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Rationale: Patients repatriated from foreign hospitals are sources of extensively drug-resistant (XDR) bacteria outbreaks. Thus, an individual benefit potential for the patient opposes a collective ecological risk potential. These ethical issues have not been well studied., Patient Concerns: We report the case of a 74-year-old patient repatriated from Mauritius to the French island of Reunion who presented mesenteric infarction evolving over several days, and who suffered a cardiac arrest before transfer., Diagnoses: In Reunion Island, a CT-scan revealed a multisegmental enlarged parietal enlargement associated with free peritoneal effusion and a suboccluded aspect of the superior mesenteric artery., Interventions: Surgical exploration showed a severe mesenteric infarction with peritonitis, and a resection of 120cm of the small intestine was conducted. This patient was infected with a vanA glycopeptide-resistant Enterococcus faecium and a carbapenem-resistant Klebsiella pneumoniae which produced carbapenemases NDM-1 and OXA-181, which required specific care and could have led to a local epidemic., Outcomes: The patient died after 9 days after being admitted to the ICU., Lessons: Repatriation of critically ill patients from abroad should be considered according to ethical criteria, evaluating, if possible, the expected benefits, and ecological risks incurred. Limiting unnecessary transfers could be an effective measure to limit the spread of XDR bacteria.

Providing critical care to cancer patients requires a high degree of practical multidisciplinary teamwork between intensivists and cancer specialists. Intensivists should have a solid basic knowledge of malignant diseases as well as of the typical complications of the underlying illness and its therapies. Hemato-oncologists should evaluate the transfer of these patients to the intensive care unit early in the course of emerging organ dysfunctions. Both parties should have a realistic impression of the short-term intensive care and long-term oncologic options and perspectives of the respective patient. Good cooperation between intensivists and cancer specialists is the basis for meaningful decisions on admission, planning of individual therapeutic aims, successful patient management, and tailored therapy, with a smooth transition into a palliative care setting whenever appropriate.

Intensive care units (ICUs) are not always able to admit all patients who would benefit from intensive care. Pressure on ICU beds is likely to be particularly high during times of epidemics such as might arise in the case of swine influenza. In making choices as to which patients to admit, the key US guidelines state that significant priority should be given to the interests of patients who are already in the ICU over the interests of patients who would benefit from intensive care but who have not been admitted. We examine four reasons that in principle might justify such a prioritization rule and conclude that none is convincing. We argue that the current location of patients should not, in principle, affect their priority for intensive care. We show, however, that under some but not all circumstances, maximizing lives saved by intensive care might require continuing to treat in the ICU a patient already admitted rather than transferring that patient out of the unit in order to admit a sicker patient who would also benefit more from intensive care. We conclude that further modelling is required in order to clarify what practical policies would maximize lives saved by intensive care., (© 2010 Blackwell Publishing Ltd.)

Purpose of Review: Given increasingly scarce healthcare resources and highly differentiated hospitals, with growing demand for critical care, interhospital transfer is an essential part of the care of many patients. The purpose of this review is to examine the extent to which hospital quality is considered when transferring critically ill patients, and to examine the potential benefits to patients of a strategy that incorporates objective quality data into referral patterns., Recent Findings: Interhospital transfer of critically ill patients is now common and safe. Although extensive research has focused on which patients should be transferred and when they should be transferred, recent study has focused on where patients should be transferred. Yet, the choice of destination hospital is rarely recognized as a therapeutic choice with implications for patient outcomes. The recent public release of high-quality, risk-adjusted and reliability-adjusted outcome data for most hospitals now offers physicians an informed basis on which to choose to which destination hospital a patient should be transferred. A strategy of 'guided transfer' that integrates public quality information into critical care transfer decisions is now feasible., Summary: Although hospitals often transfer patients, there may be substantial room for improvement in transfer patterns. Guiding transfers on the basis of objective quality information may offer substantial benefits to patients, and could be incorporated into quality improvement initiatives.

An elderly patient who underwent a complex emergency abdominal aneurysmectomy two weeks ago is in coma, ventilator dependent, and in severe multisystem organ failure with a deteriorating prognostic index score. The family has become increasingly hostile towards Dr S. Cold, the consultants, the ICU nurses, and the janitorial staff. An estranged wife has called once to defer decision-making to the children. Three children intermittently visit and are openly critical of the medical care. One child is an ICU nurse supervisor at a small local suburban hospital. Dr Cold spoke to the family yesterday about instituting DNR orders and discontinuing some supportive therapy that was not working. The family first required another consultation and then demanded that Dr Cold transfer the patient to the hospital where the daughter works. The hospital does not provide tertiary care. A physician there is willing to assume responsibility. How should Dr Cold respond? A. Do as they request. B. Refuse outright. C. Call the accepting physician and explain why the case is futile. D. Take the matter to the ethics committee to prevent transfer. E. Call the wife and children to schedule an exploratory family conference and insist they come to a decision.