Skip to main content
SpringerLink
Log in

Ethische Aspekte in der Therapie kritisch kranker Tumorpatienten

Ethical aspects in the critical care of tumor patients

  • ÜBERSICHT
  • Published:
Intensivmedizin und Notfallmedizin

Abstract

Tumor patients in need of critical care medicine often ignite discussions between hemato-oncologists and intensive care physicians regarding benefit, reason and objectives of intensive care therapy gainst the background of narrow resources. But a general limitation of intensive care measures in oncological patients is neither medically nor ethically justified. As a basic principle the patient’s will is pivotal for the implementation or omission of intensive care measures, but a medical therapy that is not indicated does not have to be offered by the caring physicians.

In situations where the patient can not be asked due to medical reasons (unconsciousness, confusion, sedation, etc.), appropriate means to find out his will (advance directives of the patient, discussions with family members, etc.) have to be used. In cases with foreseeable course of disease a dialogue at an early stage between the patient and the caring physician about prognosis of the disease and therapeutical and personal goals of the patient should be encouraged.

In everyday life advance directives are lacking in most cases. Moreover due to their more general character their usefulness in concrete medical situations is limited. Therefore we recommend in all medical situations a stepwise procedure when the patient is in need of intensive care but where either the medical basis for decision or the patient’s will is unclear. Initially all necessary intensive care measures should be started to offer the patient every option he needs and to obtain time for the intensive care physician to gather all necessary information and to enter into a discussion with family members and all physicians looking after the patient. The clinical situation of the patient should be reevaluted on a regular basis giving the therapeutic team (i.e. the intensive care team and all physicians involved in the treatment of the patient) the option to adapt their measures according to the decision- relevant facts.

Zusammenfassung

Die intensivmedizinische Versorgung kritisch kranker Tumorpatienten führt häufig zwischen den betreuenden Ärzten zu Diskussionen um Nutzen, Sinn und Zielsetzung intensivmedizinischer Maßnahmen vor dem Hintergrund knapper Ressourcen. Eine generelle Limitierung intensivmedizinischer Maßnahmen bei Tumorpatienten ist weder medizinisch gerechtfertigt noch ethisch vertretbar. Grundsätzlich gilt, dass der Patientenwille für die Durch führung oder Nichtdurchführung intensivmedizinischer Maßnahmen entscheidend ist. Allerdings muss eine medizinisch nicht indizierte Therapie ärztlicherseits nicht angeboten werden. Sollte der Patient in der konkreten Situation aufgrund der medizinischen Umstände (Bewusstlosigkeit, Verwirrtheit, Sedierung bei künstlicher Beatmung etc.) nicht zu seinem Willen befragt werden können, müssen entsprechende Hilfsinstrumente zur Willensermittlung (Patientenverfügung, Angehörigengespräche etc.) herangezogen werden. Hier ist bei absehbarem Krankheitsverlauf das frühzeitige Gespräch zwischen betreuendem Arzt und Patient über Prognose sowie therapeutische und persönliche Zielsetzungen besonders wichtig. Im Alltag fehlen jedoch in vielen Fällen derartige Vorabbestimmungen des Patientenwillens. Zudem lassen diese sich aufgrund ihres generellen Charakters in konkreten medizinischen Problemsituationen oft nicht unmittelbar anwenden. Es ist daher in allen Situationen, in denen die medizinische Entscheidungsgrundlage oder der Patientenwille unklar sind, die Anwendung eines Stufenplanes zu empfehlen, der dem Patienten zu Beginn alle intensivmedizinischen Optionen offen lässt und die Möglichkeit bietet nach regelmäßiger Reevaluation aller entscheidungsrelevanten Tatsachen im Dialog mit betreuendem Onkologen, Intensivmedizinern und Angehörigen, die intensivmedizinische Therapie der jeweiligen Lage anzupassen.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Literatur

  1. Abdulla W (2006) Interdisziplinäre Intensivmedizin. Urban & Fischer, Jena, pp 39 ff

  2. Arbeitsgruppe „Therapiebegrenzung“ des Klinischen Ethikkomitees am Universitätsklinikum Erlangen (2005) Empfehlungen zur Therapiebegrenzung auf Intensivstationen Version 1.4. Universitätsklinikum Erlangen. http://www.klinikum.uni-erlangen.de/ e1768/e2332/e6087/e6097/inhalt6098/ KEK_TherapiebegrenzungText_ 050405.pdf

