In a bygone era, doctors thought every life was important. Treatment was aggressive and persistent in intensive care units even when it might be futile.
In the 21st century world, resources are the first consideration, and there are plenty of ideas about ways to curb treatment and lower costs. A new analysis finds that doctors could try a little less in the intensive care unit - because otherwise they are causing other ill patients needing medical attention to wait for critical care beds.
UCLA and RAND health scholars behind the current paper may have a point. American health care is very expensive - it is also very good and that is why wealthy people leave their government health care countries and journey to the U.S. But expensive excellence may not be needed for everyone and with government increasingly paying for it, some corners may have to be cut to more efficiently use limited healthcare resources.
"Many people do not realize that there is a tension between what medicine is able to do and what medicine should do. Even fewer realize that medicine is commonly used to achieve goals that most people, and perhaps most of society, would not value – such as prolonging the dying process in the intensive care unit when a patient cannot improve," said senior author Dr. Neil S. Wenger, a UCLA professor of medicine, a RAND Health scientist and director of the UCLA Health Ethics Center at the David Geffen School of Medicine at UCLA. "But almost no one recognizes that these actions affect other patients, who might receive delayed care or, worse, not receive needed care at all because futile medical treatment was provided to someone else."
The team surveyed critical care physicians in five ICUs in one health system to identify patients that the clinicians identified as receiving treatment that would not help them get better. They then identified days when an ICU was full and contained at least one patient receiving futile treatment and looked at the number of patients waiting for ICU admission for more than four hours in the emergency department or more than one day for transfer from an outside hospital.
The study showed that on 16% of days when an ICU was full, it contained at least one patient receiving futile treatment. During those days, 33 patients were kept in the emergency department for more than four hours, nine patients waited more than one day to be transferred from an outside hospital and 15 patients canceled their transfer request after waiting more than one day. Two patients died at outside hospitals while waiting to be transferred into the academic medical center ICU.
"These findings should contribute to the public debate about the use of limited healthcare resources and whether limitations should be placed on using those resources for treatments that physicians feel will not benefit patients," Wenger said. "To date, healthcare payers have been willing to pay for any life-sustaining treatment that has already been started and the public has been unwilling to discuss the trade-offs silently made between patients receiving futile treatment and patients not receiving the treatment they need. This study demonstrates that those trade-offs occur and can be measured."
Huynh said that going forward, the research team hopes to develop interventions to decrease instances of hospitals providing critical care to patients for whom there will be no benefit.
"With advances in medicine and technology, the ICU is now able to save lives as well as prolong the dying process," said lead author Dr. Thanh Huynh, an assistant professor of medicine in the division of pulmonary and critical care medicine at the David Geffen School of Medicine at UCLA. "Because resources are not unlimited, patients receiving futile treatment can mean delayed or even denied access to care for other patients in need. This needs to change."
"It is unjust when a patient is unable to access intensive care because ICU beds are occupied by patients who cannot benefit from such care. Our findings are particularly relevant in the U.S., but are also instructive elsewhere given universal concerns regarding providing treatments that are non-beneficial," the study states. "The ethic of 'first come, first served' is not only inefficient and wasteful, but it is contrary to medicine's responsibility to apply healthcare resources to best serve society. In the context of healthcare reform, which aims to more justly distribute medical care to the nation, opportunity cost is one more reason that futile treatment should be minimized."
Published in Critical Care Medicine.
Source: University of California - Los Angeles Health Sciences