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Live-ins: A mapping of relevant actors and moral norms at the public health level Abstract: Background: Live-ins are embedded in a network of multiple actors that shape their current working and living situation. The causes and effects of live-in arrangements go far beyond the actual care relationship and include structures and stakeholders that are interconnected at the Public Health level. Besides a legal responsibility, these actors also have a moral responsibility, which the article focuses on. Aim: The article provides an overview of relevant actors and moral norms in the context of live-ins at the public health level. Methods: The method followed the "Context and Actor Analysis". Actors at the public health level that are relevant for the live-ins' situation were identified, and the responsibilities and tasks presented in their websites as well as their respective target groups were collected. The ethical dimension was extracted from these self-descriptions. Results: The 23 actors address the live-ins directly or indirectly in their various social roles. The self-given tasks and the moral norms deduced from them, for which the actors are particularly responsible, illustrate the importance of justice and respect. Conclusions: The work provides the basis for an urgently needed empirical-ethical analysis on the current state of responsibility-taking. Not only the variety of the live-ins' roles, but also the multitude of actors involved and shared norms illustrate the necessity of close cooperation to be able to fulfil their responsibility.

Background: Patients and families on Intensive Care Units (ICU) benefit from ICU diaries, enhancing their coping and understanding of their experiences. Staff shortages and a limited amount of time severely restrict the application of ICU diaries. To counteract this limitation, generating diary entries from medical and nursing records using an artificial intelligence (AI) might be a solution., Design and Purpose: Protocol for a hypothetical multi-center, mixed method study to identify the usability and impact of AI-generated ICU diaries, compared with hand-written diaries., Method: A hand-written ICU diary will be written for patients with expected length of stay ≥ 72 h by trained nursing staff and families. Additionally at discharge, the medical and nursing records are analyzed by an AI software, transformed into understandable, empathic diary entries, and printed as diary. Based on an appointment with patients within 3 months, diaries are read in randomized order by trained clinicians with the patients and families. Patients and families will be interviewed about their experiences of reading both diaries. In addition, usability of diaries will be evaluated by a questionnaire., Expected Findings and Results: Patients and families describe the similarities and differences of language and the content of the different diaries. In addition, concerns can be expressed about the generation and data processing by AI., Implications for Practice: Professional nursing involves empathic communication, patient-centered care, and evidence-based interventions. Diaries, beneficial for ICU patients and families, could potentially be generated by Artificial Intelligence, raising ethical and professional considerations about AI's role in complementing or substituting nurses in diary writing., Conclusions: Generating AI-based entries for ICU diaries is feasible, but raises serious questions about nursing ethics, empathy, data protection, and values of professional nurses. Researchers and developers shall discuss these questions in detail, before starting such projects and opening Pandora's box, that can never be closed afterwards., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

The rise in intensive care treatment procedures is accompanied by an increase in the complexity of decisions regarding the selection, administration and duration of treatment measures. Whether a treatment goal is desirable in an individual case and the treatment plan required to achieve it is acceptable for the patient depends on the patient's preferences, values and life plans. There is often uncertainty as to whether a patient-centered treatment goal can be achieved. The use of a time-limited treatment trial (TLT) as a binding agreement between the intensive care unit (ICU) team and the patient or their legal representative on a treatment concept over a defined period of time in the ICU can be helpful to reduce uncertainties and to ensure the continuation of intensive care measures in the patients' best interest., (© 2024. The Author(s).)

Relatives of intensive care patients make an important contribution to recovery and perform a variety of tasks. Due to the demands on the relatives and their services in the ICU and after their discharge, stressful psychological, physical, social, and financial consequences can arise or worsen. Relatives often compensate deficiencies in treatment, especially through a lack of communication and a lack of continuity of care. Seamless care for patients in the ICU and afterwards reduces avoidable consequences for relatives. Structured communication between relatives and the treatment team as well as active involvement in nursing treatments can alleviate stress symptoms and the feeling of powerlessness. Prescient discharge management for ICU patients and their relatives reduces PICS risk. Specific and comprehensive offerings of advice and support for relatives can help to perform and process the effort between everyday life and care tasks., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

The process recommendations of the Ethics Section of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) for ethically based decision-making in intensive care medicine are intended to create the framework for a structured procedure for seriously ill patients in intensive care. The processes require appropriate structures, e.g., for effective communication within the treatment team, with patients and relatives, legal representatives, as well as the availability of palliative medical expertise, ethical advisory committees and integrated psychosocial and spiritual care services. If the necessary competences and structures are not available in a facility, they can be consulted externally or by telemedicine if necessary. The present recommendations are based on an expert consensus and are not the result of a systematic review or a meta-analysis., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Both vulnerability and integrity represent action-guiding concepts in nursing practice. However, they are primarily discussed regarding patients-not nurses-and considered independently from rather than in relation to each other., Aim: The aim of this paper is to characterize the moral dimension of nurses' vulnerability and integrity, specify the concepts' relationship in nurses' clinical practice and, ultimately, allow a more fine-grained understanding., Design: This discursive paper demonstrates how vulnerability and integrity relate to each other in nursing practice and carves out which types of vulnerability pose a threat to nurses' moral integrity. The concept of vulnerability developed by Mackenzie et al. (2014) is applied to the situation of nurses and expanded to include the concept of moral integrity according to Hardingham (2004). Four scenarios are used to demonstrate where and how nurses' vulnerabilities become particularly apparent in clinical practice. This leads to a cross-case discussion, in which the vulnerabilities identified are examined against the background of moral integrity and the relationship between the two concepts is determined in more detail., Results and Conclusion: Vulnerability and integrity do not only form a conceptual pair but also represent complementary moral concepts. Their joint consideration has both a theoretical and practical added value. It is shown that only specific forms of vulnerability pose a threat to moral integrity and the vulnerability-integrity relationship is mediated via moral distress., Implications for the Profession And/or Patient Care: The manuscript provides guidance on how the concrete threat(s) to integrity can be buffered and moral resilience can be promoted. Different types of threats also weigh differently and require specific approaches to assess and handle them at the micro-, meso- and macro-level of the healthcare system., (© 2023 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.)

In this white paper, key recommendations for visitation by children in intensive care units (ICU; both pediatric and adult), intermediate care units and emergency departments (ED) are presented. In ICUs and EDs in German-speaking countries, the visiting policies for children and adolescents are regulated very heterogeneously: sometimes they are allowed to visit patients without restrictions in age and time duration, sometimes this is only possible from the age of teenager on, and only for a short duration. A request from children to visit often triggers different, sometimes restrictive reactions among the staff. Management is encouraged to reflect on this attitude together with their employees and to develop a culture of family-centered care. Despite limited evidence, there are more advantages for than against a visit, also in hygienic, psychosocial, ethical, religious, and cultural aspects. No general recommendation can be made for or against visits. The decisions for a visit are complex and require careful consideration., (© 2023. The Author(s).)

The glaring lack of formal and informal caregivers in Germany has not only become apparent in hospitals and nursing homes but also in home care arrangements. One tension is particularly pertinent in such arrangements: a 'family-oriented' logic of the long-term care insurance and the individual wishes of those in need of care meet the actual possibilities of family carers. This care gap has been compensated for by 24-hour care workers, so-called 'live-ins', from Eastern Europe for some years. This contribution maps the 'live-ins' situation comprehensively from an ethical perspective. Based on different constellations regarding the 'live-ins' status as a professional nurse or non-professional caregiver, which ethical principles and moral norms are affected by whom and potentially conflict with each other in such home care arrangements at a micro and meso level of care are outlined. Special attention is paid to the tension between self-care and care for others, and to questions of the shared responsibility in and social responsibility of those external services that are involved in home care in addition to the 'live-in'.In order to uncover, understand and influence the current ethical problems, an ethical framework that considers both the divergent interests of all individuals involved in the home care arrangement and their mutual dependency and vulnerability is needed.