  3. Asai A, Fukuhara S, Inoshita O, Miura Y, Tanabe N, Kurokawa K (1997) Medical decisions concerning the end of life: a discussion with Japanese physicians. J Med Ethics 23:323–327

    Article  PubMed  CAS  Google Scholar 

  4. Azoulay E, Afessa B (2006) The intensive care support of patients with malignancy: do everything that can be done. Intensive Care Med 32:3–5

    Article  PubMed  Google Scholar 

  5. Azoulay E, Chevret S, Leleu G, Pochard F, Barboteu M, Adrie C, Canoui P, Le Gall JR, Schlemmer B (2000) Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med 28:3044–3049

    Article  PubMed  CAS  Google Scholar 

  6. Azoulay E, Thiéry G, Chevret S, Moreau D, Darmon M, Bergeron A, Yang K, Meignin V, Ciroldi M, Le Gall JR, Tazi A, Schlemmer B (2004) The prognosis of acute respiratory failure in critically ill cancer patients. Medicine (Baltimore) 83:360–370

    Article  PubMed  Google Scholar 

  7. Bauer A (2001) Therapiebegrenzung und Therapieabbruch. Ein ethisches und juristisches Dilemma in der Intensivmedizin. Zeitschrift für Medizinische Ethik 47:139–151

    Google Scholar 

  8. Bauer AW (2003) Futility-Debatte in der Onkologie. Onkologe 9:1325–1334

    Article  Google Scholar 

  9. Bauer AW (2006) Autonomie am Lebensende: Realität, Ideal, Illusion? Universitas 61:115–131

    Google Scholar 

  10. Beauchamp TL, Childress JF (2001) Principles of biomedical ethics. Oxford University Press, Oxford

  11. Benbenishty J, Ganz FD, Lippert A, Bulow HH, Wennberg E, Henderson B, Svantesson M, Baras M, Phelan D, Maia P, Sprung CL (2006) Nurse involvement in end-of-life decision making: the ETHICUS Study. Intensive Care Med 32:129–132

    Article  PubMed  Google Scholar 

  12. Benoit DD, Depuydt PO, Vandewoude KH, Offner FC, Boterberg T, De Cock CA, Noens LA, Janssens AM, Decruyenaere JM (2006) Outcome in severely ill patients with hematological malignancies who received intravenous chemotherapy in the intensive care unit. Intensive Care Med 32:93– 99

    Article  PubMed  Google Scholar 

  13. Borasio GD, Putz W, Eisenmenger W (2003) Neuer Beschluss des Bundesgrichtshofs: Verbindlichkeit von Patientenverfügungen gestärkt. – Vormundschaftsgericht soll in Konfliktlagen entscheiden. Deutsches Ärzteblatt 100:A2062–A2065

    Google Scholar 

  14. Brenner H, Stegmaier C, Ziegler H (2002) Long-term survival rates of cancer patients achieved by the end of the 20th century: a period analysis. Lancet 360:1131–1135

    Article  PubMed  Google Scholar 

  15. Brenner H, Stegmaier C, Ziegler H (2005) Verbesserte Langzeitüberlebensraten von Krebspatienten. Deutsches Ärzteblatt 102:A2628-A2633

    Google Scholar 

  16. Bruennler T, Mandraka F, Zierhut S, Siebig S, Wrede C, Klebl F, Holler E, Salzberger B, Schoelmerich J, Langgartner J (2007) Outcome of hematooncologic patients with and without stem cell transplantation in a medical ICU. submitted

  17. Bundesärztekammer (2004) Grundsätze der Bundesärztekammer zur ärztlichen Sterbebegleitung. Deutsches Ärzteblatt 101:A1298–A1299

    Google Scholar 

  18. Charles C, Gafni A, Whelan T (1997) Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med 44:681–692

    Article  PubMed  CAS  Google Scholar 

  19. Charles C, Gafni A, Whelan T (1999) Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med 49:651–661

    Article  PubMed  CAS  Google Scholar 

  20. Covinsky KE, Fuller JD, Yaffe K, Johnston CB, Hamel MB, Lynn J, Teno JM, Phillips RS (2000) Communication and decision-making in seriously ill patients: findings of the SUPPORT project. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. J Am Geriatr Soc 48:S187–S193

