Futile Care in ICU a Common Occurrence, Doctors Say

Costly treatments are not always in line with patient's prognosis, researcher contends

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Tuesday, September 10, 2013

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TUESDAY, Sept. 10 (HealthDay News) -- Critical care doctors at a major teaching hospital believe they provided futile treatment to about one in five intensive care unit patients, needlessly prolonging their lives.
ICU doctors in the UCLA Health System said they were certain they provided futile care for 11 percent of the critically ill patients they saw over a recent three-month period, and they strongly suspected that they had provided futile treatment for another 8.6 percent of patients.
The reported episodes of definite futile care cost the health system about $2.6 million during the study period, according to an article published online Sept. 9 in JAMA Internal Medicine.
"Doctors have fantastic tools at their disposal and frequently rescue people who would otherwise die," said senior author Dr. Neil Wenger, a professor of medicine and director of the UCLA Healthcare Ethics Center in the David Geffen School of Medicine. "These data suggest that some patients are so sick that even with these tools, doctors recognize they can't make them much better."
The study focused on 1,125 patients who received care between Dec. 15, 2011 and March 15, 2012 at one of the UCLA system's five ICUs.
The critical care specialists treating these patients filled out a brief daily questionnaire asking whether they were providing futile care, defined as intensive care interventions that sustain life without achieving an outcome that the patient can meaningfully appreciate.
Patients who received futile care "tended to be the patients who were sicker and the patients who were older, and particularly patients who had been transferred in from nursing homes and long-term care hospitals," Wenger said.
The most common reason doctors perceived an instance of care as futile was that the burdens to the patients, their families and their care providers grossly outweighed the benefits. Doctors cited this as a reason 58 percent of the time.
Other reasons given included:

Treatment could never reach the patient's goals (51 percent).
Death was imminent (37 percent).
The patient would never be able to survive outside an ICU (36 percent).

Doctors were certain that 123 patients had received futile care, and time bore out their assessment -- 68 percent of those patients died during the hospitalization. Survivors were left in severely compromised health and often dependent on life support.
The average cost for a day of futile treatment in the ICU was about $4,000, the researchers reported. For the 123 patients perceived as definitely receiving futile ICU care, total costs during the three months of the study amounted to $2.6 million.
"If this is happening in hospitals across the country, then consumers of health care are not always getting the treatments that are best targeted to their prognosis, and sometimes resources are used inappropriately," Wenger said.
At least one expert disagrees with the study conclusions, however.
The findings are limited because they are based solely on physician perceptions at one academic institution, said Dr. Howard Epstein, chief health systems officer at the Institute for Clinical Systems Improvement in St. Paul, Minn.
"The term 'futile' is one I really abhor," Epstein said. "Instead of 'futile,' I use 'non-beneficial care' or 'low-yield treatment.' Because futility, like beauty, is in the eye of the beholder. It's totally dependent on your perspective. If you're a loved one at the bedside with someone near and dear to you, your perspective on futility may be different."
The questionnaire did not go deeper into why "futile" care occurs, and the researchers will next work to identify those factors and consider how they might be minimized.
Wenger offered some possible explanations. "Very often, there hasn't been good enough communication about the fact that a patient won't survive," he said. "Families may be pushing for continued aggressive care, hoping against hope."
A doctor's drive to save lives at any cost also might play a role.
"That's what intensive care units are for, to rescue people," Wenger said. "What's startling is the doctors here told us they were no longer using intensive care in a useful way for the patients."
A more thorough discussion of the costs and benefits of continued treatment could help doctors and families better judge whether the care would be helpful or futile, but Wenger said the parties involved are often reluctant to have that type of talk when a loved one lies dying.
"It means having a lot of hard conversations. It means talking about what the course of care should be if the surgery doesn't work or if the patient doesn't get better," he said.
"It's much easier to focus on the positive only," he added. "If those conversations don't happen, it's the family left to decide what to do, never having had the opportunity to talk with the patient about it."

SOURCES: Neil Wenger, M.D., professor, medicine, and director, Healthcare Ethics Center, David Geffen School of Medicine, University of California at Los Angeles; Howard Epstein, M.D., chief health systems officer, Institute for Clinical Systems Improvement, St. Paul, Minn., and board member, Society of Hospital Medicine; Sept. 9, 2013, JAMA Internal Medicine, online

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