Based on shared experiences and values, the patient and their families form a relational unit. This social unity is especially valid in the situation of illness. Patients' relatives in intensive care units experience an exceptional emotional situation, associated with uncertainty, feelings of being overwhelmed, fear, and the desire for the best possible medical care. The principles of family-centered intensive care offer orientation and relief not only for the patients and their relatives, but also for the interprofessional team. Related measures, such as open visiting hours, appreciative communication, interprofessional team structures, and internal hospital standards can support all those involved in shaping and overcoming this critical situation together., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

The treatment situation in intensive care is characterised by a specific asymmetry in the relationship between patients and the team: Patients are particularly dependent on their environment and often show impaired consciousness and capacity to consent. This facilitates the use of coercion or enables and/or provokes it. The aim of this recommendation is to show ways to recognise patients with their wishes and needs and to integrate them into treatment concepts in the intensive care unit in order to reduce and avoid coercion whenever possible. The recommendation shows the variety of possible forms of coercion and discusses the moral standards to be considered in the ethical weighing process as well as legal conditions for justifying its use. It becomes obvious that treatment measures which may involve the use of coercion always require a careful and self-critical review of the measures in relation to the indication and the therapeutic goal. The recommendation's intention therefore is not to disapprove the use of coercion by interprofessional teams. Instead, it aims to contribute to a sensitive perception of coercion and to a critical and caring approach to formal and especially informal (indirect) coercion., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Nosocomial infections represent a serious challenge for healthcare systems worldwide. Adherence to hand hygiene plays a major role in infection prevention and control. These adherence rates can be improved through behaviour tracking innovations. This requires the systems to be widely implemented and accepted. Therefore, both a systematic analysis of the normative issues related and the evaluation of technology acceptance are equally important., Objectives: To explore and describe relevant aspects regarding the acceptance of technology and ethical implications using a tracking device to measure and improve adherence to hand hygiene., Research Design: A quantitative study with a descriptive design was performed., Participants and Research Context: A total of 75 questionnaires were collected in three hospitals in Germany. Acceptance of technology was measured with n = 60 participants (n = 50 nurses; n = 9 physicians; n = 1 not disclosed) and ethical assessment with n = 15 participants (nurses only)., Ethical Considerations: Ethical approval for this study was obtained from the institutional review board., Findings: The acceptance of technologies improving hygiene in general was good (median = 80.5, interquartile range = 28, range: 0-100). The experience with technologies in general (median = 48.5, interquartile range = 57, range: 0-100) and the acceptance of the specific technology (mean = 82.23, standard deviation = 15.16 (range: 23-138)) was moderate. There was a significant positive correlation between the acceptance and experience of technology in general ( r = 0.217, p = .025). Ethical concerns played a minor role. The need for practical support was a key topic., Discussion: Study participants accepted technologies improving hygiene; however, the specific device implemented was only moderately accepted. This creates specific opportunities in the implementation process for higher later acceptance. More practical support and an increase in experience may create opportunities for device implementation with high acceptance and low ethical concerns., Conclusion: Study results indicate a vast potential for improving the implementation process of hand hygiene technologies. Ethical concerns in this study did not seem to be a relevant barrier for successful implementation of hand hygiene technologies.

Early interprofessional learning among nursing and medical students provides various benefits for future collaboration among professionals, and high-quality care for patients. Expert committees, thus, urge the integration of interprofessional education (IPE) in undergraduate studies to achieve significant sustainable improvements in health-care practice. In Germany, IPE interventions are already implemented in some health-care disciplines, but Health-care Ethics are scarcely regarded in undergraduate education. There are, however, several reasons why Health-care Ethics is particularly appropriate for teaching in an interprofessional format. Thus, after reviewing the legal framework and the current curricula of both professions, an IPE course on Health-care Ethics for medical and nursing students was developed and implemented, consisting of seven classes of 180 minutes each. Drawing on the evaluation results after two rounds of the course, this interprofessional education and practice guide reports on challenges, obstacles and perspectives for improvement of an IPE course on Health-care Ethics. It aims to provide guidance for teaching pioneers and innovators who implement similar projects and to foster practice-oriented and open discussion about the possibilities and limits of IPE in Health-care Ethics.

