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The Opportunity Cost of Futile Treatment in the ICU*

Huynh, Thanh N. MD, MSHS; Kleerup, Eric C. MD; Raj, Prince P. MHA; Wenger, Neil S. MD, MPH

Critical Care Medicine:
doi: 10.1097/CCM.0000000000000402
Feature Articles
Abstract

Objective: When used to prolong life without achieving a benefit meaningful to the patient, critical care is often considered “futile.” Although futile treatment is acknowledged as a misuse of resources by many, no study has evaluated its opportunity cost, that is, how it affects care for others. Our objective was to evaluate delays in care when futile treatment is provided.

Design: For 3 months, we surveyed critical care physicians in five ICUs to identify patients that clinicians identified as receiving futile treatment. We identified days when an ICU was full and contained at least one patient who was receiving futile treatment. For those days, we evaluated the number of patients waiting for ICU admission more than 4 hours in the emergency department or more than 1 day at an outside hospital.

Setting: One health system that included a quaternary care medical center and an affiliated community hospital.

Patients: Critically ill patients.

Interventions: None.

Measurements and Main Results: Boarding time in the emergency department and waiting time on the transfer list. Thirty-six critical care specialists made 6,916 assessments on 1,136 patients of whom 123 were assessed to receive futile treatment. A full ICU was less likely to contain a patient receiving futile treatment compared with an ICU with available beds (38% vs 68%, p < 0.001). On 72 (16%) days, an ICU was full and contained at least one patient receiving futile treatment. During these days, 33 patients boarded in the emergency department for more than 4 hours after admitted to the ICU team, nine patients waited more than 1 day to be transferred from an outside hospital, and 15 patients canceled the transfer request after waiting more than 1 day. Two patients died while waiting to be transferred.

Conclusions: Futile critical care was associated with delays in care to other patients.

Author Information

1Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA.

2Emergency Room, Ronald Reagan-UCLA Medical Center, Los Angeles, CA.

3UCLA Health Ethics Center, Los Angeles, CA.

4Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA.

5RAND Health, Santa Monica, CA.

* See also p. 2127.

Drs. Huynh, Kleerup, and Wenger contributed to study concept and design. Drs. Huynh and Raj contributed to data collection. Drs. Huynh, Kleerup, Raj, and Wenger contributed to analysis and interpretation of data. Drs. Huynh and Wenger contributed to statistical analysis. Drs. Huynh and Wenger contributed to drafting of the article. Drs. Huynh, Kleerup, Raj, and Wenger contributed to critical revision of the article. Drs. Huynh and Wenger had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Supported, in part, by a donation from James D. & Mary Kay Farley to RAND Health. The funder played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the article.

Dr. Huynh was supported by UCLA Kennamer Fellowship (supported by the Parvin Foundation), National Institutes of Health (NIH) T32 training grant, and the NIH Loan Repayment Program. Dr. Huynh received support for travel from the UCLA Pulmonary Division and received support for article research from the NIH. Dr. Kleerup’s institution received grant support from GlaxoSmith Kline, Boehringer Ingelheim, Pfizer, Novartis, Centocor, Johnson & Johnson, Pearl, NIH, Astute Medical, Sunovion, and Actillion. Dr. Wenger’s institution received support from a private donor donation to RAND Health, NIH, and CMS. Dr. Raj has disclosed that he does not have any potential conflicts of interest.

For information regarding this article, E-mail: thuynh@mednet.ucla.edu

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