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Seeking to Reduce Nonbeneficial Treatment in the ICU: An Exploratory Trial of Proactive Ethics Intervention*

Andereck, William S. MD1; McGaughey, J. Westly BA1,2; Schneiderman, Lawrence J. MD1,3; Jonsen, Albert R. PhD1,4

doi: 10.1097/CCM.0000000000000034
Clinical Investigations

Objective: To investigate whether the proactive intervention of a clinical ethicist in cases of prolonged lengths of stay in a critical care setting reduces nonbeneficial treatment while increasing perceived patient/surrogate and provider satisfaction and reducing associated costs. Nonbeneficial treatment is defined here as the use of life-sustaining treatments delivered to patients who had been in the ICU for 5 days and did not survive to discharge.

Design: Prospective randomized exploratory trial from October 2007 to February 2010 in the adult ICU of a large, urban, not-for-profit community hospital.

Setting: Medical/surgical ICU of California Pacific Medical Center, a large tertiary not-for-profit hospital in San Francisco, CA.

Patients: Three hundred eighty-four patients with ICU lengths of stay of five days or greater. Patients were randomized to either an intervention arm (Proactive Ethics Intervention) (n = 174) or control arm (n = 210). There were 56 patients in the intervention arm and 52 patients in the control arm who did not survive to discharge.

Interventions: Proactive ethics intervention involves a trained bioethicist in the care of all ICU patients with a length of stay greater than or equal to 5 days. The intervention used a nine step process model designed to look for manifest or latent ethics conflicts and address them.

Measurements and Main Results: The primary outcome measures were days in the ICU; overall length of hospital stay; mortality; nonbeneficial treatments, for example, provision of nutritional support; surrogate and survivor satisfaction, and cost. The intervention and control arms showed no significant difference in mortality. Proactive Ethics Intervention, at the 95% CI, was not associated with reductions of overall length of stay (23 d for intervention and 21 d for control, p = 0.74), ICU days (11 in each arm, p = 0.91), life-sustaining treatments (days on ventilator: intervention, 14.6; control, 13.7; p = 0.74; days receiving artificial nutrition and hydration: intervention, 16.5; control, 15.9; p = 0.85), or cost ($167,350.00 for intervention and $164,670.00 for control, p =0.92) in patients who did not survive to discharge. Perceptions of quality of care by patients and providers showed no difference between intervention and control arms.

Conclusion: Our study finds that Proactive Ethics Intervention, provided to all patients in a critical care setting for 5 days, and before an ethical conflict has been recognized, is ineffective in reducing overall length of hospital stay, ICU days, nonbeneficial treatments, or hospital costs. It is also not effective in increasing perceptions of quality of care by patients or providers.

1Program in Medicine and Human Values, California Pacific Medical Center, San Francisco, CA.

2Lorry I. Lokey Graduate School of Business, and School of Public Policy, Mills College, Oakland, CA.

3Department of Family and Preventive Medicine, University of California, San Diego, CA.

4Department of Medical History and Ethics, University of Washington School of Medicine, Seattle, WA.

* See also p. 983.

Currently listed as ClinicalTrials.gov (NCT00996814).

All the authors designed and conceived the study, drafted the manuscript, and critically revised the manuscript for important intellectual content. Dr. Andereck obtained funding. Mr. McGaughey acquired, analyzed, and interpreted the data. He had statistical expertise and gave administrative, technical, or material support.

Supported, in part, by The Hearst Foundation, the Wallace Alexander Gerbode Foundation, and private donations.

Dr. Andereck is an employee of the Program in Medicine and Human Values of California Pacific Medical Center. His institutions received grant support from Wallace Alexander Gerbode Foundation and The Hearst Foundations. Mr. McGaughey is an employee of the Program in Medicine and Human Values of California Pacific Medical Center. His institutions received grant support from Wallace Alexander Gerbode Foundation and The Hearst Foundations. Dr. Schneiderman lectured for various entities and was also reimbursed for his work in this study by the Program in Medicine and Human Values of California Pacific Medical Center. Dr. Jonsen is an employee of the Program in Medicine and Human Values of California Pacific Medical Center. His institution received grant support from Wallace Alexander Gerbode Foundation and The Hearst Foundations.

For information regarding this article, E-mail: drbill@andereck.com

© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins