April 08, 2014

Futility in the ICU: Perception is everything

Dr. David Oxman, Assistant Professor of Medicine, Division of Pulmonary and Critical Care Medicine at Thomas Jefferson University Hospital reviews The Frequency and Cost of Treatment Perceived to Be Futile in Critical Care Thanh N. Huynh, MD, MSHS; Eric C. Kleerup, MD; Joshua F. Wiley, MA; et al. JAMA Intern Med. 2013;():-. doi:10.1001/jamainternmed.2013.10261.

While the capacity for modern critical care medicine to save lives has progressed incredibly over the years, there are limits. In many cases life can be sustained but cure remains impossible and an extended ICU course may only prolong an inevitable death. In some of these cases physicians may feel forced by patients or their surrogates to continue aggressive treatment when there is little hope of meaningful benefit. Continued intensive treatments – such as mechanical ventilation -- in these situations have been termed “futile” care.

Futile care in the intensive care unit can be costly. Not just in dollars potentially wasted, but also in the demoralization it causes amongst doctors and nurses who are made to render it. How often is “futile” care delivered in the ICU? In a recent study published in JAMA-Internal Medicine, Hyunh and colleagues set out to study the prevalence and cost of care that intensivists at one academic health care system considered to be futile.

In the study futile treatment was defined as treatment provided when there was either: imminent death, inability to survive outside an ICU, permanent unconsciousness or the perception that the treatment was overly burdensome or could not achieve the patient’s goals. Probably not surprising to most intensivists the study found that clinician-perceived futile care was common and costly. About 10% of patients received futile care during their ICU course. The most common reason the care was considered futile was that "the burdens grossly outweighed the benefits.” Patients receiving clinician-perceived futile care were older and more likely to come from a skill-nursing home or long-term acute care hospital. The mean cost of 1 day of futile treatment was $4000 and the total cost for all clinician-perceived futile care was $2.6 million.

Clearly, the study suggests that there are many patients receiving ICU care with little benefit. However, defining the magnitude of that benefit and whether or not it is worth it is much more challenging. The study did not discuss patient families’ perceptions of futility. Families of dying patients and clinicians may have very different perspectives and beliefs. One person’s futility may be another’s reasonable decision. As to the cost of this clinician-perceived futile care, while it was certainly not insignificant, the authors admit it was only a small percentage of critical care expenses during the study period.

While perceptions of clinicians are important, they are only a piece of the puzzle. Many "futile" cases are really cases in which communication has been poor or there is misunderstanding about the severity of disease. While physicians should never simply go along with treatment plans they think are not in the patient’s best interest, approaching these cases from the perspective of clinician perception alone is unfair. As many ethicists and researchers in end of life care have noted, while we should always strive to direct critical care to the achievement of reasonable goals -- and stop it when it these goals are unachievable -- there will inevitably be disputes about what is appropriate. As an accompanying editorial to the study puts it, clinicians responses to requests for inappropriate treatments should be “to increase communication with the patient or the patient’s surrogate … provide emotional support, discuss the patient’s prognosis, elicit the patient’s values and preferences … strive to understand the surrogate’s perspective and to find a mutually agreeable treatment plan.”  And when conflict is indeed intractable – which empirical research shows is uncommon – a formal dispute resolution process should be initiated. Simply labeling these difficult cases as "futile" may make us feel better temporarily, but in the end it doesn't help us run our ICUs more efficiently, or give our patients better care.