Critical Care Plus
Who Gets What in Critical Care?
Task force tackles care rationing initiative to yield ethical guidelines for limiting treatment
Two severely ill patients in the emergency department of your hospital need admission to intensive care, but only one bed is available. Who gets admitted first?
Another critical care patient is severely ill, with several coexisting conditions. A costly new medication is available to treat one problem, but her treatment may be complicated due to the other comorbidities. The new treatment also is in short supply. If she gets the medication, it might be unavailable for other patients who could benefit more. Should the physician take a chance and prescribe the medication, anyway?
These are some of the dilemmas that critical care specialists face nearly every day in the United States—limited resources and overwhelming demand.
The end result, say experts, is that most are now engaging in bedside rationing—deciding on a case-by-case basis which treatments to restrict or offer based on their assessment of the potential benefit to the patient vs. the costs to the system and to others.
In a 2002 survey of more than 5,000 members of the Society of Critical Care Medicine (SCCM) two-thirds of the respondents stated they would withhold from one patient a medication, test, or service that is in limited supply in order to give it to a patient who might benefit more.1
In addition, more than half of those providers reported routinely withholding medications, tests, or services from patients when they felt that costs outweighed the potential benefit. Yet most also indicated they wanted more guidance on how to make such decisions.
"The survey basically showed that a high percentage of physicians ration and, at the same time, feel badly that they do," says Mitchell Levy, MD, FCCM, FCCP, a critical care specialist at Brown Medical School/Rhode Island Hospital in Providence and chair of Brown University’s Values, Ethics and Rationing in Critical Care (VERICC) Task Force. "You have people making decisions at the bedside on resource allocation in a relatively haphazard way, not a measured way. We all struggle to deliver the highest quality of care possible for our patients, and we are successful to varying degrees. But some of the decisions that we make are not made from the broad overview perspective but from a more focused, bedside perspective."
In June, the VERICC Task Force announced a new, 18-month research and education initiative aimed at developing a national consensus on rationing in critical care—to include guidelines to help hospitals and critical care specialists determine how to make treatment decisions when resources are in short supply.
The task force plans to conduct a larger nationwide attitudinal survey of critical care physicians, nurses, hospital administrators and the public to determine what rationing practices take place and the attitude the various groups of people have toward them.
Then, the VERICC group will conduct focus groups, summit meetings and conferences for clinicians, hospital CEOs and administrators that will lead to the development of resource allocation practice guidelines for critical care clinicians.
The task force also wants to develop a comprehensive database and sophisticated software capable of assisting ICU personnel in making resource allocation decisions, no matter where in the country they are located.
"What you’d really like to do [as a physician] is to take into account your patient’s perspectives—what they want—and then a more global perspective of what works and what doesn’t work and be able to make a more measured decision about the most effective way to apply resources at the bedside," Levy explains. "Unfortunately, there are no guidelines and no clear ways to go about it."
Bringing it Out in the Open
The first step for the task force will be to initiate discussions that encourage physicians to begin talking about their rationing decisions, to educate the public about how and why rationing is necessary, and to foster public dialogue about the moral and ethical values that need to be addressed, says Dan W. Brock, PhD, senior scientist in the Department of Clinical Bioethics at the National Institutes of Health in Bethesda, MD, and a member of the VERICC Task Force.
"There is a denial that it happens on the part of both the health care system and the public," Brock says. "On the part of the public, there is always a concern about getting the care they need, and this sort of belief that rationing does not occur—and if it occurs, it is wrong."
The truth is that rationing of health care services does occur and has always occurred, in some form, and that it is necessary, he adds. "We need to acknowledge that: a) it does happen and has always happened; and b) it is necessary because if we didn’t there would be enormous costs. There is an assumption, by many, that all care is beneficial. But few people would say that we should provide all possible care to everyone no matter what the cost."
The initial mission of the task force will be to educate the public about how rationing in critical care occurs, by what criteria resources might be allocated and the processes by which they might be rationed.
Health care providers also must be more willing to discuss rationing in an open way, adds Levy. "We don’t want to admit that or talk about these decisions: Who should get the bed if I have one left? How much time do I spend with the patient? Who is going to get the more acute nursing care? Which patient should I send down [for a test] if I have to send down one first? Who do I want to insist get the test today and who can wait until tomorrow.’ Rationing happens at a very subtle level, and making those decisions is part of medical judgment. But we could provide better help for physicians if we were willing to talk a little more in public."
Models of Ethical Decision Making
The bioethicists on the VERICC panel will help the task force explore the different criteria that might be used to allocate scarce resources, Brock adds.
For example, many may feel that scarce resources should be reserved for those who will most benefit.
"But there are also concerns about justice in medicine—about preserving care for those worst off," he adds.
Patients who have not had adequate access to primary care or care early in a disease process may end up sicker than patients who have had the benefit of better health care overall. Restricting critical care based on the potential for a good outcome may leave out those patients, he notes.
"There are also questions about what weight should be given to patient age," Brock continues. "Should priority be given to younger patients rather that to the old?"
Discussions Guide Rationing Model
The task force is made up of ICU physicians, nurses, bioethicists, hospital CEOs, chairs of hospital departments of medicine, and other policy makers.
Initially, they will sponsor conferences and meetings designed to establish a common taxonomy, Levy says. "We need a unified terminology—when I say the word rationing’ does it mean what others think it means?" he says. "Then, we need to develop some examples of what we mean, some models of rationing."
At that point, they will initiate the national survey of critical care providers and other stakeholders to find out what methods of rationing and resource allocation currently are used.
The final phase will be a large consensus conference that will work on developing guidelines on critical care resource allocation, he notes.
The guidelines will not be a blueprint for how each treatment, medication, or service should be allocated in each setting, but an effort to guide facilities in determining how they will make their decisions.
Hospitals may end up choosing different criteria on which to base their decisions, depending on the values of their community and the patients that they see and treat, Brock notes.
"It may be that there is not widespread consensus on any one issue," he notes.
The task force also intends to examine a number of factors related to critical care outcomes, however, and it may be that many of the guidelines will cover general issues not related to individual patient care at the bedside, say both Levy and Brock.
For example, the role of nursing ratios and patient outcomes will be examined, as will allocation of hospital funding for critical care services.
"The third phase of our project will be to actually build a computerized modeling program that would allow us to figure out in a more careful way what is the impact of allocating different resources," says Levy. "If I am trying to decide between hiring new nurses or buying a new X-ray machine vs. getting expensive new drugs, where am I likely to see the most benefit? So, some of the rationing that is going to occur is going to occur up front and not have to trickle down to the bedside level."
More information on the VERICC project can be found on the group’s web site at www.vericc.org. And information on rationing in critical care medicine at the national survey of critical care providers can be found on the web site of the Society for Critical Care Medicine at: www.sccm.org. (Editor’s note: For more information contact Dan Brock, at Human Values in Medicine, Department of Philosophy and Program in Medicine, Providence, RI 02912, and Mitchell Levy, MD, at Box G-RIH, Brown University, Providence, RI 02912-G).
1. Levit K, et al. Trends in U.S. health care spending, 2001. Health Affairs. 2003;22:154-164.