Despite social laws, overtreatment, undertreatment, and incorrect treatment are all present in the German health care system. Overtreatment denotes diagnostic and therapeutic measures that are not appropriate because they do not improve the patients' length or quality of life, cause more harm than benefit, and/or are not consented to by the patient. Overtreatment can result in considerable burden for patients, their families, the treating teams, and society. This position paper describes causes of overtreatment in intensive care medicine and makes specific recommendations to identify and prevent it. Recognition and avoidance of overtreatment in intensive care medicine requires measures on the micro-, meso- and macrolevels, especially the following: (1) frequent (re-)evaluation of the therapeutic goal within the treating team while taking the patient's will into consideration, while simultaneously attending to the patients and their families; (2) fostering a patient-centered corporate culture in the hospital, giving priority to high-quality patient care; (3) minimizing improper incentives in health care financing, supported by reform of the reimbursement system that is still based on diagnose-related groups; (4) strengthening of interprofessional co-operation via education and training; and (5) initiating and advancing a societal discourse on overtreatment.

Definition of the Problem: The COVID-19 pandemic poses a considerable challenge to the capacity and functionality of intensive care. This concerns not only resources but, above all, the physical and psychological boundaries of nursing professionals. The question of how care for others and self-care of nurses in intensive care units are related to each other in the context of the COVID-19 pandemic has not been addressed in public and scientific discourse so far., Arguments: The present contribution reflects this relationship with reference to the Code of Ethics of the International Council of Nurses, particularly considering principlism and the Care Ethics according to Joan Tronto. As a result, it shows a corridor of ethically justifiable care with several borders, above all: (1) self-care must not be given up completely for the benefit of care for others, and (2) a categorical subordination of care for others to self-care is ethically not justifiable., Conclusion: The article makes an important contribution to a differentiated ethical consideration of the rights and responsibilities of intensive care nurses as moral actors within the pandemic in Germany. It, thus, provides a first starting point for a broad social and political discourse which is urgently needed not only during but also after the pandemic in order to improve the situation of intensive care nurses and those who are cared for., (© The Author(s) 2021.)

Background: Proficiency in medical terminology is an essential competence of physicians which ensures reliable and unambiguous communication in everyday clinical practice. The attendance of a course on medical terminology is mandatory for human and dental medicine students in Germany. Students' prerequisites when entering the course are diverse and the key learning objectives are achieved to a varying degree., Methods: A new learning space, the "TERMInator", was developed at the University Medicine Greifswald to meet the medical students' individual learning needs better. The interactive e-learning course serves as a supplement to the seminars, lectures and tutorials to rehearse and practically apply the course contents at an individual pace. It uses gamification elements and is supplied via the learning platform Moodle. The TERMInator was pilot implemented in two consecutive winter terms (2018/19, 2019/20) and comprehensively evaluated based on the general course evaluations and an anonymous questionnaire covering aspects of content, layout and user friendliness of the TERMInator and questions concerning the students' learning preferences., Results: The TERMInator was rated very positively overall, which was also fed back to the lecturers during the classes. Students appreciate the new e-learning tool greatly and stress that the TERMInator should be further expanded. The handling of the TERMInator was considered to be very easy and, therefore, almost no training time was needed. The tasks were easy to understand and considered a good supplement to the seminar contents. The extent and quality of the images were seen rather critically. The students' learning strategies differ. Although e-learning options were generally rated as very important, student tutorials were considered by far the most important., Conclusions: Medical terminology classes are characterised by heterogeneous learning groups and a high workload within a short time, which can lead to major challenges for the teaching staff. Complementary gamified e-learning tools are promising in view of the students' different knowledge levels and changing learning behaviour., Trial Registration: Not applicable.

