Critical care treatment for patients that was perceived to be
futile cost an estimated US$2.6 million at one academic medical centre during a
three-month period, according to a study first published online last month in
JAMA Internal Medicine. One in five patients in the study received treatment
the physicians perceived as futile or potentially futile.
Thanh N. Huynh, of the David Geffen School of Medicine at the University of California, Los Angeles, and colleagues sought to quantify the prevalence and cost of treatment thought to be futile in adult critical care.
Researchers asked critical care specialists to identify patients they believed were receiving futile treatment in five intensive care units (ICUs) at an academic medical centre on a daily basis for three months.
Thirty-six critical care specialists assessed 1,136 patients, and judged that 904 (80 percent) never received futile treatment, 98 (8.6 percent) received probably futile treatment, 123 (11 percent) received futile treatment and 11 (1 percent) received futile treatment only on the day they transitioned to palliative care, according to the results.
“The most common reason treatment was perceived as futile was that the burdens grossly outweighed the benefits (58 percent). This reason was followed by treatment could never reach the patient’s goals (51 percent), death was imminent (37 percent), and the patient would never be able to survive outside an ICU (36 percent),” according to the study results.
The average cost for one day of treatment in the ICU that was perceived as futile was US$4,004. For the 123 patients categorised as receiving futile care, hospital costs (ICU and subsequent non-ICU days) for the care that was thought to be futile totalled US$2.6 million, which was 3.5 percent of the total hospital costs for the 1,136 patients in the study, the results also indicate.
“In our health system, critical care physicians frequently perceived that they are providing futile treatment, and the cost is substantial. Identifying and quantitating ICU treatment that is perceived as futile is a first step toward refocusing care on treatments that are more likely to benefit patients,” the authors conclude.
In an associated commentary Robert D. Truog of Harvard Medical School, Boston, and Douglas B. White of the University of Pittsburgh School of Medicine, urge caution in interpreting the findings. The study did not take into account opinions of other members of the clinical team or patients and families in judging if treatment was futile. In addition, the financial analysis did not include what would be saved if the futile treatments were not provided.
Truog and White go on to make recommendations for how clinicians in critical care units should conceptualise and respond to requests for treatment that they judge to be futile or wrong. They suggest using the term ‘potentially inappropriate’ rather than ‘futile’, and argue that, from an ethical and legal standpoint, these disputes are often more complicated than they seem. Clinicians’ initial response to requests for treatments that they believe are wrong should be to increase communication with the patient or the patient’s surrogate rather than simply refuse the request. Clinicians should pursue a fair process of dispute resolution rather than refusing unilaterally to provide treatment. “When disputes arise despite sustained efforts to prevent them, a stepwise procedural approach to resolving conflicts is essential,” they conclude.
Huynh TN, Kleerup EC, Wiley JF et al. (2013 Sep 9) The frequency and cost of treatment perceived to be futile in critical care. JAMA Intern Med, doi:10.1001/jamainternmed.2013.10261. [Epub ahead of print] Truog RD, White DB (2013 Sep 9) Futile treatments in intensive care units. JAMA Intern Med, doi:10.1001/jamainternmed.2013.7098 [Epub ahead of print]