Thanks to extraordinary advances in medicine, critical care providers can save lives even when the cards are stacked against their patients. However, there are times when no amount of care, however cutting-edge it is, will save a patient. In these instances, when physicians recognize that patients will not be rescued, further critical care is said to be “futile.” In a new study, my RAND and UCLA colleagues and I find that critical care therapies that physicians regard as “futile” are not uncommon in intensive care units, raising some uncomfortable questions.
Of course, we’re fortunate to have such fantastic technology at our disposal — but we must address how to use it appropriately when the patient may not benefit from high-intensity measures. When aggressive critical care is unsuccessful at achieving an acceptable level of health for the patient, treatment should focus on palliative care.
In our study, my colleagues and I quantified the prevalence and cost of “futile” critical care in the journal JAMA Internal Medicine. This can be seen as the first step toward reevaluating the status quo and better optimizing care for critical care patients.
After convening a group of critical care clinicians to determine a consensus definition of “futile treatment,” our research team analyzed nearly 7,000 daily assessments of more than 1,000 patients.
We found that 11 percent received futile treatment, while an additional 9 percent received “probably futile” treatment.
So physician-perceived futile critical care is indeed prevalent. But what about the cost?
The average cost of a day of “futile” treatment was roughly $4,000. For the 123 patients in our study deemed to have received futile treatment, this amounted to $2.6 million over three months. On average, that’s more than $21,000 per patient. While this was only 3.5 percent of hospital costs for all the patients we studied, the cost is not insignificant.
These findings raise issues about whether physicians and patients and their families are communicating well enough for all to be on the same page, which is critical to timely, patient-centered decision making. Furthermore, the data might make one wonder whether healthcare resources are always well targeted to achieve the benefits that highly technical care aims to attain.
In the future, we hope to examine the full range of factors that might be contributing to the prevalence and cost of “futile” critical care. This is a complex issue, and we’ve only taken the first step toward refocusing treatment to better serve patients.
Neil Wenger, M.D., is the director of the Assessing Care of Vulnerable Elders (ACOVE) project at the non-profit, non-partisan RAND Corporation and a professor of medicine at the University of California, Los Angeles. This post originally appeared in The RAND Blog on September 13, 2013.
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その友達とか名乗った奴だ。だから本人たちじゃなく、そいつが電話してきた」「アキって、奴かな」「おそらくな」柿沢は答えた。そして皮肉げに唇を歪めた。「用心深い若造だ」「え？」「普通、詳しい情報を取ろうとすれば、必ず直にやっ
あ、みんなは信じないかもしれないが、本当に残念だと思っているんだぜ。これまで五体でやってきたのに、これでもうだめになるってことがさ」逃げられないことを悟り、首がうなだれる。もうテッドに会えないことが理解できた。「ずっとう
Let us attack the $4,000 number.
Intensive care is greatly overpriced, and so are the drugs often used in intensive care.
Most other nations would expect hospitals to make do on much less.
Very interesting study; the whole paper is available free & I recommend those interested in the topic take a look:
http://archinte.jamanetwork.com/article.aspx?articleid=1735897
Based on a focus group, clinicians in the study could pick one of the following as why treatment seemed futile: “burdens grossly outweigh benefits, patient will never survive outside an ICU, patient is permanently unconscious, treatment cannot achieve the patient’s goals, or death is imminent.”
Most striking to me was that the researchers seem to have not captured any data as to whether the clinicians told families that the treatment might be futile: “We were unable to characterize the reasons that treatment perceived as futile was provided.”
Because when I hear that ICU docs have been providing care they thought was futile, my first thoughts are: “What have you told the family? What’s their understanding of the situation?”
Important point, well made.
As a senior caregiver in my post-retirement avocation I have seen too many cases of denial at the end of life, often less on the part of the person facing death than family members unable to come to terms with that person’s condition. As the baby boomers come along these attitudes will be forced to change.
More discussions of palliative care are needed, together with clear explanations of the difference between palliative care and hospice. My understanding is they are not the same. And neither obviates reasonable therapeutic treatment. I’m aware of more than one instance of people on hospice being decertified when they either improved or failed to die as expected.
The sad reality is that too many patients and families fail to take advantage of hospice until the final few days. Meantime, the dying person endures both the physical and emotional trauma of denial.
So what’s your definition of futile care? You don’t include ..
In your abstract you write:
“Advances in medicine enable critical care specialists to save lives as well as prolong dying. An admission to the intensive care unit (ICU) should be considered a therapeutic trial—aggressive critical care should transition to palliative care once it is clear that the treatment will not achieve an acceptable health state for the patient.1- 2 However, intensive care interventions often sustain life under circumstances that will not achieve an outcome that patients can meaningfully appreciate … “
Yes. But who decides?
Do you? The patient’s family? The patient? The government?