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Exitus letalis
Abstract
Als relativ seltenes Ereignis wirft der Exitus in tabula eine Reihe von speziellen medizinrechtlichen Fragen auf, welche in diesem Artikel diskutiert werden. Beim Exitus letalis ist mit hherer Wahrscheinlichkeit ein Behandlungsfehlervorwurf zu befrchten, weil in diesem Falle fr medizinische Laien die Annahme eines Behandlungsfehlers vermeintlich nher liegt als bei sonstigen Todesfllen im Krankenhaus. Fragen der Aufklrungspflicht und Verantwortlichkeit werden diskutiert. Wichtige Aspekte wie adquate Kommunikation mit den Hinterbliebenen, transparente chronologische Dokumentation der Todesumstnde, Fragen zur Todesbescheinigung und Obduktion zur Klrung der Todesursache, Klrung des Behandlungsvorwurfes, Schweigepflicht und Information der Haftpflichtversicherungsgesellschaft werden durchleuchtet. Im speziellen wird auf den Exitus in tabula eines Zeugen Jehovas eingegangen.Since death on the operating table is a relatively rare incident, it raises a number of special medicolegal questions that are discussed in this article. One of the major concerns for medical personnel is being accused of malpractice during treatment, as it is an obvious presumption on the part of laymen that death was directly related to the medical treatment as compared with other in-hospital deaths. Questions such as who is responsible for the issues of informed consent and liability are discussed. Other important aspects such as communication with the bereaved, transparent chronological documentation of the death circumstances, questions regarding certification of death, questions arising from the autopsy done to determine the reason for the death, questions about malpractice, legal requirements concerning confidential medical communication and information about what must be sent to the professional indemnity insurance company are elucidated. There is also some special information presented for cases that involve the deaths of Jehovahs Witnesses.
... The patient's hemoglobin concentration must never decline below 6 g/dL 7 . In the last decade, several studies have described major surgical procedures pefrormed on Jehovah's Witnesses [8][9][10][11][12][13][14][15][16][17][18][19][20][21] . This case report outlines the surgical treatment of a Jehovah's Witness patient in need of an extensive cytoreductive ...
... Radical aggressive abdominal surgery poses an enormous challenge for the anaesthesiologist when the patient in question is a Jehovah's Witness and requires specifical procedural constraints 9 . Advancements in the safety and efficacy of general anaesthesia are due largely to key improvements in surgical equipment, particularly in the development and use of new techniques such as end-tidal capnography, pulse oximetry, and others, all of which are described in any standard anaesthesia reference handbook 10 . ...
Jehovah's Witnesses are a well-known patient demographic in medicine because of their religious-based refusal of blood transfusion. This case report outlines the treatment of a Jehovah's Witness patient in need of an extensive cytoreductive surgery due to a peritoneal carcinomatosis of ovarian origin. The surgeons carried out all the recommended surgical and anaesthetic measures concluding that extensive cytoreductive surgery on a Jehovah's Witness is possible and that a complete cytoreduction can be safely performed.
Jehovah's carcinoma, Peritoneal carcinoma, Transfusions.
Leichenschaurecht und Obduktionsrecht sind Angelegenheit der Bundesländer. Für Obduktionen (klinische, anatomische, gerichtliche, versicherungsrechtliche und seuchenrechtliche Sektionen sowie die Feuerbestattungssektionen) gibt es eine Reihe unterschiedlicher aber nicht alle Fallkonstellationen erfassende Rechtsgrundlagen.
Die Obduktionsquote in der Bundesrepublik Deutschland ist im internationalen Vergleich skandalös niedrig bei weiterhin bestehenden erheblichen Diskrepanzen zwischen klinischer Diagnose und Obduktionsergebnis. Als Ausweg werden verschiedene Modelle diskutiert (Zustimmungslösung, Widerspruchslösung), die erst in einzelnen Bundesländern und teilweise nur für die klinische und die anatomische Sektion realisiert wurden.
Depending on the prevailing legal situation, physicians can be made liable for medical malpractice. The majority of cases involve civil claims for damages and compensation. Although rarer, criminal charges are generally brought in the form of claims of negligent bodily harm or negligent homicide. However, claims of breach of a duty of care, illegal bodily harm despite the patient’s consent, illegal termination of a pregnancy, issuing an erroneous medical certificate, as well as culpable homicide upon patient request are also seen. In addition, professional sanctions in the case of culpable medical error are also possible.
