Critical care in hospital intensive care units (ICUs) has brought patients back from the brink of death to health on innumerable occasions. However, not uncommonly, seriously ill patients receive critical care that does not restore health; it merely prolongs the dying process. This situation is known as futile critical care treatment. A new study by researchers at UCLA and RAND Health has reported that futile critical care not only provides no benefit to the patient but also denies that treatment for other patients who are likely to benefit from it. The findings were published in the August edition of the peer-reviewed journal Critical Care Medicine.
The study authors note that providing futile treatment in the ICU sets off a chain reaction that causes other critically ill patients needing medical attention to wait for critical care beds. The study is the first to report that when unbeneficial critical care is provided, other patients who might be able to benefit from treatment are harmed, explained 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.
The findings also have implications for the fairness of the American healthcare system, and stresses the need for policy improvements to more efficiently use limited healthcare resources, noted 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. He explained, “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. 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 investigators surveyed critical care physicians in five ICUs in one health system to identify patients that the doctors identified as receiving treatment that would not help them improve. 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. They found 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 had their transfer request canceled after waiting more than one day. Two patients died at outside hospitals while waiting to be transferred into the 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,” noted Dr. Wenger. He added, “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.”
Dr. Huynh noted that the next phase of the research will focus on the development of interventions to decrease instances of hospitals providing critical care to patients for whom there will be no benefit. He explained, “With advances in medicine and technology, the ICU is now able to save lives as well as prolong the dying process. 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.”
The study authors wrote: “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 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.”