    PubMed  CAS  Google Scholar 

  21. Cuomo A, Delmastro M, Ceriana P, Nava S, Conti G, Antonelli M, Iacobone E (2004) Noninvasive mechanical ventilation as a palliative treatment of acute respiratory failure in patients with end-stage solid cancer. Palliat Med 18:602–610

    Article  PubMed  Google Scholar 

  22. Darmon M, Azoulay E, Alberti C, Fieux F, Moreau D, Le Gall JR, Schlemmer B (2002) Impact of neutropenia duration on short-term mortality in neutropenic critically ill cancer patients. Intensive Care Med 28:1775–1780

    Article  PubMed  Google Scholar 

  23. Dettmeyer R (2006) Medizin und Recht. Rechtliche Sicherheit für den Arzt. Springer, Heidelberg

  24. Deutsch E, Spickhoff A (2003) Medizinrecht. Arztrecht, Arzneimittelrecht, Medizinprodukterecht und Transfusionsrecht. Springer, Berlin

  25. Earle CC (2006) Do unto others. J Clin Oncol 24:3331–3332

    Article  PubMed  Google Scholar 

  26. Earle CC, Neville BA, Landrum MB, Ayanian JZ, Block SD, Weeks JC (2004) Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol 22:315–321

    Article  PubMed  Google Scholar 

  27. Ernst J, Schwarz R (2006) Patienten im medizinischen Entscheidungsprozess – Befunde und Fragen zum Shared-Decision-Making bei Tumorpatienten. Brandenburgisches Onkologie- Forum 28–32

  28. Fassier T, Lautrette A, Ciroldi M, Azoulay E (2005) Care at the end of life in critically ill patients: the European perspective. Curr Opin Crit Care 11:616–623

    Article  PubMed  Google Scholar 

  29. Ganz FD, Benbenishty J, Hersch M, Fischer A, Gurman G, Sprung CL (2006) The impact of regional culture on intensive care end of life decision making: an Israeli perspective from the ETHICUS study. J Med Ethics 32:196–199

    Article  PubMed  CAS  Google Scholar 

  30. Garin N (2005) Intensive care unit admission of critically ill cancer patients. Rev Med Suisse 45:2935–2938

    Google Scholar 

  31. Giacomini M, Cook D, DeJean D, Shaw R, Gedge E (2006) Decision tools for life support: a review and policy analysis. Crit Care Med 34:864–870

    Article  PubMed  CAS  Google Scholar 

  32. Hawryluck L (2006) Ethics review: position papers and policies – are they really helpful to front-line ICU teams? Crit Care 10:242

    Article  PubMed  Google Scholar 

  33. Hufeland CW (1806) Die Verhältnisse des Arztes. Neues Journal der practischen Arzneykunde und Wundarzneykunst, hg.v.Chr.W.Hufeland, Berlin: Commission bei L.Wittlich, 16,3 (= 23,3 Journal der practischen Arzneykunde und Wundarzneykunst), 15 f

  34. Klemperer D (2005) Shared Decision Making und Patientenzentrierung – vom Paternalismus zur Partnerschaft in der Medizin. Teil 1: Modelle der Arzt-Patient-Beziehung. Balint-Journal 6:71–79

    Article  Google Scholar 

  35. Kress JP, Christenson J, Pohlman AS, Linkin DR, Hall JB (1999) Outcomes of critically ill cancer patients in a university hospital setting. Am J Respir Crit Care Med 160:1957–1961

    PubMed  CAS  Google Scholar 

  36. Lamont EB, Christakis NA (2001) Prognostic disclosure to patients with cancer near the end of life. Ann Intern Med 134:1096–1105

    PubMed  CAS  Google Scholar 

  37. Larche J, Azoulay E, Fieux F, Mesnard L, Moreau D, Thiéry G, Darmon M, Le Gall JR, Schlemmer B (2003) Improved survival of critically ill cancer patients with septic shock. Intensive Care Med 29:1688–1695

    Article  PubMed  Google Scholar 

  38. Lautrette A, Ciroldi M, Ksibi H, Azoulay E (2006) End-of-life family conferences: Rooted in the evidence. Crit Care Med 34:S364–S372