Im Rahmen der bundesweiten multizentrischen Studie zur rechtsmedizinischen Behandlungsfehlerbegutachtung (BMGS-Studie) wurden 4450Flle eines behaupteten letalen Behandlungsfehlers aus den Jahren 1990–2000 hinsichtlich verschiedener Kriterien analysiert. Dabei konnten seit Jahren zunehmende Fallzahlen registriert werden. Die Kenntniserlangung der Ermittlungsbehrden von einem potenziellen Behandlungsfehler, die inhaltliche Qualitt der Behandlungsfehlervorwrfe, die Einleitung eines strafrechtlichen Ermittlungsverfahrens, aber auch die rechtsmedizinische Bearbeitung des Obduktions- und des Gutachtensauftrags differieren jedoch. Eine systematische Erfassung von Behandlungsfehlervorwrfen gibt es in Deutschland nur ansatzweise; deren Nutzbarmachung fr z.B. Fehlermeldesysteme ist im Interesse der Patientensicherheit geboten und Teil einer Fehlervermeidungsstrategie. Die Studienergebnisse bzw. die Auswertung der Archivunterlagen zu Behandlungsfehlervorwrfen zeigen anzustrebende Konsequenzen sowohl im gesetzgeberisch-administrativen Bereich als auch fr den klinikinternen Umgang mit Behandlungsfehlervorwrfen auf.In a multicenter study 4,450 medical malpractice charges collected from 1990 to 2000 in 17 Institutes of Forensic Medicine were evaluated. A rising number of cases during this period is evident. The charges of practice falling below the standard of care were surveyed to determine who informed the prosecution, whether the medical malpractice charges were substantiated, the reaction of the prosecution, the quality of forensic autopsy reports und the expert opinions of forensic pathologists. There is nearly no systematic registration of medical malpractice charges in Germany, although this should be initiated to build up and improve error reporting systems and to improve patient safety.
Das österreichische Patientenverfügungsgesetz (PatVG) wurde im Frühjahr 2006 parlamentarisch verabschiedet und trat wenige
Wochen nach seiner Kundmachung am 1. Juni 2006 in Kraft.1 Die Stellungnahmen zu diesem Gesetz, die bis Ende des Jahres 2006 vorliegen,2 sind allesamt recht kritisch ausgefallen. Niemand bezeichnet das PatVG als den „großen Wurf“. Die Mehrheit der Autoren bringt
eher zum Ausdruck, dass manche der im Gesetz verankerten Basiswertungen kaum oder gar nicht im Einklang mit unseren moralischen
Intuitionen stehen und dass es mehr als fraglich sei, ob die für den Vollzug von Patientenverfügungen zuständigen Ärzte mit
den Aufgaben, deren Erledigung ihnen das Gesetz zur Pflicht macht, zurande kommen werden.
Unzulässige Operationserweiterung, indikationslose Sectio caesarea und versuchter Totschlag an einem NeugeborenenStGB §§ 212 Abs. 1, 218 Abs. 1 S. 1, Abs. 4 S. 1, 22, 223 Abs. 11.Zur Unzulässigkeit einer Operationserweiterung gegen den ausdrücklichen Willen des Patienten bei benignem Schnellschnitt-Befund.2.Versuchter Schwangerschaftsabbruch durch indikationslose Sectio caesarea bei fetaler Skelettfehlbildung („Zwergenwuchs“; Hypochondrogenesis) in der 29. Schwangerschaftswoche.3.Versuchter Totschlag an einem Neugeborenen bei zuvor eingeleiteten Reanimationsmaßnahmen.BGH-Urt. v. 20.05.2003—5 StR 595/02—(LG Görlitz)Nach den Feststellungen des LG Görlitz war der Angeklagte z. Z. der Taten Chefarzt für Gynäkologie und Geburtshilfe. Die Tatvorwürfe, u. a. wegen versuchten Totschlags betreffen 2 Fälle.Fall 1—SachverhaltDie 40-jährige Patientin wurde mit der Einweisungsdiagnose eines persistierenden Tumors des linken Eierstockes stationär aufgenommen. Vor der geplanten diagnostischen Bauchsp ...
Death during an operation represents a severe event for physicians and family of the deceased. A further difficulty arises when certifying the cause and manner of death because medical staff are often afraid that they will incriminate themselves when declaring an unnatural death or an unclear manner of death but are also afraid to issue a false statement by declaring a natural death. In such cases of mors in tabula it is recommended to declare an unclear manner of death because this leads to police investigations and in the majority of the cases to exoneration of the medical staff.
