a coma, can use them to later fill in the gaps left by their time in the ICU. These diaries record examinations, and family members and friends can document their visits and add their own notes.
„"Primum non nocere, secundum cavere, tertium sanare" means: First, do no harm; second, preserve; and third, heal. It is the principle of morally required medical practice and was already written down as a guiding principle by Scribonius Largus in 50 BC.
Currently, due to staff shortages, only 28 of the 38 beds in my intensive care unit in Nuremberg are operational. In addition to the staff shortage, other resources are also scarce. In particular, blood products (red blood cell concentrates, platelet concentrates), but also some medications, are frequently in short supply.
In order to decide who is admitted and when to be transferred from the intensive care unit, there are the four pillars of ethical action according to Beauchamp and Childress 1977:
- Respect for the patient's autonomy (the patient, as far as he can see, may decide whether he wishes to consent to a proposed therapy)
- Non-harm
- Care, assistance
- Equality and justice (Justice is difficult because it refers simultaneously to justice towards the individual and to society. Can I, as a society, afford to use an extremely expensive medication for an individual, or should this resource of money be used for something else?)
Advance healthcare directive and power of attorney
Plan your medical future with an advance healthcare directive and a power of attorney. Specify which measures you want and who should make decisions on your behalf. Learn more.
From an ethical standpoint, a great deal is possible in intensive care medicine, but there are, of course, limits. It is now legal for the medical team to discontinue treatment if no further treatment options are available. To gain a better understanding of the patient, patient resource questionnaires are used in Nuremberg to determine how the patient lived before their stay in intensive care and what their goals are.
The fear of dying, especially the fear of suffocating, is significant. One of the important tasks in the intensive care unit is to openly discuss the available treatment options and their limitations. Thus, a patient with end-stage COPD, who is on a ventilator and relatively alert in the ICU without pain, may well choose the palliative solution when faced with the choice between being transferred to a nursing home with a tracheostomy or dying painlessly and without shortness of breath surrounded by their loved ones in the ICU.
A very important form of support is a completed advance healthcare directive, in which the patient specifies in writing which medical interventions they consent to and refuse towards the end of their life. This decision-making aid is not only a valuable guideline for the medical team, but it also relieves family members of the burden of making potentially difficult decisions should the patient no longer be able to do so themselves.
From a purely medical perspective, the power of attorney for healthcare decisions has become less important for married couples. Since 2023, there has been a statutory right of spouses to act as their representative in healthcare matters in cases of acute illness. However, this only applies to married couples who are not separated and is limited to six months.
Any representation extending beyond the scope of the power of attorney, which may also encompass financial matters, still requires a power of attorney for health care and financial matters. This allows a trusted person to be appointed in advance to handle the legal affairs of the represented individual within the scope of the granted power of attorney, should the need arise. A power of attorney for health care and financial matters allows for a high degree of self-determination but requires complete trust in the person to be granted this power.
I wish you time
I don't wish you all possible gifts.
I wish you only what most people don't have:
I wish you time to be happy and laugh,
And if you use them, you can make something of them.
I wish you time for your actions and your thoughts,
not only for yourself, but also as a gift.
I wish you time – not for rushing and racing,
but rather the time to be able to be content.
I wish you time – not just to pass the time.
I hope you have some left over.
as a time for wonder and a time for trust,
instead of just looking at the time on the clock.
I wish you time to reach for the stars,
and time to grow, that is, to mature.
I wish you time to hope anew, to love anew.
There's no point in postponing this time.
I wish you time to find yourself,
To experience every day, every hour as a blessing.
I wish you time, also to forgive guilt.
I wish you: Time to live!
Elli Michler
