Decisional responsibility for mechanical ventilation and weaning: an international survey

Introduction: Optimal management of mechanical ventilation and weaning requires dynamic and collaborative decision making to minimize complications and avoid delays in the transition to extubation. In the absence of collaboration, ventilation decision making may be fragmented, inconsistent, and delayed. Our objective was to describe the professional group with responsibility for key ventilation and weaning decisions and to examine organizational characteristics associated with nurse involvement.

Methods: A multi-center, cross-sectional, self-administered survey was sent to nurse managers of adult intensive care units (ICUs) in Denmark, Germany, Greece, Italy, Norway, Switzerland, Netherlands and United Kingdom (UK). We summarized data as proportions (95% confidence intervals (CIs)) and calculated odds ratios (OR) to examine ICU organizational variables associated with collaborative decision making.

Results: Response rates ranged from 39% (UK) to 92% (Switzerland), providing surveys from 586 ICUs. Interprofessional collaboration (nurses and physicians) was the most common approach to initial selection of ventilator settings (63% (95% CI 59 to 66)), determination of extubation readiness (71% (67 to 75)), weaning method (73% (69 to 76)), recognition of weaning failure (84% (81 to 87)) and weaning readiness (85% (82 to 87)), and titration of ventilator settings (88% (86 to 91)). A nurse-to-patient ratio other than 1:1 was associated with decreased interprofessional collaboration during titration of ventilator settings (OR 0.2, 95% CI 0.1 to 0.6), weaning method (0.4 (0.2 to 0.9)), determination of extubation readiness (0.5 (0.2 to 0.9)) and weaning failure (0.4 (0.1 to 1.0)). Use of a weaning protocol was associated with increased collaborative decision making for determining weaning (1.8 (1.0 to 3.3)) and extubation readiness (1.9 (1.2 to 3.0)), and weaning method (1.8 (1.1 to 3.0)). Country of ICU location influenced the profile of responsibility for all decisions. Automated weaning modes were used in 55% of ICUs.

Conclusions: Collaborative decision making for ventilation and weaning was employed in most ICUs in all countries although this was influenced by nurse-to-patient ratio, presence of a protocol, and varied across countries. Potential clinical implications of a lack of collaboration include delayed adaptation of ventilation to changing physiological parameters, and delayed recognition of weaning and extubation readiness resulting in unnecessary prolongation of ventilation.

The Tragedy of Darfur and the Limits of the Responsibility to Protect

The view that states which claim sovereign status must comply with the responsibility to protect their own citizens is gaining ground in international politics. When a state is unable or unwilling to meet this responsibility, the international community is justified in intervening militarily to end widespread human rights violations. This article argues that a diffuse responsibility to protect, as currently conceived, may have important negative consequences. By using the ongoing tragedy of Darfur as an example, the article argues that the responsibility to protect is reactive and focused on the short term, contributes to the outbreak of violence and perversely provides repressed groups with a further incentive to continue their armed struggle after war breaks out. The tragedy of Darfur shows that effective protection requires case-specific policies aimed at prevention, democratization and economic and political development.

Genocide and the International Court of Justice: Finally, a Duty to Prevent the Crime of Crimes

The International Court of Justice has issued its long-awaited decision in the suit filed by Bosnia and Herzegovina against Serbia and Montenegro with respect to the 1992–1995 war. The decision confirms the factual and legal determinations of the International Criminal Tribunal for the former Yugoslavia, ruling that genocide was committed during the Srebrenica massacre in July 1995 but that the conflict as a whole was not genocidal in nature. The Court held that Serbia had failed in its duty to prevent genocide in Srebrenica, although—because, the Court said, there was no certainty that it could have succeeded in preventing the genocide—no damages were awarded. The judgment provides a strong and authoritative statement of the general duty upon states to prevent genocide that dovetails well with the doctrine of the responsibility to protect.

The politics of ethical foreign policy::A responsibility to protect whom?