Anaesthesia-related risk has been significantly reduced within the last decade. Nevertheless the risk and the possibility of dying or suffering permanent damage still exist. To improve patient safety, risk assessment and analysis must lead to the development of preventive strategies. For this purpose anaesthesia can rely on the concepts of other “high reliability” organisations such as aviation or nuclear power plants. Analyses of critical incidents in the different fields confirm that next to technical problems human factors account for most of the preventable mishaps. Human factors are responsible for individual mistakes as well as for organisational errors. Therefore besides traditional concepts of risk reduction (e.g. guidelines) new strategies (e.g. full-scale simulation) must be applied to minimise the negative impact of human factors on patient safety. Risk management has to consider technical, organisational and human factors to implement a higher standard of patient safety.
We performed a prospective multi-center study in order to determine the causes of 30-day perioperative mortality.
Methods: In accordance with the CEPOD-Study and with the kind permission of Dr. N. Lunn, we forwarded two different questionnaires to 135 hospitals. One questionnaire was to be answered by the anaesthetist and the other one by the surgeon involved in cases of perioperative death within the first 30 days after the operation. 12 out of 135 addressed hospitals agreed to participate in the study. These included four small hospitals, six medical centres of medium capacity (about 500 beds) and two University hospitals. In order to obtain an exact description of the events leading to perioperative death, the questionnaires consisted of approximately 60 questions for the collection of demographic data and the surgical as well as anaesthesiological perioperative management.
Results: From 1989 to 1993 more than 300 cases of perioperative death were reported. Only 200 cases could be analyzed due to incompletely answered or unreturned questionnaires. The mean risk-classification (ASA) was 3.46, mean age 74.6 years. Approximately 40 percent of deaths occurred in patients older than 80 years. More than 80 percent of patients had at least one pre-existing cardiovascular disease with prevalence of 41% for pulmonary and gastrointestinal diseases. In the majority of cases abdominal operations were performed, followed by hip-surgery and surgery of the aorta. In 86% of the cases, the surgeon was experienced and had performed the respective operation more than 20 times. In 38.2% an anaesthetist intraining was responsible for anaesthesia, but only 11.6% were without supervision of a specialist anaesthetist. The majority of patients received general anaesthesia (78%) and 8.5% had a combination of EDA and general anaesthesia. Regional anaesthesia was performed in 12.5%, local anaesthesia in only 1%. The average blood loss was approximately 1.600 ml (with a very wide range) and 42.5% of the patients needed a transfusion of blood components, primarily in the form of packed red blood cells. Seventeen serious incidents occurred intraoperatively, including three „exitus in tabula”. Four patients died shortly after the operation in the ICU, the other ten incidents were managed in the operating room. In 11 of 17 incidents the patients suffered a cardiac arrest; nine patients were resuscitated. Two patients were not resuscitated in view of pre-existing diseases and inoperability. All of the hospitals had an ICU for postoperative care, but two of the smaller hospitals had no recovery rooms. In 22 cases of emergency operations, there was a delay due to a lack of personnel or to logistic problems. In five of these cases, the delay was described as a possible cofactor of perioperative mortality. The most frequent causes of perioperative death were myocardial failure (33.7%) and multi-organ-failure (19.2%), followed by respiratory insufficiency (13%) and septic shock in 9.3%. A necropsy was carried out in only 28 of 200 perioperative deaths (14%); 13% of the cases were discussed in a surgical and only 2.5% in an anaesthesiological mortality-conference. In 9 out of 12 hospitals no mortality-conferences were held. All surgeons and anaesthetists were asked for self-assessment on the basis of an analog scale ranging from 0 and 10 points. The average score was 8.52 points (surgical management) and 9.36 points (anaesthesiological management respectively), which is not always in correspondance with the information provided in the questionnaires.
Conclusions: In order to further reduce perioperative mortality in critically ill patients, every hospital should aim to optimize the structure of the surgical and anaesthesiological departments. A delay due to logistical or personnel problems may be a co-factor in perioperative mortality. Recovery rooms with experienced personnel should be the standard in postoperative anaesthesiological care. All cases of perioperative death should be discussed in a mortality conference by anaesthetists and surgeons in order to determine possible medical or logistic problems and avoid them in future.
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