[Ethics and monetary values. Influence of economical aspects on decision-making in intensive care]

Healthcare expenditure continues to grow and the demand for cost-cutting measures has increased. Critical care medicine is characterized by extremely high expenditure and thus appears to be a suitable candidate for rationing. Based on the hospital address book of Germany, a questionnaire consisting of 25 multiple choice questions was sent out to 1,000 intensive care units (ICU). The questionnaire was focused on obtaining information on whether and how rationing takes place in Germany. A total of 540 questionnaires were returned and analyzed. Only approximately 25% of intensive care units stated that a special budget is available. Approximately 59% answered that therapeutic decisions were never or rarely influenced by economic reasons, but in 9% economics often influenced decisions. Advanced age was not considered to be a reason to limit the use of extremely expensive medication or the use of renal replacement therapy (RRT) in 88% of the answers. Incurable cancer was also no reason to refuse RRT (91%). For 35% of the answers there were no contraindications for admission to intensive care, whereas for 35% an incurable disease was a contraindication, for 10% a non-resuscitation order and for 84% the patients' wishes played a decisive role. Of the intensive care units 67% were convinced that rationing is a matter of fact in ICUs in Germany and 53% were of the opinion that rationing should not occur. Of the answers 43% considered that limiting ICU therapy would be the best when rationing is necessary. Rationing therapy in critical care appears to occur daily in German ICUs. Due to the high costs, intensive care therapy will represent a very important battleground in the inevitable healthcare spending limitations of the future. Rationing cannot be determined exclusively by ICU doctors, thus clear and probably unpopular decisions on this issue are expected to be announced by the politicians.