Background: Concepts of health have been widely discussed in the philosophy and ethics of medicine. Parallel to these theoretical debates, numerous empirical research projects have focused on subjective concepts of health and shown their significance for individuals and society at various levels. Only a few studies have so far investigated the concepts of health of non-professionals and professionals involved in long-term home care and discussed these empirical perspectives regarding moral responsibilities., Objectives: To identify the subjective concepts of the health of non-professionals (care recipients, informal caregivers) and professionals (registered nurses) involved in long-term home care and to discuss them against the background of existing normative guidelines addressing non-professionals and professionals' responsibilities and rights concerning health., Research Design: A qualitative design was chosen to explore subjective concepts of health. Data were collected by semi-structured interviews; content analysis was applied according to Mayring., Participants and Research Context: Twenty-eight interviews were conducted with non-professionals and professionals in long-term home care arrangements in Northern Germany., Ethical Considerations: Ethics approval was obtained from the Institutional Review Board at the University Medicine Greifswald (BB123/16)., Findings: Non-professionals and professionals consider health as a capability that enables them to participate in social activities and live their own lives according to their preferences. The former regard health particularly as a feeling and an attitude, the latter as the absence of disease with a focus on mental and emotional well-being. Both groups highlight the unsurpassable value of health and the personal responsibility for it., Discussion: Normative guidelines applicable to practice in long-term home care discuss responsibilities and rights unevenly and raise several problems regarding non-professionals and professionals' subjective concepts of health., Conclusion: Individuals' concepts of health are relevant for the subsequent interpretation of rights and responsibilities and should, thus, be reflected upon to address health-related needs effectively.

Background: A growing proportion of older people in Germany receive long-term care from informal and professional caregivers at home. Their personal assessment of the individual care situation is scarcely considered., Aim: This study aimed to explore the subjective views of care recipients, informal and professional caregivers on the adequacy of care provision in long-term home care arrangements., Design and Methods: Qualitative semi-structured face-to-face interviews were conducted with ten care recipients, ten professional caregivers and eight informal caregivers to capture their perspectives on the adequacy of the care received and delivered. Qualitative content analysis was applied using MAXQDA software., Results: All groups highlighted that they perceive an underprovision of care, even though their explanations differed. The underprovision was mainly described regarding the quality rather than quantity of services. It occurs especially in interpersonal relationships and social inclusion, where the gap between the self-perceived current situation and the desires of those affected is most prominent. The ambivalent impact of home care on social participation becomes apparent. Perceptions of an overprovision of care range from the view that it appears mainly with respect to informal care to the statement that it is currently non-existent or generally impossible. Misprovision of care is experienced as serious whenever the interviewees face the challenge of preserving existing abilities or regaining certain skills., Competing Interests: All authors (AHS, MB, SS, IB) declare that they have no financial or non‐financial competing interests. All authors declare that they have no financial relationships that might be perceived as a potential conflict of interest., (© 2020 The Authors. Nursing Open published by John Wiley & Sons Ltd.)

The decision-making environment in intensive care units (ICUs) is influenced by the transformation of intensive care medicine, the staffing situation and the increasing importance of patient autonomy. Normative implications of time in intensive care, which affect all three areas, have so far barely been considered. The study explores patterns of decision making concerning the continuation, withdrawal and withholding of therapies in intensive care. A triangulation of qualitative data collection methods was chosen. Data were collected through non-participant observation on a surgical ICU at an academic medical centre followed by semi-structured interviews with nurses and physicians. The transcribed interviews and observation notes were coded and analysed using qualitative content analysis according to Mayring. Three themes related to time emerged regarding the escalation or de-escalation of therapies: influence of time on prognosis, time as a scarce resource and timing in regards to decision making. The study also reveals the ambivalence of time as a norm for decision making. The challenge of dealing with time-related efforts in ICU care results from the tension between the need to wait to optimise patient care, which must be balanced against the significant time pressure which is characteristic of the ICU setting., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Challenge: Injuries, especially traumatic brain injury, or specific illnesses and their respective sequelae can result in the demise of the patients afflicted despite all efforts of modern intensive care medicine. If in principle organ donation is an option after a patient's death, intensive therapeutic measures are regularly required in order to maintain the homeostasis of the organs. These measures, however, cannot benefit the patient afflicted anymore-which in turn might lead to an ethical conflict between dignified palliative care for him/her and expanded intensive treatment to facilitate organ donation for others, especially if the patient has opted for the limitation of life-sustaining therapies in an advance directive., Method: The Ethics Section and the Organ Donation and Transplantation Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) have convened several meetings and a telephone conference and have arrived at a decision-making aid as to the extent of treatment for potential organ donors. This instrument focusses first on the assessment of five individual dimensions regarding organ donation, namely the certitude of a complete and irreversible loss of all brain function, the patient's wishes as to organ donation, his or her wishes as to limiting life-sustaining therapies, the intensity of expanded intensive treatment for organ protection and the odds of its successful attainment. Then, the combination of the individual assessments, as graphically shown in a {Netzdiagramm}, will allow for a judgement as to whether a continuation or possibly an expansion of intensive care measures is ethically justified, questionable or even inappropriate., Result: The aid described can help mitigate ethical conflicts as to the extent of intensive care treatment for moribund patients, when organ donation is a medically sound option. NOTE: Gerald Neitzke und Annette Rogge contributed equally to this paper and should be considered co-first authors.

