Providing futile treatment in the intensive care unit sets off a chain reaction that causes other ill patients who need medical attention to wait for critical care beds, according to a study by UCLA and RAND Health.
The research is the first to show that when non-beneficial medical care is provided, others who might be able to benefit from treatment are harmed, said Dr. Thanh Huynh, the study’s lead author and an assistant professor of medicine in the division of pulmonary and critical care medicine at the David Geffen School of Medicine at UCLA.
The findings also have implications for the fairness of the American health care system, and they point toward policy improvements that would guide more efficient use of our limited health care resources, said senior author Dr. Neil Wenger, a UCLA professor of medicine and RAND Health scientist.
“Many people do not realize that there is a tension between what medicine is able to do and what medicine should do,” said Wenger, who also is director of the UCLA Health Ethics Center at the Geffen School of Medicine. “Even fewer realize that medicine is commonly used to achieve goals that most people, and perhaps most of society, would not value — such as prolonging the dying process in the intensive care unit when a patient cannot improve.
“But almost no one recognizes that these actions affect other patients, who might receive delayed care or, worse, not receive needed care at all because futile medical treatment was provided to someone else.”
The study appears in the August issue of the peer-reviewed journal Critical Care Medicine.
The research team surveyed critical care physicians in five ICUs in one health system to identify patients that the clinicians determined were receiving treatment that would not help them get better. They then identified days when an ICU was full and there was at least one patient receiving futile treatment and counted the number of patients who were waiting for more than four hours to be admitted to the ICU or for more than one day to be transferred from an outside hospital.
They found that on 16 percent of days when an ICU was full, at least one patient was receiving futile treatment. During those days, 33 patients were kept in the emergency department for more than four hours, nine patients waited more than one day to be transferred from an outside hospital and 15 patients canceled their transfer request after waiting more than one day. Two patients died at other hospitals while waiting to be transferred into the academic medical center’s ICU.
“These findings should contribute to the public debate about the use of limited health care resources and whether limitations should be placed on using those resources for treatments that physicians feel will not benefit patients,” Wenger said.
“To date, health care payers have been willing to pay for any life-sustaining treatment that has already been started, and the public has been unwilling to discuss the tradeoffs silently made between patients receiving futile treatment and patients not receiving the treatment they need,” he said. “This study demonstrates that those tradeoffs occur and can be measured.”
Huynh said that the research team hopes to develop interventions that would decrease the incidence of of hospitals providing critical care to patients for whom there will be no benefit.
“With advances in medicine and technology, the ICU is now able to save lives as well as prolong the dying process,” Huynh said. “Because resources are not unlimited, patients receiving futile treatment can mean delayed or even denied access to care for other patients in need. This needs to change.”
The study reads, in part: “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. Our findings are particularly relevant in the U.S., but are also instructive elsewhere given universal concerns regarding providing treatments that are non-beneficial. The ethic of ‘first come, first served’ is not only inefficient and wasteful, but it is contrary to medicine’s responsibility to apply healthcare resources to best serve society. In the context of healthcare reform, which aims to more justly distribute medical care to the nation, opportunity cost is one more reason that futile treatment should be minimized.”
Funding for the research was provided by the late philanthropist Mary Kay Farley through a donation to RAND Health.
The challenge is accepting submissions through May 1, 2019