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By Betty Tran, MD, MS
Assistant Professor of Medicine, Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago
Dr. Tran reports no financial relationships relevant to this field of study.
SYNOPSIS: This prospective, single-center study reported that critical care perceived to be futile is common, is associated with certain patient factors, and can be quite costly.
SOURCE:Huynh TN, et al. The frequency and cost of treatment perceived to be futile in critical care. JAMA Intern Med 2013;173:1887-1894.
As members of the critical care team, we have doubtless cared for patients whom we knew had no hope of recovery. The treatments provided to these patients may be described by some as "futile," although there is no uniform definition of that term, which is inherently controversial from medical, ethical, and legal perspectives. Huynh and colleagues sought to quantify the prevalence and cost of treatment perceived to be futile in the ICU in a single center.
A questionnaire was devised based on responses from a focus group of physicians from surgery, anesthesia, cardiology, and pulmonary/critical care exploring reasons that treatment may be considered futile, and subsequently administered to attending critical care physicians in five ICUs located in an academic health care system. For each ICU patient under the physician's care on a given day, the physician was asked whether the patient was receiving, probably receiving, or not receiving futile treatment and, if applicable, the reason treatment was futile: burdens grossly outweigh benefits, patient would never survive outside the ICU, patient is permanently unconscious, treatment cannot achieve patient's goals, or death is imminent. Patient and physician demographic and clinical data were collected as well as daily charges from which costs were estimated.
Over a 3-month period, 6916 assessments were performed on 1136 patients, of whom 98 (8.6%) were perceived to receive probably futile treatment and 123 (11%) were perceived to have received futile treatment. Assessments of futile treatment accounted for 6.7% of all assessments. Overall, physicians cited multiple reasons why a patient was receiving futile treatment. The most common reason was because the burdens outweighed the benefits (58%), followed by treatment could never reach the patient's goals (51%), death was imminent (37%), the patient would never survive outside the ICU (36%), and the patient was permanently unconscious (30%). Patients who were perceived as receiving probably futile treatment or futile treatment were older, more likely to be male, had higher Medicare Severity Diagnosis-Related Group (MS-DRG) weights, had longer lengths of stay, and were more likely to be admitted from a skilled nursing or long-term acute care facility. No physician descriptor was a significant predictor of the perception of futile treatment, although patients in the MICU were significantly more likely to be perceived as receiving futile treatment than in the cardiac or cardiothoracic care units. The average cost for 1 day of treatment in the ICU that was perceived to be futile was $4004. For the 123 patients who were perceived to be receiving futile treatment, hospital costs for the days considered futile amounted to $2.6 million.
Given significant advances in critical care medicine in prolonging life, this study highlights concerning perceptions among critical care physicians at the front lines of providing such treatments. The reasons treatment is perceived to be "futile" in the study are not surprising, and from personal experience, are often verbalized among the treating medical team members when discussing the patient on rounds or stated in the medical chart. What should happen afterward, however, is a discussion, or more realistically, multiple discussions with and an assessment of the views of the patient or surrogate decision maker. In certain instances where this alone is not enough, input from a third party (e.g., second physician opinion, hospital ethics committee, transfer of the patient to a different institution) may be needed to help resolve conflicts. Although it is unclear whether any of this occurred in the present study and may be outside its intended scope, the complexity of this topic highlights limitations regarding how this study was presented and potential difficulties in how its findings could be interpreted or applied.
The authors sought to describe the prevalence of ICU treatment perceived to be "futile," but given the lack of standard criteria, the prevalence reported is solely subjective and based on the opinion of a single physician on any given day. The authors rightfully acknowledge that it is unclear if other physicians would agree if asked or whether patients or their families would agree, which seems unlikely. Furthermore, in an editorial accompanying the article, Truog and White point out that the use of the term "futile" is problematic as ICU interventions are often never technically "futile" (i.e., incapable of producing any useful result).1 More often, there is a discrepancy between the values of the patient or surrogate decision maker of "doing everything" to prolong life and the judgment of medical providers that certain interventions come at high cost with little overall benefit.1 To make matters even more complex, there may be differences in opinion even among physicians as to what interventions are acceptable at the end of life.
Finally, the authors quote a significant cost of providing ICU treatment that is considered "futile" on the order of $2.6 million as 3.5% of the total hospital costs for the total number of patients included in the study. As they also acknowledge, however, this number is deceptive in that there are no data to support the implication that limiting ICU treatments considered "futile" would result in significant cost savings. As argued by Luce and Rubenfeld,2 not only are we unable to predict successfully which critically ill patients will be the most expensive or will die shortly after arrival in the ICU, but denying ICU treatments to these patients will unlikely result in significant cost savings because the vast majority of ICU costs are fixed. In summary, the perception of inappropriate medical treatment among critical care physicians is an important issue with significant clinical and ethical considerations, but defining the true prevalence and cost implications of such care is much more complex than what is presented here.