Der Anaesthesist
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Physicians who allow a suicide attempt to happen, which from an ex ante viewpoint was completely voluntary, cannot be held punishable for homicide or failing to provide medical assistance when the suicide corresponds to the putative will of the patient according to plausible information supplied by an authorized person with healthcare proxy. Guidelines for resuscitation also play a central role in the forensic practice for assessment of whether and when resuscitation can be terminated; therefore, it is urgently advised to follow and implement these guidelines: deviations are possible if they can be factually justified. ⋯ If such a directive is not available, the putative will must be elucidated. If this is not possible, the objective welfare of the patient must be upheld and the blood transfusion carried out (in dubio pro vita).
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Unilateral spinal anesthesia is a cost-effective and rapidly performed anesthetic technique. An exclusively unilateral block only affects the sensory, motor and sympathetic functions on one side of the body and offers the advantages of a spinal block without the typical adverse side effects seen with a bilateral block. The lack of hypotension, in particular, makes unilateral spinal anesthesia suitable for patients with cardiovascular risk factors e. g. aortic valve stenosis or coronary artery disease. ⋯ An injection of 5 mg (1 ml) hyperbaric bupivacaine 0.5 % provides an hour-long block to T 12, and a dose of 7.5 to 10 mg (1.5-2.0 ml) extends the block to T 6. Adding clonidine (0.5 to 1.0 µg/kg BW) to the injection prolongs the duration of the block to approximately two to three hours. During the 20-minute fixation period, the cephalad spread of the block can be influenced to a certain extent by raising or lowering the head of the table.
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Review
[Autonomy and welfare in intensive care medicine : Practical approach in difficult situations].
In intensive care units far-reaching decisions are often made at short notice that require the consent of the informed patient. If this is not possible due to the patient's condition, physicians and legal representatives must ascertain the previously expressed or presumed will of the patient and act accordingly. The legal principles are specified in the Patient Advance Directives Act and the Patient Rights Act. ⋯ To avoid conflicts between patient autonomy and medical treatment, the aims of therapy must be regularly discussed with the patient, representatives or relatives and documented in a written form. Checklists can be useful for structured consultations, to promote transparency and to avoid misunderstandings. Ethics consultations can help to deescalate critical situations.