[Legal aspects of injuries due to positioning of the patient in urology].

Each positioning of the patient has method specific risks and risk increasing factors which depend on the type of surgery carried out. The causes of damage during positioning are pressure and strain when the protective reflexes are out of action, as well as a reduction of the shielding muscle tone through anaesthesia. The surgeon is responsible for the positioning of the patient, and the anaesthetist for the "infusion arm".

[Preoperative fasting. An update].

In Germany the predominant standard of preoperative care for elective surgery is fasting after midnight, with the aim of reducing the risk of pulmonary aspiration. However, for the past several years the scientific evidence supporting such a practice has been challenged. Experimental and clinical studies prove a reliable gastric emptying within 2 h suggesting that, particularly for limited intake of clear fluids up to 2 h preoperatively, there would be no increased risk for the patient.

[Determining responsibility for surgical positioning of the patient and malpractice for damage caused by patient position].

The cooperation of surgeon and anaesthetist in positioning of the patient is subject to the principles of horizontal division of labour recognized in the interdisciplinary agreement and confirmed by the legislature: anaesthetist and surgeon carry out their respective tasks independently of each other, each bearing full responsibility for their own work (principle of strict separation of functions), they tailor their procedures to fit in with each other (duty of coordination), and each is entitled to expect and rely on due care in the other (principle of trust). In the case of conflict--when the best position for the specific intervention leads to a higher anaesthesiological risk--the principle of predominance of the actual requirements applies. If no agreement is reached it is incumbent on the surgeon to make the decision; this means that the surgeon bears the medical and legal responsibility for appropriate deliberation.

[Allocation of responsibility for positioning patients for surgery and liability for damages consequent on faulty positioning].

The cooperation of surgeon and anaesthetist in positioning of the patient is subject to the principles of horizontal division of labour recognized in the interdisciplinary agreement and confirmed by the legislature: anaesthetist and surgeon carry out their respective tasks independently of each other, each bearing full responsibility for their own work (principle of strict separation of functions), they tailor their procedures to fit in with each other (duty of coordination), and each is entitled to expect and rely on due care in the other (principle of trust). In the case of conflict--when the best position for the specific intervention leads to a higher anaesthesiological risk--the principle of predominance of the actual requirements applies. If no agreement is reached it is incumbent on the surgeon to make the decision; this means that the surgeon bears the medical and legal responsibility for appropriate deliberation.

[Quality practice].

Risk-management, prospective and preventive quality-management and liability of doctors are important topics in daily practice and administration of justice.

[Treatment of patients incapable of giving their consent. Legal requirements in anesthesia and intensive care medicine].

A treatment procedure requires the consent of the patient, but this is legally effective only if he is capable of giving his consent and can be informed accordingly. Because of demographic development and the progress of medicine, the number of patients who are not able to give their consent is increasing. In practice, we make do with the presumed consent of the patient or, for procedures that can wait, with the consent of legitimate family members.

[Limits to the duty to treat in intensive care. 1. Explanation of the guidelines in the DGAI].

Every form of active euthanasia is a punishable offence under sections 216 of the Penal Code; nor is there any ethical justification for it from a medical point of view. The many strands of the movement in favour of making "death on demand" exempt from punishment in Germany as it is in The Netherlands cannot change this. In the area of passive euthanasia the limits of the intensive care team's duty to treat depends on various factors: The patient's declared or assumed wishes.

[Patient preparation and premedication--legal aspects].

The legal demands concerning the methods of treatment required of an anaesthetist are determined by the quality of the specialist and the professional standard. As long as there is no premedication procedure which is generally considered superior to all others, the anaesthetist can freely choose the procedure, while carefully considering benefits and risks on the basis of the individual circumstances of each case. The patient must be informed about the anaesthesia before premedication since the latter inhibits his/her ability to make decisions.