The goal of critical care is to reverse patients' acute problems in effective and ethical ways with minimum costs. Unlike in other medical fields, the quality of Korean critical care has lagged behind that of advanced countries. Moreover, the level of critical care quality differs significantly between university hospitals. The suboptimal critical care level has multifactorial causes. The major challenge to Korean intensivists is, therefore, how to overcome barriers in the current critical care delivery system to improve outcomes for critically ill patients and reduce medical errors in error-prone Intensive Care Unit (ICUs). A long-term task force including all stakeholders should address the multifactorial barriers to better outcomes. The Korean Society of Critical Care Medicine should perform the central role to dismantle the barriers step by step with a long-term vision for a desirable critical care delivery system in our society. A capable critical care team with full-time intensivists is the most urgent requirement for proper, timely care in ICUs. Intensivists should focus on basic but essential management so scarcity of resources can be minimized. Publicity about ICU to the general public is also urgently required to draw the attention of medical policy makers to the current suboptimal level of our critical care system.
Administrative Personnel ; Advisory Committees ; Critical Care* ; Critical Illness ; Hospitals, University ; Humans ; Intensive Care Units ; Korea ; Medical Errors

No abstract available.

When considering the establishment of the Korean Society of Critical Care Medicine (KSCCM) in 1980, the beginning of intensive care in Korea was not behind the time. However, the level of our intensive care quality lags behind that of advanced countries. The unreasonable reimbursement system in Korea for required critical care costs staggers critical care development, along with the full time intensivist shortage problem in intensive care units (ICUs). Currently, the reimbursement rates are estimated to support around 30~50% of the cost. Due to our odd critical care reimbursement system, the more financial losses for intensive care occur, the better critical care is conducted by enhancing critical care delivery system, such as the nurse-to-bed ratio. This inappropriate critical care delivery system results in poor outcomes for our critically ill patients. Critically ill patients present many diagnostic and therapeutic problems. The need to cope with those complicated patients' problems has evolved over the last four decades into a critical care subspecialty in Western countries. The KSCCM has been the only organization in Korea that represents all professional components for critical care. After the 6 year long discussion with other related medical societies, the KSCCM launched the critical care subspecialty board under the auspice of the Korean Academy of Medical Societies on April 15th, 2008. After reviewing the applicants' carriers in critical care and their research achievements, 1,040 critical care subspecialties were born this February. Their primary specialties include Anesthesiology, Emergency Medicine, Internal Medicine, Neurology, Neurosurgery, Pediatrics, Surgery, and Thoracic Surgery. 91.7% of them are university hospital faculty members and they should renew their critical care subspecialty in every 5 years. The required items for the renewal are not easily fulfilled without working as a critical care physician. The structured critical care training program began in designated training hospitals on March 1st, 2009. Over the past few decades, the activities of intensive care units have considerably changed. Recent advances in critical care technology facilitate early detection of patients' problems. Much clinical information derived through research has been evolved as bundles of clinical managements for the indicated patients. The evidences of clinical researches show that the right application of the recommended management bundles at the right time improves patient outcomes. Therefore, the meaning of the critical care subspecialty is to perform the right care at the right time for critically ill patients. We think that the implementation of the critical care specialty and of core critical care education and training system can significantly enhance quality of critical care and patient outcomes. In order to achieve these goals, the critical care delivery system should be urgently enhanced. The enhancement includes the right compensation of critical care cost and the correction of the absurd medical law, ruling on our ICU care. The KSCCM will continuously offer a variety of activities that promote excellence in patient care, education, critical care delivery system, research, and collaboration with other countries' critical care societies. It is our hope that all critically ill patients should receive professional and humane care in Korean ICUs and the inappropriately designed health care system should not jeopardize patients' health.
Achievement ; Anesthesiology ; Compensation and Redress ; Cooperative Behavior ; Critical Care ; Critical Illness ; Delivery of Health Care ; Emergency Medicine ; Humans ; Intensive Care Units ; Internal Medicine ; Jurisprudence ; Korea ; Neurology ; Neurosurgery ; Patient Care ; Pediatrics ; Phosphatidylethanolamines ; Societies, Medical ; Specialty Boards ; Thoracic Surgery