Ethical foreign policy persists as a problem of international relations, especially regarding humanitarian intervention. However, despite apparent international upheavals, the debate about the ethics of humanitarian intervention has remained fundamentally unchanged. To escape the limits of this debate, this article deconstructs British claims to ethical foreign policy since 1997, reading these claims against themselves and against contemporary humanitarian intervention literature. It finds that Britain’s ethical framework, the ‘doctrine of international community’, which justifies interventions in Kosovo, Sierra Leone and Afghanistan, is undone by the anomalous, yet exemplary, invasion of Iraq. This demonstrates the politics of ethical foreign policy: first, that any intervention, no matter how ‘ethical’ or ‘right’, produces suffering and death; and, second, that we cannot know for sure whether we are doing the right thing by intervening. Embracing, rather than effacing, the political nature of ethical foreign policy opens up a more intellectually honest and positive potential future for relating to the foreign in a responsible manner.

Corporate Social Responsibility within the Northern Ireland Construction Industry: A Regional Review

As the construction industry continues to struggle with a poor societal image, many organizations have adopted a positive corporate social responsibility (CSR) towards their surrounding environment, with the objective of improving their persona within social circles. The aim of this research is to identify and document the various approaches adopted by UK contractors in relation to their international counterparts to aid in the identification of possible future benefits which may be exploitable.
In order to acquire the relevant information, a number of qualitative methodologies are adopted including a review of the current literature on the topic along with a detailed semi-structured interview with a UK based industry professional that specializes in corporate social responsibility. Through assessing the findings using qualitative analysis software, it is possible to disseminate the information, resulting in the identification of key findings. This research concludes that a number of factors profoundly affect corporate social responsibility within the UK versus other regions. These factors are identified as the effect of the recession, implementation and reporting along with competitiveness within the sector.
The impaction for practice within the UK construction sector of this research is that it enables various industry leaders to actively consider the findings of the research while also vigorously encouraging the establishment and development of corporate social responsibility, not only within their respective organizations, but within the construction industry as a whole. This would not only result in a more environmentally sustainable industry, but would also raise the awareness of the sector locally, nationally and internationally, therefore improving the overall perception of the sector on a variety of levels. This will ultimately lead to a more sustainable, environmentally friendly and collective industry while also considering the needs of one of its most important external stakeholders – the local community.

Reparative Complementarity: Ensuring an Effective Remedy for Victims in the Reparation Regime of the International Criminal Court

This article examines the reparation regime of the International Criminal Court in light of its first reparation decision. Based on the reparation jurisprudence established in international law and human rights law to provide victims of international crimes an effective remedy, this article suggests that in order for the International Criminal Court to achieve this objective it needs to go beyond individual criminal responsibility due to its limitations. This article considers the role of reparative complementarity in ensuring an effective remedy to victims of international crimes as part of the reparation regime of the International Criminal Court.

Beyond Attribution: Responsibility of Armed Non-State Actors for Reparations in Northern Ireland, Colombia and Uganda

This chapter explores the responsibility of armed non-state actors for reparations to victims. Traditionally international law has focused on the responsibility of the state, and more recently the responsibility of convicted individuals before the International Criminal Court, to provide reparations for international crimes. Yet despite the prevalence of internal armed conflict over the past few decades, there responsibility of armed groups for reparations has been neglected in international law. Although there is a tentative emerging basis for armed groups to provide reparations under international law, such developments have not yet crystallized into hard law. However, when considering the more substantive practice of states in Northern Ireland, Colombia and Uganda, a greater effort can be discerned in ensuring that such organizations are responsible for reparations. This paper finds that not only can armed non-state actors be held collectively responsible for reparations, but due to the growing number of internal armed conflict they can play an important role in ensuring the effectiveness of reparations in remedying victims’ harm. Yet, finding armed groups responsible for reparations is no panacea for accountability, due to the nature of armed conflicts, responsibility may not be distinct, but overlapping and joint, and such groups may face difficulties in meeting their obligations, thus requiring a holistic approach and subsidiary role for the state.

Accountability for Forced Displacement in Democratic Republic of Congo and Uganda before the International Criminal Court

This article examines the challenges of investigating and prosecuting forced displacement in the Central African countries of Democratic Republic of Congo and Uganda, where higher loss of life was caused by forced displacement, than by any other. In the Democratic Republic of Congo, armed groups intentionally attacked civilian populations displacing them from their homes, to cut them off from food and medical supplies. In Northern Uganda, the government engaged in a forced displacement policy as part of its counter-insurgency against the Lord’s Resistance Army, driving the civilian population into “protected villages”, where at one point the weekly death toll was over 1,000 in these camps. This article critically evaluates how criminal responsibility can be established for forced displacement and alternative approaches to accountability through reparations.