JAMA Network | JAMA Internal Medicine | The Frequency and Cost of Treatment Perceived to Be Futile in Critical Care
Importance Physicians often perceive as futile intensive care interventions that prolong life without achieving an effect that the patient can appreciate as a benefit. The prevalence and cost of critical care perceived to be futile have not been prospectively quantified.
Conclusions and Relevance In 1 health system, treatment in critical care that is perceived to be futile is common and the cost is substantial.
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. Such treatments are often perceived to be “futile” by health care providers.3 A survey of ICU physicians in Canada found that as many as 87% believed that futile treatment had been provided in their ICU in the past year.3 In a single-day cross-sectional study performed in Europe, 27% of ICU clinicians believed that they provided “inappropriate” care to at least 1 patient, and most of the inappropriate care was deemed such because it was excessive.4
In the United States, critical care accounts for 20% of all health costs and 1% of the gross national domestic product.5,6 Because approximately 20% of deaths in the United States occur during or shortly after a stay in the ICU, critical care is scrutinized for the provision of potentially futile resource-intensive treatment.2,7- 9 However, information is lacking on the prospective identification of patients who are perceived as receiving futile treatment, factors associated with these perceptions, and the outcomes and costs of the care.
The Opportunity Cost of Futile Treatment in the ICU | RAND
Treatment that cannot achieve a patient’s goals or that simply maintains a state such as ICU dependence or permanent coma is contrary to professional values, inappropriately uses health care resources, and creates moral distress.3,10,11 Nonetheless, the determination of futility is often value laden. We convened a focus group of critical care physicians to establish reasons why treatment might be considered futile. Using these reasons, we surveyed critical care physicians daily during a 3-month period to identify patients whom they perceived to be receiving futile treatment.
OBJECTIVE: When used to prolong life without achieving a benefit meaningful to the patient, critical care is often considered "futile." Although futile treatment is acknowledged as a misuse of resources by many, no study has evaluated its opportunity cost, that is, how it affects care for others. Our objective was to evaluate delays in care when futile treatment is provided.
MEASUREMENTS AND MAIN RESULTS: Boarding time in the emergency department and waiting time on the transfer list. Thirty-six critical care specialists made 6,916 assessments on 1,136 patients of whom 123 were assessed to receive futile treatment. A full ICU was less likely to contain a patient receiving futile treatment compared with an ICU with available beds (38% vs 68%, p < 0.001). On 72 (16%) days, an ICU was full and contained at least one patient receiving futile treatment. During these days, 33 patients boarded in the emergency department for more than 4 hours after admitted to the ICU team, nine patients waited more than 1 day to be transferred from an outside hospital, and 15 patients canceled the transfer request after waiting more than 1 day. Two patients died while waiting to be transferred.
CONCLUSIONS: Futile critical care was associated with delays in care to other patients.
- BACKGROUND: In imminently dying patients, mechanical ventilation withdrawal is often a comfort measure and avoids prolonging the dying process.
- OBJECTIVE: The aim of the study was to identify factors associated with palliative withdrawal of mechanical ventilation and time to death after extubation.
- RESULTS: Of the 322 ventilated deaths, 159 patients had palliative withdrawal of mechanical ventilation and 163 patients died on the ventilator. Clinical service was associated with palliative withdrawal of mechanical ventilation: Patients withdrawn from the ventilator were less likely to be on the surgery service and more likely to be on the neurology/neurosurgical service. The median time to death was 0.9 hours (range 0–165 hours). Fraction of inspired oxygen (FIO2) greater than 70% (hazard ratio [HR] 1.92, 95% confidence interval [CI ]1.24–2.99) and a requirement for vasopressors (HR 2.06, 95% CI 1.38–3.09) were associated with shorter time to death. Being on the neurology/neurosurgical service at the time of ventilator withdrawal was associated with a longer time to death (HR 0.60, 95% CI 0.39–0.92).
- CONCLUSIONS: Palliative withdrawal of mechanical ventilation was performed in only half of dying mechanically ventilated patients. Because clinical service rather than physiologic parameters are associated with withdrawal, targeted interventions may improve withdrawal decisions. Considering FIO2 and vasopressor requirements may facilitate counseling families about anticipated time to death.
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