BACKGROUND: The effect of PEEP(ed note: Define PEEP.) on the lung volume in patients with auto-PEEP during mechanical ventilation is not even. In patients with an expiratory limitation such as COPD, a PEEP of 85% from an auto-PEEP can be used with minimal increase in the lung volume. However, the application of PEEP to patients without an expiratory flow limitation can result in progressive lung. This study was carried out to evaluate the different PEEP effects on the lung volume according to the different pulmonary diseases. METHODS: Sixteen patients who presented with auto-PEEP during mechanical ventilation were enrolled in this study. These patients were divided into 3 groups: asthma, COPD and tuberculosis sequela (patients with severe cicatrical fibrosis as a result of previous tuberculosis and compensatory emphysema). A PEEP of 25, 50, 75 and 100% of the auto-PEEP was applied, and the lung volume increments were estimated using the trapped lung volume. RESULTS: In the asthma group, the trapped lung volume was not increased at a PEEP of 25 and 50% of the auto-PEEP. This group showed a significant lung volume increment from a 75% PEEP. In the COPD group, the lung volume was increased only at 100% PEEP. In the tuberculosis sequela group, the lung volume was increased progressively from low PEEP levels. However, a significant increment of the lung volume was noted only at 100% PEEP. CONCLUSION: The effects of the applied PEEP on the lung volume were different depending on the underlying lung pathology. The level of the applied PEEP >50% of the auto-PEEP might increase the trapped lung volume in patients with asthma.
Asthma ; Fibrosis ; Humans ; Lung Diseases* ; Lung* ; Pathology ; Positive-Pressure Respiration, Intrinsic* ; Pulmonary Disease, Chronic Obstructive ; Respiration, Artificial ; Tuberculosis

No abstract available.
Positive-Pressure Respiration, Intrinsic*

The level of end-of-life (EOL) care quality in the Republic of Korea has been regarded as inferior to more advanced countries. The EOL care delivered has varied depending on physicians' perceptions and patients' family requests for care. A consensus guideline on withdrawing life-sustaining therapies, which has been endorsed by the Korean Medical Association, Korean Academy of Medical Sciences, and Korean Hospital Association, was published on 13 October 2009. However, the guideline seems to be still not widely applied in our hospitals. The acknowledgment of patient wish, reflected by such as an advance directives (AD) is the most important ethical and legal requirement in EOL care decisions. However, there are barriers to adopting the AD as a solely legitimate tool of EOL decision making even in Western societies. Advance care planning depending on a patient's condition seems to be a more reasonable approach for better EOL care. For an appropriate advance care planning, open communications between physicians and patients or their surrogates is crucial. The lack of an open approach to discussing EOL care with patients results in inappropriate prolongation of patients' dying process. In summary, physicians, who know the clinical signficance of treatments to be delivered to EOL patients, should play a central role based on the 2009 consensus guideline to help patients and their families make good decisions on EOL care. EOL care should be individualized to meet a patient's and family's wishes about the forgoing of life-sustaining therapy. Moreover, concerted actions between the public sector and a governmental organization are required to address ongoing public demands for better EOL care. social requests.
Advance Care Planning ; Advance Directives ; Consensus ; Decision Making ; Humans ; Personal Autonomy ; Public Sector ; Republic of Korea ; Terminal Care ; Withholding Treatment

No abstract available.