    Article  PubMed  Google Scholar 

  39. Lim Z, Pagliuca A, Simpson S, Cottam S, Ervine M, Ho AY, Devereux S, Mufti GJ (2007) Outcomes of patients with haematological malignancies admitted to intensive care unit. A comparative review of allogeneic haematopoietic stem cell transplantation data. Br J Haematol 136:448–450

    Article  PubMed  Google Scholar 

  40. Marckmann G (2004) Lebensverlängerung um jeden Preis? Ethische Entscheidungskonflikte bei der passiven Sterbehilfe. Ärzteblatt Baden-Württemberg 59:379–382

    Google Scholar 

  41. Massion PB, Dive AM, Doyen C, Bulpa P, Jamart J, Bosly A, Installe E (2002) Prognosis of hematologic malignancies does not predict intensive care unit mortality. Crit Care Med 30:2260–2270

    Article  PubMed  Google Scholar 

  42. Matsuyama R, Reddy S, Smith TJ (2006) Why do patients choose chemotherapy near the end of life? A review of the perspective of those facing death from cancer. J Clin Oncol 24:3490–3496

    Article  PubMed  Google Scholar 

  43. Meert AP, Berghmans T, Hardy M, Markiewicz E, Sculier JP (2006) Noninvasive ventilation for cancer patients with life-support techniques limitation. Support Care Cancer 14:167–171

    Article  PubMed  Google Scholar 

  44. Naeem N, Reed MD, Creger RJ, Youngner SJ, Lazarus HM (2006) Transfer of the hematopoietic stem cell transplant patient to the intensive care unit: does it really matter? Bone Marrow Transplant 37:119–133

    Article  PubMed  CAS  Google Scholar 

  45. Nelson JE, Meier DE (1999) Palliative Care in the Intensive Care Unit: Part I. J Intensive Care Med 14:130–139

    Google Scholar 

  46. Pelegrino ED (1985) The virtuous Physician, and the Ethics of Medicine. In: Shelp EF (ed) Virtue and Medicine. Reidel Publishing Co, Dordrecht, pp 237–255

  47. Pene F, Aubron C, Azoulay E, Blot F, Thiéry G, Raynard B, Schlemmer B, Nitenberg G, Buzyn A, Arnaud P, Socie G, Mira JP (2006) Outcome of Critically Ill Allogeneic Hematopoietic Stem-Cell Transplantation Recipients: A Reappraisal of Indications for Organ Failure Supports. J Clin Oncol 24:643–649

    Article  PubMed  Google Scholar 

  48. Rauprich O, Steger F (Hrsg) (2005) Prinzipienethik in der Biomedizin. Moralphilosophische und medizinische Praxis. Campus, Frankfurt/ Main, New York

  49. Rauprich O (2005) Prinzipienethik in der Biomedizin – Zur Einführung. In: Rauprich O, Steger F (Hrsg) Prinzipienethik in der Biomedizin. Moralphilosophische und medizinische Praxis. Campus, Frankfurt/Main, New York, S 11–45

  50. Reisfield GM, Wallace SK, Munsell MF, Webb FJ, Alvarez ER, Wilson GR (2006) Survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: a meta-analysis. Resuscitation 71:152–160

    Article  PubMed  Google Scholar 

  51. Rothenbacher D, Lutz MP, Porzsolt F (1997) Treatment decisions in palliative cancer care: patients’ preferences for involvement and doctors’ knowledge about it. Eur J Cancer 33:1184–1189

    Article  PubMed  CAS  Google Scholar 

  52. Salomon F (2006) Leben erhalten und Sterben ermöglichen. Entscheidungskonflikte in der Intensivmedizin. Anaesthesist 55:64–69

    Article  PubMed  CAS  Google Scholar 

  53. Schweitzer S, van Oorschot B, Kohler N, Leppert K, Steinbach K, Hausmann C, Anselm R (2005) Der Patient und seine Familie – Einstellungen und Mitsprachemöglichkeiten von Angehörigen palliativ behandelter Tumorpatienten. Psychother Psychosom Med Psychol 55:298–304

