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Background: End-of-life care is common in German intensive care units (ICUs) but little is known about daily practice. Objectives: To study the practice of end-of-life care. Methods: Prospectively planned, secondary analysis comprising the German subset of the worldwide Ethicus‑2 Study (2015–2016) including consecutive ICU patients with limitation of life-sustaining therapy or who died. Results: Among 1092 (13.7%) of 7966 patients from 11 multidisciplinary ICUs, 967 (88.6%) had treatment limitations, 92 (8.4%) died with failed CPR, and 33 (3%) with brain death. Among patients with treatment limitations, 22.3% (216/967) patients were discharged alive from the ICU. More patients had treatments withdrawn than withheld (556 [57.5%] vs. 411 [42.5%], p< 0.001). Patients with treatment limitations were older (median 73 years [interquartile range (IQR) 61–80] vs. 68 years [IQR 54–77]) and more had mental decision-making capacity (12.9 vs. 0.8%), advance directives (28.6 vs. 11.2%), and information about treatment wishes (82.7 vs 33.3%, all p< 0.001). Physicians reported discussing treatment limitations with patients with mental decision-making capacity and families (91.3 and 82.6%, respectively). Patient wishes were unknown in 41.3% of patients. The major reason for decision-making was unresponsiveness to maximal therapy (34.6%). Conclusions: Treatment limitations are common, based on information about patients’ wishes and discussion between stakeholders, patients and families. However, our findings suggest that treatment preferences of nearly half the patients remain unknown which affects guidance for treatment decisions.

Angehörigengespräche zur Organspende sind Teil eines komplexen Entscheidungsprozesses. Fehlt das direkte Einverständnis eines potenziellen Spenders zur Organspende, müssen Angehörige Auskunft über einen möglichen Organspendewunsch geben, im Rahmen der erweiterten Zustimmung in eine Organspende einwilligen und gleichzeitig das akute Versterben eines nahestehenden Menschen bewältigen. Was ist beim Angehörigengespräch zu beachten, um Angehörige während des Entscheidungsprozesses optimal zu unterstützen? Narratives Review. Im Rahmen eines möglichen oder vorliegenden irreversiblen Hirnfunktionsausfalls dienen Gespräche mit Angehörigen bzw. juristischen Stellvertretern dem Überbringen der schlechten Nachricht, der Feststellung eines potenziellen Organspendewunschs und der Erläuterung der resultierenden Vorgehensweisen. Eine Gesprächsstrategie, wie die SPIKES- oder VALUE-Strategie, unterstützt Angehörige bei der emotionalen und kognitiven Bewältigung und gibt den Behandlern Sicherheit in der Gesprächsführung. Ein respektvoller, wertschätzender und kompetenter Umgang des Teams mit dem Patienten bzw. Verstorbenem und den Angehörigen trägt zur Zustimmung von Angehörigen zur Organspende bei. Vertrauensvolle Betreuung der Angehörigen im Prozess der Entscheidung hinsichtlich einer möglichen Organspende verlangt auch vom Behandlungsteam das Beherrschen von den Gesprächstechniken, die in Krisensituationen Anwendung finden. Besteht eine belastbare Beziehung zwischen Behandlungsteam und Angehörigen, die auf Informationsvermittlung, Offenheit, Vertrauen und Empathie beruhen, können Angehörige viel eher eine für sie tragbare und nachhaltige Entscheidung treffen. Communication with relatives is a central part of the decision-making process. In the absence of the patient’s direct consent to a potential organ donation, the next of kin must provide information about a potential wish to donate and give permission in the context of an extended consent solution. At the same time, family members must also cope with the death of a loved one. To determine how relatives can be optimally supported during the decision-making process. Narrative review. In the context of potential or confirmed irreversible brain death, communication with family members or legal representatives serves to deliver bad news as well as to determine whether the patient had a wish to donate his/her organs and to clarify the resultant steps. Communication strategies such as the SPIKES or VALUE models provide emotional and cognitive support for relatives and strengthen clinicians’ communication skills. Clinicians’ behavior towards patients, deceased, and next of kin may influence relatives’ decision-making; respectful and competent behavior seems to contribute towards relatives granting permission for organ donation. Clinicians must be trained and skilled in communication strategies which are used in critical situations to provide emotional support to relatives during the organ donation decision-making process. Relatives are more likely to achieve a satisfying and sustainable decision if a strong relationship exists between clinicians and relatives based on information giving, openness, trust, and empathy.

Objective. Current recommendations controversially discuss local infiltration techniques as specific treatment for refractory pain syndromes. Evidence of effectiveness remains inconclusive and local infiltration series are discussed as a therapeutic option in patients not responding to standard therapy. The aim of this study was to investigate the effectiveness of infiltration series with techniques such as sphenopalatine ganglion (SPG) block and ganglionic local opioid analgesia (GLOA) for the treatment of neuropathic pain in the head and neck area in a selected patient group. Methods. In a retrospective clinical study, 4960 cases presenting to our university hospital outpatient pain clinic between 2009 and 2016 were screened. Altogether, 83 patients with neuropathic pain syndromes receiving local infiltration series were included. Numeric rating scale (NRS) scores before, during, and after infiltration series, comorbidity, and psychological assessment were evaluated. Results. Maximum NRS before infiltration series was median 9 (IQR 8–10). During infiltration series, maximum NRS was reduced by mean 3.2 points (SD 3.3, p<0.001) equaling a pain reduction of 41.0% (SD 40.4%). With infiltration series, mean pain reduction of at least 30% or 50% NRS was achieved in 54.2% or 44.6% of cases, respectively. In six percent of patients, increased pain intensity was noted. Initial improvement after the first infiltration was strongly associated with overall improvement throughout the series. Conclusion. This study suggests a beneficial effect of local infiltration series as a treatment option for refractory neuropathic pain syndromes in the context of a multimodal approach. This effect is both significant and clinically relevant and therefore highlights the need for further randomized controlled trials.