Quantitative research has called attention to the burden associated with informal caregiving in home nursing arrangements. Less emphasis has been placed, however, on care recipients' subjective feelings of being a burden and on caregivers' willingness to carry the burden in home care. This article uses empirical material from semi-structured interviews conducted with older people affected by multiple chronic conditions and in need of long-term home care, and with informal and professional caregivers, as two groups of relevant others. The high burden of home-care arrangements is unanimously stressed by all three groups involved in the triangle of care. An empirical-ethical investigation of what can be legitimately expected from family members and informal caregivers, informed by Frith's symbiotic empirical ethics approach, was undertaken. Key tenets from the special goods theory and nursing professionalism are used as analytical tools. The study concludes that the current situation may hinder professional development and can reinforce feelings of being a burden to relevant others., (© 2019 John Wiley & Sons Ltd.)

The Ethics Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) recently published a documentation for decisions to withhold or withdraw life-sustaining therapies. The wish to donate organs was not considered explicitly. Therefore the Ethics Section and the Organ Donation and Transplantation Section of the DIVI together with the Ethics Section of the German Society of Medical Intensive Care Medicine and Emergency Medicine worked out a supplementary footnote for the documentation form to address the individual case of a patient's wish to donate organs.

Background: The concepts of disease, illness and sickness capture fundamentally different aspects of phenomena related to human ailments and healthcare. The philosophy and theory of medicine are making manifold efforts to capture the essence and normative implications of these concepts. In parallel, socio-empirical studies on patients' understanding of their situation have yielded a comprehensive body of knowledge regarding subjective perspectives on health-related statuses. Although both scientific fields provide varied valuable insights, they have not been strongly linked to each other. Therefore, the article aims to scrutinise the normative-ethical implications of patient perspectives in building a bridge to the empirical ethics debates., Main Text: Three potential fields of tension between the illness and the disease perspective are presented. Consequently, findings from empirical research examining patient perspectives on illness are displayed and the practical implications and associated ethical issues which arise are discussed. This leads to the conclusion that an explicit and elaborate empirical-ethical methodology is needed to deal appropriately with the complex interaction between patients' views and the medico-professional view of disease. Kon's four-stage model of normative-empirical collaboration is then applied against the background of empirical data on patient perceptions. Starting from this exemplary approach, the article suggests employing empirical-ethical frameworks for further research on the conceptual and normative issues, as they help to integrate perspectives from the philosophy of medicine with socio-empirical research., Conclusion: The combination of theoretical and empirical perspectives suggested contributes to a more nuanced discussion of the normative impact of patients' actual understanding of illness. Further empirical research in this area would profit from explicitly considering potential ethical issues to avoid naturalistic fallacies or crypto-normative conclusions that may compromise healthcare practice. Vice versa, medico-theoretical debates could be enriched by integrating subjective views of those people who are immediately affected.