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Study: Treatment perceived as futile pervades critical care

Sunday September 22, 2013
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Critical care treatment that was perceived to be futile was common and cost an estimated $2.6 million at one academic medical center during a three-month period, according to a report.

Thanh N. Huynh, MD, MSHS, 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.

For a study published Sept. 9 on the website of the JAMA Internal Medicine, they asked critical care specialists to identify patients they believed were receiving futile treatment in five ICUs at an academic medical center on a daily basis for three months.

Thirty-six critical care specialists assessed 1,136 patients and judged that 904 (80%) never received futile treatment, 98 (8.6%) received treatment deemed as probably futile, 123 (11%) received futile treatment and 11 (1%) received futile treatment only on the day they transitioned to palliative care, according to the results.

The authors noted the most common reasons treatment was perceived as futile: the burdens grossly outweighed the benefits (cited by 58% of the respondents); treatment could never achieve the patient’s goals (51%); death was imminent (37%); and the patient would not be able to survive outside an ICU (36%).

The average cost for one day of treatment in the ICU that was perceived as futile was $4,004. For the 123 patients categorized as receiving futile care, hospital costs (ICU and subsequent non-ICU days) for the care thought to be futile totaled $2.6 million, which was 3.5% of the total hospital costs for the 1,136 patients in the study.

“In summary, in our health system, critical care physicians frequently perceived that they are providing futile treatment, and the cost is substantial,” the authors wrote. “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.”

In an accompanying commentary, Robert D. Truog, MD, of Harvard Medical School, Boston, and Douglas B. White, MD, MAS, of the University of Pittsburgh School of Medicine, offered four suggestions for how clinicians in critical care units should conceptualize and respond to requests for treatments they judge to be futile or wrong:

• Clinicians should generally avoid using the term “futile” to describe such treatment and instead use the term “potentially inappropriate.”

• From an ethical and legal standpoint, these disputes often are more complicated than they seem.

• Clinicians’ initial response to requests for treatments they believe are wrong should be to increase communication with the patient or the patient’s surrogate rather than simply refuse the request.

• If the conflict becomes intractable despite intensive communication, 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 concluded.

Study: http://archinte.jamanetwork.com/article.aspx?articleid=1735897


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