[Ethically challenging determination of treatment goals in the intensive care unit: reasons, frequency and possible...

Modern intensive care medicine enables many patients to recover and return to normal life despite suffering from very severe acute illnesses. However, as intensive care patients are increasingly elderly and frail or suffer from advanced incurable chronic diseases, it is important to discuss the limits of intensive care medicine. Some medical interventions in the intensive care unit (ICU) may not support patients' individual therapeutic goals which are tailored to patients' conditions and in accordance with personal wishes. Such interventions can be experienced as ethically challenging by ICU staff and can be burdensome and stressful for patients and their relatives. This review paper discusses the issue of potentially inappropriate care in ICUs from the perspective of patients and their relatives, ICU staff and society. Possible reasons for the occurrence of potentially inappropriate treatment are identified and possible ways for avoidance are shown. The reasons for potentially inappropriate treatment are multifaceted and include patient-related and staff-related reasons. Treatment teams, patients and family members are facing numerous uncertainties concerning the patient's will and medical prognoses, e.g. possible future cognitive impairment. Structured communication and time-limited trials are possible strategies to avoid potentially inappropriate treatment, to explore patient wishes and decide upon individually tailored treatment strategies. It is indispensable to regularly re-evaluate therapeutic goals. Interprofessional support by palliative teams, psychologists, counselling and ethics advisory boards can be useful to improve patient-centered care. A structured approach is needed when deciding to withhold or withdraw care. There are a number of strategies that treatment teams in ICUs can implement to reduce the stress caused by potentially inappropriate care. Ultimately, however, a societal debate on the topic is indispensable.