    Article  PubMed  Google Scholar 

  54. Soares M, Carvalho MS, Salluh JI, Ferreira CG, Luiz RR, Rocco JR, Spector N (2006) Effect of age on survival of critically ill patients with cancer. Crit Care Med 34:715–721

    Article  PubMed  Google Scholar 

  55. Soubani AO, Kseibi E, Bander JJ, Klein JL, Khanchandani G, Ahmed HP, Guzman JA (2004) Outcome and prognostic factors of hematopoietic stem cell transplantation recipients admitted to a medical ICU. Chest 126:1604–1611

    Article  PubMed  Google Scholar 

  56. Thiéry G, Azoulay E, Darmon M, Ciroldi M, De Miranda S, Levy V, Fieux F, Moreau D, Le Gall JR, Schlemmer B (2005) Outcome of Cancer Patients Considered for Intensive Care Unit Admission: A Hospital- Wide Prospective Study. J Clin Oncol 23:4406–4413

    Article  PubMed  Google Scholar 

  57. Thompson BT, Cox PN, Antonelli M, Carlet JM, Cassell J, Hill NS, Hinds CJ, Pimentel JM, Reinhart K, Thijs LG (2004) Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003: executive summary. Crit Care Med 32:1781–1784

    Article  PubMed  Google Scholar 

  58. van Oorschot B, Hausmann C, Kohler N, Leppert K, Schweitzer S, Steinbach K, Anselm R (2004) Patienten als Partner in der letzten Lebensphase. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 47:992–999

    Article  PubMed  CAS  Google Scholar 

  59. Vincent JL (2004) Ethical principles in end-of-life decisions in different European countries. Swiss Med Wkly 134:65–68

    PubMed  Google Scholar 

  60. von Engelhardt D (2006) Ethik in der Onkologie – Dem kranken Menschen gerecht werden. Im Focus Onkologie 09/2006:65–68

    Google Scholar 

  61. Wachter RM, Luce JM, Hearst N, Lo B (1989) Decisions about resuscitation: inequities among patients with different diseases but similar prognoses. Ann Intern Med 111:525–532

    PubMed  CAS  Google Scholar 

  62. Wallace SK, Martin CG, Shaw AD, Price KJ (2001) Influence of an advance directive on the initiation of life support technology in critically ill cancer patients. Crit Care Med 29:2294–2298

    Article  Google Scholar 

  63. Weiss E, Lange D, Hiddemann W (2003) Ethische Brennpunkte in der Onkologie. Onkologe 9:115–127

    Article  Google Scholar 

  64. White DB, Curtis JR (2005) Care near the end-of-life in critically ill patients: a North American perspective. Curr Opin Crit Care 11:610–615

    Article  PubMed  Google Scholar 

  65. White DB, Curtis JR, Lo B, Luce JM (2006) Decisions to limit life-sustaining treatment for critically ill patients who lack both decision-making capacity and surrogate decision-makers. Crit Care Med 34:2053–2059

    Article  PubMed  Google Scholar 

  66. Wolff HP (1999) Arzt und Patient. In: Sass H-M (Hrsg) Medizin und Ethik. Reclam, Stuttgart, S 184–211

  67. Young GB, Plotkin DR (2000) ICU: ineffective communication unit. Crit Care Med 28:3116–3117

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Abteilung für Hämatologie und internistische Onkologie, Klinikum der Universität Regensburg, 93042, Regensburg, Germany

    Joachim Hahn

  2. Klinik und Poliklinik für Innere Medizin I, Klinikum der Universität Regensburg, 93042, Regensburg, Germany

    Falitsa Mandraka

  3. Institut für Philosophie, Universität Regensburg, 93040, Regensburg, Germany

    Günter Fröhlich

Authors
  1. Joachim Hahn
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Falitsa Mandraka
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Günter Fröhlich
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Joachim Hahn.

Additional information

Serie:

Die Notfall- und Intensivtherapie bei hämatologischen und onkologischen Erkrankungen

Herausgegeben von E. Holler und C. Wrede (Regensburg)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Hahn, J., Mandraka, F. & Fröhlich, G. Ethische Aspekte in der Therapie kritisch kranker Tumorpatienten. Intensivmed 44, 416–428 (2007). https://doi.org/10.1007/s00390-007-0819-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00390-007-0819-1

Key words

Schlüsselwörter

Search

Navigation