BACKGROUND: Many physicians hesitate to discuss do-not-resuscitate (DNR) orders with patients or family members in critical situations. In the intensive care unit (ICU), delayed DNR decisions could cause unintentional cardiopulmonary resuscitation, patient distress, and substantial cost. We investigated whether the timing of DNR designation affects patient outcome in the medical ICU. METHODS: We enrolled retrospective patients with written DNR orders in a medical ICU (13 bed) from June 1, 2014 to May 31, 2015. The patients were divided into two groups: early DNR patients for whom DNR orders were implemented within 48 h of ICU admission, and late DNR patients for whom DNR orders were implemented more than 48 h after ICU admission. RESULTS: Herein, 354 patients were admitted to the medical ICU and among them, 80 (22.6%) patients had requested DNR orders. Of these patients, 37 (46.3%) had designated DNR orders within 48 hours of ICU admission and 43 (53.7%) patients had designated DNR orders more than 48 hours after ICU admission. Compared with early DNR patients, late DNR patients tended to withhold or withdraw life-sustaining management (18.9% vs. 37.2%, p = 0.072). DNR consent forms were signed by family members instead of the patients. Septic shock was the most common cause of medical ICU admission in both the early and late DNR patients (54.1% vs. 37.2%, p = 0.131). There was no difference in in-hospital mortality (83.8% vs. 81.4%, p = 0.779). Late DNR patients had longer ICU stays than early DNR patients (7.4 ± 8.1 vs. 19.7 ± 19.2, p < 0.001). CONCLUSIONS: Clinical outcomes are not influenced by the time of DNR designation in the medical ICU. The late DNR group is associated with a longer length of ICU stay and a tendency of withholding or withdrawing life-sustaining treatment. However, further studies are needed to clarify the guideline for end-of-life care in critically ill patients.
Advance Directives ; Cardiopulmonary Resuscitation ; Consent Forms ; Critical Illness* ; Hospital Mortality ; Humans ; Intensive Care Units ; Resuscitation Orders* ; Retrospective Studies ; Shock, Septic

No abstract available.
Humans ; Medical Errors ; Patient Safety

Patients should be treated with dignity and respect toward the end of their lives, being freed from unnecessary and painful life-sustaining therapy in hospitals. In Korea, the quality of endof-life (EOL) care has been variable, a major factor being the physicians' perception to the care. A firm consensus of EOL care decision-making has not yet explicitly stated in Korean law and ethics until recently. However, movements to make a law of so-called "the death with dignity act" are presently making its way to the National Assembly, initiated by a law case that allowed the hospital to withdraw mechanical ventilator support per request by the patients' family of a permanently vegetative patient. Socially agreed guidelines for EOL care can facilitate clinical decision process and communication between health service provider and the patient or his/her family. At the same time, EOL care should be individualized also in the same line of guideline to meet patient' and patient' family wish regarding the withdrawal of life-sustaining therapy. The painful EOL care experience of the loved one remains in the memory of the relatives who live on. Physicians should identify, document, respect, and act on behalf of the hospitalized patients' needs, priorities, and preference for EOL care. It has been advocated that competent patients can express their right of self-determination on EOL care through advance directives in Western countries. Advance directives are considered as a tool to facilitate EOL decision making. However, there are barriers to adopt the advance directives as a legitimate tool for an EOL decision making in Korea. For one thing, the reality of death and dying is rarely discussed in our society. In addition, the discussion about EOL care with chronically and critically ill patients has been considered as a taboo in the hospitals. In spite of these difficulties, physicians could do better EOL care by the open communication with patients or with their surrogates. Through the communication, physician should set a goal how to manage the EOL patient. The set goal should be shared among the caregivers to achieve the maximum benefit of the patient. The lack of open discussion with patient prior to EOL care results in inappropriate protraction of a patient's dying process. In summary, physicians, who know the clinical significance of delivering treatments to EOL patients, should play a central role in assisting patients' and their families' to make the best decision on EOL care. Moreover, the concerted actions to improve EOL care in our society among general public, professionals, stakeholders for EOL care, and governmental organizations are required to address ongoing social requests, although a policy or a guideline is made in this time.
Advance Directives ; Caregivers ; Complement Factor B ; Consensus ; Critical Illness ; Decision Making ; Ethics, Medical ; Health Services ; Humans ; Jurisprudence ; Korea ; Love ; Memory ; Physician's Role ; Right to Die ; Taboo ; Ventilators, Mechanical