2.1 Goals of intensive care medicine
In general, patients are admitted to the ICU for curative treatment. Intensive care medicine provides medical and nursing therapies, medical devices, expertise and high staffing ratios in order to gain time for recovery of impaired or failing vital organ functions. The main objective is to ensure that patients—even if they do not recover completely—can lead a life that is independent from ICU care. Thus, in case of success, intensive care medicine enables survival and the patient’s return to a life that is as independent and self-determined as possible [
14]. However, time and again a patient becomes completely—and sometimes irreversibly—dependent on life-sustaining medical devices. In other cases, intensive care treatment results in survival with major mental and physical deficits that cause a considerable reduction in the patient’s quality of life and constitute a great and persistent burden for relatives [
3,
8].
2.2 Appropriateness/inappropriateness
When discussing treatment approaches, the question whether or not a treatment is overall meaningful and appropriate must always be taken into account. This refers to the meaning and relevance of the therapeutic goal and the diagnostic, therapeutic or nursing measures derived from this goal. The questions about meaning and relevance cannot be answered in an objective way, but must take into consideration individual and subjective attitudes of the patients for instance about the meaning of life, death and suffering and assessments of quality of life, way of living and lifetime goals. These considerations take place both intuitively, based on “gut feeling” and by a reflective, rational process.
Activities or conditions are considered to be appropriate and meaningful if they are in some way relevant to achieve one’s (life) goals. What is regarded as a worthwhile life sustaining treatment by one person might be considered as a meaningless torture and mere prolongation of the dying process by another. Thus, the assessment of appropriateness in the sense of being meaningful permits different results for the same treatment measures. Depending on the point of view, the same measure may be rated as either “appropriate” or “inappropriate”. Between these two extremes, a continuum of assessments unfolds in the sense that something can be rated as more or less appropriate. The question about appropriateness includes two components: instrumental rationality and value rationality. Both can be considered and discussed separately.
Instrumental rationality describes the adequacy of a measure to attain a certain purpose/goal (example: “It is appropriate to treat this infection with antibiotics.”). In this sense, medical or nursing measures are appropriate/meaningful if sufficient experience or evidence exists to expect that the measure will bring about a success of treatment with a given probability.
By contrast, a measure is value rational if it expresses or asserts ethical values (example: “It is appropriate to help a patient who suffers from an infection.”). These fundamental values are culture- and time-dependent, and deeply rooted in the individual conceptions of mankind and moral attitudes. Therefore, several issues need to be clarified when assessing the appropriateness of a treatment, including questions about the value of the treatment goal, about the meaning of suffering and illness, about subjective assessments of quality of life, and about the significance of professional and family support.
Assessing the overall appropriateness of a measure always includes both components mentioned above. For this reason, the statement that a treatment option is appropriate/meaningful contains an assessment of its instrumental rationality (it is appropriate from a technical/scientific point of view) as well as of its value rationality (it is appropriate from a humane point of view). Attribution of appropriateness may vary depending on the perspective. Therefore, it must be assessed on a case-by-case basis how physicians, nursing staff, patients and relatives arrive at their evaluation of appropriateness/meaningfulness, and which consequences for treatment decisions arise from this assessment.
If the physician (after examination of the criteria listed in point 3.1) determines that a treatment option is appropriate, this option can be offered to the patient. Now it is up to the patient to assess the appropriateness of this option from his point of view (see 3.2). In case the physician does not recognize any degree of appropriateness for a certain therapeutic measure (after examination of the criteria in point 3.1), the treatment is not indicated and must not be offered. This medical judgment protects patients from inappropriate and pointless treatments.