It is not always feasible to serve all masters in medicine. From a resource utilization standpoint, unfortunately, one missed opportunity is with regard to how we approach futile care. We have all experienced the care of a patient who, regardless of testing and therapy, has zero chance of meaningful recovery. To terminate care for these patients sometimes requires difficult conversations, and can snowball out of control with adverse legal and public relations consequences.
But, as this report from UCLA and RAND details, our failures to properly address futile care and end-of-life issues result in direct downstream harms to other patients. These authors surveyed ICU physicians each day across 5 different ICUs, enquiring as to whether any of the patients under their care were receiving futile treatment. Overall, 1,136 patients over 3 months were assessed – with 123 reported to be receiving futile treatment. On 72 days during the survey period, an ICU was full and providing futile care – and these periods of ICU capacity resulted in 33 patients boarding >4 hours in the Emergency Department, 9 patients waiting >1 day to transfer in from an outside hospital, and 15 additional transfer requests being cancelled after waiting >1 day. Two patients died while awaiting transfer during times in which an ICU was at capacity while a patient was receiving futile care.
While this is just a single-center experience, I am certain we have all experienced ED boarding or transfer difficulties as a result of ICU capacity. These patients are subject to proven harms due to delays in care, and, as such, I agree with the authors’ conclusion:
“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….The ethic of “first come, first served” is not only inefficient and wasteful but it is also contrary to Medicine’s responsibility to apply healthcare resources to best serve society.”
“The Opportunity Cost of Futile Treatment in the ICU”
http://www.ncbi.nlm.nih.gov/pubmed/24810527